CIF management requires complex technologies, multidisciplinary and multiprofessional activity, and expertise to care for both the underlying gastrointestinal disease and to provide HPN support. The rarity of the condition impairs the development of RCTs. As a consequence, most of the recommendations have a low or very low grade of evidence. However, two-thirds of the recommendations are considered strong. Specialized management and organization underpin these recommendations.

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The COVID-19 pandemics has created unprecedented challenges and threats to patients and healthcare systems worldwide. Acute respiratory complications that require intensive care unit (ICU) management are a major cause of morbidity and mortality in COVID-19 patients. Among other important risk factors for severe COVID-19 outcomes, obesity has emerged along with undernutrition-malnutrition as a strong predictor of disease risk and severity. Obesity-related excessive body fat may lead to respiratory, metabolic and immune derangements potentially favoring the onset of COVID-19 complications. In addition, patients with obesity may be at risk for loss of skeletal muscle mass, reflecting a state of hidden malnutrition with a strong negative health impact in all clinical settings. Also importantly, obesity is commonly associated with micronutrient deficiencies that directly influence immune function and infection risk. Finally, the pandemic-related lockdown, deleterious lifestyle changes and other numerous psychosocial consequences may worsen eating behaviors, sedentarity, body weight regulation, ultimately leading to further increments of obesity-associated metabolic complications with loss of skeletal muscle mass and higher non-communicable disease risk. Therefore, prevention, diagnosis and treatment of malnutrition and micronutrient deficiencies should be routinely included in the management of COVID-19 patients in the presence of obesity; lockdown-induced health risks should also be specifically monitored and prevented in this population. In the current document, the European Society for Clinical Nutrition and Metabolism (ESPEN) aims at providing clinical practice guidance for nutritional management of COVID-19 patients with obesity in various clinical settings.

47Growing evidence underscores the important role of glycemic control in health and recovery from illness. 48Carbohydrate ingestion in the diet or administration in nutritional support is mandatory, but carbohydrate intake 49 can adversely affect major body organs and tissues if resulting plasma glucose becomes too high, too low, or highly 50 variable. Plasma glucose control is especially important for patients with conditions such as diabetes or metabolic 51 stress resulting from critical illness or surgery. These patients are particularly in need of glycemic management to 52 help lessen glycemic variability and its negative health consequences when nutritional support is administered. 53Here we report on recent findings and emerging trends in the field based on an ESPEN workshop held in Venice, 54Italy, 8-9 November 2015. Evidence was discussed on pathophysiology, clinical impact, and nutritional 55 recommendations for carbohydrate utilization and management in nutritional support. The main conclusions 56 were: a) excess glucose and fructose availability may exacerbate metabolic complications in skeletal muscle, 57 adipose tissue, and liver and can result in negative clinical impact; b) low-glycemic index and high-fiber diets, 58 including specialty products for nutritional support, may provide metabolic and clinical benefits in individuals with 59 obesity, insulin resistance, and diabetes; c) in acute conditions such as surgery and critical illness, insulin resistance 60 and elevated circulating glucose levels have a negative impact on patient outcomes and should be prevented 61 through nutritional and/or pharmacological intervention. In such acute settings, efforts should be implemented 62 towards defining optimal plasma glucose targets, avoiding excessive plasma glucose variability, and optimizing 63 glucose control relative to nutritional support. 64 65 66 3

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Background and aimNo marker to categorise the severity of chronic intestinal failure (CIF) has been developed. A 1-year international survey was carried out to investigate whether the European Society for Clinical Nutrition and Metabolism clinical classification of CIF, based on the type and volume of the intravenous supplementation (IVS), could be an indicator of CIF severity.MethodsAt baseline, participating home parenteral nutrition (HPN) centres enrolled all adults with ongoing CIF due to non-malignant disease; demographic data, body mass index, CIF mechanism, underlying disease, HPN duration and IVS category were recorded for each patient. The type of IVS was classified as fluid and electrolyte alone (FE) or parenteral nutrition admixture (PN). The mean daily IVS volume, calculated on a weekly basis, was categorised as <1, 1–2, 2–3 and >3 L/day. The severity of CIF was determined by patient outcome (still on HPN, weaned from HPN, deceased) and the occurrence of major HPN/CIF-related complications: intestinal failure-associated liver disease (IFALD), catheter-related venous thrombosis and catheter-related bloodstream infection (CRBSI).ResultsFifty-one HPN centres included 2194 patients. The analysis showed that both IVS type and volume were independently associated with the odds of weaning from HPN (significantly higher for PN <1 L/day than for FE and all PN >1 L/day), patients’ death (lower for FE, p=0.079), presence of IFALD cholestasis/liver failure and occurrence of CRBSI (significantly higher for PN 2–3 and PN >3 L/day).ConclusionsThe type and volume of IVS required by patients with CIF could be indicators to categorise the severity of CIF in both clinical practice and research protocols.

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