Nutrition risk prevalence and nutrition care recommendations for hospitalized and critically-ill patients with COVID-19.

As of February 14th, 2021, the coronavirus disease 2019 (COVID-19) pandemic caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) resulted in 108 million cases and 2.4 million deaths worldwide, with new cases and deaths still being reported [1]. Clinical presentation of COVID-19 at illness onset and over the course of the disease vary from asymptomatic to severe pneumonia with acute respiratory distress syndrome (ARDS), with the most common symptoms being fever, cough, and fatigue [2,3]. Though an individual of any age can contract COVID-19, increasing age and co-morbidities are strong risk factors for severe illness with most patients aged 30–79 years with at least one comorbidity [4,5]. The most commonly reported comorbidities are hypertension, diabetes, and cardiovascular disease (CVD) [3]. Both age and comorbidities are positively associated with disease severity and mortality risk [5]. Overall, approximately 14% of all COVID-19 cases are considered severe and about 5% of all cases and 20% of the hospitalized population require admission to an intensive care unit (ICU) [6]. Multiple chronic diseases or co-morbidities, including diabetes and cardiovascular disease, affect more than 70% of hospitalized adult patients and are often associated with increased risk and prevalence of malnutrition and poorer outcomes [[7], [8], [9]]. The presence of co-morbidities adds complexity to meeting nutritional needs due to the interactions of the diseases, disease state, and nutrition status. In hospitalized patients with co-morbidities, the healthcare team often struggles with prioritizing nutritional management of the primary disease while juggling the underlying nutritional demands of concurrent diseases [8]. Recognizing nutritional risk in these patients is crucial in intervening early to address nutritional needs that may impact outcomes. Similarly, recognizing and treating nutritional risk may play a role in disease severity and outcomes in hospitalized patients with COVID-19 who have multiple co-morbidities. In fact, malnutrition is the leading cause of immunodeficiency and is associated with increased viral infection disease severity, such as in the case of the 1918 influenza pandemic [10,11]. Critically ill hospitalized patients are at higher risk of malnutrition, with 38–78% of patients in the ICU being malnourished; and malnutrition is associated with worse clinical outcomes in the ICU [12]. Despite the obviously important relationship between nutritional status and clinical outcomes in severely or critically ill COVID-19 patients, the prevalence, severity, and treatment of malnutrition in this population remains to be fully elucidated. As concluded in a recent scoping review, many gaps exist in the clinical evidence for nutritional management of hospitalized COVID-19 patients [13]. In response to the limited evidence during the rapidly changing circumstances related to COVID-10, many editorials, review articles, and guidance were published using inference to other disease states to guide health care professionals. However, this can be difficult to extrapolate. The phenotype exhibited by acute COVID-19 is unique as characterized by severe hyperglycemia, severe renal failure, increased rate of thrombotic events, and infrastructural problems such as shortage of pumps and lack of protocols. As the scientific literature is rapidly expanding in this population, new data is available that can further guide and improve the nutrition care process and clinical outcomes. The purpose of this review is to summarize recently published evidence and guidance on nutritional status and medical nutrition therapy (MNT) and its relationship to outcomes in hospitalized and critically ill COVID-19 patients following each stage of the nutrition care process.