Approaches to Nutritional Screening in Patients with Coronavirus Disease 2019 (COVID-19)

Abstract

Malnutrition is common among severe patients with coronavirus disease 2019 (COVID-19), mainly elderly adults and patients with comorbidities. It is also associated with atypical presentation of the disease. Despite the possible contribution of malnutrition to the acquisition and severity of COVID-19, it is not clear which nutritional screening measures may best diagnose malnutrition in these patients at early stages. This is of crucial importance given the urgency and rapid progression of the disease in vulnerable groups. Accordingly, this review examines the available literature for different nutritional screening approaches implemented among COVID-19 patients, with a special focus on elderly adults. After a literature search, we selected and scrutinized 14 studies assessing malnutrition among COVID-19 patients. The Nutrition Risk Screening 2002 (NRS-2002) has demonstrated superior sensitivity to other traditional screening measures. The controlling nutritional status (CONUT) score, which comprises serum albumin level, cholesterol level, and lymphocytes count, as well as a combined CONUT-lactate dehydrogenase-C-reactive protein score expressed a predictive capacity even superior to that of NRS-2002 (0.81% and 0.92% vs. 0.79%) in midlife and elder COVID-19 patients. Therefore, simple measures based on routinely conducted laboratory investigations such as the CONUT score may be timely, cheap, and valuable alternatives for identifying COVID-19 patients with high nutritional risk. Mini Nutritional Assessment (MNA) was the only measure used to detect residual malnutrition and high malnutrition risk in remitting patients—MNA scores correlated with hypoalbuminemia, hypercytokinemia, and weight loss. Older males with severe inflammation, gastrointestinal symptoms, and pre-existing comorbidities (diabetes, obesity, or hypertension) are more prone to malnutrition and subsequently poor COVID-19 prognosis both during the acute phase and during convalescence. Thus, they are in need of frequent nutritional monitoring and support while detecting and treating malnutrition in the general public might be necessary to increase resilience against COVID-19.

Screening for Sarcopenia (Physical Frailty) in the COVID-19 Era

“…COVID-19 patients either treated at home or in the hospital, especially in the ICU, are prone to wasting and muscle loss [ 39 , 41 ]—in particular, patients with polypharmacy, prolonged hospital stay, immobility (in the prone position for a long time), body protein loss, and gastrointestinal symptoms that decrease food intake or increase nutrient loss (anorexia, vomiting, and diarrhea) [ 28 , 37 , 38 ]. Therefore, skeletal muscle assessment may be necessary in severe patients exhibiting weight loss and malnutrition or a high risk for malnutrition [ 28 , 38 ].…”

“…Despite their simplicity and low cost, TBK and PBK are not favorable for estimating muscle mass because muscle mass calculations are based on many assumptions that may not hold in aged or diseased individuals such as constant intracellular potassium content, nitrogen content, and hydration coefficient of lean body mass [ 99 , 120 ]. In this regard, this technique may not suit COVID-19 patients because they exhibit hypoproteinemia, multiple micronutrient deficiencies, and electrolyte imbalance [ 28 , 37 ].…”

“…However, physical performance may not be seriously altered despite muscle wasting/weakness [ 7 ]. Therefore, measures of frailty may be unfavorable for assessing skeletal muscle injury, which is the result of excessive protein degradation that leads primarily to muscle loss/weakness in hospitalized COVID-19 patients, usually over short periods of time [ 3 , 28 , 37 , 38 ]. This notion gets support from the findings of a large-scale study predicting COVID-19 prognosis based on two measures of frailty: (1) FI, a 49-item scale that describes aspects of health, disease, disability, and mental wellbeing and (2) the frailty phenotype defined by Fried et al based on five criteria: weight loss, exhaustion, physical activity, walking speed, and grip strength [ 49 ].…”

“…Although weight loss is higher in ICU-admitted patients [ 39 , 40 ], it was also recorded in patients treated at home [ 41 ]. Fatigue and myalgia are common symptoms in severe and fatal COVID-19 patients while markers of muscle damage (e.g., creatine kinase, CK) are rather high [ 3 , 28 , 37 , 38 ]. Body composition estimation in ICU-admitted COVID-19 patients denotes excessive loss of muscle mass following their ICU stay [ 42 ]—highlighting the high vulnerability of these patients to ICU-acquired weakness [ 38 ].…”

“…Screening for physical frailty in non-COVID-19 patients and in older populations has been integrated in primary healthcare in some countries as an attempt to target immune vulnerability among these individuals during the current outbreak [ 50 – 52 ]. Likewise, identification of COVID-19 patients liable to skeletal muscle injury may be necessary to provide adequate nutritional and physical rehabilitation therapies in order to facilitate recovery and prevent postrecovery disability [ 28 , 38 , 46 ]. Given that routine clinical care for COVID-19 patients focuses primarily on promoting survival, the estimation of muscle quantity or muscle strength is less considered, which may be associated with extreme later suffering after discharge out of the development of disability, even in young individuals [ 15 ].…”