A former article (Holdoway, 2020) on the nutritional management of patients during and after COVID-19 illness highlighted the impact of the infection and associated symptoms on dietary intake. The article emphasised how community nurses could identify the risk of malnutrition when working remotely, but also support patients and carers to adjust diet to achieve optimum nutrition while facing the adverse effects of a pandemic, including dealing with the disease itself as well as its impact on daily life. Since that time, through international collaboration, our knowledge on the effects of COVID-19 has expanded rapidly. Data published worldwide have further illustrated the negative sequelae associated with a severe infection of COVID-19, including the impact on nutritional status and function, along with the emergence and recognition of long COVID.
Age and comorbidities have proved to be powerful predictors of hospitalisation, with oxygen impairment and inflammatory markers most strongly associated with critical illness (British Medical Journal, 2020). After age, a body mass index of 40 kg/m2 was one of the strongest predictors of hospitalisation. Poor glycaemic control associated with diabetes and the disease itself were both found to be contributory factors underlying severity of COVID-19 and outcomes (Bornstein et al, 2020; Holman et al, 2020). Anabolic resistance arising from the inflammatory response associated with a COVID-19 infection also has a marked effect on muscle synthesis, resulting in rapid loss of muscle mass among thousands affected (Welch et al, 2020).
As our knowledge of the cascade of events has improved, so, too, has the recognition of the poor nutritional status reflected in the high incidence of weight loss and malnutrition among COVID-19 survivors. Independent of hospitalisation, significant loss of muscle mass and function have been found to occur in survivors of COVID-19, with older adults and the most critically unwell patients being the most at risk (Welch et al, 2020).
Many patients affected-those with comorbidities and older people-comprise those who were already nutritionally vulnerable. The importance of nutrition screening in these vulnerable groups should not be overlooked. Given the prevalence of obesity among those severely affected by COVID-19, health professionals and patients alike perceived a possible benefit from the rapid unintentional weight loss experienced, but, in reality, the large amounts of muscle loss have had profound effects on recovery and impeded the return to pre-illness function. The role of nutrition screening, initially sidelined as healthcare teams were under pressure and routines were disrupted, has been recognised as being paramount for all patients to identify the risk or presence of malnutrition associated with rapid unintentional weight loss that can hamper recovery.
The diversity of patient body types and the prevalence of comorbidities undoubtedly present a conundrum in the nutritional management of patients recovering from COVID-19. Among those who have lost weight and are underweight, a high-calorie, high-protein diet is indicated. For those who have lost weight but remain overweight or obese, dietary advice to optimise protein intake while avoiding excessive calories that would result in regain of fat mass and potentially exacerbate pre-existing conditions, is likely to be indicated.
Breathlessness, fatigue, dysphagia (including that post-intubation), loss of smell and taste and inflammation have all been noted to persist after acute COVID-19 infection, affecting underweight and overweight patients alike (Arnold et al, 2020; Carfì et al, 2020; Doykov et al, 2020; Mandal et al, 2020; Sudre et al, 2020). Similar symptoms experienced by those with other conditions, such as chronic obstructive pulmonary disease (COPD) and cancer, can have a profound effect on the pleasure usually associated with eating and drinking and further contribute to a poorer quality of life. Dietary advice, including modifications that can help alleviate symptoms, should therefore form an integral part of care in those recovering and in those experiencing long COVID.
For those with pre-existing conditions (including poor cardiometabolic health and diabetes), patients and family members may be left unclear about previous dietary advice provided to manage a long-term condition versus the need to relax dietary restrictions to manage a poor appetite and improve nutritional status. Advice from a registered dietitian might be helpful.
While more research is required to understand factors affecting recovery from an acute COVID-19 infection and long COVID, knowledge from other respiratory illnesses including acute respiratory distress, demonstrates that rapid unintentional weight loss and low muscle mass negatively affect patient outcomes and increase healthcare use (Chan et al, 2018; Anderson et al, 2020). In particular, loss of muscle mass is associated with higher rates of infections, poorer tolerance to chemotherapy, hospitalisation, fractures, reduced quality of life and reduced survival (Prado et al, 2018). Such knowledge provides a blueprint and insights into the potential role of nutritional therapy in facilitating recovery, and protein intake combined with resistance training is likely to be needed if the low muscle mass is to be reversed and the return to pre-illness function is to be optimised.
Appropriate nutritional strategies
COVID-19 has shone a light on the poor state of the health of our nation. Those severely affected by COVID-19 have comprised some of the most vulnerable members of the population with the poorest nutritional health. Implementing nutritional management strategies has been recognised as crucial for hospitalised patients, particularly those in intensive care or older people and those with multi-morbidities (Barazzoni et al, 2020). Furthermore, recent research suggests that individuals managing or recovering from COVID-19 symptoms at home should receive counselling on how to optimise dietary intake and, where poor appetite prevails, maintain an adequate intake of calories, protein and fluids (Di Filippo et al, 2020). It is suggested that strategies, such as using remote nutritional screening tools recently developed for primary practice, should continue to be adopted to improve the nutritional management of patients managed at home (Di Filippo et al, 2020). In an era where self-management is being encouraged, patients can self-screen where appropriate (www.malnutritionselfscreening.org/). To assist healthcare professionals undertake remote nutritional screening, relevant information can be found at https://tinyurl.com/wawuhek.
Resources to assist nurses and patients in accessing appropriate dietary advice during recovery
Nursing teams are likely to be involved in the care of patients recovering from a severe infection of COVID-19 and long COVID for some time to come. With pre-existing comorbidities, the number of older people affected and the disease itself affecting dietary intake and nutritional status, a tailored nutritional approach is likely to be required. It is clear that some patients will require referral to a dietitian for specialist advice, and equally, there will be many who will remain under the care of various members of the healthcare team. Many patients value the holistic approach that lies at the heart of nursing care, and it is likely that patients and carers will seek advice from nurses.
To support community healthcare professionals in the management of patients who have COVID-19 or are recovering from the infection, the Malnutrition Pathway has developed ‘A community healthcare professional guide to the nutritional management of patients during and after COVID-19 illness’ (https://tinyurl.com/t22y75ae). This includes a COVID-19-specific nutrition care pathway and advice on screening for malnutrition via remote consultations.
A separate guide has been developed for care homes to assist care home staff in the nutritional care of patients who have or are recovering from COVID-19 illness (https://tinyurl.com/47zz2rn5).
For all individuals, advice should be meaningful and appropriate to enhance recovery while managing underlying conditions and body weight, to optimise long-term health. To facilitate and tailor advice to individual needs, patient information leaflets are available. Three leaflets have been created for patients at low, medium or high risk of malnutrition and are accompanied by a resource finder to assist professionals and patients in identifying the correct advice according to the nutritional status of the patient. These are available here: https://tinyurl.com/c9e88ky7. The leaflets include tips on coping with symptoms related to COVID-19 illness and encouraging activity combined with good nutrition. For patients who are not at risk of malnutrition but may have lost muscle mass and strength due to COVID-19 infection and ongoing symptoms, the advice should focus on ensuring adequate protein in the diet combined with strength training adjusted to the individual.
Additional fact sheets on incorporating protein into the diet for both healthcare professionals and patients are also available at https://tinyurl.com/rrctdf6e. Information on managing dysphagia is also available at https://tinyurl.com/y3vvdte7.
For individuals who are underweight or continuing to lose weight following COVID-19 infection, nutrition support in the form of a high-energy, high-protein diet is indicated, with the use of oral nutritional supplements when patients are unable to increase their intake or meet requirements through diet alone (Malnutrition Pathway, 2020).
With the COVID-19 pandemic creating considerable stress on the NHS, many NHS trusts across the UK are using the COVID-19 nutritional resources as part of their discharge packs for patients. In the first 2 months of 2021 alone, nearly 10 000 copies of the COVID-19 and nutrition patient leaflets were downloaded from the Malnutrition Pathway website. With an increasing number of patients now experiencing the longer-term effects of COVID-19, including long COVID, it is hoped that these resources will assist community healthcare professionals in advising patients on the role that nutrition can play in aiding their recovery and influence long-term health and wellbeing.
KEY POINTS
- Poor nutrition is reflected in the high incidence of unintentional weight loss (and primarily loss of muscle mass) among COVID-19 survivors
- Nutrition screening for patients with COVID-19 should not be overlooked; it is paramount to identifying malnutrition risk associated with unintentional weight loss and guiding subsequent advice
- Muscle loss has a profound effect on recovery, impeding return to pre-illness function. Dietary advice, including modifications to alleviate symptoms, combined with strength training for those with muscle loss and weakness, should be an integral part of the care for those severely affected by COVID-19
- A high-calorie, high-protein diet is indicated for those who have lost weight and are underweight, but, for those who remain overweight or obese, dietary advice should focus on optimising protein intake while avoiding excessive calories
CPD REFLECTIVE QUESTIONS
- What nutritional considerations should be kept in mind for patients recovering from severe long COVID?
- Why is nutrition important for recovery from COVID-19?
- What comorbidities need particular attention from nurses caring for those recovering from long COVID?