Assessing patients' nutritional needs and setting realistic goals during COVID-19 recovery

Information on assessment tools and how to refer to a NHS dietitian and other healthcare professionals

Assessing nutritional needs and setting realistic goals

Nutrition assessment examines an individual’s risk of nutrition problems in more detail than screening. Anyone identified as at risk of nutritional problems in screening should be assessed in more detail.

Nutrition can be affected by wider factors such as sociodemographics (e.g. Black, Asian Minority ethnic groups), food insecurity (disruption of food intake or eating patterns due to lack of money and other resources) (Gundersen and Ziliak, 2015) and hospitalisation amongst others (Mechanick et al., 2020). These are factors considered in a nutrition assessment, but may not be part of screening.

There are not many studies (yet) on nutritional assessment or screening in patients with COVID. Most of this information is based on what we already know in other patient groups. The National Taskforce of COVID-19 stated that reduced nutritional status and weight loss are part of the symptoms of post acute care COVID-19 therefore it needs to be assessed (National COVID-19 Clinical Evidence Taskforce, 2021).

A French study delivered enriched meals to people with weight loss and found that early nutrition support is essential to avoid readmission, refeeding syndrome and for an improved recovery (Bedock et al., 2021). An Italian study has documented malnutrition in 26-45% of patient with COVID-19 and therefore concluded that it is essential to assess swallowing function, nutritional status and functional independence (Nalbandian et al., 2021). A research team in the UK (Greenhalgh et al., 2020) proposed a series of assessments to diagnose long COVID in primary care:
- Clinal assessment including physical examination, assess morbidities and associated social and financial circumstances.
- Clinical testing such as electrolyte, troponin, C reactive protein amongst others to assess inflammatory states.
- Referral is recommended when patients have worsening breathlessness, unexpected chest pain, new confusion, focal weakness or PaO2<96%.

Because COVID has many and wide ranging symptoms a holistic assessment of symptoms is advised including, how the symptoms affect the individual (NICE, 2020), the effect on underlying conditions, and the risk of malnutrition. This can be done one week to three months after the onset of symptoms (Barazzoni et al., 2020).

Nutritional deficiencies, obesity and other diet related co-morbidities (e.g. diabetes, cardiovascular disease etc) are also important to consider and address nutritionally.

You can watch a Diet and COVID video by Registered Dietitian Elaine Anderson that explains what type of foods can help to address symptoms on our Nutrition and COVID-19 Recovery page.

How to assess

This section provides structured guidance on how to do a brief but effective nutritional assessment for malnutrition and obesity (metabolic syndrome risk).

We encourage you to follow and use locally developed and agreed guidance and pathways for identifying and managing malnutrition.

Assessment should establish causes and duration of any nutritional issues.

In the first instance, we advise you to use the patients association nutrition checklist. Note that section B can be adapted for local use and section A is already validated.

For a more comprehensive assessment as well as for setting goals, you can follow the ABCDE process (Anthropometric, Biochemical, Clinical, Dietary Information, Economic and social status) which is adapted for COVID-19 recovery monitoring here. It includes a list of factors advised to consider when assessing patients:

Anthropometric

The following information will indicate loss of muscle and/or strength, and changes in body size and composition.

  • Measure height and weight to calculate body mass index
  • Calculate percent weight loss over time (usually the last 3-6 months if you have a previous weight)
  • Hand grip strength (you will need a dynamometer) will indicate muscle strength. Aiming to regain muscle strength is an important part of recovery. The six-minute walk test (Barazzoni et al., 2020; Cawood et al., 2020) is an alternative method to judge physical abilities or performance.
  • MUAC (mid upper arm circumference) (Lawrence et al., 2021) indicates overall body size and is useful if you cannot weigh the patient.
  • Triceps Skin-Fold thickness (TSF) and Arm Muscle Circumference (AMC) indicate levels of fat and muscle, but is a specialist measure only.
  • Neuroinflammatory responses can perpetuate inflammation and wasting, as well as weight loss in vulnerable populations. Regain of weight needs to be monitored through body composition (Di Filippo et al., 2021).


Biochemical

  • Haemoglobin (HB), Total Protein (TP), Albumin (ALB), Prealbumin (PA) can all be useful measures in assessing nutrition (Yang et al., 2019).


Clinical

There is a range of factors to consider including:

  • Post-hospitalisation there may be significant gastrointestinal symptoms (vomiting, gastric retention, diarrhoea, abdominal distention, and hyperglycaemia)
  • Presence of PICS (post intensive care syndrome)
  • Hyper-inflammation
  • Frailty and weight management issues, soft tissues pressure sores, cognitive decline, depressive symptoms and dependency care, delirium, breathlessness (Lawrence et al., 2021).
  • Fatigue is a key symptom of COVID and can be assessed using the Analogue Scale of Fatigue (for 18-55 year olds) [PDF] (Shahid et al., 2011).
  • There are some tests that can be conducted with patients or by themselves to assess their taste or smell loss guided by scientific research and best practice https://www.fifthsense.org.uk/smell-training/

Dietary

  • Food intake (measured using food and fluid charts, food frequency, diet history, recalls) (Barazzoni et al., 2020; Cawood et al., 2020)
  • Reduced desire to eat and appetite (Barazzoni et al., 2020; Cawood et al., 2020)
  • Other symptoms to ask about include: anosmia, diarrhoea, nausea, vomiting. Address swallowing issues and dysphagia (which can appear after the infection and last for 21 days–4 months) (Lawrence et al., 2021). These can be assessed using the Eating Assessment Tool (EAT-10). Available to view and download from the Melbourne Ent Group [PDF]
  • There is a list of procedures utilised by the multidisciplinary team when assessing dysphagia that have been categorised according to their risk of COVID-19 transmission in Miles et al (2020). Other considerations for the use of telehealth when assessing and monitoring dysphagia have been proposed (Miles et al., 2020).
  • Check compliance with any dietary advice received (Malnutrition Pathway, 2020).


Economic and Social

  • Quality of life (QoL, EQ-5D-3L),
  • Daily activities using the Work and Social Adjustment Scale (WSAS) [PDF] (Lawrence et al., 2021)
  • Self reported activity of daily living (Malnutrition Pathway, 2020)
  • Physical function (fatigue, breathlessness, physical fitness test) (Malnutrition Pathway, 2020)
  • Sitting to stand test – One-minute sit to stand test instructions [PDF]
  • Mental wellbeing (PHQ, GAD or informal questions) (Jin, Ying-Hui et al., 2020)

Making a referral
  • GPs or other health professionals in the community can refer to a dietitian or registered nutritionist.
  • Local hospitals or primary care settings sometimes operate a ‘self-referral’ system so patients can refer themselves.
  • Local policies and guidelines should be followed as these vary, including differences between primary and secondary care.
  • Contact your dietetic services to find out if there are access criteria for those recovering from COVID-19.


Understanding what a dietitian can do:

  • Find out what a dietitian is and the differences between a dietitian and a nutritionist from the British Dietetic Association (BDA) website.
  • View a comparison table between the different nutrition professionals from the Association for Nutrition [PDF] website.
  • Find a registered dietitian and view a comparison table from the NHS website.
  • Find out whether the person advising you is a registered nutritionist from the Association for Nutrition website.


Referring to other healthcare professionals working in health and social care services

There must be clear referral pathways to prevent disjointed care and people waiting a long time for appointments with multiple specialists. This could be addressed with a one-stop clinic, and many of these have been set up in the UK (NHS, 2020). National guidance for these clinics can be found on the Patient Safety Learning website.

According to NHS, NICE and National Institute for Health and Care Research (NIHR), local systems should consider innovative and locally appropriate approaches to clinical leadership and skill mix, and need to be alert to whether people need support from (Aytür et al., 2020; Cawood et al., 2020; Lawrence et al., 2021):

  • Dietetics and nutrition, gastroenterology – they can advise on impact of COVID-19 in nutritional status
  • Psychologists
  • Occupational therapist
  • Physiotherapists (especially exercise tolerance test)
  • Specialist nurses
  • Rehabilitation services
  • Occupational health
  • Speech and language therapist (particularly for dysphagia)
  • Fitness instructors
  • Social services


Referral to post-COVID syndrome clinic

This can be done by primary and secondary care, community services, depending on local approach (NHS, 2020).

  • Should happen with people with new, worsening or ongoing symptoms after acute phase – if available.
  • Should happen promptly to increase effectiveness of interventions. 
  • It is advisable that GPs rule out any underlying pathology that may be causing the symptom presentation.

There are 69 post-COVID syndrome assessment clinics across the UK, the locations of these clinics can be found on the NHS website.


Referral to third sector (social services)

The following is just an example of what a charity can provide in terms of nutrition related services. Contact your local authority community services to find out what other organisations are available.

Age UK

If the contact person is worried about malnutrition or have other dietary concerns, Age UK offers strategies to encourage eating more and provides useful dietary tips.

They can support with:

  • shopping
  • escorted services
  • home delivery services
  • internet shopping.

Find out more information on the Age UK website.

To support self-referral and contact social prescribers, One Health Lewisham provides a patient-focused link that healthcare professionals can signpost to.

This is the list of people or professionals that can refer to Age UK services or receive a referral for AgeUK:

  • GPs.
  • Hospital discharge teams.
  • Dietitian (EG LAMP).
  • Adult Social Services.
  • British Red Cross hospital discharge support.
  • Internal Age UK Lewisham and Southwark services (Information and advice, safe and independent living team, day centre clients, etc).
  • Age UK Lambeth.
  • BlindAid.
  • Alzheimer’s Society.
  • Time & Talents, Blackfriars Settlement, Irish Centre, Link Age Southwark, Southwark Carers, Southwark Pensioners Centre (local organisations).
  • Supported Housing Scheme staff.
  • GP Federations (EG One Health Lewisham).
  • Housing Association staff.
  • Self referrals.
  • Referrals by family, friends, carers, neighbours.
  • Mutual Aid Groups.
  • GoodGym.
  • Food banks.

If there is not enough information for you, you can talk with your GPs, community nurse or other health professionals for further advice. In some areas there are specific services to support those at risk of malnutrition e.g. Lambeth and Southwark Action on Malnutrition Project (LAMP).

Contact us

This knowledge hub is constantly being reviewed and updated. We welcome your comments or feedback about it.

Please contact abigail.troncohernandez@plymouth.ac.uk and we will get back to you promptly.

References

Aytür, Y.K. et al. (2020) ‘Pulmonary rehabilitation principles in SARS-COV-2 infection (COVID-19): A guideline for the acute and subacute rehabilitation’, p. 17.

Barazzoni, R. et al. (2020) ‘ESPEN expert statements and practical guidance for nutritional management of individuals with SARS-CoV-2 infection’, Clinical Nutrition, 39(6), pp. 1631–1638. doi:10.1016/j.clnu.2020.03.022.

Bedock, D. et al. (2021) ‘Evolution of nutritional status after early nutritional management in covid-19 hospitalized patients’, Nutrients, 13(7), p. 2276. doi:10.3390/nu13072276.

Cawood, A.L. et al. (2020) ‘A Review of Nutrition Support Guidelines for Individuals with or Recovering from COVID-19 in the Community’, Nutrients, 12(11), p. 3230. doi:10.3390/nu12113230.

Di Filippo, L. et al. (2021) ‘COVID-19 is associated with clinically significant weight loss and risk of malnutrition, independent of hospitalisation: A post-hoc analysis of a prospective cohort study’, Clinical Nutrition, 40(4), pp. 2420–2426. doi:10.1016/j.clnu.2020.10.043.

Greenhalgh, T. et al. (2020) ‘Management of post-acute covid-19 in primary care’, BMJ, p. m3026. doi:10.1136/bmj.m3026.

Gundersen, C. and Ziliak, J.P. (2015) ‘Food Insecurity And Health Outcomes’, Health Affairs, 34(11), pp. 1830–1839. doi:10.1377/hlthaff.2015.0645.

Jin, Ying-Hui et al. (2020) ‘A rapid advice guideline for the diagnosis and treatment of 2019 novel coronavirus (2019-nCoV) infected pneumonia (standard version)’, Military Medical Research, 7(1), p. 4. doi:10.1186/s40779-020-0233-6.

Lawrence, V. et al. (2021) ‘A UK survey of nutritional care pathways for patients with COVID-19 prior to and post-hospital stay’, Journal of human nutrition and dietetics: the official journal of the British Dietetic Association, 34(4), pp. 660–669. doi:10.1111/jhn.12896.

Malnutrition Pathway (2020) ‘A Community Healthcare Professional Guide to the Nutritional Management of Patients During and After COVID-19 Illness’, p. 9.

Mechanick, J.I. et al. (2020) ‘Clinical Nutrition Research and the COVID‐19 Pandemic: A Scoping Review of the ASPEN COVID‐19 Nutrition Taskforce’, Journal of Parenteral and Enteral Nutrition, p. jpen.2036. doi:10.1002/jpen.2036.

Miles, A. et al. (2020) ‘Dysphagia Care Across the Continuum: A Multidisciplinary Dysphagia Research Society Taskforce Report of Service-Delivery During the COVID-19 Global Pandemic’, Dysphagia [Preprint]. doi:10.1007/s00455-020-10153-8.

Nalbandian, A. et al. (2021) ‘Post-acute COVID-19 syndrome’, Nature Medicine, 27(4), pp. 601–615. doi:10.1038/s41591-021-01283-z.

National COVID-19 Clinical Evidence Taskforce (2021) MEDBOX. Available at: https://www.medbox.org/pdf/612f6f47b1615427876e4b26 (Accessed: 16 March 2022).

NHS (2020) National guidance for post-COVID syndrome assessment clinics (6 November 2020), Patient Safety Learning – the hub. Available at: https://www.pslhub.org/learn/coronavirus-covid19/guidance/national-guidance-for-post-covid-syndrome-assessment-clinics-6-november-2020-r3465/ (Accessed: 9 January 2021).

NICE (2020) ‘COVID-19 rapid guideline: managing the long-term effects of COVID-19’, p. 35.

Shahid, A. et al. (2011) ‘Visual Analogue Scale to Evaluate Fatigue Severity (VAS-F)’, in Shahid, A. et al. (eds) STOP, THAT and One Hundred Other Sleep Scales. New York, NY: Springer New York, pp. 399–402. doi:10.1007/978-1-4419-9893-4_100.

Yang, P.-H. et al. (2019) ‘Effect of Nutritional Intervention Programs on Nutritional Status and Readmission Rate in Malnourished Older Adults with Pneumonia: A Randomized Control Trial’, International Journal of Environmental Research and Public Health, 16(23), p. 4758. doi:10.3390/ijerph16234758.

Why we created this page

In creating the knowledge hub we worked with expert panels to form a consensus on the nutritional care for people recovering from COVID-19 infection. Each section of the knowledge hub includes a consensus statement produced by the relevant expert panel.  For information on the background of the Nutrition and COVID-19 recovery knowledge hub project visit the 'about us' page.

Consensus statements from expert panels

  • It is necessary to use a comprehensive battery of tests and methods (not only routine or traditional, e.g. assess vitamin levels, microbiome, etc) to screen and assess symptoms that are linked to nutrition and diet.
  • Adapting and providing tools for self-screening, assessment, referral to non-dietitians (nurses, GPs, physiotherapists or any other allied health professional) and social care professionals (social prescribers, social workers, care home's professionals and third sector representatives) that are nevertheless trusted sources is essential.
  • There is a need to create a symptom-based, patient-led assessment, for healthcare professionals and social care staff and resources to overcome nutrition-related issues and symptoms.
  • There are some issues which should be explored from the first healthcare professional contact with patients, regardless of undertaken tests or negative COVID results:

  – appetite and interest in eating
  – actual food consumption
  – changes and or distortion of smell and taste
  – general challenges about eating and drinking
  – ask about blood tests, food allergies, bowel habits
  – current dietary and nutrition knowledge and preferences
  – specific nutrition related symptoms (e.g. gut symptoms)