Nutritional parameters associated with prognosis in non-critically ill hospitalized COVID-19 patients: The NUTRI-COVID19 study

Abstract

Background & Aims To investigate the association between the parameters used in nutritional screening assessment (body mass index [BMI], unintentional weight loss [WL] and reduced food intake) and clinical outcomes in non-critically ill, hospitalized coronavirus disease 2019 (COVID-19) patients. Methods This was a prospective multicenter real-life study carried out during the first pandemic wave in 11 Italian Hospitals. In total, 1391 patients were included. The primary end-point was a composite of in-hospital mortality or admission to ICU, whichever came first. The key secondary end-point was in-hospital mortality. Results Multivariable models were based on 1183 patients with complete data. Reduced self-reported food intake before hospitalization and/or expected by physicians in the next days since admission was found to have a negative prognostic impact for both the primary and secondary end-point (P<0.001 for both). No association with BMI and WL was observed. Other predictors of outcomes were age and presence of multiple comorbidities. A significant interaction between obesity and multi-morbidity (≥2) was detected. Obesity was found to be a risk factor for composite end-point (HR=1.36 [95%CI, 1.03-1.80]; P=.031) and a protective factor against in-hospital mortality (HR=0.32 [95%CI, 0.20-0.51]; P<.001) in patients with and without multiple comorbidities, respectively. Secondary analysis (patients, N=829), further adjusted for high C-reactive protein (>21 mg/dL) and LDH (>430 mU/mL) levels yielded consistent findings. Conclusions Reduced self-reported food intake before hospitalization and/or expected by physicians in the next days since admission was associated with negative clinical outcomes in non-critically ill, hospitalized COVID-19 patients. This simple and easily obtainable parameter may be useful to identify patients at highest risk of poor prognosis, who may benefit from prompt nutritional support. The presence of comorbidities could be the key factor, which may determine the protective or harmful role of a high body mass index in COVID-19.

Recovery Focused Nutritional Therapy across the Continuum of Care: Learning from COVID-19

“…The nutritional consequences of COVID- 19 are not yet fully understood, but the knowledge from severely ill patients with acute respiratory distress syndrome suggests that patients are likely to experience the adverse effects of the loss of muscle mass and skeletal muscle dysfunction for weeks to years. The knowledge from a range of disease states and chronic conditions illustrates that low muscle mass is associated with higher rates of infections, poorer tolerance to chemotherapy, hospitalisation, fractures, reduced quality of life and reduced survival, with implications for patient outcomes and healthcare utilisation [15].…”

“…Obesity may mask malnutrition and muscle loss, but body composition, as assessed by computed tomography, confirms the loss of lean body mass in obese ICU COVID-19 patients, which could lead to the development of sarcopenic obesity [18]. In a recent study of non-critically ill hospitalised COVID-19 patients, obesity (body mass Index (BMI) ≥ 30 kg/m 2 ) in combination with two or more comorbidities were associated with increased in-hospital mortality, whereas the presence of obesity with less than two comorbidities appeared to be a protective prognostic factor [19].…”

“…Indeed, related factors are likely to be present at all stages of the patient journey, as outlined in Table 1. A prospective multi-centre study of non-critically ill hospitalised COVID-19 patients showed that a reduced self-reported food intake before admission to hospital and/or predicted by physicians post-admission was associated with an increased risk of in-hospital mortality or admission to the ICU [19]. In COVID-19 patients in the ICU, achieving a satisfactory caloric intake on day 4 was associated with a lower ICU mortality in a prospective study conducted during the first wave of the pandemic [25].…”

“…Practical guidelines for the nutritional management of acutely unwell inpatients with COVID-19 recommend enteral nutrition (EN) in patients unable to meet their nutritional requirements orally with food-based strategies and oral nutritional supplements (ONS) [11,43]. This is particularly important, since it has recently been shown that a reduced food intake in hospitalised non-critically COVID-19 patients is associated with negative clinical outcomes [19]. A pragmatic approach was proposed early in the pandemic, and based on the existing guidance, it provides a protocol for nutritional screening and support in acute care either before ICU admission or during step-down care from ICU stay [44].…”

Body weight, vitamin D and zinc: A review of associations with coronavirus disease (COVID-19)

“…It has been suggested that the mechanism explaining this association is driven by insulin resistance and increased circulating inflammatory cytokines [17]. It has not been shown that weight loss reduces anxiety; on the contrary, reduced food intake prior to hospitalization has been identified as a predictor of poor outcomes in patients admitted with COVID; moreover, obesity was found to be protective against in-hospital mortality among people without comorbidities [18].…”