key: cord-0769324-z3xfpytt
authors: Sriram, Krishnan
title: Nutrition therapy in COVID is not that simple
date: 2021-02-25
journal: JPEN J Parenter Enteral Nutr
DOI: 10.1002/jpen.2091
sha: eb961bb660ee428be63cf59680efaa29f12ec3ba
doc_id: 769324
cord_uid: z3xfpytt

nan

The commentary by Ochoa and others 1 in a recent issue of JPEN, based on the experience of clinicians working in Latin America, is timely. Recommendations are suggested based on existing practice on non-COVID patients but applicable with modifications to patients with severe COVID. There are however some areas where I humbly disagree with the authors.

Capturing disease-related malnutrition has always been elusive. 2 Documenting a diagnosis of "malnutrition" is important, to encourage initiation of early interventions. The authors point out the benefits of Subjective Global Assessment (SGA) but state that this method "demands training". Urgent training for non-experts has been initiated in many countries to help them manage COVID patients, including basic ventilator techniques and advanced hemodynamic monitoring. I submit that SGA, in vogue for decades, can be easily taught online.

The use of laboratory tests to diagnose malnutrition is unnecessary. 2 This has been suggested for many years, but old habits die hard. The authors recommend 3 tests: vitamin D, serum albumin and hemograms. Obtaining vitamin D levels in critically-ill patients, and attempting to correct low levels by administering even high doses of vitamin D3, have been conclusively shown to have no benefit. 3 In fact, low vitamin D levels obtained after resuscitation may represent hemodilution and not true deficiency. 4 Serum albumin (SA) level, deeply entrenched in the minds of nutritionists, has no positive or negative predictive values and is not needed to make a diagnosis of malnutrition. 5 The authors do point out that SA levels merely correlate with inflammation, which is anyway detected by C-reactive protein (CRP) levels recommended by the authors. Except for glucose levels, electrolytes (including Mg & P) and a few other tests for metabolic management (eg. coagulation tests), all other tests are unnecessary for nutrition-related purposes, and none are required specifically for the purpose of making a diagnosis of malnutrition thus saving resources.

The authors' opinion, quoting a reference on parenteral nutrition, is to resort to hypocaloric feeding during the first week of ICU stay and recommend that goals are reached only by the end of that period. This controversy aside, their recommendation to continue this practice beyond the first week is more problematic. They quote ESPEN's expert statement specific to COVID-19 that we should target to achieve 100% of calculated energy goals, but give two unsubstantiated reasons why they do not agree. The first reason is "ongoing inflammatory response" and the second is "obesity". Inflammation per se , difficult to identify clinically and quantify, is not a contraindication to nutrition therapy. The metabolic derangements in obesity that they allude to are hyperglycemia and hypertriglyceridemia. Hyperglycemia is easily controlled, by judicious use of both oral agents and/or parenteral insulin, even in COVID patients on dexamethasone or other corticosteroids. 8 Triglyceride elevation is generally not a problem with enteral feeding.

The authors mention a Phase 2 trial using a newer high protein formula where excess energy was avoided, glucose levels were controlled and "a potential" decrease in CO 2 production. The reference quoted is not any particular study but the 2016 SCCM/ASPEN guidelines. Perturbations of the Respiratory Quotient, specifically due to higher CO 2 production due to excess carbohydrate calories, does not occur with the current calorie goals of 25 to 35 kcal/kg.

In summary, it is appreciated that the authors have expressed their frank opinions about nutrition therapy during the current virus crisis. However, it is suggested that readers review all available information and society guidelines and make individual choices.

Lessons learned in nutrition therapy in patients with severe COVID-19

Capturing the elusive diagnosis of malnutrition

Ginde AA and others for he National Heart, Lung & Blood Institute, PETAL Clinical Trials Network, Early high dose Vitamin D3 for critically ill vitamin D deficient patients

The ongoing story of vitamin D

Serum levels of prealbumin and album for preoperative risk stratification

The hospitalized patient with COVID-19 on the medical ward -Cleveland Clinic approach to management