Early Nutrition Intervention for Early Recovery....
By Dr. Dicken Weatherby & Beth Ellen DiLuglio, MS, RDN, LDN
Nutrition plays an indispensable role in immunity and it is well-known that nutrient insufficiency and outright malnutrition contribute to morbidity and mortality.
Italian researchers Caccialanza et al. graciously shared their rationale and protocols for early nutrition intervention for COVID-19, published in the journal Nutrition April 3, 2020.
These clinical nutrition support protocols are designed to identify, address, and mitigate compromised nutrition status in patients during the devastating global pandemic of 2020. Identifying nutrition risk early in the course of the disease is crucial.
As is widely observed, the most severe cases and fatalities due to COVID-19 tend to be older and have underlying metabolic disorders such as cardiovascular disease, diabetes, respiratory compromise, cancer, liver disease, or kidney disease. Notably, these disorders in turn are characterized by nutrient imbalances and insufficiencies.
Pneumonia, a life-threatening complication of COVID-19, is associated with recognized factors such as age, smoking, respiratory failure, and maximum body temperature.
However, as researchers point out, low albumin and elevated C-reactive protein are also independent prognostic markers for progression to pneumonia. Low prealbumin levels were also useful in predicting respiratory failure and need for mechanical ventilation. These biomarkers are part of a comprehensive nutrition assessment and monitoring protocol.
Once nutrition risk has been identified, oral nutrition support with calorie and protein-dense foods and supplements should be implemented as early as possible. Whey protein is especially important in supplementation because of its immunomodulatory properties and antiviral potential.
Total energy and protein needs can help guide nutrition support.
- Energy needs are calculated using the Harris-Benedict factor for basal metabolic rate multiplied by a factor of 1.5. Estimates of 25-30 kcals/day may suffice as well.
- Calculated protein needs of 1.5 grams of protein per kilogram of body weight should provide adequate amino acids for increased metabolic needs.
- Estimated needs for obese patients with a BMI greater than 30 are based on ideal body weight instead of actual body weight.
If oral intake is inadequate, intravenous supplementation with amino acids, vitamins, minerals, and trace elements should be initiated. Nasogastric enteral nutrition support may be contraindicated in those on non-invasive ventilation or CPAP therapy.
It is especially important to assess and address vitamin D status due to its ability to reduce inflammation, improve immunity against pathogens, and enhance recovery during antiviral therapy. Appropriate supplementation should be provided:
- For serum 25(OH)D below 20 ng/mL [50 nmol/L], provide 50,000 IU vitamin D3 per week
- For serum 25(OH)D 20-29 ng/mL [50-72 nmol/L], provide 25,000 IU vitamin D3 per week.
As pointed out by Grant et al. 2020, the goal of vitamin D therapy should be to maintain serum 25(OH)D concentrations of at least 40-60 ng/mL (100-150 nmol/L). For those at risk of COVID-19 or influenza, 10,000 IU/day of vitamin D3 may be indicated for two weeks followed by 5,000 IU/day until goals are reached. Researchers note that higher levels of supplementation may be useful for those already infected with the virus.
Other micronutrient needs may be ascertained using blood chemistry analysis, complete blood counts, and other available biomarkers. It must be noted that supplementation with omega-3 fatty acids during viral infection and treatment is controversial and must be considered on a case-by-case basis.
Fortunately, the place of nutrition support is becoming cemented at the forefront of immune support. Hopefully, clinicians will use that cemented step to build a strong foundation for nutrition intervention for all.
Caccialanza R, Laviano A, Lobascio F, et al. Early nutritional supplementation in non-critically ill patients hospitalized for the 2019 novel coronavirus disease (COVID-19): Rationale and feasibility of a shared pragmatic protocol. Nutrition. 2020 Apr 3:110835. [R]
Grant WB, Lahore H, McDonnell SL, et al. Evidence that Vitamin D Supplementation Could Reduce Risk of Influenza and COVID-19 Infections and Deaths. Nutrients. 2020 Apr 2;12(4).[R]
Gutiérrez S, Svahn SL, Johansson ME. Effects of Omega-3 Fatty Acids on Immune Cells. Int J Mol Sci. 2019 Oct 11;20(20). pii: E5028. [R]
Kolawole, E. M., & Evavold, B. D. (2016). Omega-3 rich diet alters T cell affinity and decreases anti-viral immunity.[R]