Although Coronavirus disease 2019 (COVID‐19) is primarily a respiratory disease, growing evidence shows that it can affect the digestive system and present with gastrointestinal (GI) symptoms. Various nutrition societies have recently published their guidelines in context of the pandemic, and several points emphasize the impact of these GI manifestations on nutrition therapy. In patients with COVID‐19, the normal intestinal mucosa can be disrupted by the severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) virus, and this could result in GI symptoms and a compromise in nutrient absorption. Optimization of oral diet is still recommended. However, given the GI effects of COVID‐19, a fraction of infected patients have poor appetite and would not be able to meet their nutrition goals with oral diet alone. For this at‐risk group, which includes those who are critically ill, enteral nutrition is the preferred route to promote gut integrity and immune function. In carrying this out, nutrition support practices have been revised in such ways to mitigate viral transmission and adapt to the pandemic. All measures in the GI and nutrition care of patients are clustered to limit exposure of healthcare workers. Among patients admitted to intensive care units, a significant barrier is GI intolerance, and it appears to be exacerbated by significant GI involvement specific to the SARS‐CoV‐2 infection. Nevertheless, several countermeasures can be used to ease side effects. At the end of the spectrum in which intolerance persists, the threshold for switching to parenteral nutrition may need to be lowered.
We wish to thank Dr Yu for his interest in our article. 1 We highly appreciate his input regarding different etiologies of acute pancreatitis and their implications for nutrition therapy. 2 In the early months of the pandemic, there was hardly any information published regarding coronavirus disease 2019 (COVID-19)-related pancreatitis. Since then, case reports and retrospective cohort studies have been published describing this association. With the angiotensinconverting enzyme 2 receptors expressed in the pancreas, entry of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) through these receptors, causing pancreatic inflammation, could indeed be plausible. Among the larger studies is a US-based retrospective cohort that revealed a point prevalence of 0.27% among 11,883 COVID-19 patients, with 69% considered as idiopathic. 3 Other literature reports have shown heterogeneous results because of the lack of standard diagnostic criteria. To date, there is still insufficient evidence to establish causality. More populationbased epidemiological studies addressing potential biases are needed. 4 However, although we recognize the potential of SARS-CoV-2 to cause acute pancreatitis, we would want to emphasize that it is important to rule out its more common etiologies first, such as gallstones, alcohol, and hypertriglyceridemia. Obtaining good history is crucial. Diagnostic workups should be done to further investigate and narrow down these etiologies.On a similar note, we agree with the authors that the association of COVID-19 with acute pancreatitis is important in the context of nutrition therapy. It has been proven that nutrition therapy for patients with acute pancreatitis is beneficial because of its immunologic effect, prevention of bacterial overgrowth, and decreased bacterial translocation and intestinal permeability. 5 As both COVID-19 infection and acute pancreatitis are considered highly catabolic disease processes, diagnosed patients are classified to have moderate to high nutrition risk, and hence, should be closely managed. The European Society for Clinical Nutrition and Metabolism (ESPEN) has crafted a guideline on the nutrition management of patients with acute pancreatitis. 6 Oral feeding should be offered as soon as clinically tolerated. Enteral feeding can be started for those with gastrointestinal intolerance and if nutrition targets are not met by oral diet alone. Parenteral nutrition should be reserved for patients who do not tolerate enteral nutrition or are unable to tolerate targeted nutrition requirements. In general, these practices have been proven to reduce overall disease severity and faster resolution of disease process, leading to shorter hospital length of stay and better clinical outcomes. 7 Although no study exists on the nutrition management of patients diagnosed with both acute pancreatitis and COVID-19, we recommend following prepandemic guidelines tempered by clinical judgment.
Introduction. Malnutrition among hospitalized patients is highly prevalent. This adversely affects outcomes with longer length of stay (LOS), higher treatment costs and increased mortality. People with diabetes mellitus (DM) are particularly vulnerable to malnutrition and its consequences.Objective. To determine the association of nutritional status with LOS and mortality among adults with Type 2 DM.Methodology. This was a retrospective study of 439 adult patients with type 2 diabetes admitted in the medical ward of a tertiary hospital from January 1, 2018 to December 31, 2018. Demographics, anthropometrics, feeding route, LOS and outcomes were taken from the Clinical Nutrition Service database; biochemical data were taken from the Healthcare System, and were analyzed.Results. In our analysis, 83.8% were found to be malnourished with 50.3% moderately-malnourished (MM) (Nutrition risk level 1-2) and 33.5% severely-malnourished (SM) (Nutrition risk level ≥3). BMI category and malnutrition were the significant confounders for LOS. After controlling for BMI, LOS was longer by a mean of 2.2 days in SM compared to well-nourished (WN) patients (95% CI=0. 49-3.95, p=0.012). Of the malnourished patients, 6.1% of SM and 0.5% of MM patients died. None of the WN patients died. Feeding route, admitted for neoplasm, low albumin levels and malnutrition were the confounding factors associated with mortality. After controlling for these factors, SM had higher odds of dying compared to MM patients p=0.046)].Conclusion. Among hospitalized non-critically ill adult patients with type 2 diabetes, SM patients but not MM patients had significantly longer LOS compared to WN patients, and greater degrees of malnutrition were associated with higher mortality.
Objectives. The study aimed to compare the performance of weight circumference (WC) measurement using the World Health Organization (WHO) versus National Institutes of Health (NIH) protocol in identifying visceral adiposity, and to determine the association of WC with cardiometabolic risk factors among overweight and obese adult Filipinos.Methodology. A retrospective study involving 221 subjects (99 males, 122 females) evaluated at an outpatient weight intervention center of a tertiary hospital. The WC was measured at the superior border of the iliac crest (WC-NIH) and midway between the lowest rib and the iliac crest (WC-WHO) for each patient. Using visceral fat rating (VF) derived via bioelectrical impedance analysis (BIA) as reference standard, diagnostic accuracy tests for both protocols (using cut-offs of ≥ 90 cm in males and ≥ 80 cm in females) were done. Cardiometabolic parameters were also obtained, and binary logistic regression was performed to determine associations with WC.Results. Among males, WC-WHO had 96% sensitivity (95% CI 88.8%-99.2%) and 25% specificity (95% CI 9.77%-46.7%) while WC-NIH had 94.7% sensitivity (95% CI 86.9%-98.5%) and 29.2% specificity (95% CI 12.6%-51.1%) to predict high VF >12. Among females, WC-WHO had 100% sensitivity (95% CI 90%-100%) and 24.1% specificity (95% CI 15.6%-34.5%) while WC-NIH had 100% sensitivity (95% CI 90%-100%) and 4.6% specificity (95% CI 1.3%-11.4%). Prevalence of high VF was significantly greater among males -75.8% (95% CI 66.1%-83.8%) vs. 28.7% (95% CI 20.9%-37.6%) in females (p<0.001). Among females, WC-NIH tended to have higher measurements than WC-WHO by an average of 4.67 cm. Females with WC-WHO measurements of at least 80 cm were approximately four times more likely to have low (<50 mg/dL) HDL levels (cOR 3.82, p=<0.05), even after adjusting for age (aOR 3.83, p=<0.05).Conclusion. WC measurement using the WHO and NIH protocols were both highly sensitive but had low specificity in predicting high VF estimated via BIA among overweight and obese adult Filipinos in this study. WC-NIH measurements tended to be higher among the females, which may affect classification of central obesity when using this protocol. WC ≥80 cm measured using the WHO protocol was associated with low HDL levels among female subjects. Prospective studies conducted among the general Filipino population are recommended to verify these findings.
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