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The European Society for Clinical Nutrition and Metabolism (ESPEN) recently released a consensus paper of expert statements and practical guidance for nutritional management of individuals with sars-cov-2-infection (coronavirus) (1). This blog post explores how the new ESPEN guidance relates to the use of oral nutrition supplements.
The consensus paper begins by stating that “acute respiratory complications that require intensive care unit (ICU) management are a major cause of morbidity and mortality in COVID-19 patients”. ICU admissions (2), comorbidities (3) and older age (4) are all associated with high risk of malnutrition, which in itself is a risk factor for increased morbidity and mortality (5).
Many ICU patients will experience an intensive catabolic response, resulting in tremendous loss of muscle mass and function (6). Additionally, ESPEN states that there may be physical, cognitive and mental impairment, which may be more prevalent in comorbid and frail patients.
The ESPEN paper suggests that “prevention, diagnosis and treatment of malnutrition should therefore be routinely included in the treatment of COVID-19 patients to improve both short-term and long-term prognosis.”
The ESPEN consensus paper mentions how supplementation and/or adequate provision of vitamins and minerals is important for prevention of viral infections. In particular, they highlight the importance of vitamins A, B, C, D and E and the trace elements zinc, selenium and iron. Whilst the majority of people can consume sufficient micronutrients from a balanced diet, targeted supplementation may be required in those with diagnosed nutritional deficiencies.
Additionally, all UK adults, including those at increased risk of vitamin D deficiency, should consume a 10 microgram (400 IU) Vitamin D supplement daily from October to April (7). People with very little or no sunlight exposure should consume 10 micrograms of vitamin D throughout the year. If a vitamin D deficiency is detected, higher dosage supplementation is recommended according to local prescribing guidance.
ESPEN states that “there is no established evidence that supplementation with micronutrients may prevent or improve clinical outcomes of COVID-19”. However, they suggest that malnourished patients at risk of or with COVID-19 should receive sufficient micronutrients to maximise defence against infections.
Patients with poor dietary intake (i.e. those with or at risk of malnutrition) may have a suboptimal intake of micronutrients. Recommended daily amounts of micronutrients could be obtained from diet, nutrition supplements and/or oral nutrition supplements. For example, AYMES 2.0 kcal and AYMES Shake both contain a range of 26 different vitamins and minerals per serving (including those highlighted as important by the new ESPEN paper.)
The ESPEN consensus paper acknowledges that “prolonged home stay may lead to increased sedentary behaviors.” They state that reduced physical activity levels is associated with “increased risk for and potential worsening of chronic health conditions, weight gain, loss of skeletal muscle mass and strength”. They conclude that “there is a strong rationale for continuing physical activity at home to stay healthy and maintain immune system function.”
In the UK, it’s recommended that older adults participate in 150 minutes of moderate exercise per week (approximately 30 minutes of exercise five days per week). It’s also recommended that older adults participate in muscle strengthening exercises twice per week. The ESPEN paper talks about the importance of adapting exercise so that it can be carried out without equipment and in confined spaces.
It’s important to choose an activity that is enjoyable and easily maintained — ESPEN suggests gardening, walking (at home or in the garden), home exercise videos, yoga, stair climbing and even chair lunges.
The ESPEN consensus paper provides different nutritional recommendations depending on the health status of the individual.
In Statement 5, they recommend that “Oral Nutritional Supplements (ONS) should be used whenever possible to meet a patient's needs, when dietary counselling and food fortification are not sufficient to increase dietary intake and reach nutritional goals”.
The recommended calorie provision, according to ESPEN, is at least 400 kcal/day including 30g or more of protein/day for at least one month. It does not specify whether this needs to be in one serving. Most ONS prescriptions range from one to three supplements per day, based upon national prescribing guidance from Prescqipp (8), MUST (9) and the Malnutrition Pathway (10). This recommended calorie and protein amount could be achieved with:
ESPEN suggests that the efficacy and expected benefit of ONS should be assessed monthly. They state that critically ill COVID-19 patients in recovery will be weak, and their rehabilitation can take up to a year. Therefore, ESPEN recommends that nutritional treatment with ONS should continue after hospital discharge until it’s no longer indicated.
1. Barazzoni R, Bischoff SC, Krznaric Z, Pirlich M, Singer P, endorsed by the ESPEN Council, Espen expert statements and practical guidance for nutritional management of individuals with sars-cov-2 infection, Clinical Nutrition, https://doi.org/10.1016/j.clnu.2020.03.022.
2. Lew CCH, Yandell R, Fraser RJL, Chua AP, Chong MFF, Miller M. Association between Malnutrition and Clinical Outcomes in the Intensive Care Unit: A Systematic Review. Journal of Parenteral and Enteral Nutrition. 2017.
3. Gomes F, Schuetz P, Bounoure L, Austin P, Ballesteros-Pomar M, Cederholm T, et al. ESPEN guidelines on nutritional support for polymorbid internal medicine patients. Clin Nutr. 2018; https://www.espen.org/files/ESPEN-Guidelines/PIIS0261561417302364.pdf
4. Fávaro-Moreira NC, Krausch-Hofmann S, Matthys C, Vereecken C, Vanhauwaert E, Declercq A, et al. Risk Factors for Malnutrition in Older Adults: A Systematic Review of the Literature Based on Longitudinal Data. Adv Nutr. 2016; https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4863272/
5. Correia MITD, Waitzberg DL. The impact of malnutrition on morbidity, mortality, length of hospital stay and costs evaluated through a multivariate model analysis. Clin Nutr. 2003; https://www.ncbi.nlm.nih.gov/pubmed/17044607
6. Hoffer LJ, Bistrian BR. Nutrition in critical illness: a current conundrum. F1000 Research. 2016; https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5070594/
7. SACN. Vitamin D and Health 2016. Sci Advis Comm Nutr. 2016.
8. Prescqipp. (2017). Guidelines for the appropriate prescribing of oral nutritional supplements (ONS) for adults in primary care; 3, 1-21. Available at: https://www.prescqipp.info/media/1512/b145-ons-guidelines-30.pdf
9. Bapen. (2003). The ‘MUST’ Explanatory Booklet. Available at: https://www.bapen.org.uk/pdfs/must/must_explan.pdf
10. Malnutrition Pathway. Managing Malnutrition: Including a Pathway for Appropriate Use of ONS. [Internet]. [Last accessed: August 2019]. Available from: https://www.malnutritionpathway.co.uk/ons