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 services.
  • Because of infection control measures self-screening (and the use of remote working) is needed.  
  • Tools adapted for nutrition self-screening, self-assessment or self-referral are needed that can be used by non-dietetic professionals.
  • Health professionals should acknowledge that patients may want nutritional advice and access to nutritional care.

 

Why is nutritional care important?

There is a broad range of symptoms in all stages of COVID-19 recovery – particularly ongoing and long COVID – that are affected and affect diet and nutrition.

Many of these have to do with systems, such as gastrointestinal and metabolic, and although others are neuropsychiatric and vascular, they still have strong links with nutrition and diet.

Different cohorts of people have been affected disproportionally by COVID-19. Some still carry an ongoing burden of underlying metabolic diseases that pose a burdensome rehabilitation from life threatening conditions such as COVID-19 (1). Malnourished people with low immunity and chronic diseases have a worse prognosis and higher mortality rates.

Good nutrition not only provides the body with immunity to diseases such as COVID-19, it is the main guarantee for the promotion of the recovery (2).

COVID-19 has made patients more vulnerable to malnutrition and has highlighted many health disparities. As a high percentage of COVID-19 patients stay at home and are not admitted to hospital, it is likely many vulnerable elderly patients with compromised immunity and comorbidity will be at risk of malnutrition and go undetected by healthcare professionals without adequate screening programmes being implemented. 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).

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 dietitian referral or support from community services is needed (5).

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 (2).

Those who survive COVID-19 may present several frailty criteria after the respiratory distress and often an admission to an intensive care unit. Clinical outcomes are variable and often include associated respiratory and psychological sequelae (6). If nutritional interventions are inadequate, patients whose health is already compromised might experience worse clinical outcomes (2).

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’.

COVID-19 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
  • and reduction of life quality. 

Internationally (though mostly in European countries) 19–72% (depending on the country) of COVID deaths occurred in care homes; however, it is unclear whether survivors experienced ongoing symptoms (8).

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 (7). They have also stressed that equity is necessary to access long COVID clinics (7). 

Applying universal nutritional principles is challenging given the difference between country regulations (9). Lack of diagnosis makes accessing services difficult. Primary care, community and helpline staff need better training and knowledge about ongoing effects of COVID-19 (3).


Reporting

One year after the pandemic started, in the UK it was reported that almost one million people had been admitted into hospital and it is assumed that almost half will need continued support (8). 67% of GPs report looking after patients with long COVID (7, 10). 

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

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) (8, 10). 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.


Symptoms

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

  • depression
  • stroke
  • cardiac injury
  • chronic renal disease
  • and Type 2 Diabetes. 
It is very 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 (11). 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 (8).

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

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 (7, 10).

Screening

Screening (promotion of self-screening and screening by others e.g. healthcare professionals) is vital to identify those who are malnourished, or at at risk of malnourishment.

Clinical judgement should be informed by any relevant recent anthropometric (the scientific study of the measurements and proportions of the human body) measurements that may be available.

  • Individual risk assessment can be utilised in order to to remotely categorise people in three potential groups. A COVID-19 individual risk assessment is available to access from the University of South Wales website.

The following section provides recommendation for screening for different patient profiles:

  • Hospitalised patients should be screened for nutritional problems and may need following up in primary care, particularly those in vulnerable or high-risk groups (7).
  • People in the community from vulnerable or high risk groups should also be screened for nutritional risk – a COVID-19 individual risk assessment is available to access from the University of South Wales website.
  • People who have concerns regarding their nutrition (e.g. any patient at risk whether they are elderly, or have polymorbid conditions) may also need access to advice (12).
  • If patients are seen from post COVID-19 clinics, they 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.
  • At first healthcare professional contact and when either (7, 13, 14):
      – there is any significant change in clinical, psychological or social condition, including patients seen by a dietitian at hospital
      –  if patients are using Oral Nutritional Supplements
      – when Enteral Nutrition is indicated
      –  if symptoms persist after 12 weeks from a diagnosis of COVID-19.
     See our Assessing patients nutritional needs and setting realistic goals during COVID-19 recovery page for a list of assessment tools in use.

Assessment

Assessment to establish causes and duration of any nutritional issues. 

This section provides structured guidance on how to do a brief but effective nutritional assessment e.g. using Patients Association checklist or the Malnutrition Pathway or using local guidance and pathways.

What to assess? 

Malnutrition and obesity (metabolic syndrome risk)

How to assess? 

Recalled and subjective measurements, virtual consultations or self-screening (13).

  • Use adapted Malnutrition Universal Screening Tool (MUST) (3, 12–14) for telehealth.
  • If no BMI is available use recalled weight (13) and history of recent unintentional weight change (loss or gain).
  • Weight loss: Look for (and ask patient and/or carers) obvious wasting and obesity, ask if clothes have become looser, history of decreased food intake or dysphagia, ask about other potentially relevant symptoms (anosmia, anxiety etc.) that could have brought an unplanned impact on weight (3).
  • Patient Association Nutrition checklist (13, 14).
  • Use Bapen's self-screening calculator to identify nutritional risk using weight loss, appetite and type of treatment received for COVID-19.
  • In the unlikely event that the above are not available, use Subjective Global Assessment criteria (SGA), or the Mini Nutritional Assessment criteria (MNA) (12, 13).

Referral

Once screened, deliver an appropriate and well documented nutrition care plan (13).

The assessment for long COVID can be done by a GP in a local system or in a COVID-19 single point of access clinic. The aim is to run a distinction between existing long-term conditions (LTCs) and COVID-19 related complications. Long COVID screening can also happen when other life-threatening conditions need to be ruled out (10).

If you think patients need specialised input, we provide suggestions on how to refer to a registered dietitian on our Assessing patients nutritional needs and setting realistic goals during COVID-19 recovery page.

  • Many barriers to providing nutrition and dietetic assistance to patients have been reported by dietitians. Nonetheless, most of these were reported at the beginning of the pandemic.
  • 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.
  • However, all healthcare professionals can support the task of screening and assessment for patients experiencing the ongoing effects of COVID-19. Early interventions are essential to recognise when a dietitian referral and/or support from community services is needed (5).


The needs of overweight and obese patients

  • 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).
  • Nutritional deficiencies from abnormal 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 (11). This patient group are therefore complex in terms of dietary advice and are more likely to require a referral to dietetics services.


Patients with other medical conditions – including long COVID

Most dietitians reported issues in patients with COVID-19 that required follow up after the acute care phase (15). Moreover, 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 where not present at the start.

The main seven categories of symptoms (16) were classed as:

  • major fatigue, muscular or articular 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.

The existing nutritional assessment on our Managing symptoms linked to nutrition during COVID-19 recovery page can guide therapeutic approach for these patients.

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:

Patients in care homes

This is an NHS approved pathway for care home residents in general, to use after screening with tools provided, with the aim of considering the level of malnutrition risk of patients.

This document from the Malnutrition Pathway highlights the importance of nutritional care for care homes.

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References

(1) 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.

(2) 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.

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

(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) 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

(6) 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.

(7) 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/

(8) 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

(9) 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.

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

(11) 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.

(12) 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.

(13) 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.

(14) 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.

(15) 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

(16) 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.