Identifying who needs nutritional care during COVID-19 recovery

Information on nutritional care and how to identify those in need of support

Consensus statements from expert panels

  • Nutrition is important for all stages of COVID-19 recovery.
  • Equity in access to post COVID-19 care is needed and should be promoted and communicated widely across health, social care and wellbeing services.
  • Because of infection control measures, self-screening (and the use of remote working) is needed.  
  • Tools adapted for nutritional self-screening, self-assessment or self-referral are needed so that they can be utilised by non-dietetic professionals.
  • Health, social care and wellbeing services professionals should acknowledge that patients may want nutritional advice and access to nutritional care.

 

Why is nutritional care important?

There are many symptoms of COVID-19 infection that are affected by, and affect, diet and nutrition. These symptoms can persist and evolve during the course of illness and recovery. COVID-19 has complex, multi-organ (or multi-system) effects that interact in various ways and that are strongly linked with nutrition and diet.

Different cohorts of people have been affected disproportionally by COVID-19 highlighting many health disparities. Those with underlying metabolic diseases will have a more burdensome rehabilitation from serious infections such as COVID-19, with considerable morbidity as well as mortality (1). Malnourished people with low immunity and chronic diseases have a worse prognosis and higher mortality rates (2).

Good nutrition not only supports immunity to diseases such as COVID-19, it is also an essential factor for the promotion of recovery (3).

Older adults and those with other chronic conditions are more at risk of malnutrition (3) and it is widely acknowledged that malnutrition is both a cause and a consequence of immune dysfunction (4).

Older adults are complex in the sense that chronic diseases are related to frailty and this leads to reduced functional reserves and reduce resistance to stress. Thus, there is often involuntary weight loss, malnutrition and acute hospitalisation (3). As a result of COVID-19, people may develop frailty syndromes due to respiratory distress and thus, may result in admission to an intensive care unit. Clinical outcomes are variable and often include associated respiratory and psychological sequelae (5).

Nutrition screening and assessment is essential to identify people experiencing low appetite, food insecurity or other nutrition risk factors. This will facilitate early intervention by helping healthcare professionals recognise when a referral to a dietitian, or support from community services is needed (6). Without adequate screening programmes in place many vulnerable or older patients, with compromised immunity and comorbidities, may go undetected as at risk of malnutrition.

If nutritional interventions are inadequate, patients whose health is already compromised might experience worse clinical outcomes (3).

Guidelines state that support for COVID-19 recovery should be available regardless of whether a positive COVID-19 test was obtained, since neither PCR testing nor antibody tests adequately captured all disease (5, 7).

Who to include for nutritional care and how to identify them?

How to identify risk of malnutrition

Risk of malnutrition can be identified using a screening tool. Screening is vital to identify those who are malnourished, or at risk of malnourishment. Self-screening has advantages due to infection control measures and the number of people with COVID-19, and should be encouraged. Nutrition screening can be carried out by any healthcare professionals.  

For self screening tools to ask your patients to use, see our Is what I eat affecting my recovery? page.

There are many screening tools available and your own organisation is likely to recommend a screening tool to use. Examples include:

Screening tools are a guide and your own clinical judgement should be used, informed by any relevant, recent measurements of the individual’s body.

The following questions were suggested by a panel of multidisciplinary experts with the aim of flagging potential nutrition and/or dietary issues that can point an appropriate direction when screening:

  • Food accessibility. Assessment of living situation. Do patients have appropriate support for their nutritional care? 
  • Is the patient currently using nutritional supplements or other specific dietary-related products?

Recommendations for the screening of different patient groups:

  • Hospitalised patients should be screened for nutritional problems and may need following up in primary care, particularly those in vulnerable or high-risk groups (8).
  • People in the community from vulnerable or high risk groups should be screened for nutritional risk: One suitable tool is a COVID-19 individual risk assessment available from the University of South Wales website.
  • People who have concerns regarding their nutrition may also need access to advice (9).
  • Those with frailty: malnutrition often occurs alongside frailty. Frailty can be assessed using the clinical frailty scale from the NHS Specialised Clinical Frailty Network.
  • Patients in post COVID-19 clinics will need screening when either the patient or healthcare professional is concerned. See our Managing patients symptoms linked to nutrition during COVID-19 recovery page for our symptom toolkit.
  • Patients should also be screened at first healthcare professional contact when (8, 10, 11):
      – there is any significant change in clinical, psychological or social condition
      – patients are using oral nutritional supplements
      – enteral nutrition is indicated
      – symptoms persist after 12 weeks from a diagnosis of COVID-19 (i.e. long COVID).

Once you have identified someone as at risk of malnutrition you should plan an appropriate and well documented nutrition care plan, including referral for specialist dietetic input (10). Go to our Assessing patients nutritional needs and setting realistic goals during COVID-19 recovery page for advice on how to do this.

Since telehealth has been established and become widely used, dietitians have been able to treat at risk patients within hospital, primary care and community settings.

For patients who require referral make sure you distinguish between existing long-term conditions and COVID-19 related complications. (12)

All healthcare professionals can support the task of screening. Early interventions are essential to improve outcomes and this includes recognising when referral to a dietitian and/or support from community services is needed.

Overweight and obese patients

Overweight and obese patients

  • People who are overweight and obese appear to be disproportionally affected by COVID-19.
  • Hospitalisation for COVID-19 has been found to be associated with adiposity-based, dysglycemia-based and cardiometabolic-based chronic diseases (e.g., hypertension, type 2 diabetes and obesity).
  • This patient group is therefore complex in terms of dietary advice and is more likely to require a referral to dietetics services (13).
  • Nutritional deficiencies from sub-optimal eating patterns lead to decreased immune function and therefore to impaired resistance to infection. These pre-existing comorbidities increase the risk of nutrition and refeeding syndrome.
  • From those suffering from ongoing and long COVID-19, there is an inflammatory process that exacerbates catabolism and anorexia, aggravating malnutrition, impeding recovery and leading to disability and reduced quality of life (14).

Patients in care homes

Internationally 19–72% (depending on the country) of COVID deaths occurred in care homes; however, it is unclear whether survivors experienced ongoing symptoms (15). There is likely to be many patients in this setting who require screening and nutrition support.

An NHS framework [PDF] supported by the Older People Specialist Group in the BDA (OPSG) and the Care Provider Alliance can be used to enhance care in care homes.

Nutrition and hydration are core care elements that each individual care setting has to deliver on. Meeting this care need should also address their nutrition needs related to COVID-19.

Dietitians are key multidisciplinary team members (MDT) that should be co-opted into the MDT meetings when needed. See the Enhanced Health in Care Homes: A guide for care homes webpage for more information.

This is an example of a whole care home approach [PDF].

Long COVID

Long COVID is also called post-COVID syndrome, chronic COVID or post-acute COVID. Patient groups may refer to themselves as ‘long haulers’.

Long COVID seems to be similar to Myalgic Encephalomyelitis (also called Chronic Fatigue) and resembles chronic fatigue syndrome. Chronic inflammation can exacerbate catabolism and anorexia, diabetes, heart disease and renal failure (14). Nutritional care is therefore crucial.

Patients have reported receiving inconsistent advice from healthcare professionals and the absence of information about fluctuating symptoms. This has resulted in patients supporting each other through media channels because this lack of recognition of symptoms and their fluctuation has isolated more people (15).

Lack of diagnosis makes accessing services difficult. Primary care, community and helpline staff need better training and knowledge about ongoing effects of COVID-19 (2).

Epidemiology and public health specialists have reinforced the need to collect comprehensive symptom data, as neither PCR testing nor antibody tests adequately captured all disease. They have also stressed that equity is necessary to access long COVID clinics (8).


Symptoms

A UK review (16) identified the 10 most common symptoms of long COVID:

  • fatigue
  • shortness of breath
  • muscle pain
  • cough
  • headache
  • joint pain
  • chest pain
  • altered sense of smell
  • diarrhoea
  • altered sense of taste.


People experiencing five or more symptoms in the first stages of the disease are more prone to suffer from long COVID (17).

More information can be found on the University of Birmingham's therapies for Long COVID page.

On-going (4-12 weeks post infection) and long COVID-19 symptoms appear to be common. Data reported in Italy found that that almost 90% of patients reported at least one symptom 60 days after onset and half of them had three symptoms including:

  • fatigue
  • breathing difficulty
  • joint pain and chest pain
  • reduction of life quality.


Another study found seven main categories of symptoms (18):

  • major fatigue, muscular or joint pains
  • neurological symptoms such as memory, mood or attention disorders
  • headaches, sensory disturbances, balance disorders, neurogenic pains
  • persistent or recurrent anosmia, hyposmia, dysgeusia, swallowing and speech disorders
  • cardiothoracic symptoms such as palpitations, chest pain
  • gastrointestinal symptoms such as diarrhoea, nausea, vomiting or abdominal pain
  • skin and vascular symptoms (related to blood and fluids in the body).


In a French cohort, scientists found that during the prolonged phase of COVID-19 more than half of patients had symptoms persisting from the onset of infection, and in 80% of the sample new symptoms arose that were not present at the start.

Dietitians have reported issues in patients with COVID-19 that required follow up after the acute care phase (19).


Prevalence

One year after the pandemic started in the UK, it was reported that almost one million people had been admitted to hospital and it is estimated that almost half will need continued support (15). 67% of GPs report looking after patients with long COVID (8, 12).

Data from Public Health England has found that at least 10% of non-hospitalised patients have reported symptoms lasting more than four weeks (20) Fluctuations in symptoms have been reported by 70% of patients and changes in the intensity of them were reported 89% of the time. (21)

The UK COVID symptom app has four million regular contributors and 10-20% report complications for longer than a month (100,000–200,000 people) (12, 15).

Dr Sarah Berry, Reader in Nutritional Sciences, Department of Nutritional Sciences, King’s College London and Elaine Anderson, Registered Dietitian (Freelance and NHS) discuss data extracted from the COVID symptom app. Watch the 'Diet and COVID' video on our Nutrition and COVID-19 Recovery page.


Co-morbidities

Long COVID can lead to an increase in chronic medical conditions such as:

  • depression
  • stroke
  • cardiac injury
  • chronic renal disease
  • Type 2 Diabetes.


More information and research are being documented from a cross disciplinary cohort of health professionals who had COVID-19 themselves. It includes a long list of symptoms and how long COVID is affecting patients:

Was this information helpful?

As a health and social care professional, did this page help you find out everything you wanted to know about this topic?

References

(1) Zabetakis I, Lordan R, Norton C, Tsoupras A. COVID-19: The Inflammation Link and the Role of Nutrition in Potential Mitigation. Nutrients. 2020 May 19;12(5):1466.

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

(3) Ferrara F, De Rosa F, Vitiello A. The Central Role of Clinical Nutrition in COVID-19 Patients During and After Hospitalization in Intensive Care Unit. SN Compr Clin Med. 2020 Aug;2(8):1064–8.

(4) Gem COVID. Post-COVID-19 global health strategies: the need for an interdisciplinary approach. Aging Clin Exp Res. 2020 Jun 11;1–8.

(5) Brika M, Bossu M, Fautrelle L, Mourey F, Kubicki A. Geriatric Rehabilitation and COVID-19: a Case Report. SN Compr Clin Med. 2020 Dec 1;2(12):2890–8.

(6) Donnelly R, Keller H. Challenges Providing Nutrition Care During the COVID-19 Pandemic: Canadian Dietitian Perspectives. J Nutr Health Aging [Internet]. 2021 Jan 9 [cited 2021 Mar 4]; Available from: http://link.springer.com/10.1007/s12603-020-1585-z

(7) Ochoa JB, Cárdenas D, Goiburu ME, Bermúdez C, Carrasco F, Correia MITD. Lessons Learned in Nutrition Therapy in Patients With Severe COVID‐19. J Parenter Enter Nutr. 2020 Sep 24;jpen.2005.

(8) 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/

(9) 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. Clin Nutr. 2020 Jun;39(6):1631–8.

(10) 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.

(11) 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. J Hum Nutr Diet. submitted.

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

(13) Burridge J, Bradfield J, Jaffee A, Broadley I, Ray S. Metabolic health and COVID-19: a call for greater medical nutrition education. Lancet Diabetes Endocrinol. 2020 Aug;8(8):665–6.

(14) 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

(15) NIHR Evidence - Living with Covid19 - webinars - Informative and accessible health and care research [Internet]. [cited 2021 Apr 26]. Available from: https://evidence.nihr.ac.uk/themedreview/living-with-covid19-webinars/?source=chainmail

(16) Ansu V, Papoutsakis C, Gletsu-Miller N, Spence LA, Kelley K, Woodcock L, et al. Nutrition care practice patterns for patients with COVID-19—A preliminary report. J Parenter Enter Nutr [Internet]. [cited 2021 May 26];n/a(n/a). Available from: https://aspenjournals.onlinelibrary.wiley.com/doi/abs/10.1002/jpen.2106

(17) Sudre CH, Murray B, Varsavsky T, Graham MS, Penfold RS, Bowyer RC, et al. Attributes and predictors of Long-COVID: analysis of COVID cases and their symptoms collected by the Covid Symptoms Study App [Internet]. 2020 Oct [cited 2021 Aug 17] p. 2020.10.19.20214494. Available from: https://www.medrxiv.org/content/10.1101/2020.10.19.20214494v1

(18) Davis HE, Assaf GS, McCorkell L, Wei H, Low RJ, Re’em Y, et al. Characterizing Long COVID in an International Cohort: 7 Months of Symptoms and Their Impact. medRxiv. 2021 Apr 5;2020.12.24.20248802

(19) Aiyegbusi OL, Hughes SE, Turner G, Rivera SC, McMullan C, Chandan JS, et al. Symptoms, complications and management of long COVID: a review. J R Soc Med. 2021 Jul 15;01410768211032850.

(20) NIHR Evidence - Living with Covid19 - webinars - Informative and accessible health and care research [Internet]. [cited 2021 Apr 26]. Available from: https://evidence.nihr.ac.uk/themedreview/living-with-covid19-webinars/

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