Early nutritional management in non-critically ill coronavirus disease 2019 patients

Abstract

Dear editor Caccialanza et al [1] present an empirical protocol to promptly and pragmatically implement nutritional care in hospitalized non-ICU coronavirus disease 2019 (Covid-19) patients. In the absence of a curative treatment, it is highly valuable to optimize supportive care of Covid-19 patients. The authors made the choice to detect nutritional risk by a simplified screening procedure. Although we routinely advocate for systematic nutritional risk screening of hospitalized patients, in the particular context of the Covid-19 epidemic we believe risk screening is not necessary and that nutritional support should be prescribed at admission to all adult patients regardless of baseline nutritional status. Hospital admission of Covid-19 patients usually occurs after 7 to 10 days of illness, during which anorexia is common, exacerbated by anosmia and ageusia. Even though most of the severely ill Covid-19 patients in industrialized countries are overweight or obese, a specific nutritional support is warranted. First, because a majority of obese adults over the age of 65 have sarcopenic obesity with lean body mass loss, aggravated by anorexia and digestive symptoms. Sarcopenia is a predictor of difficult-to-wean and mortality among critically ill patients. Secondly, obese individuals commonly have low levels of both fat- and water-soluble vitamins, in particular vitamin D. Furthermore severe Covid-19 mostly affects middle-aged to elderly people who are usually vitamin D deficient. Lung monocytes/macrophages and epithelial cells express the vitamin D receptor and vitamin D deficiency might contribute to the severity of respiratory viral infection by modulating negatively the innate and adaptive immune responses [2]. In a meta-analysis of randomized controlled trials, vitamin D supplementation prevented acute respiratory tract infection [3]. Among severe vitamin D deficient patients, high-dose vitamin D supplementation in the ICU reduced hospital mortality [4]. Other micronutrients may also affect the immune system. Vitamin C supplementation showed clinical benefit in elderly hospitalized patients with acute respiratory infection [5]. Zinc adjunction to treatment of severe pneumonia reduced mortality [6]. Even if clinical evidence is poor, host nutritional status can influence the host response to the virus, and it is suitable to prevent and compensate nutritional deficiencies. Nutritional management should be introduced early at admission. A screening procedure may limit or delay the implementation of treatment. Despite the clinical importance of body weight measurement, it is poorly recorded in hospitalized patients, especially in context of contact and droplet precautions. Although we are in agreement with Caccialanza et al [1] proposals, our protocol varies in some respects. Regarding macronutrients, it is advisable not to prescribe any restrictive diet. Sugar-restricted or salt-restricted diets are anorexiant and at risk of worsening sarcopenia. Sugar-restricted diet in diabetic patients is not recommended because hospitalized Covid-19 patients have low spontaneous intakes and preventing malnutrition is a greater issue. Oral nutritional supplements should be offered as liquid supplements, which are more easily ingested in case of dyspnea. Artificial nutrition should be initiated as soon as dietary intake becomes insufficient. Like Caccialanza et al [1], we prefer parenteral nutrition since enteral nutrition is unenforceable in the context of non-invasive ventilation, digestive symptoms, and difficult monitoring of isolated patients. Concerning vitamin D supplementation, although bolus dosing is commonly prescribed, daily dosing might be a better choice because high doses of vitamin D can dysregulate the activity of the enzymes responsible for synthesis and degradation of vitamin D. Martineau et al [3] showed that patients receiving daily or weekly vitamin D without additional bolus doses experienced the most benefit to prevent acute respiratory tract infections. Other supplementations are implemented in our center according to frequent deficiencies and nutritional requirements of the target population (table 1 ). Cobalamin is provided because commonly deficient in malnourished patients or in patients previously treated by metformin or proton pump inhibitor. The dosage of multivitamin and trace elements has been adapted to reach a sufficient amount of vitamin C [5], higher than the dietary reference intakes, but far from the toxic limit. Table 1 Nutritional management of Covid-19 in Caen Normandie University Hospital, prescribed at admission to all adult patients regardless of baseline nutritional status. Table 1 Nutritional support in conventional hospital wards Diet High-protein and high-calorie diet (default meal in Covid-19 units) Restrictive diets are prohibited Oral nutritional supplement 2 to 3 drinks /day, according to tolerance Artificial nutrition If oral intake < 70% daily calorie requirements: peripheral parenteral nutrition (central if long-term) Vitamin D 800 IU/d (ie total 1200 IU/d taking into account multivitamin complex) Vitamin B12 (Cobalamin) 1 mg orally per week Multivitamin and minerals 1 tablet daily containing:- vitamin A 5200 UI- vitamin C 240 mg- zinc 30 mg- selenium 100 μg- all other vitamins achieving 100% DRI (except vitamin K) DRI: dietary reference intakes Declaration of Competing Interest Nothing to disclose