New ESPEN Expert Guidelines: Practical Guidance for Nutritional Management in COVID-19 Patients

• ICU stays, particularly their longer duration, are well-documented risk factors for malnutrition, often characterized by loss of skeletal muscle mass and function which may lead to poor quality of life, disability, and other downstream clinical effects long after ICU discharge.
• New guidelines have been issued by the European Society for Clinical Nutrition and Metabolism (ESPEN) to provide practical steps for preserving nutritional status in COVID-19 patients, especially regarding those in the ICU setting or in the presence of older age and polymorbidity.
• Nutritional intervention and therapy should be considered as an integral part of the approach to treating COVID-19 patients in the ICU and internal medicine ward settings.

Malnutrition: what is the risk for COVID-19 patients?

COVID-19 poses an unprecedented global health risk – both to patients and healthcare systems, alike. Emerging data suggests that individuals with chronic health conditions such as cardiovascular disease, diabetes mellitus, and obesity are more likely to become critically ill from COVID-19.¹ Patients presenting to the hospital with multiple co-morbidities are also more susceptible to malnutrition, making it especially important to prevent or treat malnutrition in the event of infection and/or severe disease.²

Upon hospital admission, patients should be immediately screened for malnutrition. Global Leadership Initiative on Malnutrition (GLIM) recently proposed a two-step approach for malnutrition diagnosis²:

1. Screening to identify “at risk” status through the use of validated screening tools such as MUST or NRS-2002.
2. Assessment for diagnosis and grading the severity of malnutrition.

Nutritional treatment should be applied during hospitalization via individualized nutritional plans; this is particularly important given pre-existing nutritional risk factors continue to apply and acute disease and hospitalization are likely to worsen the risk or condition of malnutrition. Adequate assessment of nutrient intake is recommended with treatment with oral nutrition supplements or with enteral nutrition if oral route is insufficient.²

The majority of patients hospitalized for severe COVID-19 receive mechanical ventilation (often prolonged), representing a critical risk factor for higher morbidity and mortality in this patient cohort. ICU stays, mechanical ventilation, polymorbidity and older age are all commonly associated with high risk for malnutrition, with prolonged ICU length-of-stay often resulting in severe loss of skeletal muscle mass and function which may lead to disability, poor quality-of-life and additional morbidity. Prevention, diagnosis and treatment of malnutrition, including parenteral nutrition, is therefore a critical component of COVID-19 management in the ICU setting.²

Meeting patient needs with science-led guidelines

Given the importance of the prevention, diagnosis and treatment of malnutrition, the ESPEN recently issued guidance on the nutritional management of COVID-19 patients. This document adeptly outlines ten practical recommendations for nutrition management in the context of COVID-19.²

The recommendations are summarized, as follows:

1. Patients at risk for poor outcomes and higher mortality following infection with SARS-CoV-2, namely older adults and polymorbid individuals, should be checked for malnutrition through screening and assessment.
2. Subjects with malnutrition should try to optimize their nutritional status, ideally by diet counseling from experienced professionals (registered dieticians, experienced nutritional scientists, clinical nutritionists and specialized physicians).
3. Subjects with malnutrition should ensure sufficient supplementation with vitamins and minerals.
4. Patients in quarantine should continue regular physical activity while taking precautions.
5. Oral nutritional supplements (ONS) should be used whenever possible to meet patient’s needs when dietary counseling and food fortification are not sufficient to increase dietary intake and reach nutritional goals.
6. In polymorbid medical inpatients and in older persons with reasonable prognosis, whose nutritional requirements cannot be met orally, enteral nutrition (EN) should be administered. Parenteral nutrition (PN) should be considered when EN is not indicated or unable to reach targets.
7. In COVID-19 non-intubated ICU patients not reaching the energy target with an oral diet, oral nutritional supplements (ONS) should be considered first and then enteral nutrition treatment. If there are limitations for the enteral route it could be advised to prescribe peripheral parenteral nutrition in the population not reaching energy-protein target by oral or enteral nutrition.
8. In COVID-19 intubated and ventilated ICU patients, enteral nutrition (EN) should be started through a nasogastric tube; post-pyloric feeding should be performed in patients with gastric intolerance after prokinetic treatment or in patients at high-risk for aspiration.
9. In ICU patients who do not tolerate full dose enteral nutrition (EN) during the first week in the ICU, initiating parenteral nutrition (PN) should be weighed on a case-by-case basis.
10. In ICU patients with dysphagia, texture-adapted food can be considered after extubation.

The new ESPEN guidelines reinforce the critical importance of nutritional intervention for critically ill patients and presents a viable opportunity to tailor medical nutrition solutions, including parenteral nutrition.

Improving the quality of patients’ lives

At DSM, our commitment to quality extends broadly and is represented by our patient-centric approach to innovation. DSM teams are highly aware of – and sensitive to – the fact that the products we produce reach the most medically vulnerable population groups (i.e. patients with severe conditions and multiple co-morbidities, from infants to the elderly).

The stakeholder experience is at the core of our business approach; working with the patient in mind is how we internally guide our ways of working across all business functions, from quality, regulatory all the way to production and innovation. And as a purpose-led partner, DSM actively supports research related to COVID-19.

For a successful go-to-market, understanding and acceptance of the medical community is key. We support those who aspire to make a difference in the medical community with in-depth patient and consumer insights to discover opportunities to develop parenteral nutrition solutions.