Analysis

How nutrition can aid successful long-term recovery from COVID-19

Nutritional support will be vital to help patients struggling with the lasting effects of coronavirus

Nutritional support will be vital to help patients struggling with the lasting effects of coronavirus

  • People with, and who have had COVID-19 may face a long road to recovery and nutrition will play a central role
  • New guidance suggests there will be a prevalence of malnutrition among recovering patients and there is a danger this may be missed, particularly in those with obesity
  • Tips on providing nutritional care for this patient group, plus how food provision in hospitals for NHS staff has changed
Picture: iStock

More than 100,000 patients with COVID-19 have been looked after in hospitals in England alone, and most have been able to recover and leave hospital.

However, it

Nutritional support will be vital to help patients struggling with the lasting effects of coronavirus

  • People with, and who have had COVID-19 may face a long road to recovery – and nutrition will play a central role
  • New guidance suggests there will be a prevalence of malnutrition among recovering patients and there is a danger this may be missed, particularly in those with obesity
  • Tips on providing nutritional care for this patient group, plus how food provision in hospitals for NHS staff has changed
Picture: iStock

More than 100,000 patients with COVID-19 have been looked after in hospitals in England alone, and most have been able to recover and leave hospital.

However, it is clear that for many of those who have survived, the virus and the treatment they have had as a result will have a lasting impact on their health, and they will need ongoing physical and mental health support.

COVID-19 will have a long-lasting impact on patients’ health

NHS England guidance on the aftercare needs of patients recovering from COVID-19 calls for tailored rehabilitation plans – and nutrition is going to play a vital role.

British Dietetic Association (BDA) critical care specialist group committee member Louise Albrich says significant numbers of patients will need support.

More than 5,000 patients have been discharged from intensive care during the pandemic so far. Those who spend time in intensive care are at risk of what is known as intensive care-acquired weakness, characterised by fatigue, loss of muscle strength and feeling weak.

What nurses can do to support patients’ rehabilitation

Ms Albrich says the consequences for COVID-19 patients seem to be even more severe than normal for intensive care unit (ICU) patients because of the length of time they have tended to spend in ICU and the ‘amplified inflammatory state’ that characterises the disease.

100,000

people treated for COVID-19 in hospitals in England as of early July 2020

Source: NHS England

Audits show that the average length of stay is 12 days for those who survive to discharge, twice that of patients with non-COVID pneumonia.

‘Patients have experienced severe muscle and weight loss, which means post-ICU they need carefully managed nutritional plans, rich in protein and nutrients to help them recover,’ she says.

‘Nutrition is vital. We need it for every single metabolic process in the body – for fighting the disease and for healing and replenishing afterwards. It cannot be seen as a plaster to fix problems, but a building block for a long recovery journey.’

Dietitians are an essential part of multidisciplinary recovery team

Ms Albrich says the pandemic placed such sustained pressure on services that dietitians from elsewhere in the hospital and from the community had to be trained to work with critical care patients.

But she adds: ‘This is not just about patients who have ended up in intensive care. Even those without severe symptoms will need their nutritional requirements addressed.’

‘Nutrition is vital. We need it for every single metabolic process in the body – for fighting the disease and for healing and replenishing afterwards. It is a building block for a long recovery’

Louise Albrich, member of the British Dietetic Association critical care specialist group committee

Ms Albrich says addressing these problems requires a multidisciplinary team effort with dietitians working alongside nurses, healthcare assistants, allied health professionals and hospital caterers to support patients.

‘We are now seeing COVID-19 clinics and recovery programmes being introduced, and dietitians will be an essential part of that.

Malnutrition is likely to be a common problem

A number of pieces of guidance have been published to help patients and health professionals aid recovery during and after COVID-19. Crucial to the support and tailored plans patients receive will be regular screening.

The Managing Adult Malnutrition in the Community team has worked with the British Dietetic Association (BDA) and the British Association for Parenteral and Enteral Nutrition (BAPEN) to develop a range of patient information leaflets.

The leaflets are tailored to how severely unwell a patient has been.

The team warns that malnutrition, although not yet documented in COVID-19 patients, is likely to be a common problem.

Acute illness is already known to lead to poor appetite and intensive care stays, while tube feeding in intensive care can make swallowing difficult.

But added to that is the fact that many COVID-19 patients are known to experience a loss of taste, upset stomach and a general catabolic response in the body involving significant protein loss.

Read more articles on malnutrition

BAPEN is now conducting two surveys of healthcare staff – one in the community and one in hospital – to gain a better understanding of the nutritional needs of patients affected by COVID-19.

295,817

people had tested positive for COVID-19 as of 21 July 2020

Source: Department of Health and Social Care/Public Health England

The BDA has also released guidance that gives staff and patients advice about nutrition in hospital and at home after critical illness. It includes tips on what food should be consumed and how patients can be helped if they have difficulty swallowing.

Prevalence of obesity may mask cases of malnutrition

An added complication is the fact that a number of COVID-19 patients were obese when they entered hospital.

The concern – and this is recognised in the NHS England guidance – is that this may lead to malnutrition not being identified.

BAPEN’s National Nurses Nutrition Group chair Claire Campbell says that is a real risk.

‘There is a common misconception that if you are obese you have a reserve of strength, but you still need fuel for recovery. The muscle loss will be substantial.

Claire Campbell: ‘Good nutrition will
help patients fight the infection’

‘We are seeing some really weak patients come out of intensive care – and in fact even those who have been on wards have deteriorated quite significantly too.’

Ms Campbell, a nutrition support nurse specialist, says appropriate screening, for example using the Malnutrition Universal Screening Tool (MUST) should be carried out every week on patients and a detailed action plan developed for their nutritional needs.

‘The role of nutrition in rehabilitation has often been the poor relation. But as we don’t have much in the way of treatment for the disease, I think the importance of nutrition is being recognised – not just in the recovery stage, but also to help patients fight the infection when they are deteriorating.

‘We are seeing a much lower threshold for the issuing of oral nutrition supplements. That is important because when someone has breathing difficulties, eating food can be difficult.’

Nutritional care for people recovering from COVID-19: key points

  • Nutrition is a vital part of the recovery process, particularly among those who have been critically ill or experienced cardiac or pulmonary distress
  • Patients require individually tailored nutrition support, started as early as possible
  • Diet enrichment should suffice for most, but there is an increased need for oral nutritional supplements
  • Patients with dysphagia will need their food and support to be adapted
  • Some patients will need ongoing support once they have been discharged into the community
  • There is a risk of misidentifying malnutrition because of the high proportion of COVID-19 patients who are obese or overweight

Source: NHS England

Patients will need ongoing support

RCN professional lead for older people Dawne Garrett says it is also essential not to overlook the need for patients to receive support during meal times when they are in hospital.

‘My concern is whether there are enough staff available with the necessary skills to assist with feeding,’ she says.

13.57 million

antigen, antibody, blood and swab tests had been either processed or sent out in the UK as of 21 July

Source: Department of Health and Social Care/Public Health England

‘These skills sit predominantly with those who work on older people’s wards – nurses will take the lead with those who have trouble swallowing, while healthcare assistants help others.’

Dr Garrett is also worried the use of personal protective equipment could affect this. ‘For patients who may be confused or have delirium, having someone turn up with masks and visors on could be quite disturbing.’

As patients become ready for discharge, there is also going to be a need for support in the community, Dr Garrett says.

Patients should receive at least one follow-up check following discharge, with those needing ongoing support getting regular input from community dietitians.

But this, historically, has been a challenge, with discharge notes not always containing the relevant information about nutrition. Some studies suggest only 15% do, according to NHS England guidance.

Some older people will have neglected their nutrition while shielding

Dr Garrett says it is not just patients in recovery from COVID-19 who will need support with nutrition.

Dawne Garrett: ‘Older people may have
neglected their nutrition while self-isolating’

‘We are beginning to find significant numbers of people who have deteriorated in the community and are at risk of malnutrition because they have been shielding or isolating. These are frail people and the lockdown has had a huge impact on them.’

But she says this is not just a risk for these people – even those who were previously considered fit, healthy and independent may find themselves in need of help.

‘There are lots of older people who would have gone to lunch clubs and day centres or met friends for food. Without that interaction and because of fear of going to the supermarket, they may have neglected their nutritional needs.

‘District nurses and social care are already now having to deal with this. Unfortunately sourcing nutritional meals and food in the community is not always easy.

‘There are services being provided by faith groups, charities and local authorities. Many are doing some really good work, but they are not available everywhere.’

Has the pandemic changed the way food for staff is provided in hospitals?

It was one of the more positive stories to emerge from the pandemic: restaurants, pubs and shops came together to feed the NHS.

National campaigns, such as Feed NHS and Meals for NHS, raised millions in donations and supplied hundreds of thousands of meals during the peak of the pandemic.

But how much difference did it actually make? Nurses have reported being overwhelmed by the generous donations – in some places there were so many food packages and meals, some had to be passed on to food banks and local charities helping to feed vulnerable groups.

The focus on the donations has also obscured the fact that hospital caterers and staff canteens carried on working throughout the pandemic.

There are multiple examples staff canteen opening hours being extended, with Milton Keynes University Hospital NHS Trust even offering free meals to those who worked past 6pm.

Most hospital canteens have remained open throughout the pandemic

Hospital Caterers Association chair Craig Smith says: ‘There’s been a complete misconception about what happened to hospital catering during the pandemic. Some restaurants and chains had pretty slick PR – it ended up giving the impression that staff canteens just shut.

‘But by and large they have been open, with many opening extended hours. Our staff have been on the front line of this, along with doctors, nurses and porters.’

He says hospital caterers had to ‘bite their tongue’ as some of the donations flooded in.

Despite misconceptions, many hospital canteens remained open throughout lockdown Picture: Alamy

‘Hospital caterers have some of the most stringent safety and nutrition regulations. Some of the food that was donated simply wasn’t what we could serve. I have seen pictures of tables full of chocolates and cakes. In some cases we’ve had to politely decline the offers.’

Mr Smith says donations worked best where local eateries worked in close cooperation with hospital catering managers, discussing the nutritional requirements.

But with the donations now drying up and the postponed government hospital food review likely to be published in the coming months, the lasting legacy of the pandemic when it comes to food may be in the retention of some of the pop-up stores that were created.

Pop-up stores in hospitals have proved popular

A number of hospitals worked with local shops to create temporary stores, giving staff the opportunity to grab essential items like soup, pasta and toiletries rather than trying to go to supermarkets.

Some of this was motivated by the fact retail stores in hospitals closed during the lockdown.

The Royal Wolverhampton NHS Trust opened a pop-up grocery shop for staff
Picture: The Royal Wolverhampton NHS Trust

Staff have reported they have been welcome and places such as The Royal Wolverhampton NHS Trust are planning on keeping them going.

The hospital’s acute medical unit (AMU) has created a wobble room for staff to take time out from the front line. It contains a mini-shop. Items were originally donated, but it has now become self-sustaining.

Staff are able to take products for free on the basis that they top-up the store with food when they do get the chance to do their shopping.

AMU directorate manager Charlotte Keates says it is working well. ‘When staff are doing 12-hour shifts and they are exhausted, getting to the shops is not easy.’


Further information

NHS England: After-care needs of inpatients recovering from COVID-19

BDA guidance on nutrition at home after critical illness

BDA guidance on nutritional management for non-ICU COVID-19 patients

BAPEN guidance for using Malnutrition Universal Screening Tool

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