CMTF statements for nutritional management of individuals with Covid-19 infection
Malnutrition is known to be highly prevalent among patients hospitalized in acute care setting (1) and intensive care unit (ICU) (2).). Reduced food intake related to the loss of appetite or any inability to eat, in parallel with hypermetabolic conditions (inflammation, sepsis, etc.), exacerbates the development of malnutrition (3) This malnutrition leads to a change in body composition (muscle loss and/or fat loss) and diminished physical function. It well known that malnutrition has detrimental outcomes in regard to clinical complications, increased length of hospital stays, mortality and increased cost (1, 4, 5). The older age per se is very commonly associated with high risk and prevalence of malnutrition and worse outcomes (6). The prevalence of malnutrition is also high in individuals in long term care (LTC) facilities (7).
An ESPEN expert group reported that in COVID-19 patients, those with worst outcomes and higher mortality include immunocompromised subjects, namely older adults and poly-morbid individuals and malnourished people in general (8). Reports from China describe that 48.5% of COVID-19 positive patients presented to the hospital with digestive symptoms as their chief complaint. Patients with digestive symptoms had a significantly longer time from onset to admission than patients without digestive symptoms (9.0 days vs. 7.3 days). Patients with digestive symptoms had a variety of manifestations, such as anorexia, diarrhea, vomiting, all of which contribute to poor intake or reduced absorption (9). The risk for serious disease and death in COVID-19 cases increases with age (10) while 90 % of death occurring in patients aged 70 years or more (11). Observation of other countries reveals a high mortality rate during the corona virus pandemic amongst LTC residents.
Recent high quality randomized-controlled trials in medical inpatients confirm with strong evidence the effectiveness of nutritional assessment and individualized nutrition care to reduce complications and improve clinical outcomes (12, 13).
The CMTF states that the COVID-19 patients in all settings, acute care, ICU and LTC deserve the same high-quality nutritional management than any other patients and residents to ensure adequate nutrition intake and nutrition therapy. The trajectory of optimal nutrition care needs to be a continuum between the ICU, acute care unit, rehabilitation unit, LTC and even after hospital discharge. Protocols and pathways such as the Integrated Nutrition Pathway for Acute Care (INPAC), referring to a multimodal care approach, are supported. With the COVID-19 population, higher safety precautions are required to decrease risk of infection, including limiting direct contact with patients. Dietitians are encouraged to develop alternative strategies for nutrition assessment, swallowing evaluation and implementation of nutrition care plan in order to meet the increased nutritional needs of this population.
The CMTF COVID-19 Resources page provides a list of practical guidance for best practice.
Allard JP, Keller H, Jeejeebhoy K, Laporte M, Duerksen D, Gramlich L, Payette H, Bernier P, Vesnaver E, Davidson B, Teterina A and Lou W. Malnutrition at Hospital Admission—Contributors and Effect on Length of Stay: A Prospective Cohort Study From the Canadian Malnutrition Task Force. J Parenter Enteral Nutr. 2016;40 (4): 487-497
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. J Parenter Enteral Nutr 2017 Jul;41(5):744-758
Cederholm T, Barazzoni R, Austin P et al. ESPEN guidelines on definitions and terminology of clinical nutrition. Clin Nutr 2017, 36: 49-64
Curtis, L.J., Bernier, P., Jeejeebhoy, K., Allard, J., Duerksen, D., Gramlich, L., Laporte, M., & Keller, H.H. (2017). Costs of hospital malnutrition. Clinical Nutrition, 36(5), 1391-1396. https://doi.org/10.1016/j.clnu.2016.09.009
Lim SL, Ong KC, Chan YH, Loke WC, Ferguson M, Daniels L. Malnutrition and its impact on cost of hospitalization, length of stay, readmission and 3-year mortality. Clin Nutr 2012;31(3):345e50.
Volkert D, Beck AM, Cederholm T, Cruz-Jentoft A, Goisser S, Hooper L et al. ESPEN guideline on clinical nutrition and hydration in geriatrics. Clinical Nutrition 2019;38:10-47
Keller H, Carrier N, Slaughter S, Langyel C, Steele CM, Duizer L et al. Prevalence and determinants of poor food intake of Residents living in Long-Term Care. The Journal of Post-Acute and Long-Term Care Medecine 2017;18: issue 11: 941-947
Barazzoni R, Bischoff SC, Breda J, Wickramasinghe K, Krznaric Z, Nitzan D et al. ESPEN expert statements and practical guidance for nutritional management of individuals with SARS-CoV-2 infection. Clinical Nutrition; March 24 2020:1-8
PAN, Lei, MU, Mi, YANG, Pengcheng, et al. Clinical characteristics of COVID-19 patients with digestive symptoms in Hubei, China: a descriptive, cross-sectional, multicenter study. American Journal of Gastroenterology, 2020.
COVID, CDC, and Response Team. "Severe outcomes among patients with coronavirus disease 2019 (COVID-19)—United States, February 12–March 16, 2020." MMWR Morb Mortal Wkly Rep 69.12 (2020): 343-346.
Données COVID-19 au Québec https://www.inspq.qc.ca/covid-19/donnees consulted April 25 2020
Gomes F, Baumgartner A, Bounoure L, Bally M, Deutz N, Greenwald JL et al. Association of Nutritional Support with Clinical Outcomes Among Medical Inpatients Who Are Malnourished or at Nutritional Risk: An Updated Systematic Review and Meta-analysis. JAMA Network Open. 2019;2(11):e1915138. doi:10.1001/jamanetworkopen.2019.15138
Schuetz, P, Fehr R, Baechli V, Geiser M, Deiss M,Gomes F, Kutz A, Individualised nutritional support in medical inpatients at nutritional risk: a randomised clinical trial. Lancet, 2019 Jun 8;393(10188):2312-2321