Tailoring nutrition therapy amid the COVID-19 pandemic: Does it work?

Individualised energy and protein targets achieved during intensive care admission are associated with lower mortality in mechanically ventilated COVID-19 patients: The COFEED-19 study

BACKGROUND & AIMS

Malnutrition is prevalent among COVID-19 patients admitted to the intensive care unit (ICU) and it is associated with poor survival. Customized nutrition plays a vital role in enhancing outcomes for this patient population. This study explores the association between energy and protein intake and 90-day mortality in invasively mechanically ventilated COVID-19 patients, utilizing fat-free mass (FFM) and actual body weight (ABW) for nutritional requirements. Furthermore, the study investigates the occurrence of gastrointestinal (GI) intolerance in critically ill COVID-19 patients in relation to their nutritional intake and survival.

METHODS

A retrospective study was undertaken at a university-affiliated teaching hospital, focusing on COVID-19 patients on invasive mechanical ventilation admitted to the ICU between March 2020 and December 2021. The study collected demographic and clinical data, along with cumulative energy and protein goals, and recorded cumulative intake on days 4, 7, and throughout the ICU stay. Univariate and multivariable Cox regression analyses were conducted to evaluate associations between energy and protein deficits and the 90-day all-cause mortality.

RESULTS

The study included 85 patients, of whom 67 (78 %) survived 90 days after ICU admission. There were no significant differences in body composition between survivors and non-survivors. Reaching ≥70 % of the energy goal based on both ABW and FFM during the ICU stay was associated with decreased 90-day mortality (HR 0.22, 95 % CI 0.08-0.60 and HR 0.28, 95 % CI 0.09-0.85, respectively). Similarly, achieving ≥80 % of the protein target based on FFM was associated with decreased 90-day mortality (HR 0.26, 95 % CI 0.07-0.94), whereas no significant association was found for reaching protein targets based on ABW (HR 0.03, 95 % CI 0.00-3.40). Patients who reached both their energy and protein goal based on FFM during ICU admission showed a lower risk of all-cause 90-day mortality compared to those who received <70 % of the energy goal and <80 % of protein based on FFM after adjusting for age (aHR 0.12, 95 % CI 0.03-0.50). No differences in GI intolerance related symptoms between COVID-19 survivors and non-survivors were observed.

CONCLUSIONS

This study underscores the significance of providing adequate nutritional therapy to COVID-19 ICU patients who require IMV. Meeting over 80 % of the protein goals based on BIA-derived FFM was associated with lower mortality rates, which emphasizes the need for further investigation into the role of FFM in establishing nutritional targets.

COVID-19: Lessons on malnutrition, nutritional care and public health from the ESPEN-WHO Europe call for papers

With prolonged pandemic conditions, and emerging evidence but persisting low awareness of the importance of nutritional derangements, ESPEN has promoted in close collaboration with World Health Organization-Europe a call for papers on all aspects relating COVID-19 and nutrition as well as nutritional care, in the Society Journals Clinical Nutrition and Clinical Nutrition ESPEN. Although more COVID-related papers are being submitted and continue to be evaluated, ESPEN and WHO present the current editorial to summarize the many published findings supporting major interactions between nutritional status and COVID-19. These include 1) high risk of developing the disease and high risk of severe disease in the presence of pre-existing undernutrition (malnutrition) including micronutrient deficiencies; 2) high risk of developing malnutrition during the course of COVID-19, with substantial impact on long-term sequelae and risk of long COVID; 3) persons with obesity are also prone to develop or worsen malnutrition and its negative consequences during the course of COVID-19; 4) malnutrition screening and implementation of nutritional care may improve disease outcomes; 5) social and public health determinants contribute to the interaction between nutritional status and COVID-19, including negative impact of lockdown and social limitations on nutrition quality and nutritional status. We believe the evidence supports the need to consider COVID-19 as (also) a case of malnutrition-enhanced disease and disease-related malnutrition, with added risk for persons both with and without obesity. Similarities with many other disease conditions further support recommendations to implement standard nutritional screening and care in COVID-19 patients, and they underscore the relevance of appropriate nutritional and lifestyle prevention policies to limit infection risk and mitigate the negative health impact of acute pandemic bouts.

Association of Different Malnutrition Parameters and Clinical Outcomes among COVID-19 Patients: An Observational Study

Background: Malnutrition is highly prevalent in medical inpatients and may also negatively influence clinical outcomes of patients hospitalized with COVID-19. We analyzed the prognostic implication of different malnutrition parameters with respect to adverse clinical outcomes in patients hospitalized with COVID-19. Methods: In this observational study, consecutively hospitalized adult patients with confirmed COVID-19 at the Cantonal Hospital Aarau (Switzerland) were included between February and December 2020. The association between Nutritional Risk Screening 2002 (NRS 2002) on admission, body mass index, and admission albumin levels with in-hospital mortality and secondary endpoints was studied by using multivariable regression analyses. Results: Our analysis included 305 patients (median age of 66 years, 66.6% male) with a median NRS 2002-score of 2.0 (IQR 1.0, 3.0) points. Overall, 44 patients (14.4%) died during hospitalization. A step-wise increase in mortality risk with a higher nutritional risk was observed. When compared to patients with no risk for malnutrition (NRS 2002 < 3 points), patients with a moderate (NRS 2002 3−4 points) or high risk for malnutrition (NRS 2002 ≥ 5 points) had a two-fold and five-fold increase in risk, respectively (10.5% vs. 22.7% vs. 50.0%, p < 0.001). The increased risk for mortality was also confirmed in a regression analysis adjusted for gender, age, and comorbidities (odds ratio for high risk for malnutrition 4.68, 95% CI 1.18 to 18.64, p = 0.029 compared to patients with no risk for malnutrition). Conclusions: In patients with COVID-19, the risk for malnutrition was a risk factor for in-hospital mortality. Future studies should investigate the role of nutritional treatment in this patient population.

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.