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Translating the ESPEN COVID19 nutrition guidance into practice

10 practical recommendations for nutritional management of COVID-19 patients including a sample meal plan
28th Apr 2020
The European Society for Clinical Nutrition and Metabolism (ESPEN) is a multidisciplinary society devoted to the study of metabolic problems associated with acute diseases and their nutritional implications and management. The members and partners of this established authority are key European professional experts in public health and healthcare. As a response to the COVID-19 pandemic ESPEN has established concise guidance for nutritional management of COVID-19 patients by proposing 10 practical recommendations for those working in ICU, with older adults or those with polymorbidity. 

Prevention and treatment of malnutrition in individuals at risk or infected with SARS-COV-2

 The paper provides concise guidance for the nutritional management of patients with COVID-19 by suggesting 10 practical recommendations. This practical guidance is focused on those in the intensive care unit (ICU) setting or in the presence of older age and polymorbidity, both factors that are independently associated with malnutrition and its negative impact on patient survival.

The presence of at least 2 chronic diseases in the same individual can be defined as polymorbidity and is also characterised by high nutritional risk. 

  1. Screen for malnutrition
    The prevention, diagnosis and treatment of malnutrition should be routinely included in the management of individuals with COVID-19.

    High risk patients and patients with SARS-COV-2 infection, specifically older adults and polymorbid individuals, should be evaluated using the Malnutrition Universal Screening Tool (MUST) or the Nutrition Risk Screening 2002 (NRS-2002) criteria for hospitalised patients. 
  2. Optimise nutrition status
    Subjects with malnutrition are advised to optimise their nutritional status. This can be done ideally by diet counselling from an experienced professional who can adjust targets based on nutritional status, physical activity status, disease and tolerance (registered dieticians, experienced nutritional scientists, clinical nutritionists and specialized physicians).

    Energy needs can be assessed by indirect calorimeter, predictive equation (such as Henry Oxford) or a weight-based calculation:
    - 27 kcal/kg per day for polymorbid patients aged >65 years
    - 30 kcal/kg per day for severely underweight polymorbid patients*

    *The target of 30kcal/kg body weight in severely underweight patients should be cautiously and slowly achieved, as this is a population at high risk of refeeding syndrome. 

    Protein intake is to help prevent body weight loss, reduce risk of complications and hospital readmission and improve functional outcome
    - 1g protein/kg per day in older persons >65
    - > 1g protein/kg per day in polymorbid medical inpatients

    Fats and carbohydrates should be provided in an energy ration of 30:70 for patients with no respiratory deficiency or 50:50 for ventilated patients 
  3. Ensure adequate micronutrient status
    Subjects with malnutrition should ensure sufficient supplementation with vitamins and minerals:

    ● Supplementation and/or adequate provision of vitamins is part of the general nutritional approach for viral infections prevention to possibly reduce disease negative impact.

    ● In general, low levels or intakes of micronutrients such as vitamins A, E, B6 and B12, Zn and Se have been associated with adverse clinical outcomes during viral infections.

    ● Future investigations should confirm whether insufficient vitamin D status is specifically associated with COVID-19 patients. 
  4. Maintain regular physical activity
    Patients in quarantine should continue regular physical activity while taking precautions:

    ● Under particular precautions, even outdoor activities can be considered such as garden work (if a own garden is present), garden exercise (i.e. badminton), or walking/running in the forest (alone or in small family groups while maintaining a distance of 2m from others).

    ● Every day > 30 min or every second day > 1h exercise is recommended to maintain fitness, mental health, muscle 248 mass and thus energy expenditure and body composition. 
  5. Oral nutritional supplements (ONS)
    Oral nutritional supplements (ONS) should be used whenever possible to meet patient’s needs: When dietary counselling and food fortification are not sufficient to increase dietary intake and reach nutritional goals, ONS shall provide at least 400 kcal/day including 30 g or more of protein/day and shall be continued for at least one month. Efficacy and expected benefit of ONS shall be assessed once a month. 
  6. Enteral nutrition (EN)
    In polymorbid medical inpatients and in older persons with reasonable prognosis, whose nutritional requirements cannot be met orally, enteral nutrition (EN) should be administered. Parenteral nutrition (PN) should be considered when EN is unable to reach nutritional targets:

    ● Enteral nutrition should be implemented when nutritional needs cannot be met by the oral route, when oral intake is expected to be impossible for more than three days or expected to be below half of energy requirements for more than one week.

    ● In these specific cases, the use of EN may be superior to PN, due to a lower risk of infectious and non-infectious complications. 
  7. Medical nutrition in non-intubated ICU patients
    If the energy needs cannot be reached with an oral diet, ONS should be considered first and foremost followed by EN treatment. If limitations are present for the enteral route it is advised to prescribe peripheral PN in the population not reaching energy-protein target by oral or enteral nutrition.

  8. Medical nutrition in intubated and ventilated ICU patients (I)
     ● EN should be started through a nasogastric tube; post-pyloric feeding should be performed in patients with gastric intolerance after prokinetic treatment or in patients at high-risk of aspiration.

    ● Patient energy expenditure (EE) should be determined to evaluate energy needs by using indirect calorimetry when available. If calorimetry is not available, VO2 (oxygen consumption) from pulmonary arterial catheter or VCO2 (carbon dioxide production) derived from the ventilator will give a better evaluation on EE than predictive equations.

    ● Energy administration:
    Hypocaloric nutrition (not exceeding 70% of EE) should be administered in the early phase of acute illness with increments up to 80-100% after the third day. If predictive equations are used to estimate the energy need, hypocaloric nutrition (below 70% estimated 341 needs) should be preferred over isocaloric nutrition for the first week of ICU stay due to reports of overestimation of energy needs.

    ● Protein requirements:
    - During critical illness, 1.3g/kg protein equivalents per day can be delivered progressively.
    - In obese patients, in the absence of body composition measurements 1.3g/kg “adjusted body weight” protein equivalent per day is recommended.

    ** Adjusted body weight is calculated as ideal body weight + (actual body weight - ideal body weight) * 0.33 
  9. Medical nutrition in intubated ICU patients (II)
    ● In ICU patients who are unable to tolerate the full dose of EN during the 1st week in ICU, initiating parenteral nutrition (PN) should be weighed on a case-by-case basis.

    ● PN should not be started until all strategies to maximise EN tolerance have been attempted.

    ● When patients are stabilised, enteral feeding can be started ideally after measuring indirect calorimetry targeting energy supply to 30% of the measured EE. Energy administration will be increased progressively.

    ● During emergency times, the predictive equation recommending 20 kcal/kg/day could be used and energy increased to 50-70% of the predictive energy at day 2 to reach 80-100% at day 4.

    ● The protein target of 1.3 g/kg/day should also be reached by day 3-5.

    ● The use of enteral omega-3 fatty acids may improve oxygenation but there is no strong evidence supporting this.

    ● Blood glucose should be maintained at target levels between 6-8 mmol/l, along with monitoring of blood triglycerides and electrolytes including phosphate, potassium and magnesium. 
  10. Nutrition in ICU patients with dysphagia 
    ● Texture adapted food can be considered after the tube that aids in breathing is removed from patients.

    ● If swallowing is proving unsafe EN should be administered. 

Translating the ESPEN guidelines into a meal plan

Nutritics can be used to set the targets required for the individual patients needs. Click here for a sample meal plan generated using Nutritics for a hypothetical female, Polymorbid* patient with the following characteristics: 
Age: 69
Weight: 65kg
Height: 1.62m 
* Polymorbidity refers to an individual with two or more underlying chronic diseases. 

Translating the ESPEN guidelines into a meal plan for this patient 

Energy needs: 27kcal/kg per day
Protein needs: 1g/protein/kg per day
Energy ratio from fat and carbohydrates at 30:70
Fat: (440 kcals): Carbohydrate: (1,040 kcals) 

This meal plan achieves adequate micronutrient intake based on population health targets (EFSA).