Gut microbiota, malnutrition, and immunity: COVID-19's confounding triad.

The coronavirus disease has swept the world, bringing scientists from multiple disciplines together to work on a focused cause. In this forum, we discuss different roles that microbiota, malnutrition, and immunity have on severity of coronavirus disease and the importance of studying them from a gut-systemic perspective using multi-omics approaches.

Malnutrition as a major related factor of frailty among older adults residing in long-term care facilities in Korea.

OBJECTIVES: The objectives of this study were 1) to investigate the prevalence and co-existence of frailty and malnutrition and 2) to identify factors related to frailty (including malnutrition) according to the level of frailty. METHODS: Data collection was conducted from July 11, 2021, to January 23, 2022, in 558 older adults residing in 16 long-term care facilities (LTCFs) in Korea. The FRAIL-NH and Mini-Nutritional Assessment short form were used to measure frailty and nutrition, respectively. The data analysis included descriptive statistics and a multivariate logistic regression. RESULTS: The mean age of the participants was 83.68 (± 7.39) years. Among 558 participants, 37 (6.6%), 274 (49.1%), and 247 (44.3%) were robust, prefrail, and frail, respectively. At the same time, 75.8% were categorized as having malnutrition status (malnourished: 18.1%; risk of malnutrition: 57.7%), and 40.9% had co-existing malnutrition and frailty. In the multivariate analysis, malnutrition was identified as the major frailty-related factor. Compared with a normal nutritional status, the incidence of frailty in the malnutrition group was 10.35 times (95% CI: 3.78-28.36) higher than the incidence of robustness and 4.80 times (95% CI: 2.69-8.59) higher than the incidence of prefrail. CONCLUSION: The prevalence of frailty and malnutrition, and their co-existence, among older adults residing in LTCFs was high. Malnutrition is a major factor that increases the incidence of frailty. Therefore, active interventions are needed to improve the nutritional status of this population.

HIV matters when diagnosing TB in young children: an ancillary analysis in children enrolled in the INPUT stepped wedge cluster randomized study.

BACKGROUND: Children under age five years, particularly those living with HIV (CLHIV), are at risk for rapid progression of tuberculosis (TB). We aimed to describe TB clinical presentations, diagnostic pathways and treatment outcomes in CLHIV compared to children without HIV in Cameroon and Kenya. METHODS: This sub-analysis of a cluster-randomized trial evaluating the integration of pediatric TB services from May 2019 to March 2021 enrolled children age < 5 years with TB. We estimated the HIV infection rate with 95% confidence interval (CI). We compared TB clinical presentations, diagnostic pathways and treatment outcomes in CLHIV and children without HIV. Finally, we investigated whether HIV infection was associated with a shorter time to TB diagnosis (≤ 3 months from symptoms onset) after adjusting for covariates. Univariable and multivariable logistic regression analysis were performed with adjusted odds ratios (AORs) presented as measures of the association of covariates with HIV status and with shorter time to TB diagnosis. RESULTS: We enrolled 157 children with TB (mean age was 1.5 years) and 22/157 (14.0% [9.0-20.4%]) were co-infected with HIV. CLHIV were more likely to initially present with acute malnutrition (AOR 3.16 [1.14-8.71], p = 0.027). Most TB diagnoses (140/157, 89%) were made clinically with pulmonary TB being the most common presentation; however, there was weak evidence of more frequent bacteriologic confirmation of TB in CLHIV, 18% vs. 9% (p = 0.067), due to the contribution of lateral-flow urine lipoarabinomannan to the diagnosis. HIV positivity (AOR: 6.10 [1.32-28.17], p = 0.021) was independently associated with a shorter time to TB diagnosis as well as fatigue (AOR: 6.58 [2.28-18.96], p = 0.0005), and existence of a household contact diagnosed with TB (AOR: 5.60 [1.58-19.83], p = 0.0075), whereas older age (AOR: 0.35 [0.15-0.85], p = 0.020 for age 2-5 years), night sweats (AOR: 0.24 [0.10-0.60], p = 0.0022) and acute malnutrition (AOR: 0.36 [0.14-0.92], p = 0.034) were associated with a delayed diagnosis. The case fatality rate was 9% (2/22) in CLHIV and 4% (6/135) in children without HIV, p = 0.31. CONCLUSIONS: These results altogether advocate for better integration of TB services into all pediatric entry points with a special focus on nutrition services, and illustrate the importance of non-sputum-based TB diagnostics especially in CLHIV. TRIAL REGISTRATION: NCT03862261, first registration 05/03/2019.

Systematic Review and Meta-Analysis: Malnutrition and In-Hospital Death in Adults Hospitalized with COVID-19.

BACKGROUND: Malnutrition and increased malnutrition risk are frequently identified in hospitalized adults. The increase in hospitalization rates during the COVID-19 pandemic was accompanied by the documentation of adverse hospitalization outcomes in the presence of certain co-morbidities, including obesity and type 2 diabetes. It was not clear whether the presence of malnutrition increased in-hospital death in patients hospitalized with COVID-19. OBJECTIVES: To estimate the effect of malnutrition on in-hospital mortality in adults hospitalized with COVID-19; and secondarily, to estimate the prevalence of malnutrition in adults hospitalized with malnutrition during the COVID-19 pandemic. METHODS: EMBASE, MEDLINE, PubMed, Google Scholar, and Cochrane Collaboration databases were queried using the search terms malnutrition and COVID-19 and hospitalized adults and mortality. Studies were reviewed using the 14-question Quality Assessment Tool for Studies with Diverse Designs (QATSDD) (questions appropriate for quantitative studies). Author names; date of publication; country; sample size; malnutrition prevalence; malnutrition screening/diagnostic method; number of deaths in malnourished patients; and number of deaths in adequately nourished patients were extracted. Data were analyzed using MedCalc software v20.210 (Ostend, Belgium). The Q and I2 tests were calculated; a forest plot was generated, and the pooled odds ratio (OR) with 95% confidence intervals (95%CI) were calculated using the random effects model. RESULTS: Of the 90 studies identified, 12 were finally included in the meta-analysis. In the random effects model, malnutrition or increased malnutrition risk increased odds of in-hospital death by more than three-fold: OR 3.43 (95% CI 2.549-4.60), p < 0.001. The pooled prevalence estimate for malnutrition or increased malnutrition risk was 52.61% (95% CI 29.50-75.14%). DISCUSSION AND CONCLUSIONS: It is clear that malnutrition is an ominous prognostic sign in patients hospitalized with COVID. This meta-analysis, which included studies from nine countries on four continents with data from 354,332 patients, is generalizable.

Nutritional deficiencies that may predispose to long COVID.

Multiple nutritional deficiencies (MND) confound studies designed to assess the role of a single nutrient in contributing to the initiation and progression of disease states. Despite the perception of many healthcare practitioners, up to 25% of Americans are deficient in five-or-more essential nutrients. Stress associated with the COVID-19 pandemic further increases the prevalence of deficiency states. Viral infections compete for crucial nutrients with immune cells. Viral replication and proliferation of immunocompetent cells critical to the host response require these essential nutrients, including zinc. Clinical studies have linked levels of more than 22 different dietary components to the likelihood of COVID-19 infection and the severity of the disease. People at higher risk of infection due to MND are also more likely to have long-term sequelae, known as Long COVID.

Malnutrition risk frequency and independent risk factors associated with mortality in hospitalized elderly patients with COVID-19 in Turkey.

BACKGROUND AND OBJECTIVES: Malnutrition is common in elderly patients and is an important geriatric syndrome that increases mortality. We aim to examine the frequency of malnutrition and independent risk factors associated with mortality in hospitalized elderly patients with COVID-19. METHODS AND STUDY DESIGN: Patients aged 65 years and older with COVID-19, who were hospitalized between 15th March and 30th April 2020, were included. Demographic characteristics of the patients, their comorbid diseases, medications, malnutrition, and mortality status were recorded. Nutritional Risk Screening-2002 was used as a malnutrition risk screening tool. The factors affecting mortality were analyzed using multivariate Binary Logistic regression analysis. RESULTS: Of the 451 patients included in the study, the mean age was 74.8±7.46 and 51.2% of them were female. The mean number of comorbid diseases was 1.9±1.28. Malnutrition risk was 64.7%, polymorbidity rate was 57.6% and polypharmacy was 19.3%. Mortality rate was found 18.4%. The risk factors affecting mortality were presented as malnutrition risk (OR: 3.26, p=0.013), high number of comorbid diseases (OR: 1.48, p=0.006), and high neutrophil/lymphocyte ratio (OR: 1.18, p<0.001), C-reactive protein (OR: 1.01, p<0.001), and ferritin (OR: 1.01, p=0.041) in elderly patients with COVID-19. Malnutrition risk (3.3 times), multiple comorbid diseases (1.5 times), and high neutrophil/lymphocyte ratio (1.2 times) were independent risk factors that increased the mortality. CONCLUSIONS: The frequency of malnutrition risk and mortality in elderly patients with COVID-19 is high. The independent risk factors affecting mortality in these patients are the risk of malnutrition, multiple comorbid diseases, and a high neutrophil/lymphocyte ratio.

A Comparative Study between the Three Waves of the Pandemic on the Prevalence of Oropharyngeal Dysphagia and Malnutrition among Hospitalized Patients with COVID-19.

BACKGROUND: The phenotype of patients affected by COVID-19 disease changed between the waves of the pandemic. We assessed the prevalence of oropharyngeal dysphagia (OD), malnutrition (MN), and mortality between the first three waves of COVID-19 patients in a general hospital. METHODS: a prospective observational study between April 2020-May 2021. Clinical assessment for OD was made with the volume-viscosity swallowing test; nutritional assessment was performed consistent with GLIM criteria. A multimodal intervention was implemented in the second and third wave, including (a) texturized diets-fork mashable (1900 kcal + 90 g protein) or pureed (1700 kcal + 75 g protein), (b) oral nutritional supplements (500-600 kcal + 25-30 g protein), and (c) fluid thickening (250 mPa·s or 800 mPa·s). RESULTS: We included 205 patients (69.3 ± 17.6 years) in the 1st, 200 (66.4 ± 17.5 years) in the 2nd, and 200 (72.0 ± 16.3 years;) in the 3rd wave (p = 0.004). On admission, prevalence of OD was 51.7%, 31.3% and 35.1%, and MN, 45.9%, 36.8% and 34.7%, respectively; mortality was 10.7%, 13.6% and 19.1%. OD was independently associated with age, delirium, and MN; MN, with age, OD, diarrhea and ICU admission; mortality, with age, OD and MN. (4) Conclusions: Prevalence of OD, MN and mortality was very high among COVID-19 patients. OD was independently associated with MN and mortality. An early and proactive multimodal nutritional intervention improved patients' nutritional status.

Effects of malnutrition on mortality in oldest-old inpatients with COVID-19 in the GERIA-COVID cohort.

We assessed the impact of malnutrition on 14-day, 28-day, and 3-month mortality risk in oldest-old inpatients aged ≥80 years with COVID-19 in the hospital-based GERIA-COVID cohort. Malnutrition was assessed on hospital admission using the Geriatric Nutritional Risk Index (GNRI). Potential confounders were age, sex, functional abilities, number of acute health issues, CRP level, hypertension, cardiomyopathy, malignancies, use of antibiotics, and respiratory treatments. Seventy-eight participants (88.9 ± 4.3 years old, 55% women) were included. Of these, 82.1% had survived at day 14, 78.2% at day 28, and 70.5% after 3 months. No association between malnutrition according to the GNRI and 14-day (P = 0.324), 28-day (P = 0.166), or 3-month mortality (P = 0.109) was found. Thus, malnutrition according to the GNRI was not associated with mortality within the first 3 months of diagnosis of COVID-19 among oldest-old inpatients.

Impact of malnutrition on clinical outcomes in patients diagnosed with COVID-19.

BACKGROUND: Coronavirus disease 2019 (COVID-19) is now the third leading cause of death in the United States. Malnutrition in hospitalized patients increases risk of complications. However, the effect of malnutrition on outcomes in patients infected is unclear. This study aims to identify the impact of malnutrition on mortality and adverse hospital events in patients hospitalized with COVID-19. METHODS: This study used data from the National COVID Cohort Collaborative (N3C), a COVID-19 repository containing harmonized, longitudinal electronic health record data from US health systems. Malnutrition was categorized into three groups based on condition diagnosis: (1) none documented, (2) history of malnutrition, and (3) hospital-acquired malnutrition. Multivariable logistic regression was performed to determine whether malnutrition was associated with mortality and adverse events, including mechanical ventilation, acute respiratory distress syndrome, extracorporeal membrane oxygenation, and hospital-acquired pressure injury, in hospitalized patients with COVID-19. RESULTS: Of 343,188 patients hospitalized with COVID-19, 11,206 had a history of malnutrition and 15,711 had hospital-acquired malnutrition. After adjustment for potential confounders, odds of mortality were significantly higher in patients with a history of malnutrition (odds ratio [OR], 1.71; 95% confidence interval [CI], 1.63-1.79; P < 0.001) and hospital-acquired malnutrition (OR, 2.5; 95% CI, 2.4-2.6; P < 0.001). Adjusted odds of adverse hospital events were also significantly elevated in both malnutrition groups. CONCLUSIONS: Results indicate the risk of mortality and adverse inpatient events in adults with COVID-19 is significantly higher in patients with malnutrition. Prevention, diagnosis, and treatment of malnutrition could be a key component in improving outcomes in these patients.

Malnutrition among patients admitted to the subacute geriatric ward during the COVID-19 pandemic era: A cross-sectional study in a tertiary hospital in Malaysia.

BACKGROUND: Acute illness and hospitalisation detriment the nutritional status of older patients. This study aimed to describe the prevalence of malnutrition, characteristics and in-hospital outcomes associated with malnutrition, and nutritional management among patients who were admitted to the Subacute Geriatric Ward. METHODS: This is a retrospective study of older patients (age ≥ 60) who were admitted to the Subacute Geriatric Ward of Kuala Lumpur Hospital from 1 March 2021 to 31 May 2021. Malnutrition was identified using the Mini Nutritional Assessment-Short Form (MNA-SF). The in-hospital outcomes evaluated were hospital-associated complications, namely delirium, functional decline, incontinence, inpatient falls, inpatient pressure injuries, hospital-acquired infection, institutionalisation, and inpatient mortality. RESULTS: Seventy-three patients were included (mean age 74.7, female 58.9%), of which 28 (38.4%) and 27 (37.0%) were malnourished and at risk of malnutrition, respectively. Poorer nutritional status was associated with increased age, comorbidity burden, frailty, immobility, impaired basic activities of daily living, history of falls, cognitive impairment, incontinence, and arthritis. About 71.2% and 60.3% of patients were offered dietitian review and oral nutritional supplements, respectively. The in-hospital outcome rates were higher among malnourished patients, but the differences were not statistically significant. However, multiple hospital-associated complications were more common with poorer nutritional status (p = 0.018). CONCLUSION: Hospital malnutrition is prevalent among older patients, and unidentified malnutrition is not justified due to its association with multiple adverse outcomes.

Poor Physical Performance Is Associated with Postoperative Complications and Mortality in Preoperative Patients with Colorectal Cancer.

INTRODUCTION: Poor physical performance has been shown to be a good predictor of complications in some pathologies. The objective of our study was to evaluate, in patients with colorectal neoplasia prior to surgery, physical performance and its relationship with postoperative complications and in-hospital mortality, at 1 month and at 6 months. METHODS: We conducted a prospective study on patients with preoperative colorectal neoplasia, between October 2018 and July 2021. Physical performance was evaluated using the Short Physical Performance Battery (SPPB) test and hand grip strength (HGS). For a decrease in physical performance, SPPB < 10 points or HGS below the EWGSOP2 cut-off points was considered. Nutritional status was evaluated using subjective global assessment (SGA). The prevalence of postoperative complications and mortality during admission, at 1 month, and at 6 months was evaluated. RESULTS: A total of 296 patients, mean age 60.4 ± 12.8 years, 59.3% male, were evaluated. The mean BMI was 27.6 ± 5.1 kg/m2. The mean total SPPB score was 10.57 ± 2.07 points. A total of 69 patients presented a low SPPB score (23.3%). Hand grip strength showed a mean value of 33.1 ± 8.5 kg/m2 for men and 20.7 ± 4.3 kg/m2 for women. A total of 58 patients presented low HGS (19.6%). SGA found 40.2% (119) of patients with normal nourishment, 32.4% (96) with moderate malnutrition, and 27.4% (81) with severe malnutrition. Postoperative complications were more frequent in patients with a low SPPB score (60.3% vs. 38.6%; p = 0.002) and low HGS (64.9% vs. 39.3%, p = 0.001). A low SPPB test score (OR 2.57, 95% CI 1.37-4.79, p = 0.003) and low HGS (OR 2.69, 95% CI 1.37-5.29, p = 0.004) were associated with a higher risk of postoperative complications after adjusting for tumor stage and age. Patients with a low SPPB score presented an increase in in-hospital mortality (8.7% vs. 0.9%; p = 0.021), at 1 month (8.7% vs. 1.3%; p = 0.002) and at 6 months (13.1% vs. 2.2%, p < 0.001). Patients with low HGS presented an increase in mortality at 6 months (10.5% vs. 3.3%; p = 0.022). CONCLUSIONS: The decrease in physical performance, evaluated by the SPPB test or hand grip strength, was elevated in patients with colorectal cancer prior to surgery and was related to an increase in postoperative complications and mortality.

The importance of nutritional status on clinical outcomes among both ICU and Non-ICU patients with COVID-19.

BACKGROUND AND AIMS: The current Covid-19 outbreak becomes a tremendous public health concern worldwide. Since a little information is available on nutritional status and its devastating effects on covid-19 complications in Iran, in the present study, we aimed to evaluate nutritional status of covid-19 population and its related factors. METHODS: We performed this observational study by recruiting 400 hospitalized covid-19 subjects. Thereafter, the needed clinical and para clinical data were collected and their nutritional status was then assessed using NRS-2002. RESULTS: Approximately 36% of the total sample size and 100% of the ICU- admitted cases were at the severe risk of malnutrition. The patients with NRS≥ 5 were significantly older (p < 0.0001). Non-survivals obtained higher scores in terms of both severity of disease (86%) and impaired nutritional status (67%), and this relationship was found to be statistically significant (p < 0.0001). In regard to the obtained prognostic inflammatory scores, 86% of the non-survivals obtained significantly highest scores for GPS (P = 0.015). CONCLUSION: Nutritional status has a considerable effect on clinical outcomes of covid-19 patients, which should be evaluated. Thereafter, rapid subsequent nutritional interventions must be implemented in this regard. As well, special attention must be paid to both elderly population and individuals with underlying diseases.

Analysis of the Relationship among Cognitive Impairment, Nutritional Indexes and the Clinical Course among COVID-19 Patients Discharged from Hospital-Preliminary Report.

Numerous data indicate the presence of cognitive impairment in people who have undergone COVID-19, often called COVID Fog (CF). This phenomenon persists even 6 months after infection, and its etiology and pathogenesis are not fully known. The aim of this article was to analyze the relationship among cognitive functioning, clinical data and nutrition indexes in patients discharged from the COVID-19 hospital of the Military Institute of Medicine, Warsaw, Poland. The sample comprised 17 individuals-10 women and 7 men, with ages of 65 ± 14 years. Cognitive impairment was measured with the use of the Montreal Cognitive Assessment (MoCA). The nutrition parameters included: hemoglobin, red blood cells, total cholesterol and its fractions, triglycerides, total protein, albumin, urea, creatinine, phosphates, calcium and sodium. The analysis showed that albumin concentration significantly correlated with the total MoCA score and especially with the short-term memory test score. Conversely, total cholesterol, and especially LDL concentrations, were highly and negatively associated with the MoCA score. In conclusion: markers of nutritional status are correlated with the severity of CF. Individuals with malnutrition or risk of malnutrition should be screened for CF. Further studies need to be performed in this area.

Case presentation and panel discussion: Critical illness.

Despite a mounting evidentiary base, controversies surrounding critical care nutrition support persist. Anchored by a case of a 60-year-old male with esophageal cancer who develops acute hypoxemic respiratory failure and septic shock, five panelists from the American Society of Parenteral and Enteral Nutrition (ASPEN) 2021 Pre-Conference discuss key clinical dilemmas in critical care nutrition, including hierarchy of evidence, bedside evaluation of malnutrition, optimal protein dose, use of fiber, and therapies targeting gut function and gut microbiota .

Thymic Dysfunction and Atrophy in COVID-19 Disease Complicated by Inflammation, Malnutrition and Cachexia.

Background: The current COVID-19 pandemic has put millions of people, especially children at risk of protein-energy malnutrition (PEM) by pushing them into poverty and disrupting the global food supply chain. The thymus is severely affected by nutritional deficiencies and is known as a barometer of malnutrition. Aim: The present commentary provides a novel perspective on the role of malnutrition-induced thymic dysfunction, involution and atrophy on the risk and severity of disease in children during the COVID-19 pandemic. Methods: A review of pertinent indexed literature including studies examining the effects of malnutrition on the thymus and immune dysfunction in COVID-19. Results: Protein-energy malnutrition and micronutrient deficiencies of zinc, iron and vitamin A are known to promote thymic dysfunction and thymocyte loss in children. Malnutrition- and infection-induced thymic atrophy and immune dysfunction may increase the risk of first, progression of COVID-19 disease to more severe forms including development of multisystem inflammatory syndrome in children (MIS-C); second, slow the recovery from COVID-19 disease; and third, increase the risk of other infections. Furthermore, malnourished children may be at increased risk of contracting SARS-CoV-2 infection due to socioeconomic conditions that promote viral transmission amongst contacts and create barriers to vaccination. Conclusion: National governments and international organizations including WHO, World Food Program, and UNICEF should institute measures to ensure provision of food and micronutrients for children at risk in order to limit the health impact of the ongoing COVID-19 pandemic.

Impact of COVID-19 Infection and Persistent Lingering Symptoms on Patient Reported Indicators of Nutritional Risk and Malnutrition.

Persistent malnutrition after COVID-19 infection may worsen outcomes, including delayed recovery and increased risk of rehospitalization. This study aimed to determine dietary intakes and nutrient distribution patterns after acute COVID-19 illness. Findings were also compared to national standards for intake of energy, protein, fruit, and vegetables, as well as protein intake distribution recommendations. Participants (≥18 years old, n = 92) were enrolled after baseline visit at the Post-COVID Recovery Clinic. The broad screening battery included nutritional assessment and 24-h dietary recall. Participants were, on average, 53 years old, 63% female, 69% non-Hispanic White, and 59% obese/morbidly obese. Participants at risk for malnutrition (48%) experienced significantly greater symptoms, such as gastric intestinal issues, loss of smell, loss of taste, or shortness of breath; in addition, they consumed significantly fewer calories. Most participants did not meet recommendations for fruit or vegetables. Less than 39% met the 1.2 g/kg/day proposed optimal protein intake for recovery from illness. Protein distribution throughout the day was skewed; only 3% met the recommendation at all meals, while over 30% never met the threshold at any meal. Our findings highlight the need for nutritional education and support for patients to account for lingering symptoms and optimize recovery after COVID-19 infection.