Dietitians play an important role in ensuring adequate nutrition and hydration and preventing malnutrition in COVID-19 patients post-hospital discharge¹. More than 350,000 COVID-19 patientshave been cared for in hospitals across the United Kingdom, and whilst the majority of patients have recovered and been discharged from hospital, the effects of the virus itself, as well as invasive treatment regimens are likely to have a long-term impact on these patients.
At the time of writing, the number of active COVID-19 cases in the United Kingdom remains high, and there has been a recent focus on the long-term recovery of discharged COVID-19 inpatients. Nutrition is a vital part of the recovery process for all patients with COVID-19, particularly those who have experienced cardiac or pulmonary complications, as well as those who have developed frailty, sarcopenia or significant weight loss². These patients require individually tailored dietetic support as early as possible in their journey to recovery.
COVID-19 may cause symptoms such as a fever, coughing, general weakness, pain, difficulty breathing and changes to taste and smell (anosmia). Additionally, anorexia may be observed in COVID-19 patients; this is thought to be due to the effects of anosmia and loss of taste on appetite, as well as elevated levels of pro-inﬂammatory cytokines³. These symptoms can have both short and long-term effects on nutritional status, some of which we will explore later in this article.
Sarcopenia describes low muscle strength, low muscle quality or quantity, and low physical performance, and it is commonly observed in the critically ill⁴. COVID-19 patients treated in the Intensive Care Unit (ICU) have been shown to experience loss of muscle mass and function as well as significant weight loss⁵. This is thought to be due to a significant catabolic response coupled with bed rest and mechanical ventilation⁶. Patients discharged from hospital who have not required ICU treatment also demonstrate weight loss and sarcopenia⁷.
Older people and those with pre-existing health conditions are thought to be at greater risk of severe illness from coronavirus⁸. Due to government shielding recommendations, some patients may have been less physically active for a number of weeks or months prior to a diagnosis of COVID-19. A reduction in physical function is a key risk factor for accelerating the loss of muscle strength and function (sarcopenia)⁹. This, combined with malnutrition, increases the risk of frailty.
The term ‘frailty’ is used to describe a range of conditions and symptoms such as general debility, sarcopenia, weight loss, increased vulnerability and cognitive impairment. Frail people are at higher risk of adverse outcomes such as falls, delirium, readmission to hospital, or the need for long-term care¹⁰.
Patients recovering from COVID-19 may also experience lung damage¹¹ and may continue to experience feelings of fatigue, shortness of breath and reduced exercise tolerance in their recovery period¹². These symptoms may affect appetite and reduce oral food intake¹³, which could further exacerbate malnutrition, frailty and/or sarcopenia.
Dysphagia, or difficulty swallowing, can be a consequence of mechanical ventilation. A prospective clinical audit of 446 COVID-19 ICU patients¹⁴ indicated that 29% had prolonged post-extubation swallowing dysfunction at discharge with some residual swallowing disorders for up to four months¹⁵. Complications of dysphagia include malnutrition and dehydration¹⁶. Patients with dysphagia should be offered foods and drinks that are a safe and appropriate texture for their current level of dysphagia. This should be assessed and regularly monitored by a registered speech and language therapist alongside dietetic input if indicated.
Patients recovering from severe COVID-19 disease may develop psychological difficulties as a result of their experiences of illness and treatment. Research shows that patients admitted to critical care with Acute Respiratory Distress Syndrome (ARDS) experience ongoing anxiety (40%), depression (30%) and Post Traumatic Stress Disorder (PTSD) (20%) post-discharge¹⁷. Some may also present with varying degrees of communication and/or cognitive impairment, which can significantly reduce a patient’s capacity for self-care. All of these factors can compromise nutritional intake during recovery.
Comparative data² from one-year outcomes in survivors of ARDS has shown that recovering patients had persistent functional disability and significant muscle wasting and weakness (sarcopenia) up to a year post-discharge. On an individual level, sarcopenia is associated with:
On a wider level, untreated sarcopenia has been associated with increased hospital readmissions and healthcare costs²⁶.
The European Society for Parenteral and Enteral Nutrition (ESPEN) expert statements and practical guidance for nutritional management of individuals with SARS-CoV-2 infection¹⁵ recommends that prevention, diagnosis and treatment of malnutrition should be routinely included in the management of COVID-19 patients post-discharge.
In May 2020, the British Dietetic Association, (BDA), published the ‘Nutrition and the COVID-19 Discharge Pathway’27 (see Figure 1), emphasising the importance of screening for malnutrition in recovered COVID-19 patients, regardless of Body Mass Index (BMI). Over 70% of patients with COVID-19 have a BMI which classifies them as overweight or obese. During admission with COVID-19, these patients may experience significant muscle loss, indicating sarcopenic obesity¹. Patients with a higher BMI should be screened for malnutrition and, where indicated, offered nutrition support advice to replenish and prevent further muscle mass loss28.
Figure 1: Recommendations for discharge of COVID-19 patients (adapted from the British Dietetic Association*, (BDA), ‘Nutrition and the COVID-19 Discharge Pathway’27
*For the full BDA pathway, see: Nutrition and the COVID-19 discharge pathway. BDA Education, Professional Development and Policy team. 2020. Available from (https://www.bda.uk.com/resource/nutrition-and-the-covid-19-discharge-pathway.html)
Nutrition goals for discharged COVID-19 patients are to prevent or treat malnutrition and to replenish and prevent further muscle mass loss whilst optimising nutrition status¹⁵. Dietetic support is vital for these patients, to ensure adequate consumption of energy, protein and micronutrients28. In patients with a higher BMI, restriction of energy intake with the aim of reducing body weight is not appropriate during recovery due to the risk of reducing lean body mass, strength and function.
Nutrition support for these patients should focus on providing sufficient protein and energy to replenish and prevent further muscle mass loss. This is particularly important in patients aged >65 years27. Strategies to help patients meet their energy and protein requirements include dietary counselling (i.e. food-first advice), dietary modification (i.e. texture-modified diets for those with dysphagia), and the prescribing of oral nutritional supplements (ONS) when indicated²⁸. Individual care should be adjusted to address complications such as dysphagia, shortness of breath, fatigue, dry mouth, and taste and smell changes³¹.
Achieving a sufficient energy intake to maintain a healthy BMI is important for the prevention of malnutrition; a contributing factor in the pathogenesis of sarcopenia²⁹. Similarly, ensuring an adequate intake of protein is important for preventing and treating sarcopenia. When calculating energy and protein requirements for patients requiring nutritional support, ESPEN and the National Institute of Clinical Excellence (NICE)³⁰ recommend targets of 25–35 kcal/kg/day with a protein intake of 1.0-1.5 g/kg body weight/day. Additionally, patients should maintain adequate intakes of fluids (30–35 ml fluid/kg), electrolytes, minerals, micronutrients (taking into consideration any pre-existing deficiencies, excessive losses or increased demands) and fibre, if appropriate¹⁵.
The use of high-energy, high-protein oral nutritional supplements (ONS) may be indicated in patients who are unable to meet their nutritional requirements through an oral diet alone. ONS products are used for medical purposes in patients who meet the Advisory Committee on Borderline Substances (ACBS) prescribing criteria, have been screened using a validated malnutrition screening tool such as MUST³¹ and have been deemed to be at nutritional risk. ONS should always be given under medical supervision and must be used appropriately.
The 2020 ESPEN consensus paper on nutritional management of COVID-19 patients recommends that “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”¹⁵.
ONS should supply, according to ESPEN, at least 400 kcal/day including 30g or more of protein/day for at least one month. The efficacy and expected benefit of ONS should be assessed monthly. Rehabilitation for COVID-19 patients can take up to a year. Therefore, ESPEN recommends that ONS prescriptions should continue during this period until it’s no longer indicated¹⁵.
The effects of the virus itself, as well as invasive treatment regimens are likely to have a long-term impact on the nutritional status of COVID-19 patients post-hospital discharge. Dietitians play an important role in optimising the nutritional status of COVID-19 patients post-discharge. Nutrition support in the community, with a focus on meeting protein and energy requirements, is recommended for up to one year following discharge.