Evaluating the Impact of Nutrition Support on Clinical Outcomes in Critically Ill Patients With COVID-19: A Retrospective Study

Background: Patients with COVID-19 experience prolonged ICU stays. The rate of malnutrition in hospitalized patients remains controversial as well as the appropriate nutrition therapy for these patients. The purpose of the study was to evaluate the impact of nutrition support on clinical outcomes in critically ill patients with COVID-19. Method(s): This was a retrospective chart review involving 48 adults, critically ill patients admitted with confirmed SARS-CoV-2 infection. Data extracted included demographic, anthropometric, medical history, biochemical tests, medications, nutrition support protocol, clinical outcomes, length of stay, and ventilator status. We tested associations between aspects of nutrition support (such as early versus delayed feeding, adequacy, and patient positioning) and clinical outcomes (ICU length of stay, weight status, malnutrition status, refeeding syndrome, and ventilator days) using Chi-square, and t-tests, with significance established at the level of p <= 0.05. Result(s): Thirty-eight percent (18) of the patients met the criteria for malnutrition using the Global Leadership Initiative on Malnutrition (GLIM) tool. Approximately 83% of these patients did not have a documented diagnosis of malnutrition in the electronic medical record. More than half of the patients in the study (58.3%) were placed in prone position as part of their treatment and only 7% of these had documented signs of feeding intolerance. None of the patients were switched to total parenteral nutrition (TPN). Only 37% of the patients received adequate protein within the first week of nutrition support while 98% had adequate or exceeded caloric needs. There was no difference in percent weight loss among patients who received inadequate protein compared to those who had adequate protein. Inadequate protein intake was associated with shorter ICU stays (p = 0.04) and fewer ventilator days (p = 0.01) compared to those with adequate protein. Patients who received inadequate or exceeded their calories needs also had shorter ICU stays and fewer ventilator days (p > 0.05). In the context of this study, shorter ICU stays translated into fewer days of life, as 98% of the studied population died before ICU discharge. There were no associations between early nutrition support and selected biochemical parameters. Conclusion(s): The rate of malnutrition was remarkable and largely undocumented. Most patients did not meet the minimum estimated protein needs. Studies with larger sample sizes are needed to examine appropriate protein needs and the effect of nutrition support in patients with COVID-19. Diagnosing and documenting malnutrition warrants heightened attention.

Healthy Aging at Family Mealtimes: Associations of Clean Cooking, Protein Intake, and Dining Together with Mental Health of Chinese Older Adults amid COVID-19 Pandemic.

The present study aims to examine whether multiple dietary factors affect the mental health of older adults amid the COVID-19 pandemic. It proposes an integrative dietary framework that highlights environmental, nutritional, and social aspects of diet for healthy aging. Based on a sample of 7858 Chinese older adults, the associations between diet and depressive symptoms, along with the rural-urban divide, were examined using zero-inflated negative binomial regression. Overall, protein intake (incidence-rate ratio [IRR] = 0.89, p < 0.001), frequency of family dining together (IRR = 0.98, p < 0.001), and using tap water for cooking (IRR = 0.92, p < 0.01) were associated with lower incidence rates of depressive symptoms among older adults. Among rural older adults, frequency of family dining together (IRR = 0.97, p < 0.001) and tap water use (IRR = 0.89, p < 0.001) were associated with fewer depressive symptoms. However, urban residents who had a higher frequency of family dining together (IRR = 0.98, p < 0.05) and protein intake (IRR = 0.81, p < 0.001) exhibited fewer depressive symptoms. The findings revealed multifaceted dietary pathways towards healthy aging, which call for policies and interventions that improve diet quality for community-dwelling older adults.

Potential benefits of using an energy-dense, high-protein formula enriched with ß-hydroxy-ß-methylbutyrate, fructo-oligosaccharide, and vitamin D for enteral feeding in the ICU: A pilot case-control study in COVID-19 patients.

OBJECTIVES: The aim of this study was to investigate the potential benefits of using an energy-dense, high-protein (HP) formula enriched with ß-hydroxy-ß-methylbutyrate (HMB), fructo-oligosaccharide (FOS), and vitamin D (VitD) for enteral feeding in the intensive care unit (ICU). METHODS: This was a nested case-control multicenter study. Mechanically ventilated patients with COVID-19 in whom enteral nutrition was not contraindicated and receiving an energy-dense, HP-HMB-FOS-VitD formula (1.5 kcal/mL; 21.5% of calories from protein; n = 53) were matched (1:1) by age (±1 y), sex, body mass index (±1 kg/m2) and Sequential Organ Failure Assessment score (±1 point) and compared with patients fed with a standard HP, fiber-free formula (1.25-1.3 kcal/mL; 20% of calories from protein; n = 53). The primary end point was daily protein intake (g/kg) on day 4. Protein-calorie intake on day 7, gastrointestinal intolerance, and clinical outcomes were addressed as secondary end points. RESULTS: The use of a HP-HMB-FOS-VitD formula resulted in higher protein intake on days 4 and 7 (P = 0.006 and P = 0.013, respectively), with similar energy intake but higher provision of calories from enteral nutrition at both times (P <0 .001 and P = 0.017, respectively). Gastrointestinal tolerance was superior, with fewer patients fed with a HP-HMB-FOS-VitD formula reporting at least one symptom of intolerance (55 versus 74%; odds ratio [OR], 0.43; 95% confidence interval [CI], 0.18-0.99; P = 0.046) and constipation (38 versus 66%; OR, 0.27; 95% CI, 0.12-0.61; P = 0.002). A lower rate of ICU-acquired infections was also observed (42 versus 72%; OR, 0.29; 95% CI, 0.13-0.65; P = 0.003), although no difference was found in mortality, ICU length of stay, and ventilation-free survival. CONCLUSIONS: An energy-dense, HP-HMB-FOS-VitD formula provided a more satisfactory protein intake and a higher provision of caloric intake from enteral nutrition than a standard HP formula in mechanically ventilated patients with COVID-19. Lower rates of gastrointestinal intolerance and ICU-acquired infections were also observed.

Refeeding Syndrome and Its Related Factors in Critically Ill Coronavirus Disease 2019 Patients: A Prospective Cohort Study.

Background and Aim: Malnutrition and its complications is usually neglected in critically ill COVID-19 patients. We conducted the present study to investigate the prevalence of refeeding syndrome and its related factors in this group of patients. Methods: In this prospective cohort study, 327 patients were assessed for being at risk and developing refeeding syndrome. The criteria was ASPEN consensus recommendations for refeeding syndrome released in 2020. Malnutrition was assessed based on global leadership initiative on malnutrition (GLIM) criteria. The relation between actual protein, calorie intake, and refeeding syndrome was also evaluated via cox regression model. The data concerning calorie and protein intake were gathered for 5 days after initiating feeding. The daily protein and calorie intake were divided by kilogram body weight in order to calculate the actual protein (g/kg/day) and energy (kcal/kg/day) intake. Results: Among the subjects, 268 (82%) were at risk of refeeding syndrome and 116 (36%) got involved in this syndrome. Malnutrition, according to the GLIM criteria, was found in 193 (59%) of the subjects. In the at-risk population, the risk of refeeding syndrome was reduced by 90% with the rise in protein intake (CI; 0.021-0.436, P = 0.002), increased by 1.04 times with the increase in age (CI; 1.032-1.067, P < 0.001), and by 1.19 times with the rise in the days from illness onset to admission (CI; 1.081-1.312, P < 0.001) in adjusted cox model analysis. Conclusion: The incidence of refeeding syndrome is relatively high, which threatens the majority of critically ill COVID-19 patients. Increased protein intake was found to reduce the occurrence of refeeding syndrome.

Strengthening the Immune System and Reducing Inflammation and Oxidative Stress through Diet and Nutrition: Considerations during the COVID-19 Crisis.

The coronavirus-disease 2019 (COVID-19) was announced as a global pandemic by the World Health Organization. Challenges arise concerning how to optimally support the immune system in the general population, especially under self-confinement. An optimal immune response depends on an adequate diet and nutrition in order to keep infection at bay. For example, sufficient protein intake is crucial for optimal antibody production. Low micronutrient status, such as of vitamin A or zinc, has been associated with increased infection risk. Frequently, poor nutrient status is associated with inflammation and oxidative stress, which in turn can impact the immune system. Dietary constituents with especially high anti-inflammatory and antioxidant capacity include vitamin C, vitamin E, and phytochemicals such as carotenoids and polyphenols. Several of these can interact with transcription factors such as NF-kB and Nrf-2, related to anti-inflammatory and antioxidant effects, respectively. Vitamin D in particular may perturb viral cellular infection via interacting with cell entry receptors (angiotensin converting enzyme 2), ACE2. Dietary fiber, fermented by the gut microbiota into short-chain fatty acids, has also been shown to produce anti-inflammatory effects. In this review, we highlight the importance of an optimal status of relevant nutrients to effectively reduce inflammation and oxidative stress, thereby strengthening the immune system during the COVID-19 crisis.

COVID-19-Associated Acute Kidney Injury and Quantified Protein Catabolic Rate: A Likely Effect of Cytokine Storm on Muscle Protein Breakdown.

RATIONALE & OBJECTIVES: Previously we reported a cohort of patients with coronavirus disease 2019 (COVID-19)-associated acute kidney injury (AKI) with striking biochemical evidence of tissue breakdown in the absence of apparent rhabdomyolysis. We sought to quantify the extent of tissue catabolism in similar patients. STUDY DESIGN: During acute peritoneal dialysis (PD) in patients with COVID-19-associated AKI, we measured urea Kt/V adequacy and calculated the daily urea nitrogen generation rate while quantifying daily protein intake. SETTING & POPULATION: We did calculations in 8 patients with COVID-9-associated AKI undergoing acute PD at Mount Sinai Hospital in New York City. As a comparator, we obtained urea kinetic parameters from our database of ambulatory patients receiving maintenance PD. EXPOSURE OR PREDICTORS: 8 patients with COVID-19-associated AKI undergoing acute PD. OUTCOMES: Urea nitrogen generation rate in relation to daily protein intake. ANALYTICAL APPROACH: Urea nitrogen generation rate from urea kinetics was related to measured daily dietary protein intake in these patients and we compared it with this relationship in ambulatory maintenance PD patients for whom both parameters were calculated from urea kinetics. RESULTS: Urea nitrogen generation rate in patients with AKI was 10.2 ± 5 g/d, which is more than 2-fold higher than for stable outpatients receiving maintenance PD (4.7 ± 3 g/d) despite similar dietary protein intake (74.8 ± 11 vs 67.2 ± 29 g/d, respectively). This strongly suggests endogenous protein breakdown, probably from muscle. Urea nitrogen generation rate in these patients with AKI corresponds to 315 g/d of ongoing muscle breakdown and cumulative 2.5 kg of muscle breakdown during the early course of AKI. LIMITATIONS: Small number of participants and assumptions in comparing urea nitrogen generation rate with protein intake. CONCLUSIONS: In highly catabolic patients, an endogenous source of urea generation such as muscle protein breakdown seems to be the most likely explainable cause for our findings. This is the first study that we are aware of to quantify the degree of endogenous protein breakdown induced by COVID-19-related cytokine storm.