Recovery focused nutritional therapy across the continuum of care​

With the emergence of Covid 19, the spotlight turned to ICU and long-term recovery across different care settings. The pandemic saw many medical and nutritional societies update key guidelines to enable healthcare professionals (HCPs) and systems to respond to the crisis and optimize care pathways.

A group of experts published a review paper emphasizing how healthcare professionals could take the learnings of the Covid 19 pandemic and apply it more broadly by using an assertive, multi-modal nutrition support approach. The publication emphasizes the need for continued medical nutrition therapy through different settings and particularly at hospital discharge, where break points in care are often found. ​


Publication in Nutrients​

The publication ‘Recovery Focused Nutritional Therapy across the Continuum of Care: Learning from COVID-19’ has now been published. This review paper is of relevance to doctors and other HCPs in acute care and primary care worldwide since it addresses early, multi-modal individualized nutrition intervention across the continuum of care to improve patient outcomes in COVID-19 with learnings to extend to the care of vulnerable, hospitalized patient groups.

Impact of inadequate nutrition​

The paper looks at the value of nutritional intervention along the entire continuum of care. Inadequate nutrition can have an impact on body weight, muscle mass and physical performance across the patient journey. Table shows symptoms, metabolic, nutritional status and nutritional intake factors contributing to malnutrition and impaired/delayed recovery across the continuum of care. It is well characterized that many patients that have extended ICU stays never return to their original level of ability, with it often taking years to fully recover.​

The primary goal of the publication is to prevent complications where possible and support recovery to enable COVID-19 patients to achieve the best possible nutritional, physical, functional and mental health status and to apply learning to date from the COVID-19 pandemic to other patient groups experiencing acute severe illness.

Page 1 publication

Feeding decision tree supporting patients​

Targeted nutritional therapy must be started early in severe illness, such as in COVID-19, and sustained through to recovery to improve clinical and patient-centred outcomes [1].

Page 9 publication

This feeding decision tree provides a concrete, credible, and guideline supported visual to enable HCPs to ensure patient’s nutritional needs are being actively addressed.

At Nutricia we value the ability to provide nutritional solutions for patients at every step towards their recovery.  Alongside the feeding decision tree, we have placed key products to support healthcare professionals select products based on the patient’s clinical need. ​

From hospital to home​

Multiple nutritional challenges highlight the need for early  individualized  nutrition intervention.1

Potential impact of
pre‌-‌existing factors
Non-communicable diseases, such as obesity or diabetes and/or pre-existing malnutrition, frailty, sarcopenia
Effects of
acute illness
Stress/inflammatory response, increased resting energy expenditure (REE) and protein catabolism, bed rest/sedation, oropharyngeal dysphagia, gastrointestinal (GI) disturbances, muscle atrophy
in intake
“Substantial nutrient intake deficits can accumulate quickly during hospital stay and without effective handover can be overlooked as patients move through different care levels e.g. ICU, step-down care and ward care.”
“Malnutrition, loss of lean body mass and physical function contributing to impaired or delayed recovery” See table 1, page 4 of publication

Nutritional care in ICU​

​Learn more on enabling individualized nutritional care during hospitalization, including in the ICU on page 5 and 6 of the publication1.

“Need for early, assertive nutrition intervention in critically ill and non-critically ill hospitalised patients to mitigate (..) malnutrition, loss of lean body mass and function that in turn impair and delay recovery”

“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)”

COVID-19 patients show progressive hypermetabolism and considerable variation in REE throughout ICU stay

  • Indirect Calorimetry recommended when possible to measure REE
  • Early EN using continuous gastric feeding starting within 24-36 hours of ICU admission or within 12 hours of intubation
  • Aim to provide 70% of estimated or 100% of measured requirements reached over 4‌-‌5 days

Did you know?

“Nutrient deficits accumulate during hospital stay”

  • “More than 50% of patients do not finish their meals in the ward”
  • “Only 56% of ICU patients meet their requirement for energy and 52% for protein”
  • “Up to 60% of post ICU patients on oral nutrition alone do not meet their energy requirements and up to 70% do not meet their protein targets”

Nutritional care during hospitalization​

​Learn more on enabling individualized nutritional care during hospitalization, at the ward as well as ICU on page 5 and 6 of the publication.

“Need for early, assertive nutrition intervention in critically ill and non-critically ill hospitalised patients to mitigate (..) malnutrition, loss of lean body mass and function that in turn impair and delay recovery”

“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)”

“Patients with oropharyngeal dysphagia must be prospectively identified. Compensatory treatments, including a texture-modified diet, fluid thickening and specific rehabilitation procedures, should be provided, with EN continued until oral intake is sufficient to meet the energy and protein needs”

  • Multi-modal nutritional therapy means the use of multiple methods employed by the multi-disciplinary team and based on the individual needs and goals identified during nutritional assessment.
  • A combination of nutritional interventions, e.g., dietary counselling, food fortification, food texture modification, thickened fluids, oral nutritional supplements, enteral or parenteral nutrition, should be used, depending on patient needs.

Did you know?

“Ongoing nutritional needs frequently not addressed at discharge”

  • “88% received ONS in hospital, but only 6.6% scripted post-discharge”
  • “Only 11% of HCPs estimated that all patients with COVID-19 were discharged from hospital with a clear nutrition plan”

After hospital discharge​

Since hospital stay is increasingly short, resolution of malnutrition cannot be achieved in the acute care setting. It is therefore paramount that nutritional care is carefully coordinated at hospital discharge.

Page 7 of the publication[1]

Key challenges at discharge​

Key challenges in nutritional care at hospital discharge include: ​

  • Low awareness on the critical role of nutrition in recovery and lack of monitoring of nutritional therapy​
  • High prevalence of obesity and non-communicable disease: need to integrate management of underlying conditions and presence of sarcopenic obesity​
  • Lack of specialist follow up and individualized approach may lead to providing a single mode of intervention and “wait-and-see” for 1-3 months which may not be suitable for complex patients​​

A review of nutrition support recommendations issued by clinical nutrition professional organizations in​ response to the pandemic consistently recognized the need for clear pathways from acute care to primary​ care teams, with accessible and rapid communication links. Lack of appropriate advice and ongoing​ nutritional care at and after discharge was already a concern, and is likely to be exacerbated during the​ pandemic with increased numbers of patients and rapid discharge processes.

Page 7 of the publication[1]

“Low physical functioning, reduced functional capacity and impaired performance of activities of daily life after hospitalization for COVID-19, is suggestive of low muscle strength”

“Knowledge from a range of disease states and chronic conditions illustrate 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”

“Recommended treatment to target muscle mass and function requires a multi-modal approach with a focus on optimal protein intake, vitamin D supplementation and resistance training”

“A recent study showed benefits of a muscle-targeted ONS (20g whey protein, 2.8g leucine, 800 IU Vitamin D, 500mg calcium) compared to iso-caloric placebo in sarcopenic patients during a rehabilitation program.”

The muscle-targeted ONS led to a reduction in rehab duration (-27%), shorter length of stay (-10 days), more patients discharged home (+24%)2


World Sarcopenia Day 2022

World Sarcopenia Day is the perfect opportunity to increase awareness and knowledge for the prevalent disease, sarcopenia. Sarcopenia is a muscle disease that can drastically impede upon individuals physical function, independence, and overall quality of life. It is therefore vital that attention is given to appropriately diagnosing and managing this disease in order to maintain and promote overall well-being. Join us in celebration of this important day!

  1. Cereda E et al. (2021). Nutrients; 13(9): 3293​
  2. Rondanelli M et al. (2020). J Cachexia Sarcopenia Muscle; 11: 1535-1547

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