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COVID-19: Summary of Community Nutritional Support Guidance

  By Dr Abbie Cawood    
 

A summary of key messages from the review of nutrition support guidelines for individuals with or recovering from COVID-19 in the community 

Full article published in Nutrients. 2020 Oct 22;12(11):E3230 and free to download  here

COVID-19 negatively impacts nutritional status and as such identification of nutritional risk and consideration of the need for nutrition support should be fundamental in this patient group. This review summarises key themes from 15 publications of clinical nutrition professional organisations across the world. The review briefly summarises 6 other national COVID 19 documents that advocated community nutrition support. 

Key recurring themes include the importance in the community setting of:

  • Screening for malnutrition, which can be achieved by remote consultation;
  • Care plans with appropriate nutrition support, which may include food-based strategies, oral nutritional supplements (ONS) and referral to a dietitian;
  • Continuity of nutritional care between settings including rapid communication at discharge of malnutrition risk and requirements for ongoing nutrition support.

These themes, and indeed the importance of nutritional care, should be considered in clinical practice, be incorporated in primary care COVID-19 recovery pathways.

Screening for Malnutrition Risk in the Community

60% of documents recommended screening for malnutrition risk and the Malnutrition Universal Screening Tool (“MUST”) was one of the screening tools commonly highlighted.

Each patient with or recovering from COVID-19 in the community:

  • Must be screened for malnutrition with a tool such as MUST, upon first contact with a HCP, and when clinically indicated;
  • Can be screened for malnutrition risk by remote consultation; recalled and subjective measures can be used if necessary with some screening tools, whilst self-screening with a validated tool is also appropriate;
  • Must have the outcome of their malnutrition screening linked to a documented management plan appropriate for their level of risk, with review plans included.

Nutrition Support in the Community

Including information on dietary advice, ONS, micronutrients, dietitians and allied health professionals, community nutritional care pathways.

  • All documents mentioned the need for nutrition support for patients with or recovering from COVID-19.
  • Seven documents captured the role of dietary advice to optimise dietary intake.
  • Protein was a focus, as requirements can be higher in those recovering from illness, and in individuals with sarcopenia, which is relevant to COVID-19.
  • Eleven documents mentioned the use of ONS. ESPEN offered a prescriptive indication stating that “ONS should be used whenever possible to meet patient’s needs, when dietary counselling and food fortification are not sufficient to increase dietary intake and reach nutritional goals, ONS shall provide at least 400 kcal/day including 30 g or more of protein/day and shall be continued for at least one month”.
  • Some documents noted how essential it is to ensure micronutrient intakes are sufficient and Vitamin D was most frequently discussed.
  • Twelve documents highlighted the role of dietitians in the management of patients with COVID-19. Commonly, guidelines stated that individuals with COVID-19 who also have special dietary requirements (e.g., diabetes, ICU-acquired weakness) or are receiving enteral tube feeding or parenteral nutrition, should be referred to a dietitian. It was consistently recommended that dietitians should work as part of a multi-disciplinary rehabilitation service.
  • The review found one national pathway for managing malnutrition in patients with COVID-19 in the community - see the Malnutrition Pathway

Key Messages:

  • Nutrition support should be considered for individuals with COVID-19 unable to meet nutritional requirements and those who are malnourished. This includes the full range of strategies including dietary advice, ONS and tube feeding.
  • Protein requirements can be higher in those recovering from COVID-19 illness and with sarcopenia; nutrition support strategies should consider this.
  • When the diet, including food fortification, is unable to meet nutritional requirements, and/or patients are at high risk of malnutrition, ONS may be required, for a minimum of 4 weeks. The type of ONS and presentation (ready to drink or powdered) should be considered within the context of the specific needs of the individual patient.
  • Individuals with specialist dietary requirements, or complex needs, should be referred to a d
  • Nutrition support should be integrated into care pathways and multi-disciplinary rehabilitation services.
  • All nutrition support plans should include regular review and monitoring.

Continuity of Care between Settings

Thirteen documents mentioned some aspect of the discharge process from an acute to community setting for patients with COVID-19

Key Messages:

  • Effective clear and rapid communication about nutrition, between settings, is essential for continuity of care.
  • Each patient being discharged from hospital recovering from COVID-19 must have a hospital discharge plan which includes:

-A malnutrition risk score using a validated tool such as “MUST”;

-Details of nutrition care plans, as nutritional treatment should continue after discharge;

-Details of any ICU admission (if relevant).