Identifying who needs nutritional care during COVID-19 recovery

Information on nutritional care and how to identify those in need of support

Why is nutritional care important?

There are many symptoms of COVID-19 infection that are affected by, and affect, diet and nutrition. These symptoms can persist and evolve during the course of illness and recovery. COVID-19 has complex, multi-organ (or multi-system) effects that interact in various ways and that are strongly linked with nutrition and diet.

Different cohorts of people have been affected disproportionally by COVID-19 highlighting many health disparities. Those with underlying metabolic diseases will have a more burdensome rehabilitation from serious infections such as COVID-19, with considerable morbidity as well as mortality (Zabetakis et al., 2020). Malnourished people with low immunity and chronic diseases have a worse prognosis and higher mortality rates (Malnutrition Pathway, 2020).

Good nutrition not only supports immunity to diseases such as COVID-19, it is also an essential factor for the promotion of recovery (Ferrara, De Rosa and Vitiello, 2020).

Older adults and those with other chronic conditions are more at risk of malnutrition (Ferrara, De Rosa and Vitiello, 2020) and it is widely acknowledged that malnutrition is both a cause and a consequence of immune dysfunction (Gem COVID, 2020).

Older adults are complex in the sense that chronic diseases are related to frailty and this leads to reduced functional reserves and reduce resistance to stress. Thus, there is often involuntary weight loss, malnutrition and acute hospitalisation (Ferrara, De Rosa and Vitiello, 2020). As a result of COVID-19, people may develop frailty syndromes due to respiratory distress and thus, may result in admission to an intensive care unit. Clinical outcomes are variable and often include associated respiratory and psychological sequelae (Brika et al., 2020).

Nutrition screening and assessment is essential to identify people experiencing low appetite, food insecurity or other nutrition risk factors. This will facilitate early intervention by helping healthcare professionals recognise when a referral to a dietitian, or support from community services is needed (Donnelly and Keller, 2021). Without adequate screening programmes in place many vulnerable or older patients, with compromised immunity and comorbidities, may go undetected as at risk of malnutrition.

If nutritional interventions are inadequate, patients whose health is already compromised might experience worse clinical outcomes (Ferrara, De Rosa and Vitiello, 2020).

Guidelines state that support for COVID-19 recovery should be available regardless of whether a positive COVID-19 test was obtained, since neither PCR testing nor antibody tests adequately captured all disease (Brika et al., 2020; Ochoa et al., 2020).

Who to include for nutritional care and how to identify them?

How to identify risk of malnutrition
Risk of malnutrition can be identified using a screening tool. Screening is vital to identify those who are malnourished, or at risk of malnourishment. Self-screening has advantages due to infection control measures and the number of people with COVID-19, and should be encouraged. Nutrition screening can be carried out by any healthcare professionals.
For self screening tools to ask your patients to use, see our Is what I eat affecting my recovery? page.
There are many screening tools available and your own organisation is likely to recommend a screening tool to use. Examples include:
  • (MUST)
  • (MNA-SF)
Screening tools are a guide and your own clinical judgement should be used, informed by any relevant, recent measurements of the individuals body.
The following questions were suggested by a panel of multidisciplinary experts with the aim of flagging potential nutrition and/or dietary issues that can point an appropriate direction when screening:
  • Food accessibility. Assessment of living situation. Do patients have appropriate support for their nutritional care? 
  • Is the patient currently using nutritional supplements or other specific dietary-related products?
Recommendations for the screening of different patient groups:
  • Hospitalised patients should be screened for nutritional problems and may need following up in primary care, particularly those in vulnerable or high-risk groups (NHS, 2020).
  • People in the community from vulnerable or high risk groups should be screened for nutritional risk: One suitable tool is a available from the University of South Wales website.
  • People who have concerns regarding their nutrition may also need access to advice (Barazzoni et al., 2020).
  • Those with frailty: malnutrition often occurs alongside frailty. Frailty can be assessed using the from the NHS Specialised Clinical Frailty Network.
  • Patients in post COVID-19 clinics will need screening when either the patient or healthcare professional is concerned. See our Managing patients symptoms linked to nutrition during COVID-19 recovery page for our symptom toolkit.
  • Patients should also be screened at first healthcare professional contact when (Cawood et al., 2020; NHS, 2020; Lawrence et al., 2021):
    there is any significant change in clinical, psychological or social condition
    patients are using oral nutritional supplements
    enteral nutrition is indicated
    symptoms persist after 12 weeks from a diagnosis of COVID-19 (i.e. post-COVID syndrome).
Once you have identified someone as at risk of malnutrition you should plan an appropriate and well documented nutrition care plan, including referral for specialist dietetic input (Cawood et al., 2020). Go to our Assessing patients nutritional needs and setting realistic goals during COVID-19 recoverypage for advice on how to do this.
Since telehealth has been established and become widely used, dietitians have been able to treat at risk patients within hospital, primary care and community settings.
For patients who require referral make sure you distinguish between existing long-term conditions and COVID-19 related complications (NICE, 2020).
All healthcare professionals can support the task of screening. Early interventions are essential to improve outcomes and this includes recognising when referral to a dietitian and/or support from community services is needed.

Overweight and obese patients

  • People who are overweight and obese appear to be disproportionally affected by COVID-19.
  • Hospitalisation for COVID-19 has been found to be associated with adiposity-based, dysglycemia-based and cardiometabolic-based chronic diseases (e.g., hypertension, type 2 diabetes and obesity).
  • This patient group is therefore complex in terms of dietary advice and is more likely to require a referral to dietetics services (Burridge et al., 2020).
  • Nutritional deficiencies from sub-optimal eating patterns lead to decreased immune function and therefore to impaired resistance to infection. These pre-existing comorbidities increase the risk of nutrition and refeeding syndrome.
  • From those suffering from ongoing and post-COVID syndrome, there is an inflammatory process that exacerbates catabolism and anorexia, aggravating malnutrition, impeding recovery and leading to disability and reduced quality of life (Mechanick et al., 2021).

Patients in care homes

Internationally 1972% (depending on the country) of COVID deaths occurred in care homes; however, it is unclear whether survivors experienced ongoing symptoms (NIHR, 2021). There is likely to be many patients in this setting who require screening and nutrition support.

An  [PDF] supported by the Older People Specialist Group in the BDA (OPSG) and the Care Provider Alliance can be used to enhance care in care homes.

Nutrition and hydration are core care elements that each individual care setting has to deliver on. Meeting this care need should also address their nutrition needs related to COVID-19.

Dietitians are key multidisciplinary team members (MDT) that should be co-opted into the MDT meetings when needed. See the  webpage for more information.

This is an example of a  [PDF].

Post-COVID syndrome

Post-COVID syndrome is also called long COVID, chronic COVID or post-acute COVID. Patient groups may refer to themselves as long haulers.

Post-COVID syndrome seems to be similar to Myalgic Encephalomyelitis (also called Chronic Fatigue) and resembles chronic fatigue syndrome. Chronic inflammation can exacerbate catabolism and anorexia, diabetes, heart disease and renal failure (Mechanick et al., 2021). Nutritional care is therefore crucial.

Patients have reported receiving inconsistent advice from healthcare professionals and the absence of information about fluctuating symptoms. This has resulted in patients supporting each other through media channels because this lack of recognition of symptoms and their fluctuation has isolated more people (NIHR, 2021).

Lack of diagnosis makes accessing services difficult. Primary care, community and helpline staff need better training and knowledge about ongoing effects of COVID-19 (Malnutrition Pathway, 2020).

Epidemiology and public health specialists have reinforced the need to collect comprehensive symptom data, as neither PCR testing nor antibody tests adequately captured all disease. They have also stressed that equity is necessary to access post-COVID syndrome assessment clinics (NHS, 2020).


Symptoms

A UK review (Ansu et al., 2021) identified the 10 most common symptoms of post-COVID syndrome:

  • fatigue
  • shortness of breath
  • muscle pain
  • cough
  • headache
  • joint pain
  • chest pain
  • altered sense of smell
  • diarrhoea
  • altered sense of taste.

People experiencing five or more symptoms in the first stages of the disease are more prone to suffer from post-COVID syndrome (Sudre et al., 2020).

More information can be found on the University of Birmingham's  page.

On-going (4-12 weeks post infection) and post-COVID syndrome symptoms appear to be common. Data reported in Italy found that that almost 90% of patients reported at least one symptom 60 days after onset and half of them had three symptoms including:

  • fatigue
  • breathing difficulty
  • joint pain and chest pain
  • reduction of life quality.

Another study found seven main categories of symptoms (Davis et al., 2021):

  • major fatigue, muscular or joint pains
  • neurological symptoms such as memory, mood or attention disorders
  • headaches, sensory disturbances, balance disorders, neurogenic pains
  • persistent or recurrent anosmia, hyposmia, dysgeusia, swallowing and speech disorders
  • cardiothoracic symptoms such as palpitations, chest pain
  • gastrointestinal symptoms such as diarrhoea, nausea, vomiting or abdominal pain
  • skin and vascular symptoms (related to blood and fluids in the body).

In a French cohort, scientists found that during the prolonged phase of COVID-19 more than half of patients had symptoms persisting from the onset of infection, and in 80% of the sample new symptoms arose that were not present at the start.

Dietitians have reported issues in patients with COVID-19 that required follow up after the acute care phase (Aiyegbusi et al., 2021).

Prevalence

One year after the pandemic started in the UK, it was reported that almost one million people had been admitted to hospital and it is estimated that almost half will need continued support (NIHR, 2021). 67% of GPs report looking after patients with long COVID (NHS, 2020; NICE, 2020).

Data from Public Health England has found that at least 10% of non-hospitalised patients have reported symptoms lasting more than four weeks (NIHR, 2021). Fluctuations in symptoms have been reported by 70% of patients and changes in the intensity of them were reported 89% of the time (NICE, 2020).

The  has four million regular contributors and 10-20% report complications for longer than a month (100,000200,000 people) (NICE, 2020; NIHR, 2021).

Dr Sarah Berry, Reader in Nutritional Sciences, Department of Nutritional Sciences, Kings College London and Elaine Anderson, Registered Dietitian (Freelance and NHS) discuss data extracted from the COVID symptom app. Watch the 'Diet and COVID' video on our Nutrition and COVID-19 Recovery page.


Co-morbidities

Post-COVID syndrome can lead to an increase in chronic medical conditions such as:

  • depression
  • stroke
  • cardiac injury
  • chronic renal disease
  • Type 2 Diabetes.

More information and research are being documented from a cross disciplinary cohort of health professionals who had COVID-19 themselves. It includes a long list of symptoms and how post-COVID syndrome is affecting patients:

  •  (Patient-Led Research Collaborative report)
  •  (medRxiv article)

Contact us

This knowledge hub is constantly being reviewed and updated. We welcome your comments or feedback about it.

Please contact abigail.troncohernandez@plymouth.ac.uk and we will get back to you promptly.

References

Aiyegbusi, O.L. et al. (2021) Symptoms, complications and management of long COVID: a review, Journal of the Royal Society of Medicine, p. 01410768211032850. doi:10.1177/01410768211032850.

Ansu, V. et al. (2021) Nutrition care practice patterns for patients with COVID-19A preliminary report, Journal of Parenteral and Enteral Nutrition, n/a(n/a). doi:https://doi.org/10.1002/jpen.2106.

Barazzoni, R. et al. (2020) ESPEN expert statements and practical guidance for nutritional management of individuals with SARS-CoV-2 infection, Clinical Nutrition, 39(6), pp. 16311638. doi:10.1016/j.clnu.2020.03.022.

Brika, M. et al. (2020) Geriatric Rehabilitation and COVID-19: a Case Report, SN Comprehensive Clinical Medicine, 2(12), pp. 28902898. doi:10.1007/s42399-020-00613-5.

Burridge, J. et al. (2020) Metabolic health and COVID-19: a call for greater medical nutrition education, The Lancet Diabetes & Endocrinology, 8(8), pp. 665666. doi:10.1016/S2213-8587(20)30220-5.

Cawood, A.L. et al. (2020) A Review of Nutrition Support Guidelines for Individuals with or Recovering from COVID-19 in the Community, Nutrients, 12(11), p. 3230. doi:10.3390/nu12113230.

Davis, H.E. et al. (2021) Characterizing Long COVID in an International Cohort: 7 Months of Symptoms and Their Impact, medRxiv, p. 2020.12.24.20248802. doi:10.1101/2020.12.24.20248802.

Donnelly, R. and Keller, H. (2021) Challenges Providing Nutrition Care during the COVID-19 Pandemic: Canadian Dietitian Perspectives, The journal of nutrition, health & aging, 25(5), pp. 710711. doi:10.1007/s12603-020-1585-z.

Ferrara, F., De Rosa, F. and Vitiello, A. (2020) The Central Role of Clinical Nutrition in COVID-19 Patients During and After Hospitalization in Intensive Care Unit, SN Comprehensive Clinical Medicine, 2(8), pp. 10641068. doi:10.1007/s42399-020-00410-0.

Gem COVID (2020) Post-COVID-19 global health strategies: the need for an interdisciplinary approach, Aging Clinical and Experimental Research, pp. 18. doi:10.1007/s40520-020-01616-x.

Lawrence, V. et al. (2021) A UK survey of nutritional care pathways for patients with COVID-19 prior to and post-hospital stay, Journal of human nutrition and dietetics: the official journal of the British Dietetic Association, 34(4), pp. 660669. doi:10.1111/jhn.12896.

Malnutrition Pathway (2020) A Community Healthcare Professional Guide to the Nutritional Management of Patients During and After COVID-19 Illness, p. 9.

Mechanick, J.I. et al. (2021) Clinical Nutrition Research and the COVID-19 Pandemic: A Scoping Review of the ASPEN COVID-19 Task Force on Nutrition Research, JPEN. Journal of parenteral and enteral nutrition, 45(1), pp. 1331. doi:10.1002/jpen.2036.

NHS (2020) National guidance for post-COVID syndrome assessment clinics (6 November 2020), Patient Safety Learning the hub. Available at: (Accessed: 9 January 2021).

NICE (2020) COVID-19 rapid guideline: managing the long-term effects of COVID-19, p. 35.

NIHR, E. (2021) Living with Covid19 - webinars - Informative and accessible health and- care research. Available at: (Accessed: 26 April 2021).

Ochoa, J.B. et al. (2020) Lessons Learned in Nutrition Therapy in Patients With Severe COVID19, Journal of Parenteral and Enteral Nutrition, p. jpen.2005. doi:10.1002/jpen.2005.

Sudre, C.H. et al. (2020) Attributes and predictors of Long-COVID: analysis of COVID cases and their symptoms collected by the Covid Symptoms Study App, p. 2020.10.19.20214494. doi:10.1101/2020.10.19.20214494.

Zabetakis, I. et al. (2020) COVID-19: The Inflammation Link and the Role of Nutrition in Potential Mitigation, Nutrients, 12(5), p. 1466. doi:10.3390/nu12051466.

Why we created this page

In creating the knowledge hub we worked with expert panels to form a consensus on the nutritional care for people recovering from COVID-19 infection. Each section of the knowledge hub includes a consensus statement produced by the relevant expert panel. For information on the background of the Nutrition and COVID-19 recovery knowledge hub project visit the 'about us' page.

Consensus statements

  • Nutrition is important for all stages of COVID-19 recovery.
  • Equity in access to post COVID-19 care is needed and should be promoted and communicated widely across health, social care and wellbeing services.
  • Because of infection control measures, self-screening (and the use of remote working) is needed. 
  • Tools adapted for nutritional self-screening, self-assessment or self-referral are needed so that they can be utilised by non-dietetic professionals.
  • Health, social care and wellbeing services professionals should acknowledge that patients may want nutritional advice and access to nutritional care.