A Review of Nutrition Support Guidelines for Individuals with or Recovering from COVID-19 in the Community
2. Materials and Methods
3.1. Summary of Search Findings
3.2. Screening for Malnutrition Risk in the Community
- Key Messages:
- Must be screened for malnutrition with a tool such as “MUST”, upon first contact with a HCP, and when clinically indicated;
- Can be screened for malnutrition risk by remote consultation; recalled and subjective measures can be used if necessary with some screening tools, whilst self-screening with a validated tool is also appropriate;
- Must have the outcome of their malnutrition screening linked to a documented management plan appropriate for their level of risk, with review plans included.
3.3. Nutrition Support in the Community
3.3.1. Dietary Advice and Oral Nutritional Supplements
3.3.3. Tube Feeding in the Community
3.3.4. Dietitians and Allied Health Professionals
3.3.5. Community Nutritional Care Pathways
- Key Messages:
- Nutrition support should be considered for individuals with COVID-19 unable to meet nutritional requirements and those who are malnourished. This includes the full range of strategies including dietary advice, ONS and tube feeding.
- Protein requirements can be higher in those recovering from COVID-19 illness and with sarcopenia; nutrition support strategies should consider this.
- When the diet, including food fortification, is unable to meet nutritional requirements, and/or patients are at high risk of malnutrition, ONS may be required, for a minimum of 4 weeks. The type of ONS and presentation (ready to drink or powdered) should be considered within the context of the specific needs of the individual patient.
- Individuals with specialist dietary requirements, or complex needs, should be referred to a dietitian.
- Nutrition support should be integrated into care pathways and multi-disciplinary rehabilitation services.
- All nutrition support plans should include regular review and monitoring.
3.4. Continuity of Care between Settings (Hospital Discharge into the Community)
- Key Messages:
- Effective clear and rapid communication about nutrition, between settings, is essential for continuity of care.
- Each patient being discharged from hospital recovering from COVID-19 must have a hospital discharge plan which includes:
- -A malnutrition risk score using a validated tool such as “MUST”;
- -Details of nutrition care plans, as nutritional treatment should continue after discharge;
- -Details of any ICU admission (if relevant).
4. Supporting Publications from Other National and International Organisations
Conflicts of Interest
- Managing Adult Malnutrition. A Community Healthcare Professional Guide to the Nutritional Management of Patients during and after COVID-19 Illness. Available online: https://www.malnutritionpathway.co.uk/covid19-community-hcp (accessed on 19 June 2020).
- Barazzoni, R.; Bischoff, S.C.; Breda, J.; Wickramasinghe, K.; Krznaric, Z.; Nitzan, D.; Pirlich, M.; Singer, P. ESPEN expert statements and practical guidance for nutritional management of individuals with SARS-CoV-2 infection. Clin. Nutr. (Edinb. Scotl.) 2020, 39, 1631–1638. [Google Scholar] [CrossRef] [PubMed]
- British Dietetic Association: Critical Care Specialist Group. Guidance on Management of Nutrition and Dietetic Services during the COVID-19 Pandemic. Version 2. Available online: https://www.bda.uk.com/resource/critical-care-dietetics-guidance-covid-19.html (accessed on 11 May 2020).
- World Health Organisation. Clinical Management of COVID-19. Interim Guidance. Available online: https://www.who.int/publications/i/item/clinical-management-of-covid-19 (accessed on 27 May 2020).
- British Dietetic Association: Optimising Nutrition Prescribing Specialist Group. Community Guidance-MDT. Available online: https://www.bda.uk.com/resource/nutritional-guidance-for-primary-care-teams.html (accessed on 15 June 2020).
- British Dietetic Association. Nutrition and the COVID-19 Discharge Pathway. Available online: https://www.bda.uk.com/resource/nutrition-and-the-covid-19-discharge-pathway.html (accessed on 19 May 2020).
- British Dietetic Association: Older People Specialist Group. COVID-19- Recommendations for Community Action by Dietitians for Older and Vulnerable People Living in their own Home. Available online: https://www.bda.uk.com/resource/covid-19-recommendations-for-community-action-by-dietitians-for-older-and-vulnerable-people-living-in-their-own-home.html (accessed on 25 March 2020).
- British Dietetic Association Older People Specialist Group. COVID-19-Recommendations for Community Action by Dietitians to Support Care Agencies Working in Older People’s own Homes. Available online: https://www.bda.uk.com/resource/covid-19-recommendations-for-action-by-dietitians-supporting-care-agencies-working-in-older-people-s-own-homes.html (accessed on 25 March 2020).
- British Dietetic Association Older People Specialist Group. COVID-19-Recommendations for Community Action by Dietitians Supporting Care Homes. Available online: https://www.bda.uk.com/resource/covid-19-recommendations-for-community-action-by-dietitians-supporting-care-homes.html (accessed on 25 March 2020).
- British Dietetic Association Optimising Nutrition Prescribing Specialist Group. Top Tips for Prescribing Oral Nutritional Supplements and Enteral Feeds in the Community for Adults and Paediatrics. Available online: https://www.bda.uk.com/resource/top-tips-for-prescribing-oral-nutritional-supplements-and-enteral-feeds-in-the-community-for-adults-and-paediatrics.html (accessed on 4 May 2020).
- National Nurses Nutrition Group. Practical Advice and Guidance for Management of Nutritional Support during COVID-19. Version 2. Available online: https://www.nnng.org.uk/2020/04/covid-19-statement-and-information/ (accessed on 14 April 2020).
- British Association of Parenteral and Enteral Nutrition: Malnutrition Advisory Group. Practical Guidance for Using ’MUST’ to Identify Malnutrition during the COVID-19 Pandemic. Malnutrition Action Group (MAG) Update. Available online: https://www.bapen.org.uk/pdfs/covid-19/covid-mag-update-may-2020.pdf (accessed on 30 May 2020).
- British Association of Parenteral and Enteral Nutrition: Nasogastric Tube Safety Special Interest Group. Enteral Tube Feeding Safety in COVID-19 Patients (Updated 13/05/2020). Available online: https://www.bapen.org.uk/pdfs/covid-19/covid-19-and-enteral-tube-feeding-safety-13-05-20.pdf (accessed on 20 May 2020).
- The European Federation of the Association of Dietetics. Role of Dietitians in the Fight against COVID-19. EFAD Briefing Paper. Available online: http://www.efad.org/media/1985/role-of-dietitians-in-the-fight-against-covid19-efad-briefing-paper-may-2020.pdf (accessed on 13 May 2020).
- Dietheek. Nutritional Guidance During Recovery from COVID-19. Available online: https://european-nutrition.org/wp-content/uploads/2020/05/Nutritional-guidance-during-recovery-from-COVID-19.pdf (accessed on 30 May 2020).
- Mulherin, D.; Walker, R.; Holcombe, B.; Guenter, P. ASPEN Report on Nutrition Support Practice Processes with COVID-19: The First Response. ASPEN Clinical Practice Committee. Available online: https://www.nutritioncare.org/uploadedFiles/Documents/Guidelines_and_Clinical_Resources/COVID19/ASPEN%20Clinical%20Report%20on%20Nutrition%20Support%20Practice%20Processes%20with%20COVID-19%205-26-2020.pdf (accessed on 30 May 2020).
- National Institute for Health and Clinical Excellence (NICE). Nutrition Support in Adults: Oral Nutrition Support, Enteral Tube Feeding and Parenteral Nutrition (Clinical Guideline 32). Available online: https://www.nice.org.uk/guidance/cg32 (accessed on 4 August 2017).
- National Institute for Health and Clinical Excellence (NICE). Quality Standard for Nutrition Support in Adults. NICE Quality Standard 24. Available online: https://www.nice.org.uk/guidance/qs24 (accessed on 30 November 2012).
- National Institute for Health and Care Excellence (NICE). COVID-19 Rapid Evidence Summary: Vitamin D for COVID-19. Public Health England. Available online: https://www.nice.org.uk/advice/es28/chapter/Key-messages (accessed on 29 June 2020).
- National Post-Intensive Care Rehabilitation Collaborative. Responding to COVID-19 and Beyond: A Framework for Assessing Early Rehabilitation Needs Following Treatment in Intensive Care; Puthucheary, Z., Ed.; British Society of Rehabilitation Medicine & Intensive Care Society: London, UK, 2020; Available online: https://www.bsrm.org.uk/downloads/2020.06.23--icsframework-for-assessing-early-reha-(1).pdf (accessed on 24 June 2020).
- National Health Service (NHS). After-Care Needs of Inpatients Recovering from COVID-19. Version 2. Available online: https://www.pcrs-uk.org/sites/pcrs-uk.org/files/nhs-aftercarecovid.pdf (accessed on 3 August 2020).
- Matthew, W.; Adrian, H. COVID-19 Prioritisation within Community Health Services. National Health Service (NHS). Available online: https://www.birminghamandsolihullccg.nhs.uk/about-us/publications/your-health/coronavirus-advice-for-professionals/general-advice-and-management-of-suspected-cases/4128-covid-19-prioritisation-within-community-health-services/file (accessed on 19 March 2020).
- Carl, W.; Joel, M.; Andy, S. FICM Position Statement and Provisional Guidance: Recovery and Rehabilitation for Patients Following the Pandemic. The Faculty of Intensive Care Medicine. Available online: https://www.ficm.ac.uk/sites/default/files/ficm_rehab_provisional_guidance.pdf (accessed on 30 May 2020).
- Phillips, M.; Turner-Stokes, L.; Wade, D.; Walton, K. Rehabilitation in the Wake of Covid-19—A Phoenix from the Ashes. British Society of Rehabilitation Medicine. Issue 1. Available online: https://www.bsrm.org.uk/downloads/covid-19bsrmissue2-11-5-2020-forweb11-5-20.pdf (accessed on 11 May 2020).
- Castillo, M.; Costa, L.; Barrios, J.; Díaz, J.F.; Miranda, J.L.; Bouillon, R.; Gomez, J.M. Effect of calcifediol treatment and best available therapy versus best available therapy on intensive care unit admission and mortality patients hospitalized for COVID-19: A pilot randomized clinical study. J. Steroid Biochem. Mol. Bio. 2020. [Google Scholar] [CrossRef]
|Selection Criteria||Inclusion Criteria||Exclusion Criteria|
|Publication||- Health care professional organisation (i.e., society, institute, association, Royal College) at a national level with expertise in clinical nutrition|
- Specialist group affiliated to a professional organisation at a national level
- External publication endorsed by a professional organisation
- Guidelines, review, consensus of opinion, pathway, recommendations, policy, position statement
- English language
|- Publication written by an author or a group of authors that is not attributable to a specific professional organisation|
- Local area, site-specific publications
- Single expert opinion or editorial
- Webinar, online education session, slide-deck, social media blog/vlog, podcast
- Patient resources (patient information sheet)
- Non-English language
|Population||- Adults (≥18 years of age)||- Children|
|- COVID-19 illness/SARS-CoV-2 infection||- Healthy adults or those with non-COVID-19 illness|
|- Community based (e.g. outside of hospital, nursing homes, own homes)|
- Discharge into community
|- In an acute setting (e.g., hospitalised)|
- Patients established on home enteral nutrition (HEN) or parenteral nutrition (PN)
Public Health Policy
|Organisation||Country||Title of Publication||Type of Publication||Date|
|British Dietetic Association (BDA)||UK|
|Optimising Nutrition Prescribing Specialist Group||Community Guidance-MDT (please note this has since changed title) ||Guidance||15 June 2020|
|Education, Professional Development/Policy Team||Nutrition and the COVID-19 discharge pathway ||Guidance||19 May 2020|
|Older People Specialist Group||COVID-19-Recommendations for community action by dietitians for older and vulnerable people living in their own home ||Recommendations||25 March 2020|
|Older People Specialist Group||COVID-19-Recommendations for action by dietitians supporting care agencies working in older people’s own homes ||Recommendations||25 March 2020|
|Older People Specialist Group||COVID-19-Recommendations for community action by dietitians supporting care homes ||Recommendations||25 March 2020|
|Optimising Nutrition Prescribing Specialist Group||Top tips for prescribing oral nutritional supplements and enteral feeds in the community for adults and paediatrics ||Recommendations||4 May 2020|
|Critical Care Specialist Group||Guidance on the management of nutrition and dietetic services during the COVID-19 pandemic ||Guidelines/Recommendations||11 May 2020|
|National Nurses Nutrition Group (NNG)|
Supported by the Parenteral and Enteral Nutrition Specialist Group (PENG) of the BDA
|UK||Practical advice and guidance for management of nutritional support during COVID-19 ||Guidelines||April 2020|
|British Association for Parenteral and Enteral Nutrition (BAPEN)||UK|
|Malnutrition Action Group (MAG)||Practical guidance for using MUST to identify malnutrition during the COVID-19 pandemic. Malnutrition Action Group update ||Guidelines||May 2020|
|Nasogastric Tube Safety Special Interest Group||Enteral tube feeding safety in COVID-19 patients (Updated 13 May 2020) ||Guidelines||13 May 2020|
|Malnutrition Pathway Group (MPG)|
Endorsed by the BDA, BAPEN, Royal College of Nursing (RCN)
|UK||A community healthcare professional guide to the nutritional management of patients during and after COVID-19 illness ||Guidance||June 2020|
|European Society for Clinical Nutrition and Metabolism (ESPEN)||Europe||ESPEN expert statements and practical guidance for nutritional management of individuals with SARS-CoV-2 infection ||Consensus Statement||31 March 2020|
|The European Federation of the Associations of Dietitians (EFAD)||Europe||Role of Dietitians in the fight against COVID-19 ||Briefing Paper||May 2020|
(Netherlands National Association of Dietitians) (DN)
|NL||Nutritional guidance during recovery from COVID-19|
(Published in Dutch and English) 
|American Society for Parenteral and Enteral Nutrition (ASPEN)||USA||ASPEN report on Nutrition Support Practice Processes with COVID-19: the first response ||Report||5 June 2020|
|Organisation||Country||Title of Publication||Nutrition Support|
|National Health Service (NHS England)||England||After-care needs of inpatients recovering from COVID-19 (3rd August 2020) V2 ||The document describes the expected immediate and longer-term health needs of COVID-19 patients, following discharge from hospital (whether or not they received intensive care) into home and community settings, following an episode of COVID-19. This has a detailed section on Diet and Nutrition and includes dietetic support in areas including: Tracheostomy; Dysphagia; Cardiac Rehabilitation; Hospital-acquired weakness; Diabetes; Pressure Ulcers and Fatigue. Key messages include:|
|National Health Service (NHS England)||England||COVID-19 prioritisation within community health services|
(19th March 2020) 
|Discusses some aspects of therapy interventions that require dietetics support such as malnutrition, frailty and issues of weight management and obesity.|
Dietetics support for people with significant malnutrition and increased risk of frailty and functional disability.
|Faculty of Intensive Care Medicine (FICM) and ICU Steps||England||Recovery and rehabilitation for Patients following the pandemic|
(May 2020) 
|Position statement and provisional guidance for the pathway from critical care to recovery in the community. The BDA was not consulted on this document (but will be on the final). Recognise that a Dietitian is part of the rehabilitation team, specifically for: GI-swallow impairment, nutritional/weight loss assessment; Neurological-strokes, extreme fatigue; Skin/soft tissue-pressure sores; Underlying condition management-diabetes, weight management.|
|World Health Organisation (WHO)||World||Clinical Management of COVID-19 (27th May 2020) ||Nutrition mentioned in relation to rehabilitation and malnutrition in relation to older persons.|
Older person section:
Physiological changes with age lead to declines in intrinsic capacity such as malnutrition, cognitive decline, depressive symptoms, and those conditions interact at several levels. These interactions require an integrated approach to the screening, assessment and management of older people.
|British Society of Rehabilitation Medicine||UK||Rehabilitation in the wake of COVID-19—A phoenix from the ashes (11th May 2020) Issue 2 ||Rehabilitation post ICU|
-Critical care, acute medical and specialist rehabilitation teams should work closely together to develop rehabilitation pathways for patients who are recovering following treatment in intensive care and high dependency care (whether for Covid-related illness or other critical conditions).
Specialist rehabilitation should be delivered by coordinated multi-disciplinary team (includes dietitian).
|British Society of Rehabilitation Medicine and Intensive Care Society||UK||Responding to COVID-19 and beyond: A framework for assessing early rehabilitation needs following treatment in intensive care. (24th June 2020) V 1 ||This document is endorsed by the BDA (as it was published after our cut-off date, it was not included in the main review).|
Rehabilitation post ICU
Nutritional compromise due to:
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Cawood, A.L.; Walters, E.R.; Smith, T.R.; Sipaul, R.H.; Stratton, R.J. A Review of Nutrition Support Guidelines for Individuals with or Recovering from COVID-19 in the Community. Nutrients 2020, 12, 3230. https://doi.org/10.3390/nu12113230
Cawood AL, Walters ER, Smith TR, Sipaul RH, Stratton RJ. A Review of Nutrition Support Guidelines for Individuals with or Recovering from COVID-19 in the Community. Nutrients. 2020; 12(11):3230. https://doi.org/10.3390/nu12113230Chicago/Turabian Style
Cawood, Abbie L., Emily R. Walters, Trevor R. Smith, Rachel H. Sipaul, and Rebecca J. Stratton. 2020. "A Review of Nutrition Support Guidelines for Individuals with or Recovering from COVID-19 in the Community" Nutrients 12, no. 11: 3230. https://doi.org/10.3390/nu12113230