First contact with a healthcare professional
Patients should also be screened at first healthcare professional contact when:
- 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 (Long Covid)
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 recovery page for advice on how to do this.
For patients who require referral, make sure you distinguish between existing long-term conditions and COVID-19-related complications (NICE, 2020).
(NHS, 2020; Lawrence et al., 2021).
Overweight and patients living with obesity
- Malnutrition can occur in people who are living with overweight or obesity. This is why it is important to screen everyone for malnutrition risk regardless of weight. Nutritional deficiencies from sub-optimal eating patterns lead to decreased immune function and impaired resistance to infection.
- People who are living with overweight or obesity appear to be disproportionately affected by COVID-19.
- Hospitalisation for COVID-19 is 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 more likely to require a referral to dietetics services (Burridge et al., 2020).
- In those with Long Covid, the inflammatory process that exacerbates catabolism and anorexia can increase malnutrition risk and impede recovery. This may result in disability and reduced quality of life (Mechanick et al., 2021).
- 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.
Frail or sarcopenic patients
Malnutrition often occurs alongside frailty and may occur in those with sarcopenia. Assessment of frailty or sarcopenia may be appropriate.
Frailty can be assessed using the clinical frailty scale [PDF] from the NHS Specialised Clinical Frailty Network.
Sarcopenia can be assessed using a tool such as SARC-F.
Hospitalised patients
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). NICE Clinical Guideline 32 states that all hospitalised patients should be screened within 24 hours of admission for malnutrition risk using a validated tool.
It should be noted that it may not be appropriate to screen patients receiving end-of-life care or those where nutritional intervention to treat malnutrition is no longer appropriate or in the best interest of the patient. This should be discussed with the clinical team with outcomes clearly documented.
Primary care follow-up may be needed, particularly in those who are vulnerable or at high risk of malnutrition (NHS, 2020).
Community and outpatients
People in the community from vulnerable or high-risk groups should be screened for nutritional risk.
Patients should also be screened at their first contact with a healthcare professional and then as clinically indicated (Cawood et al., 2020; NHS, 2020; Lawrence et al., 2021). This may include patients who have:
- Symptoms persisting after 12 weeks from a diagnosis of COVID-19 i.e. Long Covid
- Significant change in clinical, psychological or social condition
- Nutrition support including oral nutritional supplements or enteral feeding
Patients in post-COVID-19 clinics will need screening for malnutrition risk 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.
Care homes
Internationally 19–72% (depending on the country) of COVID-19 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 NHS Framework and the Enhanced Health in Care Homes: A guide for care homes [PDF] provides guidance on good practice in care homes. Nutrition and hydration are core care elements of care, with nutritional standards for care homes provided in The Nutrition and Hydration Digest, produced by the British Dietetic Association. Following such guidance should help ensure residents' nutrition needs related to COVID-19 are addressed.
This is an example of a whole care home approach [PDF]. Dietitians are key multidisciplinary team members (MDT) that should be co-opted into the MDT meetings when needed.
Malnutrition
Screening is for malnutrition risk is vital to identify malnourished patients or those at risk of malnourishment.
Risk of malnutrition can be identified using a validated screening tool. Self-screening can also be used. This has advantages due to infection control measures and should be encouraged. Screening for malnutrition risk can be carried out by anyone who is trained working in health and social care settings.
For self screening tools to ask your patients to use, see our page Is what I eat affecting my recovery?
There are many screening tools available and your own organisation is likely to recommend a screening tool to use. Examples include:
- Malnutrition Universal Screening Tool (MUST)
- Mini-Nutrition Assessment Short Form (MNA-SF) [PDF]
Screening tools are a guide and your own clinical judgement should be used, informed by any relevant, recent measurements of the individual’s 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?