Monitoring patients during their COVID-19 recovery

Information on strategies and tools to identify nutritional issues and improve patient-centred care

How do I monitor patient’s nutritional status?
HCP should discuss goals with patients. It is advisable that goals are SMART. i.e. “specific, measurable, attainable, relevant and time based.”
Some examples that patients could report are:
  • being strong enough to flush the toilet on her own
  • have the strength to open the milk carton.
For patients who have been hospitalised it is important to assess for sarcopenia, respiratory support, cognitive status and dysphagia, additional to weight loss to improve functional status and quality of life (Brugliera et al., 2021). Guidance recommends that healthcare professionals think about remote rehabilitation care from hospital and conditions at home, ask about symptoms, specific diagnostic tests, using open questions. Monitoring of pre-existing comorbid conditions in COVID-19 survivors during rehabilitation is warranted to guarantee safety of the rehabilitative interventions, and to optimize health of these patients. This may require availability of a multidisciplinary team of medical specialists (B Balbi et al., 2020). People who suffered more severely from COVID-19 (e.g. ICU patients) need regular review and monitoring (Barazzoni et al., 2020; Cawood et al., 2020; Malnutrition Pathway, 2020).
The aims for monitoring nutritional status (Barazzoni et al., 2020): 
  • Meet all nutrient requirements, particularly protein and vitamin D (for those spending a lot of time indoors).
  • Ensure a varied and balanced diet.
  • Manage symptoms through eating adjustments.
  • Use Oral Nutritional Supplements when necessary (complies with Advisory Committee on Borderline Substances criteria), consulting a dietitian or speech and language therapist where there are swallowing difficulties (Malnutrition Pathway, 2020).
Value of support and communication
  • A clear nutrition support plan should be designed to last up to two years post discharge from hospital and when patients have ongoing or post-COVID syndrome (NIHR, 2021). Nutritional screening should be used (Cawood et al., 2020) to identify those at risk of nutritional problems.
  • The Dietitians’ role is highly relevant and referral for assessment and monitoring should be made where required. The following is an example of a dietetic assessment [Word.doc], along with steps to establish a monitoring plan (which can be performed by non-dietitians). The grey boxes contain standard letter format to GP or other health professionals to support communication of assessment and plan. The Patient Association Nutrition Checklist included is adapted to virtual consultations. This format was designed by the Lambeth and Southwark Action on Malnutrition Project (LAMP) Nutrition and Dietetics Department.
  • A holistic, patient-centred approach with multi-disciplinary input is recommended (Cawood et al., 2020; NHS, 2020). If people are fatigued, due to post-COVID syndrome and having difficulty preparing meals, then a referral to occupational therapy for coping strategies may enable them. The healthcare professional leading patient care should consider individual values, needs and preferences, and setting realistic goals. Physiotherapists, occupational therapists, social workers and GPs are most likely to signpost patients to sources of advice and support (support groups, social prescribing, online apps), explaining how to get support from social care, housing and employment, and advice about financial support (NHS, 2020; NICE, 2020). Patients reporting symptoms of chronic fatigue should be fully assessed by a specialist clinician before advising graded increases in exercise/activity, as this may exacerbate symptoms.
  • It is suggested to give people a copy of their care plans, clinical records, rehabilitation plans, letters and prescriptions (NICE, 2020).
  • Interdisciplinary communication is vital. Planning care entails considering local and clinical care pathways and shared decision making to establish which healthcare professionals need to be involved (NICE, 2020); patient centred goals are preferred (Cawood et al., 2020). 
  • It is vital to ensure strong links between acute and community settings (Cawood et al., 2020) so patients are not lost to follow-up when they move from hospital (or other setting) to home. 

Strategies to ensure nutrition issues are identified and monitored

Professionals can:
  • assess the patient’s abilities and expectations (e.g. how they can address their goals and what resources they have in place to achieve them) from health services
  • involve other professionals such as social prescribers, dietetic assistants, healthcare assistants, and volunteers to support monitoring
  • signpost to support groups in the community or other community organisations
  • encourage patients to join relevant social media support groups, use apps that provide prompts and incentives to increase adherence, and actively involve their family
  • assess the patient's ability to self-monitor and encourage them to do so. Explain that keeping a record, (a user friendly) app or diary to track symptom fluctuations helps reach a decision on how to manage the symptoms.
How self-monitoring can help
Active involvement of patients is empowering and their involvement with monitoring is necessary. Self-monitoring is particularly important where infection control measures prevent face to face meetings. 
There may be situations where the patient does not wish to engage, or is unable to do so until they receive some psychological support to put coping strategies in place. Signpost to available resources and services. Watching the Psychological wellbeing and communication with healthcare professionals video with Chandanee Kotecha, our psychologist, on our Nutrition and COVID-19 Recovery talks page may help.
Self-monitoring by the patient can:
  • ensure symptoms are monitored regardless of care setting
  • ensure test results are fed back to medical records
  • ensure an approach based on the patient's specific circumstances and symptoms can be used
  • track adherence with dietary changes or other symptom management techniques.

Tools that assist in monitoring recovery
Interventions should be tailored to the individual where the dietitian will be responsible for leading on any nutritional components of the intervention. This may require for the dietitian to liaise with other members of the MDT as and when appropriate.Listed below are different tools that have been recommended to assist in monitoring recovery. Some use recalled and subjective measurements, some are suitable for virtual consultations, and some are self-assessment tools.
Older adults
  • Video call to assess frailty, metabolic risk (6 weeks post discharge if applicable) (NHS, 2020).
  • Older adults may require a family member to help them setting up video or telephone consultations to ensure appropriate assessment and treatment.
  • Unintentional weight loss is a main concern for those shielding or with other risk factors such as older age or lack of appetite (Butler et al., 2020).
  • RECENT Public Health England document Wider impacts of COVID-19 on physical activity, deconditioning and falls in older adults (PDF) (Aug 2021) makes recommendations for older adults:
  • Older adults should participate in daily physical activity to gain health benefits. Some physical activity is better than none: even light activity brings some health benefits compared to being sedentary.
  • Older adults should break up prolonged periods of being sedentary with light activity when physically possible, or at least with standing, as this has distinct health benefits for older people.
  • Older adults should maintain or improve their physical function by undertaking activities aimed at improving or maintaining muscle strength, balance and flexibility on at least 2 days a week.
  • Each week older adults should aim to accumulate at least 150 minutes (2½ hours) of moderate intensity aerobic activity, building up gradually from current levels.
  • Each recommendation is listed with relevant resources and considerations.
Suggested test and/or monitoring goals
  • Emerging or new symptoms ruling out any other conditions that could have caused complications (Eekholm et al., 2020) Mini Nutritional Assessment (Bauer and Morley, 2021).
  • A before and after study (Gobbi et al., 2021) shows 60% (29/48) of older adults admitted to rehab after a hospital stay for COVID-19 were malnourished (using GLIM) moderately (7) and severely (22). Following individually tailored nutritional support (multi-vitamin and mineral supplement, probiotic, essential amino acids, carnitine and protein and energy supplements to meet needs) and exercise programme (strength and aerobic training), no further weight loss was seen, some measures of muscle mass and function improved, and timed-up-&-go test improved (physical performance). This was a small uncontrolled trial, but it suggests high levels of nutritional risk in this patient group which may respond to nutrition support and exercise rehabilitation.
  • World Health Organisation has produced a toolkit: Living with the Times. This is a new toolkit to help older adults maintain good mental health and wellbeing during the COVID-19 pandemic. It is useful for care homes, hospitals, community services, etc. Ideally it is delivered by a facilitator and a mental health worker, but resources are available for people to read in their own time (WHO, 2021). The toolkit is based on five questions:
  1. How can I stay healthy?
  2. What can I do to improve my mood?
  3. How can I feel connected to my family and community?
  4. Where can I get help if I need it?
  5. How can I cope with grief and loss?
Those who are under hospital care or have recently been discharged from hospital 
  • Follow your local guidance to guide monitoring timescales, however patients who are severely malnourished will require more frequent monitoring. However in recent studies, nutritional interventions suggested short term benefits post ICU (Goodwin et al., 2021).
  • For more information about what to monitor and when, follow the NICE guidelines.
  • Look for allergies, lifestyle (physical activity, diet, alcohol consumption), past and present symptoms of COVID-19, treatment received for COVID-19 for instance oxygen, antibiotics or other immunomodulators (Gem COVID, 2020).
  • GI: stool and urine analysis, gastrointestinal symptoms, irritable bowel syndrome symptoms, severity score. 
  • Nutrition: anthropometric and biochemical evaluation. 
  • For patients admitted to hospital, schedule early and regular reviews to assess ongoing symptoms, starting approximately one month after discharge (Cawood et al., 2020; Lawrence et al., 2021).
  • People who were in ICU should be offered multi-disciplinary assessment at discharge and 4–6 weeks later (NHS, 2020). 
  • For post discharge consider evaluation of impairments in physical, functional, cognitive, psychosocial, and occupational aspects (Aytür et al., 2020).
Suggested tests and/or monitoring goals
  • Use validated tools to monitor progress according to NICE guidelines. See more details in our Identifying who needs nutritional care during COVID-19 recovery section.
  • Body mass index, body circumferences, bioelectric impedance analysis (simple, quick, non invasive technique to measure body fat and muscle mass).
  • Assessment should at least include measures that allow understanding of persistent physiological limitations (e.g., lung function, exercise and functional capacity, muscle function, balance) and patient-reported outcomes (e.g., symptoms and health-related quality of life) (B Balbi et al., 2020).
  • Exercise training and/or physical activity coaching in non-infectious COVID-19 patients with residual lung function impairment should be done by a health professional with previous experience in rehabilitation of patients with respiratory limitations (B Balbi et al., 2020).
  • Sarcopenia, respiratory support, impact on cognitive status and dysphagia, additional to weight loss should be monitored to improve functional status and quality of life (Brugliera et al., 2021).
Specific conditions and how these need a tailored approach 
  • People with chronic respiratory diseases (e.g. COPD).
Suggested test and/or monitoring goals
  • Monitored by dietitians to monitor quality and quantity of diet, especially energy (kcal) and vitamin D (Weekes, Emery and Elia, 2009).
  • Monitoring of pre-existing comorbid conditions in COVID-19 survivors during rehabilitation is warranted to guarantee safety of the rehabilitative interventions, and to optimize health of these patients. This may require availability of a multidisciplinary team of medical specialists (B Balbi et al., 2020).
  • People with diabetes.
Suggested test and/or monitoring goals
  • A lower caloric intake but higher protein may be beneficial (Ochoa et al., 2020).
  • People being tube fed at home.
Suggested test and/or monitoring goals
  • Should be monitored by a dietitian and difficulties with swallowing pathology should be monitored by a Speech and Language Therapist and dietitians and if necessary, specific diagnostic tests (NHS, 2020).
  • For more information on diagnostic tests please see our Identifying who needs nutritional care during COVID-19 recovery
Everybody
  • Use MUST with modifications for remote consultations and ask also about gastrointestinal symptoms. If malnutrition is evident, use this advice (Barazzoni et al., 2020). ABCDE (anthropometric, biochemical, clinical, dietary, environmental) – more information can be found on the Bapen website. It is also important to analyse energy and protein and micronutrient intake to provide nutritional recommendations to support the functional recovery of post acute COVID-19 (Gem COVID, 2020).
Suggested test and/or monitoring goals
  • Prediction equations or weight-based formulae or indirect calorimetry if necessary.

What sort of goals are useful to agree and prioritise?
Goals should be based on what matters to the person and what they see as their priorities. It is nonetheless important to prevent muscle mass loss and provide support for patient to improve stamina, resume normal hobbies, achieve functional independence and reach a desirable weight (Malnutrition Pathway, 2020). This should be combined with gradual increase of physical activity. Discussion with a physiotherapist and/or GP should occur to ensure a suitable approach for patients.
It is recommended that general monitoring plans last to up to 2 years. For nutritional care, please refer to local guidance or service level agreements.
Following dietitian assessment, if the patient is undernourished or has a poor quality diet, it is important to determine if supplements of A, C, D, E, B6 and B12, Zinc and Selenium and high fibre should be included in the diet (Chen et al., 2020). A dietitian can also explain the importance of a varied and nutritionally adequate diet and discuss frequency to assess vitamin levels how to monitor this.
For a prolonged home stay due to quarantine (for those at risk or who have COVID-19), maintenance of indoor physical activity is crucial. See below useful links for physical activity and exercise.

Patient accessible digital resources to support COVID-19 recovery
Patients who are able to self-manage and access digital services can use the following freely available resources. We also include resources that are not specifically related to nutrition but to other symptoms or post COVID syndrome and may affect nutrition and/or may be worsen or improved through diet.
Dietary advice
  • The Eatwell Guide is an NHS sponsored website to learn tips, recommendations and recipes for a healthy diet.
  • The Nutrition and diet resources website is a Scottish charity and contains various resources for swallowing difficulties and gastrointestinal issues at a cost.
  • The British Lung Foundation provides advice on how to eat and drink more easily.
  • The NHS Your COVID Recovery website provides advice on symptoms of post-COVID syndrome, such as eating well, taste and smell changes, swallowing, etc.
  • Support your recovery from Lancashire Teaching Hospitals NHS Foundation Trust. Their COVID-19: Supporting your recovery website provides an online course developed for patients that contains general advice for COVID recovery and post-COVID syndrome, as well as a section on eating well with infographics, images and tips for various dietary concerns. This webpage also contains videos with different exercises to keep patients mobile.
General for post-COVID syndrome LongCovidSOS includes a list of post COVID clinics as well as a list of online support resources in different languages that some UK or international organisations have provided, mainly about respiratory health and rehabilitation but with useful links to support groups across the world.
Physiotherapy
Post critical care recovery
Mental health
Fatigue
Loss of smell

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.

B Balbi et al. (2020) ‘Report of an ad-hoc international task force to develop an expert-based opinion on early and short-term rehabilitative interventions (after the acute hospital setting) in COVID-19 survivors (version April 3, 2020).’ doi: https://ers.app.box.com/s/npzkvigtl4w3pb0vbsth4y0fxe7ae9z9 [accessed 25.05. 20].

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.

Bauer, J.M. and Morley, J.E. (2021) ‘Editorial: COVID-19 in older persons: the role of nutrition’, Current Opinion in Clinical Nutrition and Metabolic Care, 24(1), pp. 1–3. doi:10.1097/MCO.0000000000000717.

Brugliera, L. et al. (2021) ‘Response to: Nutritional strategies for the rehabilitation of COVID-19 patients’, European Journal of Clinical Nutrition, 75(4), pp. 731–732. doi:10.1038/s41430-020-00801-5.

Butler, T. et al. (2020) Joint BACPR/BDA/PHNSG statement on nutrition and cardiovascular health post-COVID-19 pandemic. Available at: https://bjcardio.co.uk/2020/09/joint-bacpr-bda-phnsg-statement-on-nutrition-and-cardiovascular-health-post-covid-19-pandemic/ (Accessed: 22 October 2021).

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.

Chen, Q. et al. (2020) ‘Recommendations for the prevention and treatment of the novel coronavirus pneumonia in the elderly in China’, AGING MEDICINE, 3(2), pp. 66–73. doi:10.1002/agm2.12113.

Eekholm, S. et al. (2020) ‘Gaps between current clinical practice and evidence-based guidelines for treatment and care of older patients with Community Acquired Pneumonia: a descriptive cross-sectional study’, BMC Infectious Diseases, 20(1), p. 73. doi:10.1186/s12879-019-4742-4.

Gem COVID (2020) ‘Post-COVID-19 global health strategies: the need for an interdisciplinary approach’, Aging Clinical and Experimental Research, pp. 1–8. doi:10.1007/s40520-020-01616-x.

Gobbi, M. et al. (2021) ‘Nutritional status in post SARS-Cov2 rehabilitation patients’, Clinical Nutrition [Preprint], ((Gobbi, Brunani, Arreghini, Baccalaro, Dellepiane, Lucchetti, Barbaglia, Cova, Fornara, Galli, Capodaglio) Istituto Auxologico Italiano, IRCCS, Ospedale San Giuseppe, Piancavallo, Verbania, Italy). doi:10.1016/j.clnu.2021.04.013.

Goodwin, V.A. et al. (2021) ‘Rehabilitation to enable recovery from COVID-19: a rapid systematic review’, Physiotherapy (United Kingdom), 111((Goodwin, Allan, Bethel, Day, Hall, Howard, Morley, Thompson Coon, Lamb) University of Exeter, United Kingdom), pp. 4–22. doi:10.1016/j.physio.2021.01.007.

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.

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.

NIHR, E. (2021) Living with Covid19 - webinars - Informative and accessible health and- care research. Available at: https://evidence.nihr.ac.uk/themedreview/living-with-covid19-webinars/?source=chainmail (Accessed: 26 April 2021).

Ochoa, J.B. et al. (2020) ‘Lessons Learned in Nutrition Therapy in Patients With Severe COVID‐19’, Journal of Parenteral and Enteral Nutrition, p. jpen.2005. doi:10.1002/jpen.2005.

Weekes, C.E., Emery, P.W. and Elia, M. (2009) ‘Dietary counselling and food fortification in stable COPD: a randomised trial’, Thorax, 64(4), pp. 326–331. doi:10.1136/thx.2008.097352.

WHO (2021) Living with the Times: new toolkit helps older adults maintain good mental health and wellbeing during the COVID-19 pandemic. Available at: https://www.who.int/news/item/01-04-2021-living-with-the-times-new-toolkit-helps-older-adults-maintain-good-mental-health-and-wellbeing-during-the-covid-19-pandemic (Accessed: 16 March 2022).

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

  • To improve patient-centred care and follow up, self-monitoring tools should be accessible for patients to use at home.
  • Professionals should use a range of strategies (pointed below) to ensure nutritional issues that concern patients are identified and followed up.