Risk factors associated with overweight and obesity in children and adolescents during the COVID-19 pandemic in Chile.

The COVID-19 pandemic has caused changes in people's lifestyles, mainly in healthy eating habits and behaviors. Therefore, our objective was to evaluate the association of eating habits, family eating behaviors, lifestyles, and perception of nutritional status with the risk of overnutrition in children and adolescents during the COVID-19 pandemic. A cross-sectional study was conducted on a sample of 661 Chilean children and adolescents. The study tool was an online self-report questionnaire taken during the COVID-19 lockdown. We observed overnutrition in 37.5%. Habits such as sleeping the recommended number of hours by age group and having healthy family behaviors decreased the risk of overnutrition by 49.0% (OR= 0.510, p= <0.001) and 10.8% (OR= 0.892, p= 0.01), respectively. Parents' perception of weight gain during the pande-mic, the distortion of nutritional status and the health risk of their children's nutritional status increased 4.8 (OR= 4.846, p= <0.001), 8.5 (OR= 8.580, p= <0.001) and 3.8 (OR= 3.826, p= <0.001) times, respectively, the risk of overnutrition in children and adolescents. In conclusion, the COVID-19 lockdown and school closures may have affected lifestyles. In addition, the role of parents in the perception of nutritional status and family eating behaviors is fundamental since they could be a predictor of the risk of overnutrition. These findings propose further research to design plans and programs to avoid the consequences related to overweight and obesity.Copyright © 2023, Sociedad Chilena de Nutricion Bromatologia y Toxilogica. All rights reserved.

Achieving a sustainable food supply, for good health and planetary health, a focus on the international context

Globally, diet quality is poor, with populations failing to adhere to national dietary guidelines.(1) Such failure has been consistently linked with poorer health outcomes.(2) Examples of malnutrition include both under- and over-nutrition, with overweight and obesity now a significant health problem worldwide.(3) Other commonly occurring examples of malnutrition are micronutrient deficiencies with iron, vitamin A and iodine deficiencies being the most frequently occurring globally. These nutritional challenges have been influenced by recent global world events, including the COVID-19 pandemic, the war in Ukraine and the related economic uncertainties;with all of these events influencing food supply and food security. Diet and health status is socio-economically patterned, and such inequalities are likely to have been enhanced as a result of these recent events. In addition to the impact of diet on health outcomes it is increasingly recognised that what we eat, and the resulting food system, has significant environmental or planetary health impacts, and research activity is growing in terms of understanding the detail of these impacts, what changes are required to reduce these impacts and also how the impact of climate change on our food supply can be mitigated. Given the complexity of the interactions between climate change, other world events, food and health, and the different actors and drivers that influence these, a systems thinking approach to capture such complexity is essential.(4) Such an approach will help address the challenges set by the UN 2030 Agenda for Sustainable Development in the form of the Sustainable Development Goals, which are a call to action to end poverty and inequality, protect the planet, and ensure that all people enjoy health, justice and prosperity.(5) Progress against SDGs has been challenging with an ultimate target of 2030. While the scientific uncertainties regarding diet and public and planetary health need to be addressed, equal attention needs to be paid to the structures and systems, as there is a need for multi-level, coherent and sustained structural interventions and policies across the full food system/supply chain to effect behavior change. Such systems-level change must always keep nutritional status, including impact on micronutrient status, in mind. However, benefits to both population and environmental health could be expected from achieving dietary behaviour change towards more sustainable diets.

Prevalence of Malnutrition (under- and Overnutrition) and Association with Clinical Outcomes Pre- and during Covid-19 in Hospitalized Pediatric Gastroenterology Patients

Background The COVID-19 pandemic has been associated with higher rates of overnutrition. Despite concern that pandemic factors worsen risk for undernutrition, data on undernutrition prevalence during the pandemic is scarce, with minimal data on impact in hospitalized pediatric patients outside of the context of COVID-19 infection. This study sought to 1) determine the prevalence of malnutrition (both under and overnutrition) in hospitalized gastroenterology patients before and during COVID-19;and 2) study the associations between malnutrition, length of stay, and readmission rates. We hypothesize that prevalence of malnutrition increased during COVID-19 and would be associated with increased length of stay and more frequent readmissions. Methods The Boston Children's Hospital electronic database warehouse was used to identify children age >= 2 to <18 years admitted to the Pediatric Gastroenterology inpatient service from 9/1/2019 to 12/31/2019 (pre-COVID) and 9/1/2020 to 12/31/2020 (during COVID). Demographics, anthropometric measurements, length of stay and, 30 and 90 day readmission rates were obtained. Under- and overnutrition were classified using body mass index (BMI) z-scores and percentiles respectively per national society guidelines. Differences between pre- and during-COVID populations were analyzed with Fisher's exact test and Mann-Whitney U. Multivariate linear and logistic regression were performed to examine association of nutritional status with clinical outcomes. This study was deemed exempt by the Institutional Review Board. Results A total of 182 admissions occurred pre-COVID and 155 during COVID. Demographic characteristics of patients are shown in Table 1. Pre-COVID, 24% of patients were undernourished compared to 22% during COVID and 20% were overnourished pre-COVID compared to 31% during COVID (P=0.08 for distribution, Table 1). Length of stay pre-COVID was 2.3 (1.3, 4.1) days in patients with normal nutrition and during COVID was 3.0 (2.0, 5.0) days. In multivariate modeling controlling for age, gender and COVID period, undernutrition (but not overnutrition) significantly increased length of stay by 1.73 days, and those admitted during COVID showed a trend toward longer length of stay by 1.22 days (Table 2). In logistic regression modeling, readmission rates were not associated with nutrition status or COVID period (Table 2). Conclusion Rates of malnutrition (under and over nutrition) approach 50% in hospitalized pediatric gastroenterology patients. In contrast to our hypothesis, there was no significant change in overall prevalence of malnutrition pre- and during COVID. Of note, there was a suggestion of higher prevalence of overnutrition during COVID, which is congruent with recent literature and warrants further investigation. Undernutrition was associated with prolonged length of stay by 1.73 days, with a trend toward longer lengths of stay in patients admitted during COVID. (Table Presented).

Nutritional adequacy and accuracy in long-stay critically ill patients as measured by indirect calorimetry

Introduction: Nutritional optimisation is recognised as having significant impact on clinical and functional outcomes of critically ill patients.1 Clinical recommendations suggest use of indirect calorimetry guided nutrition in the intensive care unit (ICU),2 and a recent systematic review demonstrated improved outcomes from its use.3 The COVID-19 pandemic has seen a greater proportion of patients with prolonged critical illness, a cohort for whom nutritional optimisation is a key unmet need.4 Objectives: To assess rates of over and underfeeding in a tertiary centre ICU and how these relate to markers of catabolism and persistent critical illness. Methods: Serial measurements of REE (resting energy expenditure) and RQ (respiratory quotient) by indirect calorimetry were performed using Q-NRG+ device (COSMED, Rome, Italy). Nutritional intake and estimations of requirements were recorded concurrently together with routine clinical observations, and markers of critical illness, catabolism and over or underfeeding. Results: Across 30 patients, REE was lower than estimated energy requirements, 24.2 (IQR 20.0-28.1) kcal/ day/kg IBW vs. 29.1(IQR 25.4-33.1) kcal/day/kg IBW, p<0.001. 41.8% of measurements showed overfeeding (actual calorie intake >110% of REE), and 23.3% showed underfeeding (actual calorie intake <85% of REE). Obese patients (n=15) were underfed (-98kcal/day deficit) compared to non-obese patients (n=15), who were on average overfed (+256kcal/day surplus), p=0.021. Overfeeding was also associated with greater length of ICU admission (R2 0.159, p<0.005). Median day of ICU admission in overfed patients was 39 days (IQR 24-56), and in underfed patients 21.5 (IQR 7.5-45.25). However, there was no significant association between calorie surplus or deficit, and other markers of overfeeding PaCO2, insulin use, ureacreatinine-ratio. Conclusion: This service evaluation recorded measurements of REE and RQ in critically ill patients with high lengths of ICU stay (up to 66 days). We observed increased rates of overfeeding with increased duration of ICU admission, and increased overfeeding in non-obese patients.

The challenge of meeting protein requirements in critically ill patients in the COVID era

Critically ill patients often face progressive and rapid losses of body and muscle mass due to hypermetabolism and increased protein catabolism. Certain population groups (such as obese patients or those requiring Continuous Renal Replacement Therapy (CRRT) require a higher protein provision as advised by both ASPEN1 and ESPEN2. Furthermore, critically ill patients often receive significant energy provision from non-nutritional sources such as propofol. As a consequence, calorie provision via enteral feed is commonly restricted to avoid overfeeding, and protein provision to the patient is further compromised. Retrospective data was collected for 58 patients who were either confirmed or suspected of COVID-19 and admitted to the Intensive Care Unit (ICU) during April 2020. 31% (n=18) of patients were unable to meet their protein requirements from the feed formula alone, based on initial dietetic assessment. Recommended protein requirements were not achieved in any patients who were obese (n=10;defined as BMI ≥30 kg/m2) or receiving CRRT (n=6). The maximum protein provision for obese patients was 1.5g/kg IBW and 1.6g/kg for patients receiving CRRT. The situation was exacerbated for patients receiving high dose propofol (defined as >10 ml/hr), where protein provision decreased to 0.8 – 1.2g/kg and 1.1 – 1.3g/kg respectively. [Formula presented] In the non-obese, non-CRRT ICU population, the available enteral feeding regimes were appropriate to meet the majority of patients’ protein requirements (as shown in Figure 1). However the review almost certainly overestimates protein provision, as percentage feed delivery was not assessed and the results assume 100% feed delivery. We know from previous audits on our unit that feed delivery is often <80% of target, and although this review was based on COVID-19 patients, the ‘typical’ patients in ICU often have specific nutrition requirements, which includes high protein. The challenges faced during COVID-19 has raised awareness of the importance of protein delivery in ICU and our review highlights the need to continually monitor and augment protein delivery in critically ill patients. The findings support the need for a high protein supplement in specific population groups;particularly those who may be obese, require CRRT or are receiving high dose propofol in an ICU setting. 1 McClave S A, Taylor B E, Martindale R G et al. Guidelines for the Provision and Assessment of Nutrition Support Therapy in the Adult Critically Ill Patient: Society of Critical Care Medicine (SCCM) and American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.) J Parenter Enteral Nutr 2016;40(2): 159-211. 2 Singer P, Blaser A R, Berger M M et al. ESPEN Guideline on clinical nutrition in the intensive care unit Clin Nut 2019;38: 48-79

Applying learning from 1st to the 3rd wave of the COVID19 pandemic: nutritional provision in critical care

The aim of this analysis was to compare route and adequacy of nutrition support in patients with COVID19 admitted to an intensive care unit (ICU) between March-June 2020 (T1) compared to January-April 2021 (T2). Parameters related to nutrition support were collected from the records of all patients admitted to ICU with COVID19 with length of stay of ≥7days on mechanical ventilation requiring artificial nutrition support. Data was collected during the late acute phase which was defined as day 4-7 post intubation. Energy and protein intake was compared to calculated estimated nutritional requirements. 35 patients met the inclusion criteria in T1, 94% were on enteral nutrition (EN), 3% parenteral nutrition (PN) and 3% EN+PN. In T2, there were 54 patients (92% EN, 2% PN and 6% EN+PN). [Formula presented] Of patients who achieved <70% of energy and protein requirements in T1 (n=17) 35% had constipation or ileus and 47% had GI intolerance (high gastric residual volumes or vomiting). In T2 (n=19), 84% experienced constipation or ileus and 63% had GI intolerance. 35% of patients in T1 had hypernatraemia vs. 47% in T2 and 41% in T1 had hyperglycaemia vs. 100% in T2 despite only 12% and 32% of patients respectively having a history of diabetes. Despite a higher incidence of GI intolerance in T2, a statistically significant improvement in achieving energy targets was noted. Learning from T1 showed that where strategies to improve GI tolerance are unsuccessful supplementary PN should be considered without delay to optimise nutritional intake. There was a clinically significant trend in protein intake which may be attributed to prompt initiation of modular protein supplements or perhaps an earlier transition from fat-based sedation. Meeting protein requirements while preventing overfeeding remains a challenge in the ICU. Disclosure of Interest: None Declared

Chronic Disease Burden - Nutrition and Lifestyle affecting Lives and Livelihoods in the Covid-19 Pandemic

Introduction: The covid-19 pandemic had widened the health gap, further exposing the challenges that workers face. These individuals are often marginalised by job role, geographical location changes due to migration or societal stigma in terms of ethnic origin, gender and disability. This paper further explores the challenges that vulnerable workers face in terms of nutrition and lifestyle factors (as defined by the United Nations Sustainable Development Goals) that play an important role in dis-ease. Materials and Methods: A case series of workers globally affected by the above factors were researched and nutritionally relevant health factors analysed. This series covers all continents and was able to cover the burden of poor nutritional status as a contributing factor to covid 19 related mortality and morbidity. In particular, the effects nutrition being of relevance in the management of Long Covid was also flagged. Results: Poor nutritional status, in particular micronutrient deficiency and the double edged effects of both under and over nutrition have had direct and indirect effects on the susceptibility and recovery from covid-19. The findings further support that prevention and disease management is noted to be a key variable in the vulnerable worker population. Conclusions: The implementation of key nutritional parameters as part of the health and economic ecosystem is a significant factor in the saving of Lives and Livelihoods !

COVID-19 in India: challenges to health, food security and nutrition

This article presents a brief overview of the magnitude of the COVID pandemic and ongoing efforts in India to contain the spread and control COVID-19 epidemic in India, and the impact of lock down on food security. Discussed herein are facts about the aetiological agent, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), phases of the pandemic, magnitude of the pandemic in China and in India, and its global spread, measures put in place to control disease transmission such as screening of travellers, contact tracing, testing, home quarantine, and lockdowns, strategy for COVID-19 testing in India, course and outcome of COVID-19. In addition, several other topics are discussed such as providing health care to COVID-19 patients, guidelines for management of infected persons, home-based care for persons with mild infections, hospitalisation for moderate and severe cases, care of vulnerable segments of population with COVID-19, health care for persons not having COVID-19, nutrition support to persons with COVID-19, Nutrition support to general population during COVID-19 epidemic, preventing the rise of overnutrition during the COVID-19 epidemic. Furthermore, discussed here as well are topics such as COVID-19 and mental health, personal protection measures, handwashing and sanitising surfaces, wearing of masks, personal protective equipment for health care workers. Lastly, the adverse impact of COVID-19 on quality of life is discussed as well, particularly aspects such as human cost of lockdown, its effect on the economy, food supply, food security, and food safety.

Food access and experience of food insecurity in Nigerian households during the COVID-19 lockdown

The food insecurity experiences and related behaviors of Nigerian households during the COVID-19 lockdown have not been fully discussed. This study was conducted to elicit information on the impact of COVID-19 lockdown on economic and behavioral patterns related to food access. An online-based semi-structured questionnaire distributed through messaging platforms was used to collect information on characteristics, food purchasing behaviour before and during COVID-19 lockdown among respondents. Experience of food insecurity was assessed using Food Insecurity Experience Scale (FIES). A total of 883 responses were received and analyzed using SPSS Version 20.0. Most of the respondents (90.5%) were at home or had stopped going to work due to COVID-19 restrictions. Even though smaller households had higher food expenditure claims than larger households (p = 0.012), the larger the household, the more acute the challenge of economic access to food (p = 0.050). Location (p = 0.000), age (p = 0.003), occupation (p = 0.014) and income level (p = 0.000) were associated with experience of food insecurity. In conclusion, lockdown restrictions increased food expenditure and experience of food insecurity among the respondents and thus we recommend the probe of long-term consequences of deviations from usual food access on undernutrition or overnutrition in Nigerian households.

Nutrition acquisition by human immunity, transient overnutrition and the cytokine storm in severe cases of COVID-19.

The human immunity has a pivotal role in nutrition acquisition from the pathogens and damaged body tissue during the SARS-CoV-2 virus infection, which may lead to transient overnutrition in the patients, lead to lipotoxicity and further damage in non-adipose tissues, and cause hyperinflammation and cytokine storm in severe cases of COVID-19. In view of this, high-quality clinical trials on restrictive eating should be designed to investigate the possible benefits of food intake restriction on patients' recovery from COVID-19 disease.

The Burden of Malnutrition and Fatal COVID-19: A Global Burden of Disease Analysis.

Background: Although reasonable to assume, it is not yet clear whether malnourished countries are at higher risk for severe or fatal coronavirus disease 2019 (COVID-19). This study aims to identify the countries where prevalent malnutrition may be a driving factor for fatal disease after severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. Methods: Using estimates from the Global Burden of Disease 2019, country-level burden of malnutrition was quantified using four indicators: death rates for child growth failure (underweight, stunting, and/or wasting) and years lived with disability (YLD) attributed to iron and vitamin A deficiencies and high body mass index (BMI). Global mortality descriptors of the ongoing COVID-19 pandemic were extracted from the European Centre for Disease Prevention and Control, and case fatality ratios (CFRs) were calculated introducing a lag time of 10 weeks after the first death of a confirmed case. Bivariate analyses for 172 countries were carried out for malnutrition indicators and fatal COVID-19. Correlations between burden indicators were characterized by Spearman's rank correlation coefficients (ρ) and visually by scatterplots. Restricted cubic splines and underlying negative binomial regressions adjusted for countries' age-structure, prevalent chronic comorbidities related to COVID-19, population density, and income group were used to explore non-linear relationships. Results: Stratified by the World Bank income group, a moderate positive association between YLD rates for iron deficiency and CFRs for COVID-19 was observed for low-income countries (ρ = 0.60, p = 0.027), whereas no clear indications for the association with child growth failure, vitamin A deficiency, or high BMI were found (ρ < 0.30). Countries ranking high on at least three malnutrition indicators and presenting also an elevated CFR for COVID-19 are sub-Saharan African countries, namely, Angola, Burkina Faso, Chad, Liberia, Mali, Niger, Sudan, and Tanzania, as well as Yemen and Guyana. Conclusions: Population-level malnutrition appears to be related to increased rates of fatal COVID-19 in areas with an elevated burden of undernutrition, such as countries in the Sahel strip. COVID-19 response plans in malnourished countries, vulnerable to fatal COVID-19, should incorporate food security, nutrition, and social protection as a priority component in order to reduce COVID-19 fatality.