key: cord-318324-cc6rn95z authors: Handu, Deepa; Moloney, Lisa; Rozga, Mary; Cheng, Feon title: Malnutrition Care during the COVID-19 Pandemic: Considerations for Registered Dietitian Nutritionists Evidence Analysis Center date: 2020-05-14 journal: J Acad Nutr Diet DOI: 10.1016/j.jand.2020.05.012 sha: doc_id: 318324 cord_uid: cc6rn95z Abstract Recent evidence examining adults infected with COVID-19 has indicated a significant impact of malnutrition on health outcomes. Individuals who have multiple comorbidities, are older adults, or who are malnourished are at increased risk of being admitted to the intensive care unit and of mortality from COVID-19 infections. Hence, nutrition care to identify and address malnutrition is critical in treating and preventing further adverse health outcomes from COVID-19 infection. This document provides guidance and practice considerations for Registered Dietitian Nutritionists (RDNs) providing nutrition care for adults with suspected or confirmed COVID-19 infection in the hospital, outpatient, or homecare settings. In addition, this document discusses and provides considerations for RDNs working with individuals at risk of malnutrition secondary to food insecurity during the COVID-19 pandemic. Medical Nutrition Therapy (MNT) plays an important role in the prevention and treatment of 15 malnutrition. There is significant evidence to demonstrate that protein-energy malnutrition from 16 inadequate dietary intake can increase risk of infectious diseases. 1 Reciprocally, any exposure, 17 including infectious disease, that impairs immune function and causes malabsorption, increased 18 catabolism, or decreased nutrient intake can increase risk of malnutrition. Exploratory studies 19 indicate that patients infected with Coronavirus disease of 2019 (COVID-19) experience some 20 or any of the following symptoms: fever, cough, shortness of breath, muscle ache, confusion, 21 headache, sore throat, chest pain, pneumonia, diarrhea, nausea and vomiting, and loss of taste and smell, all of which may influence nutrition status, and, ultimately immune function. 2,3 The 23 term malnutrition is most simply defined as imbalanced intake of protein and/or energy over 24 prolonged periods of time and can occur in bot underweight and overweight. 4 The current 25 document provides guidance that primarily focused on protein-energy malnutrition, which can 26 result from inadequate intake, increased requirements, impaired absorption, and/or altered 27 nutrient utilization. 5 The purpose of this document is to provide general guidance and practice considerations for Adults experiencing increased food insecurity secondary to the COVID-19 pandemic. 38 While there are currently no nutrition guidelines specifically for adults with or at risk for 39 COVID-19 infection, many existing guidelines on the Evidence Analysis Library and from other 40 organizations are still applicable and can be used to provide guidance when working with adults 41 with COVID-19 infection. 6 However, some adjustments may be required to meet the increased 42 metabolic and functional needs caused by the COVID-19 infection and treatments. The It has been well-established that malnutrition is associated with poor health outcomes. 7 In the 51 context of an infection, such as COVID-19, an individual with malnutrition may have sub-52 optimal immunity, contributing to a longer or more difficult recovery. Nutrition screening aims 53 to identify patients who are at risk for malnutrition and provide a referral for RDN to deliver 54 detailed nutrition care based on the nutrition care process, 8 including assessment, diagnosis and 55 intervention by an RDN, in order to treat and prevent further malnutrition and consequent 56 adverse health outcomes. A recent systematic review and corresponding position paper published by the Academy states, 63 "based upon current evidence, the Malnutrition Screening Tool should be used to screen adults 64 for malnutrition (undernutrition) regardless of their age, medical history, or setting." 9 The MST appears to still be applicable for adults with COVID-19, as it is a quick and easy-to-66 use validated tool based on two questions addressing decreased intake due to poor appetite and 67 recent unintentional weight loss. 10 Due to limited resources and staff during the COVID-19 68 pandemic, some nutrition screening procedures may require flexibility to better meet safety 69 needs and operational needs of an organization. For example, while nurses or other team 70 members may have conducted nutrition screening prior to the COVID-19 pandemic, during the 71 pandemic, these professionals may be needed for emergency patient care and may not be able to 72 perform malnutrition screening. In these cases, the nutrition team could carry out the screening 73 process so that patients who are at risk for malnutrition can receive appropriate nutrition 74 assessment and intervention without delay. Also, special coordination, such as conducting 75 nutrition screening using patient room telephones, can be considered to minimize staff exposure. RDNs may also utilize nursing and physician notes to provide evidence of wasting as the disease 97 progresses. A comprehensive assessment should result in the RDN determining the nutrition diagnosis. Examples of potential nutrition diagnoses applicable to adults infected with COVID-19 may 100 include malnutrition, increased nutrient needs, predicted inadequate energy intake, altered 101 gastrointestinal function, or inadequate energy intake. Additionally, nutrition assessment can 102 assist in identifying the key etiology of the diagnosis, which will help the RDN determine the 103 best intervention for each patient. For example, an RDN might identify a patient's inability to 104 reach protein and energy needs orally resulting in the need for supplemental oral or enteral 105 nutrition (EN). When EN is not feasible or appropriate, PN may be necessary to treat or prevent malnutrition. 143 PN will require management by a multi-disciplinary care team due to high risk for line sepsis and 144 metabolic complications, such as refeeding syndrome and hyperglycemia. EN should initially be provided via a nasogastric (NG) tube or orogastric (OG) tube, since 148 placement of feeding tubes in the small bowel could delay initiation of feeding and could 149 increase risk of spreading infection due to the need for skilled staff and confirmation of feeding 150 tube placement. 13, 14 The height of the bed should ideally be elevated 30 to 45 degrees, 15 and the 151 nasogastric tube size should be a 10-12 french, preferably 12 french to facilitate bolus feeding if necessary. 14,16 Enteral feeding for patients in prone position is not contraindicated. However, if 153 possible, the height of the bed should be elevated 10-25 degrees. 14 154 If feeding pumps are available, continuous feeding via a feeding pump is recommended. 14,17 If 155 feeding pumps are not available, the next alternative is a gravity feed. If a gravity feed is not 156 possible, bolus feedings should be provided. 14 Bolus feeds should not be provided to patients Indirect calorimetry is typically recommended as best practice for estimating energy expenditure. In patients with NIV, feeding tube placement may be contraindicated due to potential issues such 210 as air leakage, distention of the stomach, or if the patient is in the prone position. 12 Stomach 211 distention can lead to poor feeding tolerance and impaired diaphragmatic function. If NG/OG 212 placement is appropriate, feeding pumps should be prioritized to patients on NIV so they can be 213 fed continuously. If a feeding pump is not available, a gravity drip should be considered. Bolus 214 feeds should not be used in patients with NIV due to increased risk for aspiration. 12 • Ensure adequate intake of energy and protein by, at minimum, meeting 100% of the 276 recommended dietary allowance for energy and protein based on age and gender. These 277 requirements will likely be increased due to the pathology of COVID-19 infection. • High-calorie, high-protein meals and snacks can help prevent weight loss and maintain 279 lean muscle mass. For example, RDNs can advise eating vegetables with cream, butter, 280 margarine, cheese sauce, olive oil, or salad dressing to increase energy intake and choose 281 foods high in protein, such as milk, eggs, cheese, meats, fish, poultry, nuts, and beans. 24 • Nutrient-dense foods and beverages including oral nutritional supplements are good 283 methods to increase calorie and protein intake if oral dietary intake is not adequate to 284 meet needs (e.g., protein powders and meal replacement shakes and bars). 24 • For individuals having difficulty coordinating chewing and breathing, beverages might be 286 a better option to efficiently increase energy intake compared to solid foods. • Focus on providing foods that require little handling, preparation, or effort to eat. • Ensure adequate intake of fluids to stay hydrated throughout the day and evening. If the 293 patient is suffering from vomiting and diarrhea, advise consumption of rehydration 294 drinks. Additional guidance on managing malnutrition through adequate intake of calories, protein, and 296 hydration can be found in the Academy's Nutrition Care Manual, Evidence Analysis Library, 297 and Malnutrition Quality Improvement Toolkit. 6, 25, 27 Besides nutrition management, RDNs The Academy has recent guidelines containing recommendations on malnutrition management in 319 chronic kidney disease, cystic fibrosis, and chronic obstructive pulmonary disease (COPD). 6, 30, 31 These guidelines are still relevant to patients with COVID-19 and these conditions; however, 321 implementation of these recommendations should include consideration of COVID-19 322 pathology, PPE standards set by Centers of Diseases Control, 29 and institutional guidelines. • The Academy's "Action Center" provides templates for letters to representatives or 419 senators to communicate support or opposition for bills that impact public health. RDNs 420 can "Take Action" by visiting this resource and sending a letter of support to their 421 respective lawmakers to help Americans keep food on the table during the COVID-19 422 pandemic and to urge congress to prioritize federal food assistance program funding. 54 • Monitor the Academy's Action Center to increase awareness and advocacy for food 424 assistance programs as opportunities arise. 54 • "Take Action" and monitor opportunities to support food assistance at the Food Research The COVID-19 pandemic has created an unprecedented need for RDNs to assess and address 430 food insecurity among clients and their families through innovative and conscientious nutrition 431 counseling, referral to and participation in food assistance programs, and through taking action to 432 advocate for greater access to food assistance on state and federal levels. In order to inform evidence-based nutrition and dietetics practice for individuals infected with 436 COVID-19, the Academy is seeking to gather data from RDNs who are currently working with 437 patients infected with COVID-19 or whose work has been impacted by the pandemic. In order to 438 inform evidence-based practice, the Academy is seeking to collect patient-level data as well as 439 data at a systems-or process-level using surveillance surveys. The Academy is requesting RDNs 440 register in ANDHII (www.ANDHII.org), which is the Academy's, free, de-identified system for 441 collecting patient-level data, in order to document nutrition care of patients infected with 442 COVID-19. For the patient-level data, the Academy does not specify what, when or how much 443 data RDNs enters into the ANDHII system, but requests practitioners enter data as they have the 444 time and capacity to do so. Collection of this type of patient level data is needed in order 445 elucidate effective interventions to support RDNs in their day-to-day efforts with COVID-19 446 patients and for future pandemics. The relationship between nutrition and infectious diseases: A review Epidemiological and clinical 474 characteristics of 99 cases of 2019 novel coronavirus pneumonia in Wuhan, China: a descriptive 475 study. The Lancet Clinical features of patietns infected with 2019 novel 477 coronavirus in Wuhan Malnutrition Quality Improvement Initiative. Malnutrition Quality Improvement Initiative 479 Consensus Statement of the Academy of 481 Nutrition and Dietetics/American Society for Parenteral and Enteral Nutrition: Characteristics 482 Recommended for the Identification and Documentation of Adult Malnutrition (Undernutrition) Academy of Nutrition and Dietetics Nutrition Care Process and Model update: Toward 489 realizing people-centered care and outcomes management Position of the Academy of Nutrition and Dietetics Malnutrition (Undernutrition) Screening Tools for All Adults Development of a valid and reliable malnutrition 495 screening tool for adult acute hospital patients A 497 rapid advice guideline for the diagnosis and treatment of 2019 novel coronavirus (2019-nCoV) 498 infected pneumonia (standard version) Route of Nutrition Support in Patients Requiring NIV & CPAP During the COVID-19 ESPEN expert statements and practical guidance for 503 nutritional management of individuals with SARS-CoV-2 infection American Society for Parenteral and Enteral Nutrition. Nutrition Therapy in the Patient with 505 COVID-19 Disease Requiring ICU Care Critical Illness Evidence-based Nutrition Practice 509 Guideline. Evidence Analysis Library BDA Critical Care Specialist Group COVID-19 Best Practice 511 Guidance: Bolus Enteral Feeding Guidelines for the Provision and Assessment of 515 Nutrition Support Therapy in the Adult Critically Ill Patient: Society of Critical Care Medicine 516 (SCCM) and American Society for Parenteral and Enteral Nutrition Surviving Sepsis Campaign: Guidelines on the 519 Management of Critically Ill Adults with Coronavirus Disease 2019 (COVID-19) Kidney disease is associated with in-hospital death of patients 522 with COVID-19 Nutrition Management for 524 Critically and Acutely Unwell Hospitalised Patients with COVID-19 in Australia and New Zealand Refeeding syndrome: what it is, and how to prevent and 529 treat it Predictors of 531 aspiration pneumonia: how important is dysphagia? Academy of Nutrition and Dietetics. Adult Nutrition Care Manual. Client resources for 539 Pulmonary. Pulmonary Nutrition Therapy. 540 27. Academy of Nutrition and Dietetics. Adult Nutrition Care Manual. Malnutrition. In. 541 28. World Health Organization. Home care for patients with COVID-19 presenting with mild 542 symptoms and management of their contacts. Interim Guidance. 2020. 543 29. Center of Disease Control and Prevention. What to Do If You Are Sick. In:2019. 544 30. Academy of Nutrition and Dietetics, Evidence Analysis Library. Chronic Obstructive Pulmonary 545 Disease. 546 31. Academy of Nutrition and Dietetics, Evidence Analysis Library Office of Disease Prevention and Health Promotion Food 554 Insecurity and Pediatric Malnutrition Related to Under-and Over-Weight in the United States: 555 An Evidence Analysis Center Systematic Review Food Insecurity And Health Outcomes Effects of COVID-19 Pandemic on Employment and 559 Unemployment Statistics Development and validity of a 2-item screen to identify 565 families at risk for food insecurity United States Department of Agriculture ERS The Hunger Vital Sign Identifies 570 Household Food Insecurity among Children in Emergency Departments and Primary Care. 571 Children (Basel) United States Department of Agriculture Start Simple with MyPlate: Food Planning During the 575 Feeding America. Stocking a Healthy Pantry & Fridge. COVID-19 Feeding America. Tips for Stocking and Eating Fruits and Vegetables. COVID-19 NUTRITION 2020 584 45. Academy of Nutrition and Dietetics. Providing Nutrition Services via Telehealth During the 585 COVID-19 Pandemic: What RDNs Need to Know Academy of Nutrition and Dietetics Nutrition Entrepreneurs Academy of Nutrition and Dietetics Nutrition Entrepreneurs. Tackling Telehealth and Licensure 594 Limitations United States Department of Agriculture. USDA Nutrition Assistance Programs. National 599 Agricultural Library United States Department of Agriculture, Food and Nutrition Services. FNS Response to COVID-602 19 United States Department of Agriculture, Food and Nutrition Services. Find Meals for Kids When 604 Schools are Closed United States Department of Agriculture Food and Nutrition Service. COVID-19 Congregate Meal 606 Academy of Nutrition and Dietetics Alliance to end hunger. COVID-19 Resources and Needs Maximizing WIC's Role in Supporting Health, Food Security, 615 and Safety During the COVID-19 Pandemic: Opportunities for Action 617 security-and-safety-during-the-covid-19-pandemic-opportunities-for-action The Registered Dietitian Nutritionist's (RDNs) assessment of critically ill adults should include, but not be limited to the following: • History of nutrient intake (energy intake, meal-snack pattern, macro-and micronutrients, etc.) • Adequacy of nutrient intake/nutrient delivery • Bioactive substances (alcohol intake, soy protein, psyllium, fish oil) • Previous and current diet history, diet orders, exclusions and experience, cultural and religious preferences • Changes in appetite or usual intake (as a result of the disease process, treatment, or comorbid conditions) • Disease-specific nutrient requirements • Food allergies/intolerances • Appropriateness of nutrition support therapy for the patient • Food and nutrient administration (oral, enteral or parenteral access) • Physical activity habits and restrictions Anthropometric Measurements:• Weight, Height • Weight change • Body mass index (BMI) • Body compartment estimates (fat mass, fat-free mass). • Biochemical indices (glucose, electrolytes, others as warranted by clinical condition) • Implications of diagnostic tests and therapeutic procedures (indirect calorimetry measurements, radiography for confirmation of feeding tube placement, other gastrointestinal (GI) diagnostic tests) • Nutrition-focused physical examination that includes, but is not limited to: Fluid assessment, functional status, wound status, clinical signs of malnutrition/overnutrition and/or nutrient deficiencies • Intake and output (I's and O's) including stool and fistula output, wound drainage • Existing or potential access sites for delivery of nutrition support therapy • Abdominal exam • Fluid status (edema, ascites, dehydration)• Vital signs. • Medical and family history and comorbidities • Surgical intervention • Effect of clinical status on ingestion, digestion, metabolism and absorption and utilization of nutrients • Indicators of acute or chronic nutrition support-related complications • Medication management • Factors that may influence existing or potential access sites for delivery of nutrition support therapy.Assessment of the above factors is needed to correctly diagnose nutrition problems and plan nutrition interventions. Inability to achieve optimal nutrient intake may contribute to poor outcomes. Imperative The Registered Dietitian Nutritionist's (RDNs) reassessment of critically ill adults should include:• Changes in nutrient needs • A determination of daily actual intake of enteral nutrition (EN), parenteral nutrition (PN) and other nutrient sources • EN/PN access site • Changes in clinical status, weight, biochemical data and intake and output (I's and O's) • Changes in nutrition-focused physical assessment findings.