After a year living with a pandemic that changed our lives, it makes sense to reflect on what was produced technically and what the nutritionists who were on the front lines did. To that end, we spoke to three FCNAUP alumni who are nationally respected for their excellent work. They are Liliana Sousa , who works at the Matosinhos Local Health Unit and the Pedro Hispano Hospital and is today a national reference in the area of nutrition and intensive care medicine, and who throughout this year has stood out for her work in nutritional intervention in the treatment of patients with COVID-19; Cristina Teixeira , Director of the Nutrition Service at the São João University Hospital Center, a reference institution in the treatment of COVID-19, a place of learning par excellence where FCNAUP (Faculty of Nutrition and Nutrition of the University of Porto) practically was born and where, in 2019, the first Integrated Responsibility Center for Obesity for surgical treatment in the country was created; and finally, Graça Ferro, Director of the Alto Minho Local Health Unit, an institution that is an example of excellence in the integration of care between the various areas of the nutritionist's intervention, namely Clinical Nutrition, Community Nutrition, Institutional Management and Food, Teaching/Training and Research and Scientific Advice, and which throughout this pandemic has demonstrated how nutritionists can make a difference in the fight against COVID-19.
These testimonials reveal how essential nutritionists are in the fight against COVID-19. And that they can make a difference, both in prevention and in combating this disease. We hope that the exceptional work of these colleagues will serve as inspiration for all our students and nutritionists who are feeling tired and hopeless about tomorrow these days.
At FCNAUP, between March and April 2020, shortly after the first cases appeared, we reflected on the effects of the pandemic with our students. In April 2020, Professor Alejandro Santos was the first author of a text that launched a debate on the relationship between the SARS-CoV-2 pandemic and the "pandemic" of obesity. The text concluded: "There is still much to learn about this new relationship between obesity and COVID-19, but one thing is certain: the way we will view obesity in the future, now that new and successive infectious waves are expected, whether from SARS-CoV-2 or another variant, will transform the work of healthcare professionals, and particularly nutritionists." Almost a year later, these words remain accurate, as evidenced by the testimonies of our colleagues.
It is interesting to note that there is some similarity in the testimonies and reasons for the successful interventions. Starting with the integration of nutritionists into multidisciplinary teams, particularly in inpatient settings. According to Liliana Sousa: "The main advantage may have been the fact that, even before the pandemic, I was already very integrated, on-site, into the multidisciplinary teams in inpatient settings."
Another point to emphasize seems to be the need for early intervention, both before hospitalization and in the early stages of hospitalization: "(...) it is assumed to be a hypercatabolic disease, as it presents with an exuberant inflammatory picture. In addition, its evolution and progression until hospital admission usually involves symptoms with nutritional impact, directly influencing the patients' ability to feed themselves (fever, respiratory failure, anorexia, ageusia and anosmia), and gastrointestinal symptoms such as vomiting and diarrhea are also frequent." (...) "In the hospital setting, and in these patients in particular, who have so far represented a significant portion of the hospitalized patient population, early and timely nutritional intervention is fundamental, with a view to replenishing the nutritional reserves lost in the most critical phase of the disease, contributing to a faster physical, functional and emotional recovery."
One idea valued by our colleagues is the need for an integrated response from the system and nutritionists, from prevention to patient follow-up after hospital discharge. In a way, this is the response we recently described in "The national food and nutrition strategy for the Portuguese COVID-19 response," specifically in our "National framework regarding food and nutrition during the COVID-19 pandemic response," which our colleague Graça Ferro co-authored.
Finally, it seems to us that nutritionists can play an important role in this pandemic, and the best proof of this is their active participation in this process. Again, according to Liliana Sousa, “During the pandemic, I was never relieved of my role, and perhaps that is the best reflection of our relevance as healthcare professionals during this critical period.”
This pandemic may also have been an opportunity, as it may have created a perception of how necessary the work of nutritionists is. According to Cristina Teixeira: “In our understanding, and despite all the public health implications, at the hospital level and in the country in general, that the pandemic generated, it also ended up being a window of opportunity for nutritionists to reinvent themselves, and it was possible to create new opportunities to assume a fundamental and complementary role in providing healthcare to patients.” (…) “Indeed, we were once again able to witness that other healthcare professionals valued the activity of nutritionists, insofar as they felt even more the need for effective nutritional support, particularly for these COVID-19 patients, and more often requested our collaboration and opinion.”
This sense of opportunity for the profession deserves to be highlighted and gives voice to what we wrote in April 2020, “The solution is once again in our hands. And our professional action will now be more decisive than ever. In fact, nutritionists cannot “stay at home” in these times, at the risk of becoming irrelevant.”
One area that is still undervalued, but where progress is currently being made, is the hospital discharge period. According to Cristina Teixeira, "We also believe that regular follow-up with this new type of COVID-19 patient by a nutritionist after hospital discharge is a valuable asset for everyone, as it allows for better and faster recovery and rehabilitation, thus helping to restore the quality of life of each patient more quickly (an area we are now focusing on)."
Graça Ferro shares the same understanding: “These patients mostly have excess weight and associated cardiovascular risk factors, so initiating a dietary intervention after discharge to correct this is fundamental to improving their quality of life! This task involves nutritional and lifestyle re-education, which only a nutritionist has the sensitivity and competence to carry out!”
This could also be an opportunity to give prominence to Nutrition Services and to link them with Primary Health Care. According to Graça Ferro, “In inpatient care, during the first wave we considered COVID-19 patients as patients at nutritional risk, and based on this assumption, all patients admitted to the Intensive Care Unit, Intermediate Care Unit, and Ward were observed by the Nutrition Service, carrying out the respective nutritional intervention based on the guidelines that were gradually published by ESPEN and ASPEN and by the DGS Guidance Standard on nutritional therapy in COVID-19 patients published on 6/4/20.” (…) “On 9/2/21 we started the first project to integrate nutritional care in the context of Local Health Units, and thus every patient with COVID-19 and nutritional risk upon clinical discharge is referred to a colleague at the Health Center in their area of residence who accompanies them throughout the convalescence period, and may remain in consultation if they present cardiovascular risk factors.”
But the role of the nutritionist can go beyond clinical care. According to Graça Ferro, “We started by urgently meeting with the catering company responsible for supplying hospital meals and adapting the menu plan to the contingency period, adopting new methods of providing meals to patients hospitalized with COVID-19; all the equipment and even the trays had to be quickly changed to disposable materials.” This was an area where a huge amount of work was done, although it received little attention , but it was essential to guarantee safety and a sense of confidence in the services.
This pandemic can be an opportunity to hire more nutritionists for the National Health Service (SNS), as demonstrated with intelligence and a sense of opportunity at the Alto Minho Local Health Unit (ULS): “In order to maintain the daily routine, even with 80% of the team working in person since March 2020, we prepared a justification for hiring colleagues for the Service under the Pandemic provisions, which received a favorable opinion from the Board of Directors. Thus, in May 2020 and November 2020, two nutritionists were hired, reinforcing the team with four more colleagues who remain in their positions today.”
It is worth reading the full responses below. These texts give us a sense of the quality work being done in these excellent healthcare units and the potential of nutritionists in this area. May they serve as inspiration.
How did your service respond to the COVID-19 pandemic?
How did your service respond to the COVID-19 pandemic?Liliana Sousa : The pandemic didn't exactly bring about a change, but rather a need for adaptation. Essentially, I continued doing what I was already doing in terms of procedures and intervention, but a reorganization was necessary, not only due to the circumstances required in managing these patients, but also due to the increase in hospitalized patients. The main advantage was perhaps the fact that, even before the pandemic, I was very integrated, on-site, into the multidisciplinary teams in the inpatient unit.
During the pandemic, I provided support to two COVID-19 wards. The nutritional screening upon hospital admission, which we have implemented in the hospital for several years, continued; however, there was a need to adapt to a new reality, namely the isolation of patients and, in the first wave, the confrontation with the lack of sufficient quantities of personal protective equipment, which was a reality and required us to reorganize so that the provision of nutritional care and nutritional support to patients was not compromised. Therefore, the daily visit to the ward continued; however, communication to and from the patient was now carried out through the nurse responsible for the patient's care, in order to optimize the use of equipment and resources. Thus, physical presence was maintained, but distance from the patient was a necessity, which we overcame in subsequent phases, particularly in this last wave, which was more serious, more demanding in terms of numbers, and in which we were able to fully participate with patients. This, as healthcare professionals with an active intervention role, we know is (and has proven to be) fundamental as a driving force in achieving each patient's nutritional goals. The logistics changed completely. We started working in closed environments, with circuits that we religiously have to follow, but undoubtedly the greatest reward we can have is feeling, firsthand, the importance that our presence, our attention, and our care have for the patient.
Regarding intensive care, my integration into the team has been daily and in-person for many years, and during the first wave, it became necessary, for the first time in almost 20 years, to physically distance myself from the ward. I would say that the adaptation here was practically spontaneous among everyone, and I believe to this day that it was only possible to have been done in such a harmonious way because we are a team built over all these years of integrated work. Probably even we hadn't yet realized the balance that existed between everyone as a multidisciplinary team. We maintained all the routines, namely the daily rounds, which during the first wave, for the reasons already described, were done by phone and with a remote assessment based on the doctors' "eyes" and clinical records, where I also continued to record my intervention. After that first phase, which was logistically more complicated, we resumed the usual in-person procedure routine in the ward, which we maintain to this day.
Fortunately, the first wave was the mildest of all, and as such, I believe that this need for remote intervention was a minor difficulty, easily overcome with the measures implemented. Without a doubt, in this last wave, none of us were overwhelmed, and we all made a difference by being there, not only because of the existing pressure on intensive care, but also because of the growing exhaustion among the professionals. Each of us relieved the workload of the others, and regarding my role in particular, it would be anything but sensible, I could even say it would be totally incongruous, to give them the additional task of managing the nutritional support of patients at a time of such great pressure, effort, and work, when they most needed it.
What role can nutritionists play in this fight?
Liliana Sousa : Patients hospitalized with SARS-CoV-2 are no different from, and should not receive less care than, any other patient. COVID-19 is an infectious disease that can evolve into a severe illness. Many aspects of it are still unknown, particularly regarding its metabolic behavior, but it is assumed to be a hypercatabolic disease, presenting with a pronounced inflammatory state. Furthermore, its evolution and progression to hospital admission generally involves symptoms with nutritional impact, directly influencing patients' ability to feed themselves (fever, respiratory failure, anorexia, ageusia, and anosmia), and gastrointestinal symptoms such as vomiting and diarrhea are also frequent.
We cannot allow COVID-19 to leave behind victims of the disease; on the contrary, our efforts should focus on providing basic and fundamental care, which includes nutrition, generating active survivors with the fewest possible sequelae. In the hospital setting, and particularly for these patients, who have so far represented a significant portion of the hospitalized population, early and timely nutritional intervention is fundamental to replenishing nutritional reserves lost during the most critical phase of the illness, contributing to a faster physical, functional, and emotional recovery.
In healthcare, at this moment, no professional is dispensable, and I have no doubt, from my experience, that the nutritionist is a fundamental pillar in the management of these patients. The integration of nutritional care is transversal to the various clinical conditions that a COVID-19 patient may present, as it not only proves to be preponderant in replenishing and minimizing nutritional losses during the course of the disease, but also plays an important preventive role in avoiding nutritional degradation in those patients with less nutritional impact at the time of hospital admission. Furthermore, it is also an extremely relevant factor in the post-COVID period, fulfilling the function of nutritional supply for functional rehabilitation and clinical recovery, which extends into the period following hospital discharge.
During the pandemic, I was never relieved of my role, and perhaps that is the best reflection of our relevance as healthcare professionals during this critical period. This was a time to support each other, probably more than ever. To mutually relieve each other of the weight of responsibility and, no less importantly, the enormous emotional burden we have experienced in recent times. The combined efforts focused on the patient are complementary and add to the benefits for clinical prognosis. Teams must be solid, cohesive, and open enough to allow for integration, discussion, and consolidation of objectives, which must be common.
We are all more tired, saturated with a reality that seems to stubbornly persist. And precisely for that reason, we must be there. Each doing their part, maintaining the team network that has always united us and that now asks us to do so under greater pressure, under greater care, but that we continue to do it, and that we continue to do it well.
How did your Service respond to the COVID-19 pandemic?
How did your Service respond to the COVID-19 pandemic?Cristina Teixeira : Since the beginning of the pandemic, the São João University Hospital Centre (CHUSJ) has been one of the hospitals with the most COVID-19 cases, which has had a major impact on the normal functioning of our service.
Therefore, the Nutrition Service (along with other Clinical Services) had to adapt to an unprecedented new reality, with strong pressure on its professionals and existing infrastructure. Initially, and within the field of nutrition professionals, "work schedules" were defined to avoid the risk of overcrowding of colleagues in the same workroom, while still allowing for an equitable and effective response to all patients with COVID-19 symptoms and also to other patients hospitalized in the Hospital.
More specifically, regarding nutritional support for Clinical Services with COVID-19 patients, we began providing this support by telephone and through the computer platform, with this collaboration being carried out daily and coordinated with other healthcare professionals who were physically present in these areas.
In other "non-COVID-19" clinical services, we maintained our in-person support.
Regarding outpatient consultations, these were then conducted by telephone.
Another important aspect was that during the so-called "1st phase" of the pandemic (March to June 2020), the Nutrition Service carried out various activities related to the "management" of donations/gifts from companies/individuals for hospital staff, which occupied a significant part of the team during this period.
Additionally, considering the preventive aspect and best practices, and given the needs felt by healthcare professionals in general, a document was created for everyone with recommendations for healthy eating (quick and accessible), since these professionals on the so-called "front line" did not have the time, nor easy access, to adequate nutrition for the high level of physical and psychological exertion they were subjected to.
After the first phase of the pandemic, that is, from June 2020 onwards, all support from the Nutrition Service (both at the inpatient and outpatient levels) returned to being fully in-person, with the exception of support for Clinical Services with COVID-19 patients, which continued to be provided by telephone and through the computer platform (in accordance with the internal guidelines of CHUSJ).
What role can nutritionists play in this fight?
Cristina Teixeira : In our understanding, and despite all the public health implications, at the hospital level and in the country in general, that the pandemic generated, it also proved to be a window of opportunity for nutritionists to reinvent themselves, and it was possible to create new opportunities to assume a fundamental and complementary role in providing healthcare to patients.
Indeed, we were once again able to witness that other healthcare professionals valued the activity of nutritionists, insofar as they felt even more the need for effective nutritional support, particularly for these COVID-19 patients, and more frequently requested our collaboration and opinion.
Throughout this atypical year, the nutritionist assumed an even more fundamental role, both in preventing the occurrence of complications from this disease (namely in the relationship between obesity and a higher probability of complications), and in the recovery process of these patients.
We also believe that regular follow-up with a nutritionist for this new type of COVID-19 patient after hospital discharge is beneficial for everyone, as it allows for better and faster recovery and rehabilitation, thus helping to improve the quality of life of each patient more quickly (an area we are now focusing on).
How did your Service respond to the COVID-19 pandemic?
How did your Service respond to the COVID-19 pandemic?Graça Ferro : The Nutrition and Food Service of the Alto Minho Local Health Unit quickly felt the need to adapt to this new reality, which was initially so frightening, full of doubts and fears for everyone, and we healthcare professionals were no exception.
We began by urgently meeting with the catering company responsible for supplying hospital meals and adapting the menu plan to the contingency period, adopting new methods of providing meals to patients hospitalized with COVID-19; all the equipment and even the trays had to be quickly changed to disposable materials.
There was also a need to review the distribution and positioning of tables and chairs, the capacity of the staff canteens, replacing cash with the prior purchase of vouchers, and posting new signage and recommendations in accordance with the guidelines issued by the DGS (Directorate-General of Health).
In the first wave of inpatient care, we considered COVID-19 patients to be at nutritional risk. Based on this assumption, all patients admitted to the Intensive Care Unit, Intermediate Care Unit, and ward were assessed by the Nutrition Service, which implemented the respective nutritional intervention based on the guidelines gradually published by ESPEN and ASPEN, and the DGS (Directorate-General of Health) Guidance Standard on nutritional therapy in COVID-19 patients published on April 6, 2020.
In the second and third waves, already more organized and with a better understanding of the disease's impact on the patient's nutritional status, we opted to conduct nutritional risk assessments in the wards according to the guidelines of Decree No. 6634/2018, maintaining the nutritional assessment and intervention for all inpatients at levels 2 and 3 of healthcare.
In outpatient consultations, we followed the guidelines of the Board of Directors, adapted to each phase of the pandemic. Initially, we conducted most consultations via teleconsultation, but from May 2020 onwards, we gradually resumed in-person consultations. In this third wave, we maintain approximately 80% of consultations in person. At this stage, we only do not conduct in-person consultations if the patient requests a teleconsultation.
To maintain our daily routine, even with 80% of the team working in person since March 2020, we submitted a request for the hiring of colleagues for the Service under the Pandemic provisions, which received a favorable opinion from the Board of Directors. Thus, in May 2020 and November 2020, two nutritionists were hired, reinforcing the team with four more colleagues who remain in their positions today.
This was undoubtedly the great opportunity we are seizing from this pandemic. We were able to provide the Service with more human resources, and thus we have nutritional risk assessment being carried out in all inpatient services of the 3 ULSAM Units: Luzia Hospital, Conde de Bertiandos Hospital, and the Valença Convalescence Unit. Only the Psychiatry Service is missing, which will begin during March 2021.
We maintain daily support to the Critical Care Medicine Department and regular audits of meals provided to patients at lunch and dinner.
On February 9, 2021, we started the first project for the integration of nutritional care in a ULS context, and thus every patient with COVID-19 and nutritional risk upon clinical discharge is referred to a colleague at the health center in their area of residence who accompanies them throughout the convalescence period, and may remain in consultation if they present cardiovascular risk factors.
Despite the adversity, we continue to conduct research in collaboration with universities and to receive curricular interns and the Order of Nutritionists. We only suspended this area of training between March and May 2020 and between January and February 2021. Currently, we are working while complying with all safety requirements and best practices, with the team vaccinated, and resuming all activity as we did before the pandemic!
What role can nutritionists play in this fight?
Graça Ferro : The role of the nutritionist is crucial in this fight! And in different contexts within the National Health Service!
I'll give you the example of Hospital Care…
No other health professional has the skills to manage a hospital food service and know how to minimize tasks without compromising the quality of services provided and the needs of patients according to their different pathologies.
Guiding the reorganization of public dining areas, reviewing menu plans according to the guidelines of a healthy eating pattern!
Guiding those interested in donating food to healthcare professionals, explaining the most suitable foods, the hygiene and safety of their handling, delivery and packaging!
And for me, most importantly, knowing how to assess the patient's nutritional status, often in a more subjective way, speaking only with the patient and family, knowing the symptoms prior to hospital admission, and making a nutritional intervention adapted to a series of metabolic changes that COVID-19 and the medication used will trigger.
These patients mostly have excess weight and associated cardiovascular risk factors, so initiating a dietary intervention after discharge to correct this is fundamental to improving their quality of life! This task involves nutritional and lifestyle re-education, which only a nutritionist has the sensitivity and competence to carry out!
The critically ill patient needs the constant attention of someone who manages artificial nutrition and knows its indications, the most appropriate formulas, and the combination of food and nutrition in the post-ventilator weaning phase. Optimizing the nutritional status of the critically ill patient reduces the harmful effects of disuse myopathy, leading to shorter rehabilitation periods and optimizing the patient's functional recovery.
In all the less pleasant phases of life, we can have a window of opportunity, and I think that COVID-19, given its complexity, predisposition, associated symptomatology, and the evolution of the clinical state of patients who, due to their severity, require hospitalization, is undoubtedly a challenge for the nutritionist!
Written by
Pedro Graça, Director of the Faculty of Nutrition and Food Sciences at the University of Porto
