Interventions should be tailored to the individual, where the dietitian will be responsible for leading on any nutritional components of the intervention.
This may require the dietitian to liaise with other members of the MDT as and when appropriate.
Listed below are different tools that have been recommended to assist in monitoring recovery.
Some use recalled and subjective measurements, some are suitable for virtual consultations, and some are self-assessment tools.
Suggested test and/or monitoring goals for general population
- Use the Malnutrition Universal Screening Tool ('MUST') [PDF] to assess risk of malnutrition. This has advice on how to screen even if you are unable to take a weight or height
- Ask patients to self-screen for malnutrition risk if they are having remote consultations
- Ask about gastrointestinal symptoms and other COVID-19 symptoms which may be impacting eating and nutritional state
- ABCDE (anthropometric, biochemical, clinical, dietary, environmental) – more information can be found on the BAPEN website
- It is also important to analyse energy and protein and micronutrient intake to provide nutritional recommendations to support the functional recovery of post acute COVID-19 (Gem COVID, 2020). Prediction equations or weight-based formulae or indirect calorimetry if necessary
- For more information on self-assessment tools please see our Identifying who needs nutritional care during COVID-19 recovery
Older adults
Video call to assess frailty, metabolic risk (6 weeks post discharge if applicable) (NHS, 2020).
Older adults may require a family member to help them setting up video or telephone consultations to ensure appropriate assessment and treatment.
Unintentional weight loss is a main concern for those shielding or with other risk factors such as older age or lack of appetite (Butler et al., 2020).
Public Health England (2021) published recommendations for older adults: Wider impacts of COVID-19 on physical activity, deconditioning and falls in older adults (PDF):
- Older adults should participate in daily physical activity to gain health benefits. Some physical activity is better than none: even light activity brings some health benefits compared to being sedentary
- Older adults should break up prolonged periods of being sedentary with light activity when physically possible, or at least with standing, as this has distinct health benefits for older people
- Older adults should maintain or improve their physical function by undertaking activities aimed at improving or maintaining muscle strength, balance and flexibility on at least 2 days a week
- Each week older adults should aim to accumulate at least 150 minutes (2½ hours) of moderate intensity aerobic activity, building up gradually from current levels
There are more resources on this topic in the section dedicated for patients
Suggested test and/or monitoring goals
Emerging or new symptoms ruling out any other conditions that could have caused complications (Eekholm et al., 2020), Mini Nutritional Assessment (Bauer and Morley, 2021).
A before-and-after study (Gobbi et al., 2021) shows 60% (29/48) of older adults admitted to rehab after a hospital stay for COVID-19 were malnourished (using GLIM) moderately (7) and severely (22). Following individually tailored nutritional support (multi-vitamin and mineral supplement, probiotic, essential amino acids, carnitine and protein and energy supplements to meet needs) and exercise programme (strength and aerobic training), no further weight loss was seen, some measures of muscle mass and function improved, and timed-up-and-go test improved (physical performance). This was a small uncontrolled trial, but it suggests high levels of nutritional risk in this patient group, which may respond to nutrition support and exercise rehabilitation.
The World Health Organisation has produced a toolkit: Living with the Times. This is a new toolkit to help older adults maintain good mental health and wellbeing during the COVID-19 pandemic. It is useful for care homes, hospitals, community services, etc. Ideally, it is delivered by a facilitator and a mental health worker, but resources are available for people to read in their own time (WHO, 2021). The toolkit is based on five questions:
- How can I stay healthy?
- What can I do to improve my mood?
- How can I feel connected to my family and community?
- Where can I get help if I need it?
- How can I cope with grief and loss?
Patients under hospital care or recently discharged from hospital
- Follow your local guidance to guide monitoring timescales, however patients who are severely malnourished will require more frequent monitoring. However in recent studies, nutritional interventions suggested short term benefits post ICU (Goodwin et al., 2021).
- For more information about what to monitor and when, follow the NICE guidelines.
- Look for allergies, lifestyle (physical activity, diet, alcohol consumption), past and present symptoms of COVID-19, treatment received for COVID-19 for instance oxygen, antibiotics or other immunomodulators (Gem COVID, 2020).
- GI: stool and urine analysis, gastrointestinal symptoms, irritable bowel syndrome symptoms, severity score.
- Nutrition: anthropometric and biochemical evaluation.
- For patients admitted to hospital, schedule early and regular reviews to assess ongoing symptoms, starting approximately one month after discharge (Cawood et al., 2020; Lawrence et al., 2021).
- People who were in ICU should be offered a multi-disciplinary assessment at discharge and 4-6 weeks later (NHS, 2020).
- For post discharge consider evaluation of impairments in physical, functional, cognitive, psychosocial, and occupational aspects (Aytür et al., 2020).
Suggested tests and/or monitoring goals
- Use validated tools to monitor progress according to NICE guidelines. See more details in our Identifying who needs nutritional care during COVID-19 recovery section.
- Body mass index, body circumferences, bioelectric impedance analysis (simple, quick, non invasive technique to measure body fat and muscle mass).
- Assessment should at least include measures that allow understanding of persistent physiological limitations (e.g., lung function, exercise and functional capacity, muscle function, balance) and patient-reported outcomes (e.g., symptoms and health-related quality of life) (B Balbi et al., 2020).
- Exercise training and/or physical activity coaching in non-infectious COVID-19 patients with residual lung function impairment should be done by a health professional with previous experience in rehabilitation of patients with respiratory limitations (B Balbi et al., 2020).
- Sarcopenia, respiratory support, impact on cognitive status and dysphagia, additional to weight loss should be monitored to improve functional status and quality of life (Brugliera et al., 2021).
Specific conditions needing a tailored approach
| Suggested test and/or monitoring goals | |
|---|---|
| Chronic respiratory diseases such as COPD |
Monitored by dietitians to monitor quality and quantity of diet, especially energy (kcal) and vitamin D (Weekes, Emery and Elia, 2009). Monitoring of pre-existing comorbid conditions in COVID-19 survivors during rehabilitation is warranted to guarantee safety of the rehabilitative interventions, and to optimise health of these patients. This may require availability of a multidisciplinary team of medical specialists (B Balbi et al., 2020). |
| Diabetes | A lower caloric intake but higher protein may be beneficial (Ochoa et al., 2020). |
| Enteral tube feeding at home | Should be monitored by a dietitian and difficulties with swallowing pathology should be monitored by a Speech and Language Therapist and dietitians and if necessary, specific diagnostic tests (NHS, 2020). |