In the context of the COVID-19 pandemic, although most patients infected with SARS-CoV-2 present with mild illness, it is estimated that between 6 and 10% of infected patients require hospitalization, and of these, more than 10% require treatment in Intensive Care Units (ICUs) .
In the context of COVID-19 risk groups, scientific evidence shows that individuals with metabolic disease associated with inadequate dietary habits have an increased risk of more severe disease and worse therapeutic outcomes, which are associated with slower recovery and higher mortality. In the North American population, more than two-thirds of individuals who died from COVID-19 had at least one comorbidity , namely cardiovascular disease, diabetes, chronic kidney disease, and chronic lung disease. In a Spanish and Italian population with COVID-19, hypertension was observed in 51.3% of patients, dyslipidemia in 40.0%, obesity in 23.5%, and diabetes in 19.5% – pathologies where nutritional intervention is essential. According to the same study , age, hypertension, obesity, and kidney failure were the risk factors most associated with COVID-19 mortality. The presence of comorbidities appears to predispose to more severe forms of the disease.
The severity of the respiratory infection, the hyper-inflammatory state, and the hypercatabolism associated with SARS-CoV-2 infection increase energy requirements. On the other hand, food intake is reduced as a result of infection-related anorexia, early fullness, dyspnea, dysosmia, dysgeusia, dysphagia, emotional stress, and poor appetite for hospital meals. These factors, combined with immobilization, result in a rapid deterioration of nutritional status and muscle depletion to which COVID-19 patients are more susceptible .
marked sarcopenia and deterioration of nutritional status are to be expected in this group of patients .
Therefore, nutritional therapy in the treatment of patients with SARS-CoV-2 and the control of associated comorbidities is of paramount importance.
For hospitalized COVID-19 patients, particularly those with more severe cases and specifically critically ill patients, nutritional therapy should be an integral part of their treatment approach. Nutritional support is an essential component of care for all patients admitted to wards (in areas dedicated to COVID-19 patients) and SIM (Medical Surveillance System), and can reduce the risk of complications.
Considering the importance of optimizing the nutritional status of groups at risk for COVID-19 and the nutritional therapy of patients with COVID-19, it is important to guide the clinical approach in this area. To this end, the Directorate-General of Health published, on April 6, 2020, just over 15 days after COVID-19 was declared a pandemic by the WHO, Guidance Note No. 021/2020 concerning the nutritional therapy of patients with COVID-19.
The update to this guidance, coordinated by the PNPAS and published today, was necessary in light of the most recent scientific evidence, clinical experience in the field, and the growing importance recognized for dietary and nutritional intervention in the course of COVID-19. The main updates to this guidance document for the health system are highlighted below:
1. The importance of maintaining systematic nutritional risk assessment for all hospitalized patients. Greater knowledge of this disease and the strategies needed to prevent its transmission, as well as the no longer scarce personal protective equipment, makes it possible to maintain procedures already established in a pre-pandemic phase, such as systematic nutritional risk assessment, thus seeking to maintain the quality of healthcare provided to all patients (COVID and non-COVID).
2. The importance of indirect calorimetry for determining energy requirements, in order to optimize energy administration and avoid under- and overdosing, conditions that are associated with increased mortality.
3. It is reinforced that there is no scientific evidence regarding the benefit of routine use of immunonutrients and the use of micronutrients in supra-physiological and supra-therapeutic doses. Their administration should only occur at the recommended daily doses, or they should be replenished in cases of deficiency. However, the importance of determining vitamin D levels in these patients and supplementing them in case of deficiency is highlighted, in accordance with DGS Standard 004/2019 . In cases where the plasma concentration of 25-hydroxyvitamin D (25(OH)D) is less than 50 nmol/L or less than 20 ng/m³, vitamin D supplementation should be provided.
4. Aerosolization as a risk factor for the potential contamination of healthcare professionals and the need to minimize clinical procedures that increase occupational exposure, such as the determination of gastric residual volume.
5. The importance of oral nutritional supplements in the therapeutic approach to these patients. Clinical experience has shown their relevance in the context of hospitalized COVID-19 patients in wards.
6. The importance of continued nutritional monitoring of patients in the post-hospital discharge period. COVID-19 is a highly debilitating disease, and the length of stay in the Intensive Care Unit and the prolonged post-critical illness period are factors that can contribute to marked sarcopenia and deterioration of nutritional status .
7. Lastly, and no less importantly, there is a need to strengthen nutrition services, both due to the importance of nutritional intervention in the therapeutic approach to patients with COVID-19, and also in the context of the dietary and nutritional counseling necessary to optimize the nutritional status and good metabolic control of patients with chronic pathologies, which are considered risk factors for a worse COVID-19 prognosis. In this sense, maintaining Nutrition Services within their original departments is extremely important, otherwise the provision of personalized nutritional care will be jeopardized, given its specificity and scarcity of resources.
Written by
Pedro Graça, Director of the Faculty of Nutrition and Food Sciences at the University of Porto
