covide-19 nutrition dr.Zahra Motawei.pdf

Key Aspects Of Nutrition In
Patients With Covid-19
Dr. Alzahraa M. Motawei
Lecturer Of Food Sciences And Nutrition
Faculty Of Agriculture
Mansoura University

The Speaker
• Lecturer Of Food Sciences and Dietetics - Faculty Of Agriculture - Mansoura University
• B.Sc. in Agric. Sci. “Food Industries” (2001). Mansoura University, Egypt.
• M.Sc. Degree in Food Technology (2004 - 2009) Suez Canal University Egypt.
• Biotechnology Training - Aachen university of applied science (Germany) April –
October, 2011.
• PhD Degree Nutrition Sci. (Food industries) (2011- 2014). Mansoura University, Egypt
• Visiting researcher, Post Doc In Preventive And Clinical Nutrition Department,
Nutrition, Exercise And Sports Institute, faculty of Sciences, Copenhagen university -
2015 till 2016. Denmark
• Visiting researcher , Preventive And Clinical Nutrition department, Nutrition, Exercise
and Sports institute, Faculty Of Sciences, Copenhagen University - 2016 till 2018.
Denmark
• Specialist Dietitian in Renal And Kidney Diseases Unit – Children Hospital- Mansoura
University
• NUTRITION DIPLOMA – NNI- Cairo , 2021
• Member of The Danish Diabetes Academy
7/22/2022 Dr. Alzahraa Motawei COVID-19 Nutrition
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Background
• COVID-19 is a hypercatabolic disease with possible pulmonary and
gastrointestinal symptoms, and consequent deterioration of the nutritional
status and the worst clinical prognosis.
• We will present a guide to the nutritional care of adult and elderly people
non-critically and critically ill with COVID-19. based on ESPEN Clinical
Nutrition guidelines for 2022
Reference: Clinical Nutrition ESPEN 49 (2022) 544-550
https://doi.org/10.1016/j.clnesp.2022.03.002
7/22/2022
Dr. Alzahraa Motawei COVID-19 Nutrition
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Why are patients with COVID-19 at risk of
Malnutrition?
7/22/2022 Dr. Alzahraa Motawei COVID-19 Nutrition 4

Process Of Nutritional Management
Assessment • Screening
Counselling
• Nutritional
Education
Application
• Normal oral
• Parenteral
• Enteral
Outcome
• Discharge
management
5
Find
Feed
Follow
7/22/2022 Dr. Alzahraa Motawei COVID-19 Nutrition

1. Assessing The Nutritional Status
2. Calculating Nutritional Needs
3. Initiating Nutritional Therapy
4. Monitoring during hospitalization
5. Follow up after hospital discharge.
Process Of Nutritional Management

COVID-19 PATIENTS NUTRITION
Covid-19
Non-
Critically ill
Critically ill
ICU-
Patient
Non-
Intubated
Intubated

Nutrition Support For
Non-Critically Ill Patients

Nutritional Approach
A. Complete Nutritional Assessment Considering
1. COVID-19
2. Comorbidities and injuries (medical history)
3. Number of hospitalization days before ICU (clinical diagnosis)
4. Energy balance since hospital admission (diet intake history)
5. Risk for refeeding syndrome
6. Frequent monitoring of serum Ph, Mg, K levels

B. Nutritional Needs
• Caloric and protein needs should be adjusted per age, nutritional
status, disease severity, gastrointestinal tolerance
• use predictive equations is recommended
• If re-feeding syndrome risk is present Start at 25% of caloric goal with
slow increase

Energy Needs
• Estimated needs 15-20 kcal/kg AW ,1.2 gm protein/kg AW/d
• For Elderly People (> 65 years) with comorbidities 27 kcal/kg /day.
• Patients With Severely Malnourishment Comorbidities 30 kcal/kg of body
weight per day, with the gradual progression
• Obese patients of up to 30 kcal/kg adjusted weight.
• After discharged from the ICU(30-35 kcal/kg /day) and high protein diet
(2g/kg/d)

Patients at Home
• For malnourished or at risk patients, nutritional treatment should
continue after hospital discharge with oral nutritional supplements
and individualized nutritional plans.
• In case of swallowing difficulties, texture modified food and
thickened fluids should be considered.
• Some patients may also need home enteral or parenteral nutrition.
• Nutritional care plans should be regularly monitored
• Patients should be adhered with nutritional treatment, on tools for
self-screening of nutritional risk, and when to contact health care
providers.

Macronutrients
• ESPEN recommends
• protein supply above 1 g/kg of body weight (>20% calories)
• lipids and carbohydrates of 30:70 for patients without respiratory
failure and 50:50 for those ventilated

Feeding Routes: 1- Oral
• The oral feeding route should be preferred in patients able to consume 70% of
their needs between the third and the seventh day of hospitalization, considering
the nutritional needs without risk of vomiting or aspiration.
• If meeting the nutritional needs is not possible, or the patient presents
nutritional risk through screening, oral supplements should be used .
• The meals provided by the hospital must consist of unprocessed or minimally
processed foods, including all food groups, so as to ensure an appropriate supply
of macronutrients and micronutrients.
• Appropriate nutritional support in terms of micronutrients, vitamins (mainly A, C,
E, D, and the B complex), omega-3, and trace elements (such as selenium, zinc,
and iron), helps the immune system's general functioning, control of
inflammatory processes, oxidative stress, and nutritional status.

Eat Vitamin-D Rich Foods
• In the last two and a half years, the experts have stated that eating
foods that are rich in Vitamin-D is beneficial for the management of
COVID-19 infection. Some of the foods which are rich in Vitamin D are
• Cod liver
• Egg yolk
• Sardines, Salmon fish
• Fortified orange juice
• Canned tuna

Including Vitamin-A
• Vitamin A is a fat-soluble antioxidant. It has anti-inflammatory
properties, and studies have shown that it may be beneficial for
managing pneumonia and respiratory infections. Since COVID is a
respiratory disease, one
• who is infected with coronavirus must include this in their diet.
• Chicken liver
• Leafy greens
• Carrots
• Sweet potato
7/22/2022
Dr. Alzahraa Motawei COVID-19 Nutrition
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Add Zinc To Your Plate
• Also, zinc is very important for patients who are recovering from
COVID-19. Add these
• foods which are rich in zinc content.
• Dark chocolate
• Hemp seeds
• Seafood oyster
• Pumpkin seeds
• Lentils
• Cashew nuts

OMEGA -3
Food rich in omega-3
• Olive oil
• Canola oil
• Cod liver oil
• Seeds
• Nuts
• Fish

Tips for Increasing Calories
• Aim to eat around 6 times a day (or every 2–3 hours).
• Eat small amounts frequently if larger amounts during mealtimes are
challenging.
• Choose nutrient-dense foods (including whole grains, fruits, and
vegetables) at each meal and snack.
• Increase the amounts of fats and oils added to foods, focusing on the
heathy ones (olive oil, avocado, etc).
• Add some non-salt seasonings to dishes if taste is affected.
• Use high-calorie liquid nutrition supplement

Nutrition Support For
Critically Ill Patients

Importance of Nutrition
• During the acute phase hyper catabolism leads to energy depletion
• Amino acids are mobilized from muscles leading to negative nitrogen
balance and sarcopenia
• Crucial illness leads to gut dysfunction which accentuate the
inflammatory response and lead to an increased MORE organ
dysfunction

Key recommendation #1
• Initiate early enteral nutrition
• Within 2-3 days of ICU admission
• Within 12 hr of incubation
• EN is safely preferred over PN
If can be successfully fed via gastric route

• Start a standard EN isotonic (1 kcal/ml)
high protein formula
• EN-Gastric feeding preferred over post-
pyloric
• 1- need minimal expertise
• 2- allows use of NGT/OGT placed at
incubation
• 3- Continuous
• 4- less diahrea optimizesBG control
• 5- less staff interaction needed

• Switch to PN when EN is not as an
option
• If there are persistent diarrhea, ileus,
nausea, GI intolerance
• Limit soybean lipids the first week

ESPEN 10 recommendations "Nutritional management in
individuals at risk for severe COVID-19, in subjects suffering of
COVID-19, and in COVID-19 ICU

• Check for Malnutrition: Patients at risk for worst outcomes and
higher mortality following infection with SARS-Cov-2, namely older
adults and polymorbid individuals, should be checked using the MUST
criteria or, for hospitilized patients, the NRS-2002 criteria.
• Optimization of the nutritional status: Subjects with malnutrition
should undergo diet counselling from experienced professionals.
• Supplementation with vitamins and minerals: ensure
supplementation with vitamin A, vitamin D and other micronutrients.
• Regular physical activity: Patients in quarantine should continue
regular physical activity while taking precautions.

• Oral nutritional supplements (ONS): ONS should be used whenever
possible to meet patient's needs, when dietary counselling and food
fortification are not sufficient to increased dietary intake and reach
nutritional goals.
• Enteral nutrition (EN): In patients, whose nutritional requirements
cannot be met orally, EN should be administered. Parenteral nutrition
(PN) should be considered when EN is not indicated or insufficient.

Medical Nutrition in ICU Patients

Medical nutrition in ICU patients
• Medical nutrition in non-intubated ICU patients: If the energy target
is not reached with an oral diet, ONS should be considered first and
then EN treatment. If there are limitations for the enteral route, it
could be advised to prescribe peripheral PN in the population not
reaching energy-protein target by oral or enteral nutrition.
• Medical nutrition in intubated ICU patients I: EN should be started
through a nasogastric tube; post-pyloric feeding should be performed
in patients with gastric intolerance after pro kinetic treatment or in
patients at high)risk for aspiration.

Medical NUTRITION in intubated ICU patients II
• In ICU patients who do not tolerate full dose EN during the first week
in the ICU, initiating parenteral nutrition (PN) should be weighed on a
case-by-case basis.
• Patients who need mechanical ventilatory support and orotracheal
intubation require specific nutritional care after extubation. About
10-67% of these patients present swallowing disorders.
• Nutrition in ICU patients with dysphagia: Texture-adapted food can
be considered. If swallowing is proven unsafe, EN should be
administered.

Nutrition Support Therapy

Nutritional recommendations according to the type
of respiratory support in patients with COVID-19
Oxygen support Nutritional support
Ambient air/binasal catheter Oral diet: free, mild consistency, or according to the patient's preference; High-calorie
and/or high-protein oral supplement in nutritional risk or food intake <60% of caloric needs
for 2 days;
Enteral or parenteral nutrition, if necessary.
Non-rebreather mask NRB Oral diet: homogeneous creamy or pasty consistency, or thin pasty for consumption with
the aid of a straw, in order to facilitate the intake, avoid effort, and desaturation; High-
calorie and/or high-protein oral supplementation;
Enteral or parenteral nutrition, if necessary.
Mechanical ventilation Early enteral nutrition;
Parenteral nutrition, if necessary.
Extubation Assess dysphagia and if possible, oral diet; Enteral nutrition in case of risk of
bronchoaspiration.

Main Targets Of Recommended Dietary
Compounds In Patients With Post-covid-19
Syndrome
Nutrients 2022, 14, 1305.
https://doi.org/10.3390/nu14061305
https://www.mdpi.com/journal/nutrients

Dietary recommendations for patients with
post-COVID-19 syndrome
Nutrients 2022, 14, 1305.
https://doi.org/10.3390/nu14061305

TAKE HOME MESSAGE
• Patients with COVID-19 are at nutritional risk. A complete
nutritional assessment (anthropometric, dietary, and laboratory
assessment) enables the establishment of an individualized
nutritional approach in order to contribute to better clinical and
nutritional prognoses.
• Natural minimal processed foods are preferred
• Best drink is plain water.
• Limit saturated fat and increase unsaturated omega3 rich fats
• Choose white meats and salty fish
• Reduce salt and sugars
• Avoid eating outdoor
7/22/2022
Dr. Alzahraa Motawei COVID-19 Nutrition 36

References
• National Schedule of NHS costs2019/20 Yu, Y., et al 2020.
MalnutritionProlongs the Hospitalization of Patients with COVID-19
Infection: A Clinical Epidemiological Analysis. The journal of nutrition,
health & aging, 25(3),pp.369-373.
• Nutrients 2022, 14, 1305. https://doi.org/10.3390/nu14061305
• Clinical Nutrition ESPEN 49 (2022) 544-550
https://doi.org/10.1016/j.clnesp.2022.03.002
• MNI__Covid-19_Factsheet_Poster.pdf

END

covide-19 nutrition dr.Zahra Motawei.pdf

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