Poor nutritional status and dynapenia are highly prevalent in post-acute COVID-19

Malnutrition estimates range between 5 and 69% in acute Coronavirus disease 2019 (COVID-19) patients. With respect to body composition (BC) and muscle function, low values of phase angle (PhA) and handgrip strength (HGS) have been related to poor disease outcomes. Little evidence is available in post-acute patients. We aimed to combine the evaluation of nutritional status, BC, and muscle strength in a real-life cross-sectional cohort of post-acute COVID-19 patients referred to a rehabilitation center after hospital discharge. The study population included 144 patients (M=95;mean age 64.8yrs), of which 37% bedridden (M=60%). Nutritional status was evaluated with the Mini-Nutritional Assessment (MNA) and Controlling Nutritional status (CONUT) scores. Fat-free mass (FFM), skeletal muscle (SM), and raw variables, i.e. PhA, were estimated with bioelectrical impedance analysis. HGS was measured with a digital handle dynamometer for both dominant and non-dominant body sides. Dynapenia was identified according to the 2019 EWGSOP criteria. According to MNA, 18% of patients were malnourished and 62% at risk of malnutrition. As for CONUT, 21% of patients had moderate-severe malnutrition, while 58%light malnutrition. Overall, malnutrition was highly prevalent in older patients with more comorbidities. Marked abnormalities of PhAand HGSwere more frequent in bedridden or malnourished patients, and when FFM or SM were low. Dynapenic patients were 65% males and 47% females. Malnutrition, BC alterations, and low HGS occur in post-acute COVID-19 patients. Future studies will help to tailor screening algorithms for full nutritional status assessment to appropriate care processes and rehabilitation strategies.

Short-term impact of COVID-19 on health-related physical fitness in hospitalized and home-treated patients

Assessment of health-related physical fitness (PF) and body composition (BC) may yield relevant information on body function in patients who have been affected by Coronavirus disease-2019 (COVID-19). Aim of our study was to evaluate the short-term effects of COVID-19 on physical fitness in a real-life cohort of outpatients including hospitalized and home-treated patients. Sixty-four patients (M=36;mean age 56+/-13.5 yrs) previously affected by COVID-19 (25 hospitalized vs. 39 hometreated) in the 3-6 months preceding the study measurements were enrolled. PF was evaluated with the following tests: handgrip strength (HGS), gait speed (GAIT), sit-to-stand (STS), timed up and go (TUG) and Short physical performance battery (SPPB). Phase angle (PhA) was measured by bioelectrical impedance analysis (BIA) as a proxy marker of fat-free mass composition in terms of body cell mass and cell integrity. Poor PF performance was observed in 38% of subjects for HGS, 55% for GAIT, 30% for STS, 38% for TUG, and 70% for SPPB, while low values of PA were observed in 42% of the study sample in comparison with international cut-offs. The presence of 3-5 impaired values out of five was observed in 38% of patients. All PF tests (and even more the number of abnormal PF tests) consistently correlated with PhA. No differences were reported between hospitalized and home-treated patients. In the short-run, COVID-19 causes a worsening of physical fitness regardless of baseline disease severity. More research is required to systematically measure the extent of functional impairments in COVID-19 and to address whether and how rehabilitation can promote post-infection recovery.

Very low calorie ketogenic diet combined with physical interval training for preserving muscle mass during weight loss in sarcopenic obesity: A pilot study.

Background: The prevalence of sarcopenic obesity (SO) is increasing worldwide, posing important challenges to public health and national health care system, especially during the COVID pandemic. In subjects with SO, it is essential to reduce body weight, and to preserve lean mass, to avoid worsening of muscle function. Adequate nutrition and correct physical activity is essential to counteract SO progression. Very Low Calorie Ketogenic Diet (VLCKD), a well-established nutritional intervention for obesity, has been also indicated for the treatment of SO. To date, the effects of physical training during VLCKD have not been investigated. Aim: This pilot study aims to determine the efficacy of VLCKD combined with interval training, compared to a VLCKD alone, on weight-loss, body composition, and physical performance in participants with SO. Materials and methods: Twenty-four participants with SO, aged between 50 and 70 years, who met the inclusion criteria, accepted to adhere to a VLCKD (<800 Kcal/die) and to give informed consent, were enrolled in the study. Twelve participants followed a structured VLCKD protocol (VLCKD group) and twelve followed the same VLCKD protocol combined with interval training (IT), twice per week (VLCKD + IT group). Data were collected at baseline (T0) and after 6-week of treatment (T6). Anthropometric indexes, body composition analysis by Bioelectrical Impedance Analysis (BIA), muscle strength and physical performance analysis were assessed at baseline and at the end of treatment. Results: At the end of the study, body mass index (BMI), body weight, waist circumference, and hip circumference were significantly reduced in both VLCKD group and VLCKD + IT group. Interestingly, a significant improvement in muscle strength and physical performance was observed in both groups. A multiple comparison of delta variations in all parameters between groups was performed. No differences were observed for the majority of anthropometric and biochemical parameters, with the exception of fat free mass (FFM) and fat mass (FM): notably, participants who followed a VLCKD combined with IT preserved FFM (p < 0.001) and reduced FM (p = 0.001) to a greater extent than what observed in VLCKD group. Moreover, high density lipoprotein (HDL) cholesterol plasma levels were significantly higher in the VLCKD + IT group compared to the VLCKD group. Conclusion: This pilot study confirms that VLCKD is effective in terms of body weight reduction, particularly FM; moreover, the combination of VLCKD and interval training could determine a better preservation of FFM.

Assessment of macronutrient intake in subjects with mild to moderate pneumonia due to Covid 19 classified based on their nutritional status

Malnutrition, both severe and acute in covid 19 patients are particularly serious problems, may depress the immune system further indicating a poor outcome in terms of morbidity, quality of life and mortality1. Thus, dietary intake may play a major role in determining nutritional status of patients with pneumonia due to COVID 19. Aim was to screen and evaluate the intake of macro-nutrients in subjects who could tolerate oral intake with mild to moderate pneumonia due to Covid 19 assessed for nutritional status, fat free mass index (FFMI) and basic lung function. A cross sectional study was carried out on 71 patients admitted to an ICU in an urban multispecialty hospital from August 2020 to January 2021. Nutritional status, lung function, body composition was assessed using Patient generated Subjective global assessment (PGSGA), Spirometry and Fat Free Mass Index (FFMI) respectively. Dietary intakes were assessed using Food record charts (FRCs). The results show that higher proportion of subjects were unable to meet the RDI for energy (56%), protein (90%) and fat (66%);carbohydrate intake was above RDI (41%) despite of providing oral nutritional supplements in an attempt to meet the required dietary allowance and nutritional needs in these subjects. 24 (73%) subjects out of 33 under stage B & C reported lack of appetite with early satiety. Mean age of the patients was 62± 8.8 yrs. and mean BMI on admission was 21.1± 4.2 kg/m2. [Formula presented] In conclusion subjects included in this study with better nutritional status and nutrient intakes had better lung function. Hence, early identification of malnutrition by screening, assessment with timely nutrition intervention in COVID 19 subjects by fueling of deficits in nutrient intake may preserve lean body mass, improve nutritional status, avoid deterioration of lung function due to malnutrition thus leading to a probable positive prognosis of the disease. References 1. Damayanthi HDWT, Prabani KIP. Nutritional determinants and COVID-19 outcomes of older patients with COVID-19: A systematic review. Arch Gerontol Geriatr. 2021 Jul-Aug;95:104411.

Overhydration Assessed Using Bioelectrical Impedance Vector Analysis Adversely Affects 90-Day Clinical Outcome among SARS-CoV2 Patients: A New Approach.

BACKGROUND: COVID-19 has taken on pandemic proportions with growing interest in prognostic factors. Overhydration is a risk factor for mortality in several medical conditions with its role in COVID-19, assessed with bioelectrical impedance (BI), gaining research interest. COVID-19 affects hydration status. The aim was to determine the hydration predictive role on 90 d survival COVID-19 and to compare BI assessments with traditional measures of hydration. METHODS: We studied 127 consecutive COVID-19 patients. Hydration status was estimated using a 50 kHz phase-sensitive BI and estimated, compared with clinical scores and laboratory markers to predict mortality. RESULTS: Non-surviving COVID-19 patients had significantly higher hydration 85.2% (76.9-89.3) vs. 73.7% (73.2-82.1) and extracellular water/total body water (ECW/TBW) 0.67 (0.59-0.75) vs. 0.54 (0.48-0.61) (p = 0.001, respectively), compared to surviving. Patients in the highest hydration tertile had increased mortality (p = 0.012), Intensive Care Unit (ICU) admission (p = 0.027), COVID-19 SEIMC score (p = 0.003), and inflammation biomarkers [CRP/prealbumin (p = 0.011)]. Multivariate analysis revealed that hydration status was associated with increased mortality. HR was 2.967 (95%CI, 1.459-6.032, p < 0.001) for hydration and 2.528 (95%CI, 1.664-3.843, p < 0.001) for ECW/TBW, which were significantly greater than traditional measures: CRP/prealbumin 3.057(95%CI, 0.906-10.308, p = 0.072) or BUN/creatinine 1.861 (95%CI, 1.375-2.520, p < 0.001). Hydration > 76.15% or ECW/TBW > 0.58 were the cut-off values predicting COVID-19 mortality with 81.3% and 93.8% sensitivity and 64 and 67.6% specificity, respectively. Hydration status offers a sensitive and specific prognostic test at admission, compared to established poor prognosis parameters. CONCLUSIONS AND RELEVANCE: Overhydration, indicated as high hydration (>76.15%) and ECW/TBW (>0.58), were significant predictors of COVID-19 mortality. These findings suggest that hydration evaluation with 50 kHz phase-sensitive BI measurements should be routinely included in the clinical assessment of COVID-19 patients at hospital admission, to identify increased mortality risk patients and assist medical care.

Protein requirements and provision in hospitalised COVID-19 ward and ICU patients: Agreement between calculations based on body weight and height, and measured bioimpedance lean body mass.

BACKGROUND: A large proportion of hospitalised COVID-19 patients are overweight. There is no consensus in the literature on how lean body mass (LBM) can best be estimated to adequately guide nutritional protein recommendations in hospitalised patients who are not at an ideal weight. We aim to explore which method best agrees with lean body mass as measured by bioelectric impedance (LBMBIA) in this population. METHODS: LBM was calculated by five commonly used methods for 150 hospitalised COVID-19 patients previously included in the BIAC-19 study; total body weight, regression to a BMI of 22.5, regression to BMI 27.5 when BMI>30, and the equations described by Gallagher and the ESPEN ICU guideline. Error-standard plots were used to assess agreement and bias compared to LBMBIA. The actual protein provided to ICU patients during their stay was compared to targets set using LBMBIA and LBM calculated by other methods. RESULTS: All methods to calculate LBM suffered from overestimation, underestimation, fixed- and proportional bias and wide limits of agreement compared to LBMBIA. Bias was inconsistent across sex and BMI subgroups. Twenty-eight ICU patients received a mean of 51.19 (95%-BCa CI 37.1;64.1) grams of protein daily, accumulating to a mean of 61.6% (95%-BCa CI 43.2;80.8) of TargetBIA during their ICU stay. The percentage received of the target as calculated by the LBMGallagher method for males was the only one to not differ significantly from the percentage received of TargetBIA (mean difference 1.4% (95%-BCa CI -1.3;4.6) p = 1.0). CONCLUSIONS: We could not identify a mathematical method for calculating LBM that had an acceptable agreement with LBM as derived from BIA for males and females across all BMI subgroups in our hospitalised COVID-19 population. Consequently, discrepancies when assessing the adequacy of protein provision in ICU patients were found. We strongly advise using baseline LBMBIA to guide protein dosing if possible. In the absence of BIA, using a method that overestimates LBM in all categories may be the only way to minimise underdosing of nutritional protein. TRIAL REGISTRATION: The protocol of the BIAC-19 study, of which this is a post-hoc sub-analysis, is registered in the Netherlands Trial Register (number NL8562).

Nutritional status of COVID-19 patients one year post-ICU stay

Introduction: Our aim was to describe nutritional status (NS) of critically ill COVID-19 patients 1 year post-ICU stay. Malnutrition and weight loss were observed during hospitalization. Post-ICU discharge patients often continue to suffer from physical complaints and poor nutritional intake, which can negatively affect NS. Methods: Observational study including adult COVID-19 patients 1 year post-ICU stay. NS assessment (nutrient balance, body composition and physical status) was performed. Nutritional intake (energy and protein), nutrition related complaints and losses were examined. Indirect calorimetry (Q-NRG +) was performed to determine nutritional requirements. Body composition (e.g. fat mass, fat free mass) was measured with bio-electrical impedance analysis (InbodyS10). Fat-free mass index (FFMI) and fat mass index (FMI) were calculated. Physical status was determined with handgrip strength (HGS). Overall values ≤ 10th percentile were considered too low and ≥ 90th too high. Descriptive statistics were used for analysis. Results: 48 patients were included (72% male;median age 60 years [IQR 52;65]). Median ICU stay was 19 days [IQR 10;30]. Median weight loss during ICU stay was 13% [IQR - 10;- 16] and 12% of this loss [IQR 7;16] was regained after 1 year. BMI was 26 kg/m2 [IQR 23;30] 1 year post-ICU, of which 24% was obese (BMI > 30 kg/m2). Normometabolism was predominantly observed (62%), followed by hypermetabolism (30%). Mean nutritional intake was 78% of calculated requirements. Nutrition related complaints occurred in < 5% of the patients. Most patients had a high FMI (55%) and minority had low FFMI (35%). Combination of a high FFMI and FMI was present in 17%. Three patients (6%) had low HGS. Conclusions: Weight loss was almost fully regained 1 year post-ICU, often in combination with a high fat mass. A minority had low physical function. Whereas reported calculated requirements were not met, lifestyle coaching remains indicated to optimize NS.

In-Season Body Composition Effects in Professional Women Soccer Players.

This study aimed to analyze anthropometric and body composition effects in professional soccer women players across the early and mid-competitive 2019/20 season. Seventeen players (age, height, body mass, and body mass index of 22.7 ± 6.3 years, 167.5 ± 5.6 cm, 60.7 ± 6.6 kg and 21.6 ± 0.2 kg/m2) from a Portuguese BPI League team participated in this study. The participants completed ≥80% of 57 training sessions and 13 matches. They were assessed at three points (before the start of the season (A1), after two months (A2), and after four months (A3)) using the following variables: body fat mass (BFM), soft lean mass (SLM), fat-free mass (FFM), intracellular water (ICW), extracellular water (ECW), total body water (TBW), and phase angle (PhA, 50 Khz), through InBody S10. Nutritional intake was determined through a questionnaire. Repeated measures ANCOVA and effect sizes (ES) were used with p < 0.05. The main results occurred between A1 and A2 for BFM (-21.7%, ES = 1.58), SLM (3.7%, ES = 1.24), FFM (4%, ES = 1.34), ICW (4.2%, ES = 1.41), TBW (3.7%, ES = 1.04). Furthermore, there were significant results between A1 and A3 for FFM (4.8%, ES = 1.51), ICW (5%, ES = 1.68), and PhA (10.4%, ES = 6.64). The results showed that the water parameters improved over time, which led to healthy hydration statuses. The training load structure provided sufficient stimulus for appropriate physical fitness development, without causing negative disturbances in the water compartments.

The Effects of the COVID-19 Environments on Changes in Body Composition in Japanese Elite Fencing Athlete.

The Japanese government declared a state of emergency from 7 April to 25 May to limit people's movement due to the coronavirus disease (COVID-19) pandemic. This pandemic negatively affects athletes' body composition due to inactivity. Therefore, we compared the body composition data (i.e., fat-free mass (FFM) and fat mass (FM)), of 43 Japanese elite fencers (22 men, 21 women), in September 2019 for baseline, and of 21 (12 men, 9 women) who completed the following measurements in June 2020 (POST; immediately after rescinding the emergency state) and September 2020 (POST-4M; 4-months after rescinding the emergency state). Results at baseline indicate no significant differences in body compositions among fencing disciplines. We also confirmed no significant changes in body mass during the 1-year investigation period in either sex. There were no time-course changes in men's FFM and FM; however, time-course changes in women's FM were observed. Compared to the baseline, FM values were significantly higher at POST and then returned to baseline levels at POST-4M in women. In conclusion, the 2-month stay-at-home period due to COVID-19 negatively affected women's FM changes, but not their FFM or men's FM.

Comparison of Bioelectrical Impedance-Based Methods on Body Composition in Young Patients with Obesity.

(1) Background: The determination of body composition is an important method to investigate patients with obesity and to evaluate the efficacy of individualized medical interventions. Bioelectrical impedance-based methods are non-invasive and widely applied but need to be validated for their use in young patients with obesity. (2) Methods: We compiled data from three independent studies on children and adolescents with obesity, measuring body composition with two bioelectrical impedance-based devices (TANITA and BIACORPUS). For a small patient group, additional data were collected with air displacement plethysmography (BOD POD) and dual-energy X-ray absorptiometry (DXA). (3) Results: Our combined data on 123 patients (age: 6-18 years, body mass index (BMI): 21-59 kg/m²) and the individual studies showed that TANITA and BIACORPUS yield significantly different results on body composition, TANITA overestimating body fat percentage and fat mass relative to BIACORPUS and underestimating fat-free mass (p < 0.001 for all three parameters). A Bland-Altman plot indicated little agreement between methods, which produce clinically relevant differences for all three parameters. We detected gender-specific differences with both methods, with body fat percentage being lower (p < 0.01) and fat-free mass higher (p < 0.001) in males than females. (4) Conclusions: Both bioelectrical impedance-based methods provide significantly different results on body composition in young patients with obesity and thus cannot be used interchangeably, requiring adherence to a specific device for repetitive measurements to ascertain comparability of data.

Nutritional status in post SARS-Cov2 rehabilitation patients.

BACKGROUND & AIMS: After prolonged hospitalization, the assessment of nutritional status and the identification of adequate nutritional support is of paramount importance. In this observational study, we aimed at assessing the presence of a malnutrition condition in SARS-Cov2 patients after the acute phase and the effects of a multidisciplinary rehabilitation program on nutritional and functional status. METHODS: We recruited 48 patients (26 males/22 females) admitted to our Rehabilitation Unit after discharge from acute Covid Hospitals in northern Italy with negative swab for SARS-Cov2. We used the Global Leadership Initiative on Malnutrition (GLIM) criteria to identify patients with different degrees of malnutrition. Patients underwent a 3 to 4-week individual multidisciplinary rehabilitation program consisting of nutritional intervention (energy intake 27to30 kcal/die/kg and protein intake 1-1.3 g/die/kg), exercise for total body conditioning and progressive aerobic exercise with cycle- and arm-ergometer (45 min, 5 days/week). At admission and discharge from our Rehabilitation Unit, body composition and phase angle (PhA) (BIA101 Akern), muscle strength (handgrip, HG) and physical performance (Timed-Up-and-Go, TUG) were assessed. RESULTS: At admission in all patients the mean weight loss, as compared to the habitual weight, was -12.1 (7.6)%, mean BMI was 25.9 (7.9) kg/m2, mean Appendicular Skeletal Muscle Index (ASMI) was 6.6 (1.7) kg/m2 for males and 5.4 (1.4) kg/m2 for females, mean phase angle was 2.9 (0.9)°, mean muscle strength (HG) was 21.1 (7.8) kg for males and 16.4 (5.9) kg for females, mean TUG value was 23.7 (19.2) s. Based on GLIM criteria 29 patients (60% of the total) showed a malnutrition condition. 7 out of those 29 patients (24%) presented a mild/moderate grade and 22 patients (76%) a severe grade. After a rehabilitation program of an average duration of 25 days (range 13-46) ASMI increased, with statistically significant differences only in females (p = 0.001) and HG improved only in males (p = 0.0014). In all of the patients, body weight did not change, CRP/albumin (p < 0.05) and TUG (p < 0.001) were reduced and PhA increased (p < 0.01). CONCLUSIONS: We diagnosed a malnutrition condition in 60% of our post SARS-Cov2 patients. An individualized nutritional intervention with adequate energy and protein intake combined with tailored aerobic and strengthening exercise improved nutritional and functional status.

Association of bioelectric impedance analysis body composition and disease severity in COVID-19 hospital ward and ICU patients: The BIAC-19 study.

BACKGROUND: The current severe acute respiratory syndrome coronavirus 2 pandemic is unprecedented in its impact. It is essential to shed light on patient characteristics that predispose to a more severe disease course. Obesity, defined as a BMI>30 kg/m2, is suggested to be one of these characteristics. However, BMI does not differentiate between fat mass and lean body mass, or the distribution of fat tissue. The aim of the present study was to assess the body composition of COVID-19 patients admitted to the ward or the ICU and identify any associations with severity of disease. METHODS: We performed an observational cross-sectional cohort study. Bioelectric impedance analysis was conducted amongst all confirmed COVID-19 patients admitted to the ward or ICU of our hospital in the Netherlands, between April 10 and 17, 2020. Body water measurements and derived values were recalculated to dry weight, using a standard ratio of extracellular water to total body water of 0.38. Data were compared between the ward and ICU patients, and regression models were used to assess the associations between baseline characteristics, body composition, and several indicators of disease severity, including a composite score composed of mortality, morbidity, and ICU admission. RESULTS: Fifty-four patients were included, of which 30 in the ward and 24 in the ICU. The mean age was 67 years (95%-CI 64-71), and 34 (63%) were male. Mean BMI was 29.7 (95%-CI 28.2-31.1) kg/m2 and did not differ between groups. Body composition values were not independently associated with disease severity. In multiple logistic regression analyses, a low phase angle was associated with COVID-19 severity in the composite score (OR 0.299, p = 0.046). CONCLUSION: We found no significant associations between body composition, including fat mass, visceral fat area, and fat-free mass, and disease severity in our population of generally overweight COVID-19 patients. A lower phase angle did increase the odds of severe COVID-19. We believe that factors other than body composition play a more critical role in the development of severe COVID-19.