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

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)
  •  
    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) (1) and hospitalisation amongst others (2). These are factors considered in a nutrition assessment, but may not be part of screening.

    There are no trials reported (yet) on nutritional assessment or screening in patients with COVID. The information here is based on what we already know in other patient groups.

    Because COVID has many and wide ranging symptoms a holistic assessment of symptoms is advised including, how the symptoms affect the individual (3), the effect on underlying conditions, and the risk of malnutrition. This can be done one week to three months after the onset of symptoms (4).

    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 (4, 5) is an alternative method to judge physical abilities or performance.
    • MUAC (mid upper arm circumference) (6) indicates over all 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.


    Biochemical

    • Haemoglobin (HB), Total Protein (TP), Albumin (ALB), Prealbumin (PA) can all be useful measures in assessing nutrition (7).


    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 (6).
    • Fatigue is a key symptom of COVID and can be assessed using the Analogue Scale of Fatigue (for 18-55 year olds) [PDF] (8).

    Dietary

    • Food intake (measured using food and fluid charts, food frequency, diet history, recalls) (4, 5),
    • Reduced desire to eat and appetite (4, 5)
    • 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) (6). These can be assessed using the Eating Assessment Tool (EAT-10). Available to view and download from the Melbourne Ent Group [PDF]
    • Check compliance with any dietary advice received (9).

    
    Economic and Social

    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 (11). National guidance for these clinics can be found on the Patient Safety Learning website.

    According to NHS, NICE and National Institute for Health 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 (5, 6, 12):

    • 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 long COVID clinic

    This can be done by primary and secondary care, community services, depending on local approach (11).

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

    There are 69 long COVID 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 particularly concerned about malnutrition or anything else diet-related, this charity offers strategies to encourage eating more and thinking about diet.

    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 this does not work, they make a referral to Lambeth and Southwark Action on Malnutrition Project (LAMP), which is a service that promotes healthy diets and treats nutrition-related problems. LAMP accept a referral from consultants, GPs and other healthcare professionals.

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    References

    (1) Gundersen C, Ziliak JP. Food Insecurity And Health Outcomes. Health Affairs. 2015 Nov 1;34(11):1830–9.

    (2) Mechanick JI, Carbone S, Dickerson RN, Hernandez BJD, Hurt RT, Irving SY, et al. Clinical Nutrition Research and the COVID-19 Pandemic: A Scoping Review of the ASPEN COVID-19 Task Force on Nutrition Research. JPEN J Parenter Enteral Nutr. 2021 Jan;45(1):13–31.

    (3) COVID-19 rapid guideline: managing the long-term effects of COVID-19. :35.

    (4) 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. 2020 Jun;39(6):1631–8.

    (5) Cawood AL, Walters ER, Smith TR, Sipaul RH, Stratton RJ. A Review of Nutrition Support Guidelines for Individuals with or Recovering from COVID-19 in the Community. Nutrients. 2020 Oct 22;12(11):3230.

    (6) Lawrence V, HIckson M, Weekes E, Julian A, Frost G, Murphy J. A UK survey of nutritional care pathways for Covid-19 patients post hospital stay. Journal of Human Nutrition and Dietetics. submitted.

    (7) Yang P-H, Lin M-C, Liu Y-Y, Lee C-L, Chang N-J. Effect of Nutritional Intervention Programs on Nutritional Status and Readmission Rate in Malnourished Older Adults with Pneumonia: A Randomized Control Trial. IJERPH. 2019 Nov 27;16(23):4758.

    (8) Shahid A, Wilkinson K, Marcu S, Shapiro CM. Visual Analogue Scale to Evaluate Fatigue Severity (VAS-F). In: Shahid A, Wilkinson K, Marcu S, Shapiro CM, editors. STOP, THAT and One Hundred Other Sleep Scales [Internet]. New York, NY: Springer New York; 2011 [cited 2021 Aug 17]. p. 399–402. Available from: http://link.springer.com/10.1007/978-1-4419-9893-4_100

    (9) A Community Healthcare Professional Guide to the Nutritional Management of Patients During and After COVID-19 Illness. :9.

    (10) Jin, Ying-Hui, Jin Y-H, Cai L, Cheng Z-S, Cheng H, Deng T, et al. A rapid advice guideline for the diagnosis and treatment of 2019 novel coronavirus (2019-nCoV) infected pneumonia (standard version). Military Med Res. 2020 Dec;7(1):4.

    (11) National guidance for post-COVID syndrome assessment clinics (6 November 2020) [Internet]. Patient Safety Learning - the hub. [cited 2021 Jan 9]. Available from: https://www.pslhub.org/learn/coronavirus-covid19/guidance/national-guidance-for-post-covid-syndrome-assessment-clinics-6-november-2020-r3465/

    (12) Aytür YK, Köseoğlu BF, Taşkıran ÖÖ, Ordu-Gökkaya NK, Delialioğlu SÜ, Tur BS, et al. Pulmonary rehabilitation principles in SARS-COV-2 infection (COVID-19): A guideline for the acute and subacute rehabilitation. :17.