key: cord-0937091-lo5g22vl authors: Caccialanza, Riccardo; Lobascio, Federica; Masi, Sara; Crotti, Silvia; Cereda, Emanuele title: Reply to “Nutritional approach to SARS-CoV-2 patients: our experience in 914 COVID-19 bed hospital” date: 2021-02-13 journal: Nutrition DOI: 10.1016/j.nut.2021.111203 sha: d9777b83727e83e242e6dbe4101ac6f479a8c355 doc_id: 937091 cord_uid: lo5g22vl nan We read with interest the letter of Zanardi et al. (1) , who presented the nutritional management protocol for coronavirus disease 2019 (COVID-19) patients admitted to their Hospital Company. We fully agree with the authors with regards to the need of pragmatism and simplicity in implementing nutritional support protocols for the management of hospitalized COVID-19 patients. However, we would like to point out that our protocol referred to non-critically ill patients (2), while for those admitted in the intensive/sub-intensive care setting, enteral nutrition (EN) via naso-gastric tube has been the first choice for nutritional support in our hospital, too. With this regards, we are currently conducting a prospective study aimed at assessing the occurrence and the clinical impact of early caloric deficit in ICU patients, as we believe that despite the implementation of appropriate shared protocols like the one presented by our Italian Colleagues, the provision of timely and adequate nutritional support might have been very challenging and often insufficient in a relevant proportion of COVID-19 patients (3), particularly during the first pandemic wave. We congratulate with Zanardi and co-authors for their reported results in patients ventilated with CPAP, but we believe that beyond treatment tolerance and the impact of EN on respiratory function, the actual provision of calories and proteins and its impact on relevant clinical outcomes should be primarily taken into consideration when assessing nutritional support efficacy. We share with our Italian Colleagues the awareness on the utility of oral nutritional supplements (ONS), which could be a feasible way to maintain or increase energy-protein intake and improve clinical outcomes not only during hospitalization (4), but also during the rehabilitation phase (5). Particularly during this latter, which often occurs at home, the free provision of ONS should be strongly recommended, in order to enhance the recovery of adequate nutritional status, but unfortunately, at least in Italy, it can occur only in the few contexts where structured Clinical Nutrition Services/Units are actively integrated into the health care system organization. Like our Colleagues in Turin, we have implemented a multidisciplinary outpatient clinic, which includes the systematic consultation by registered dietitians, aimed at facilitating the recovery of adequate energy-protein intake, which is crucial in the rehabilitation process (6), in particular for patients with previous admission in ICU, in whom the occurrence of muscle loss and sarcopenia is more plausible (7) . With regards to vitamin D supplementation, several epidemiological and observational studies support the hypothesis of its protective role (8) , but most of these are still based on retrospective data or small case series, while some prospective observations, despite underlying the high prevalence of vitamin D deficiency in hospitalized COVID-19 patients, do not confirm the association between vitamin D 25OH levels and clinical outcomes (9). Zanardi and Colleagues opted for early supplementation in all hospitalized patients with 30,000 IU due to the long time needed to obtain the blood dosage of vitamin D. In light of the above considerations, we believe that this approach could have been justified only by the previous emergency scenario, as it is likely to result futile in the absence of periodic monitoring of vitamin D serum levels. In conclusions, we confirm our satisfaction in noticing once again that our article stimulated the elaboration of several protocols aimed at promptly implementing nutritional care in COVID-19 patients, and we would like to further underline the need for systematic and appropriate nutritional management in all COVID-19 patients both during hospitalization and rehabilitation. Nutritional approach to patients with coronavirus: Our experience in a 914 COVID-19-bed hospital Early nutritional supplementation in non-critically ill patients hospitalized for the 2019 novel coronavirus disease (COVID-19): Rationale and feasibility of a shared pragmatic protocol Challenges of Maintaining Optimal Nutrition Status in COVID-19 Patients in Intensive Care Settings Effectiveness of nutritional interventions in older adults at risk of malnutrition across different health care settings: Pooled analyses of individual participant data from nine randomized controlled trials Prioritizing nutrition during recovery from critical illness. Curr Opin Clin Nutr Metab Care A Review of Nutrition Support Guidelines for Individuals with or Recovering from COVID-19 in the Community Intensive Care Unit-Acquired Weakness: Not just Another Muscle Atrophying Condition Perspective: Vitamin D deficiency and COVID-19 severity -plausibly linked by latitude, ethnicity, impacts on cytokines, ACE2 and thrombosis Vitamin D 25OH deficiency in COVID-19 patients admitted to a tertiary referral hospital The authors declare no conflict of interest.