Medical Nutrition Therapy in Critically Ill Patients with COVID-19-A Single-Center Observational Study.

Medical nutrition should be tailored to cover a patient's needs, taking into account medical and organizational possibilities and obstacles. This observational study aimed to assess calories and protein delivery in critically ill patients with COVID-19. The study group comprised 72 subjects hospitalized in the intensive care unit (ICU) during the second and third SARS-CoV-2 waves in Poland. The caloric demand was calculated using the Harris-Benedict equation (HB), the Mifflin-St Jeor equation (MsJ), and the formula recommended by the European Society for Clinical Nutrition and Metabolism (ESPEN). Protein demand was calculated using ESPEN guidelines. Total daily calorie and protein intakes were collected during the first week of the ICU stay. The median coverages of the basal metabolic rate (BMR) during day 4 and day 7 of the ICU stay reached: 72% and 69% (HB), 74% and 76% (MsJ), and 73% and 71% (ESPEN), respectively. The median fulfillment of recommended protein intake was 40% on day 4 and 43% on day 7. The type of respiratory support influenced nutrition delivery. A need for ventilation in the prone position was the main difficulty to guarantee proper nutritional support. Systemic organizational improvement is needed to fulfill nutritional recommendations in this clinical scenario.

Malnutrition in older adults.

Malnutrition is a highly prevalent condition in older adults, and poses a substantial burden on health, social, and aged-care systems. Older adults are vulnerable to malnutrition due to age-related physiological decline, reduced access to nutritious food, and comorbidity. Clinical guidelines recommend routine screening for malnutrition in all older adults, together with nutritional assessment and individually tailored nutritional support for older adults with a positive screening test. Nutritional support includes offering individualised nutritional advice and counselling; oral nutritional supplements; fortified foods; and enteral or parenteral nutrition as required. However, in clinical practice, the incorporation of nutritional guidelines is inadequate and low-value care is commonplace. This Review discusses the current evidence on identification and treatment of malnutrition in older adults, identifies gaps between evidence and practice in clinical care, and offers practical strategies to translate evidence-based knowledge into improved nutritional care. We also provide an overview of the prevalence, causes, and risk factors of malnutrition in older adults across health-care settings.

Risk of Malnutrition in Hospitalized COVID-19 Patients: A Systematic Review and Meta-Analysis.

(1) Background: Studies have reported that COVID-19 may increase the risk of malnutrition among patients. However, the prevalence of such risk in hospitalized COVID-19 patients is uncertain due to the inconsistent use of assessment methods. (2) Methods: PubMed, Web of Science, and EMBASE were searched to identify studies on the nutritional status of hospitalized COVID-19 patients. A pooled prevalence of malnutrition risk evaluated by Nutrition Risk Score (NRS-2002) was obtained using a random effects model. Differences by study-level characteristics were examined by hospitalization setting, time of assessment, age, and country. Risk of bias was assessed using the Newcastle−Ottawa Scale. (3) Results: 53 studies from 17 countries were identified and summarized. A total of 17 studies using NRS-2002, including 3614 COVID-19 patients were included in the primary meta-analysis. The pooled prevalence of risk of malnutrition was significantly higher among ICU patients (92.2%, 95% CI: 85.9% to 96.8%) than among general ward patients (70.7%, 95% CI: 56.4% to 83.2%) (p = 0.002). No significant differences were found between age groups (≥65 vs. <65 years, p = 0.306) and countries (p = 0.893). (4) Conclusions: High risk of malnutrition is common and concerning in hospitalized patients with COVID-19, suggesting that malnutrition screening and nutritional support during hospitalization are needed.

Preferences of oral nutritional supplement therapy among postoperative patients with gastric cancer: Attributes development for a discrete choice experiment.

BACKGROUND: Adherence to oral nutritional supplement therapy among postoperative patients with gastric cancer is low. There is little knowledge about patients' priorities and needs regarding oral nutritional supplement therapy. The discrete choice experiment is an innovative method used to elicit patients' preferences. Good practice guidelines emphasize that the development of attributes and levels is a fundamentally important process. OBJECTIVE: To comprehensively describe the identification, refinement, and selection of attributes and levels for a discrete choice experiment. METHODS: A mixed-methods approach, consisting of three consecutive steps: a literature review, in-depth interviews, and focus groups. First, the literature review allowed quick identification of attributes and levels. Then, 15 in-depth interviews were conducted to gather a rich description of the experience of patients taking oral nutritional supplements after gastrectomy and to verify and enrich the attributes and levels list. Finally, four focus group participants discussed the wording of the attributes and levels and reduced the number of attributes to manageable numbers through voting ranking methods. RESULTS: Following the literature review and qualitative data collection, eight attributes were finally generated, each with two to three levels. The following attributes were included: 1) information provider; 2) health guidance approach; 3) adverse reactions; 4) flavor; 5) follow-up method; 6) follow-up frequency; 7) psychological support; 8) cost. These attributes covered the important attributes of nutritional preparations and health guidance included in ONS therapy that were relevant to patients. CONCLUSIONS: This study's mixed-methods approach has been found highly suitable to identify, refine and select attributes and levels for a discrete choice experiment. The three methods have pros and cons, and they complement each other, especially the analysis of qualitative data led to a deeper and broader understanding of attributes and levels.

Effect of early nutrition support on length of stay, mortality, and extubation in patients with COVID-19.

BACKGROUND: Many hospitals have been using nutrition support guidelines for patients with coronavirus disease 2019 (COVID-19) as outlined in the April 2020 article released by the American Society for Parenteral and Enteral Nutrition (ASPEN) and the Society of Critical Care Medicine (SCCM). Currently, there are insufficient data on the outcomes of following these guidelines. METHODS: This was a retrospective, observational study of 131 adult inpatients with COVID-19 admitted to an intensive care unit (ICU) at Banner Health to observe differences in length of stay, mortality, and number of days intubated based on the timing of nutrition support start relative to hours intubated and hours in the ICU. RESULTS: There were no statistically significant differences between length of stay, mortality, or number of days intubated between patients who started nutrition support within <12 h of intubation, >12 h of intubation and <36 h in the ICU, or >36 h of intubation and those who were not intubated. Patients who started nutrition support after >36 h in the ICU had the longest lengths of stay (median [25th, 75th percentile] = 25.5 [19.25, 35.25] days; P > 0.05) and number of days intubated (16.5 [10.0, 24.75] days; P > 0.050); however, it was not statistically significant. There was a significant difference between the three intubated groups and the nonintubated group on Sequential Organ Failure Assessment scores (P = 0.01). CONCLUSIONS: Prospective, multicenter trials are needed; however, following the SCCM/ASPEN guidelines for nutrition support in patients with COVID-19 may be found to decrease length of stay and number of days intubated.

Nutrition support practices for critically ill patients with severe acute respiratory syndrome coronavirus-2: A multicentre observational study in Singapore.

INTRODUCTION: To improve the nutritional care and resource allocation of critically ill patients with severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2), we described their characteristics, treatment modalities and clinical outcomes, and compared their nutrition interventions against the American Society for Parenteral and Enteral Nutrition (ASPEN) recommendations. METHODS: This was a retrospective observational study conducted in 5 tertiary hospitals in Singapore. Characteristics, treatment modalities, clinical outcomes and nutrition interventions of critically ill patients with SARS-CoV-2 who received enteral and parenteral nutrition were collected between January and May 2020. RESULTS: Among the 83 critically ill patients with SARS-CoV-2, 22 (28%) were obese, 45 (54%) had hypertension, and 21 (25%) had diabetes. Neuromuscular blockade, prone therapy and dialysis were applied in 70% (58), 47% (39) and 35% (29) of the patients, respectively. Refeeding hypophosphataemia and hospital mortality occurred respectively in 6% (5) and 18% (15) of the critically ill patients with SARS-CoV-2. Late enteral nutrition and cardiovascular comorbidities were associated with higher hospital mortality (adjusted relative risk 9.00, 95% confidence interval [CI] 2.25-35.99; 6.30, 95% CI 1.15-34.40, respectively). Prone therapy was not associated with a higher incidence of high gastric residual volume (≥250mL). The minimum caloric (15kcal/kg) and protein (1.2g/kg) recommendations of ASPEN were achieved in 54% (39) and 0% of the patients, respectively. CONCLUSION: The high obesity prevalence and frequent usage of neuromuscular blockade, prone therapy, and dialysis had considerable implications for the nutritional care of critically ill patients with SARS-CoV-2. They also did not receive adequate calories and protein. More audits should be conducted to refine nutritional interventions and guidelines for this ever-evolving disease.

Nutritional priorities in patients with severe COVID-19.

PURPOSE OF REVIEW: The COVID-19 pandemic has altered the profile of critical care services internationally, as professionals around the globe have struggled to rise to the unprecedented challenge faced, both in terms of individual patient management and the sheer volume of patients that require treatment and management in intensive care. This review article sets out key priorities in nutritional interventions during the patient journey, both in the acute and recovery phases. RECENT FINDINGS: The current review covers the care of the acutely unwell patient, and the evidence base for nutritional interventions in the COVID-19 population. One of the biggest differences in caring for critically ill patients with acute respiratory failure from COVID-19 is often the time prior to intubation. This represents specific nutritional challenges, as does nursing patients in the prone position or in the setting of limited resources. This article goes on to discuss nutritional support for COVID-19 sufferers as they transition through hospital wards and into the community. SUMMARY: Nutritional support of patients with severe COVID-19 is essential. Given the longer duration of their critical illness, combined with hypermetabolism and energy expenditure, patients with COVID-19 are at increased risk for malnutrition during and after their hospital stay.

A retrospective analysis of malnutrition risk, nutritional support and outcomes in COVID-19 patients.

BACKGROUND: The association between obesity and disease severity in COVID-19 has been reported, whilst the impact of undernutrition remains less well-defined. Here we describe nutritional risk profiles of consecutive COVID-19 hospital inpatients, together with clinical outcomes and the impact of nutritional therapy. METHODS: This was a retrospective case-control study of adult inpatients admitted to University College London Hospital between February and July 2020 with PCR-confirmed SARS-CoV-2. Data were extracted from electronic health records and compared to a control group of consecutive patients admitted between March and April 2019. COVID-19 patients were classified as at low, moderate or high nutritional risk according to a local nutritional screening tool on admission. Data relating to demographics, nutritional therapy and clinical outcomes were collected and compared between nutritional risk groups. RESULTS: A significantly higher proportion of the COVID-19 group were found to be at high nutritional risk (132/381, 34.6% vs. 105/468, 22.4%; p < 0.0001). Within the COVID-19 group, multivariate analysis showed that those at moderate and high nutritional risk had increased odds of having an above-average peak CRP (p = 0.004) and a below-average nadir albumin (p = 0.0002). Inpatient length of stay was on average 5.8 days longer for COVID-19 patients at moderate and high nutritional risk compared to those at low nutritional risk (p = 0.0008). COVID-19 patients at moderate nutritional risk on admission had a higher proportion of ICU admissions (28/89, 31.5% vs. 32/160, 20.0%; p = 0.01). Mortality was significantly worse in COVID-19 patients at high nutritional risk compared to those at low nutritional risk (52/132, 39.4% vs. 24/160, 15.0%; p < 0.0001). Prescription of enteral nutrition in ward-based COVID-19 patients at high nutritional risk was associated with lower inpatient mortality (20/67, 29.9% vs. 22/38, 57.9%; p = 0.009). In crude analysis, the 30-day mortality rate post-discharge was higher in those at moderate and high nutritional risk compared to those at low nutritional risk (13/151, 8.6% vs. 4/136, 2.9%, p < 0.05). Amongst patients at high nutritional risk, nutritional therapy was less common amongst non-white patients compared to white patients (12/29, 41.4% vs. 46/66, 70.0%; p = 0.006). CONCLUSION: Patients admitted with COVID-19 were at significant risk of undernutrition, which was associated with adverse clinical outcomes in our study. This risk was reduced by simple nutritional interventions. Mortality amongst patients at high nutritional risk persisted beyond discharge, suggesting close nutritional follow up in the period following hospital admission is warranted.

Clinical nutrition approach in medical management of COVID-19 hospitalized patients: A narrative review.

BACKGROUND: Malnutrition in COVID-19 hospitalized patients is associated with a high-risk condition to increase disease severity and prolonging the recovery period. Therefore, nutritional therapy, including supplements plays a critical role to reduce disease-related complications and the length of hospital stay. AIM: To review the latest evidence on nutritional management options in COVID-19 hospitalized patients, as well as possibly prescribed supplements. Methods: This review was conducted by considering the latest recommendations, using the guidelines of the American Society of Enteral and Parenteral (ASPEN) and the European Society of Enteral and Parenteral (ESPEN), and searching Web of Science, PubMed/Medline, ISI, and Medline databases. The relevant articles were found using a mix of related mesh terms and keywords. We attempted to cover all elements of COVID-19 hospitalized patients' dietary management. Results: Energy demand in COVID-19 patients is a vital issue. Indirect Calorimetry (IC) is the recommended method to measure resting energy expenditure. However, in the absence of IC, predictive equations may be used. The ratio of administered diet for the macronutrients could be based on the phase and severity of Covid-19 disease. Moreover, there are recommendations for taking micronutrient supplements with known effects on improving the immune system or reducing inflammation. Conclusions: Nutritional treatment of COVID-19 patients in hospitals seems to be an important element of their medical care. Enteral nutrition would be the recommended feeding method for early nutrition support. However, data in the COVID-19 nutritional domain relating to micronutrient supplementation are still fragmentary and disputed, and further study is required.

Relation between nutrition therapy in the acute phase and outcomes of ventilated patients with COVID-19 infection: a multicenter prospective observational study.

BACKGROUND: Optimal nutrition therapy has not yet been established for the acute phase of severe coronavirus disease 2019 (COVID-19) infection. OBJECTIVES: We aimed to examine the effects of nutrition delivery in the acute phase on mortality and the long-term outcomes of post-intensive care syndrome (PICS). METHODS: A multicenter prospective study was conducted on adult patients with COVID-19 infection requiring mechanical ventilation during an intensive care unit (ICU) stay. Daily total energy (kcal/kg) and protein (g/kg) deliveries in the first week of the ICU stay were calculated. The questionnaire for PICS evaluation was mailed within a median of 6 mo after hospital discharge. The primary outcome was in-hospital mortality, and secondary outcomes were the PICS components of physical impairment, cognitive dysfunction, and mental illness. RESULTS: Among 414 eligible patients, 297 who received mechanical ventilation for 7 d or longer were examined. PICS was evaluated in 175 patients among them. High protein delivery on days 4-7 correlated with a low in-hospital mortality rate. In contrast, high protein delivery on days 1-3 correlated with physical impairment. A multivariate logistic regression analysis adjusted for age, sex, BMI, and severity revealed that average energy and protein deliveries on days 4-7 correlated with decreased in-hospital mortality (OR: 0.94; 95% CI: 0.89, 0.99; P = 0.013 and OR: 0.40; 95% CI: 0.17, 0.93; P = 0.031, respectively). Nutrition delivery did not correlate with PICS outcomes after adjustments. In the multivariate regression using a restricted cubic spline model, in-hospital mortality monotonically decreased with increases in average nutrition delivery on days 4-7. CONCLUSIONS: In patents with COVID-19 on mechanical ventilation for ≥7 d, nutrition delivery in the late period of the acute phase was monotonically associated with a decrease in in-hospital mortality. Adequate protein delivery is needed on days 4-7.This trial was registered at https://www.umin.ac.jp as UMIN000041276.

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 .

Nutritional support protocol for patients with COVID-19.

BACKGROUND & AIMS: COVID-19 is a hypercatabolic disease with possible pulmonary and gastrointestinal symptoms, and consequent deterioration of the nutritional status and the worst clinical prognosis. This study presents a protocol to guide the nutritional care of adult and elderly people non-critically and critically ill with COVID-19. METHODS: A critical review of the literature was carried out in the databases PubMed, Scielo, Bireme, and Science Direct, in search of articles and guidelines that presented assessment criteria and nutritional conduct for COVID-19 and Severe Acute Respiratory Syndrome (SARS), as well as guidelines for managing the symptoms presented by patients. RESULTS: The results are recommendations based on the literature and the professional experience of nutritionists who provide nutritional assistance to individuals hospitalized with COVID-19 since the beginning of the pandemic in Brazil. We present tools and suggestions for assessing the nutritional status, calculating nutritional needs, initiating nutritional therapy and monitoring tolerance to it, nutritional monitoring during hospitalization, and guidelines for hospital discharge. CONCLUSION: Patients with COVID-19 are at nutritional risk. A complete nutritional assessment (anthropometric, dietary, and laboratory assessment) enables the establishment of an individualized nutritional approach in order to contribute to better clinical and nutritional prognoses.

Effect of a Nutritional Support System to Increase Survival and Reduce Mortality in Patients with COVID-19 in Stage III and Comorbidities: A Blinded Randomized Controlled Clinical Trial.

The COVID-19 evolution depends on immunological capacity. The global hospital mortality rate is 15-20%, but in México it is 46%. There are several therapeutic protocols, however, integral nutrition is not considered. In this study, a Nutritional Support System (NSS) was employed to increase survival and reduce mortality in patients with stage III COVID-19. A randomized, blinded, controlled clinical trial was performed. Eighty patients (aged 30 to 75 years, both sexes) were assigned to (1) "Control Group" (CG) hospital diet and medical treatment or (2) "Intervention Group" (IG) hospital diet, medical treatment, and the NSS (vitamins, minerals, fiber, omega-3, amino acids, B-complex, and probiotics). IG significantly increased survival and reduced mortality compared to CG (p = 0.027). IG decreased progression to Mechanical Ventilation Assistance (MVA) by 10%, reduced the intubation period by 15 days, and increased survival in intubated patients by 38% compared to CG. IG showed improvement compared to CG in decrease in supplemental oxygen (p = 0.014), the qSOFA test (p = 0.040), constipation (p = 0.014), the PHQ-9 test (p = 0.003), and in the follow-up, saturation with oxygen (p = 0.030). The NSS increases survival and decreases mortality in patients with stage III COVID-19.

Malnutrition and nutrition support in COVID-19: The results of a nutrition support protocol.

INTRODUCTION: COVID-19 is characterized by various clinical manifestations, mainly respiratory involvement. Disease-related malnutrition is associated with impaired respiratory function and increased all-cause morbidity and mortality. Patients with COVID-19 infection carry a high nutritional risk. After designing a specific nutritional support protocol for this disease, we carried out a retrospective study on malnutrition and on the use of nutritional support in patients with COVID-19. METHODS: We performed a retrospective study to determine whether nutritional support positively affected hospital stay, clinical complications, and mortality in patients with COVID-19. We compared the results with those of standard nutritional management. Our secondary objectives were to determine the prevalence of malnutrition in patients with COVID-19 and the value of nutritional support in the hospital where the study was performed. RESULTS: At least 60% of patients with COVID-19 experience malnutrition (up to 78.66% presented at least 1 of the parameters studied). The specialized nutritional support protocol was indicated in only 21 patients (28%) and was started early in only 12 patients (16%). Hospital stay was significantly shorter in patients managed with the early protocol (5.09 days, 95% CI, 1.338-8.853, p<0.01). Similarly, in this group, respiratory distress was less severe and less frequent (41% vs 82.5%, p<0.007), and statistically significantly fewer complications were recorded (9/12 vs 91/63; p<0.001). CONCLUSIONS: COVID-19 is associated with high rates of disease-related malnutrition. Early implementation of a specialized nutritional support plan can improve the prognosis of these patients by reducing hospital stay, the possibility of more severe respiratory distress, and complications in general.

Exploring the Experiences and the Nutritional Supports of LGBTQ+ Canadians during the COVID-19 Pandemic.

Purpose: The COVID-19 pandemic has impacted the lives of lesbian, gay, bi, trans, queer, and other groups (LGBTQ+) within Canada. This research aimed to explore the experiences of LGBTQ+ Canadians in relation to their nutritional needs, practices, and supports during the COVID-19 pandemic.Methods: The qualitative study was framed within a poststructuralism and queer theory paradigm and consisted of an online questionnaire. Participants were recruited and asked to complete open-ended questions. Responses were coded using thematic analysis.Results: Seventy participants completed the questionnaire. Data analysis resulted in 3 major themes, including (i) (dis)comforts of food and eating, (ii) shifting views of food and food practices, and (iii) what supports? The themes revealed that many LGBTQ+ individuals experienced stress and anxiety during the COVID-19 pandemic. It was a time in which their views and practices of food, cooking, and eating were changed. Nutritional supports were discussed in terms of family, friends, and partners.Conclusion: The findings highlight the complexity to the meanings people give to food, cooking, and eating during stressful times. It is recommended that dietitians familiarize themselves with the experiences of LGBTQ+ people, especially during times of global health emergencies to ensure equitable health care for LGBTQ+ communities.

Strategies to ensure continuity of nutritional care in patients with COVID-19 infection on discharge from hospital: A rapid review.

BACKGROUND & AIMS: The risk of malnutrition in people with COVID-19 is high; prevalence is reported as 37% in general medical inpatients, 53% in elderly inpatients and 67% in ICU. Thus, nutrition is a crucial element of assessment and treatment. This rapid review aimed to evaluate what evidence is available to inform evidence-based decision making on the nutritional care of patients hospitalised with COVID-19 infection. METHODS: Cochrane Rapid Reviews guidance was followed; the protocol was registered (CRD42020208448). Studies were selected that included patients with COVID-19, pneumonia, respiratory distress syndrome and acute respiratory failure, in hospital or the community, and which examined nutritional support. All types of studies were eligible for inclusion except non-systematic reviews, commentaries, editorials and single case studies. Six electronic databases were searched: MEDLINE, Embase, Cochrane Central Register of Controlled Trials, PubMed, CINAHL and MedRxiv. RESULTS: Twenty-six articles on COVID-19 were retrieved, including 11 observational studies, five guidelines and 10 opinion articles. Seven further articles on pneumonia included three RCTs, one unblinded trial, three observational studies, and one systematic review on rehabilitation post-ICU admission for respiratory illness. The evidence from these articles is presented narratively and used to guide the nutritional and dietetic care process. CONCLUSIONS: Older patients with COVID-19 infection are at risk of malnutrition and addressing this may be important in recovery. The use of nutritional management strategies applicable to other acute conditions are recommended. However, traditional screening and implementation techniques need to be modified to ensure infection control measures can be maintained. The most effective nutritional interventions require further research and more detailed guidance on nutritional management post-discharge to support long-term recovery is needed.

Debate: healthcare professionals in nutrition support teams.

INTRODUCTION: The debate from the course preceding the SENPE (Spanish Society of Clinical Nutrition and Metabolism) 2020 Conference gathered together well-known professionals who form part of nutritional support teams (NSTs), as well as other specialists from departments whose patients benefit from the services offered by these NSTs. In this article, relevant points from the round table, including strengths and weaknesses detected in the implementation of nutrition support teams, are summarized.

INTRODUCCIÓN: El debate del curso previo al congreso de la Sociedad Española de Nutrición Clínica y Metabolismo (SENPE) 2020 reunió en una mesa redonda a profesionales de prestigio que forman parte de unidades de nutrición y dietética, y a otros especialistas de servicios cuyos pacientes se benefician de los servicios de estas unidades. En este artículo se muestran los puntos relevantes que se trataron en el mismo y se muestran algunas fortalezas y debilidades que se han detectado en la implementación de las unidades de nutrición.