News Round-up
New Patient Information Leaflets to Advise those with COVID-19 Illness on Good Nutrition for Recovery
Whilst 32% of COVID-19 cases will require hospitalisation, 68% of those affected will remain in the community.1 We know that disease related malnutrition is prevalent amongst those of older age and those with chronic diseases,2 and is likely therefore that underlying malnutrition in these patients may impair immune response3 and further worsen COVID-19 severity.
Not only do symptoms of COVID-19 have the potential to exacerbate malnutrition already present but they may also predispose previously well-nourished patients to the risk of malnutrition as a result of elevated nutritional requirements associated with infection arising at a time when appetite is diminished.4 Those who have had a serious case of COVID-19, and particularly those recovering after leaving hospital, may require additional dietary support in order to regain lost muscle mass.
The Managing Adult Malnutrition in the Community team has worked with the British Dietetic Association (BDA) and the British Association for Parenteral and Enteral Nutrition (BAPEN) to develop a range of patient information leaflets to advise those who have COVID-19 illness, or who are recovering after the illness, on eating well to assist in their recovery.
“Dietary advice for people who have or have had COVID-19 illness needs to be considered in relation to a number of factors including severity of their illness, any underlying conditions they have, whether their appetite has been affected and if they are overweight or underweight,” says Anne Holdoway, Consultant Dietitian and Chair of the BDA COVID-19 Clinical Guidance Group. “One size does not fit all when it comes to diet and, for this reason, we’ve developed a number of different resources to enable people to access the dietary advice suited to their need. The resources have been developed on the nutritional issues associated with COVID-19 based on what we understand to date. They have been created to help members of the MDT and patients and carers access information, however for those who have been severely unwell and in particular those who were required intensive care I would stress the need for individualised dietary advice by a registered dietitian.”
Three different nutritional information leaflets have been developed, each tailored to the differing nutritional requirements of individuals who have been affected by COVID-19. The leaflets aim to help those who have had a mild/moderate illness and have been coping at home and also for those who have been in hospital with a more serious illness. The leaflets are free to download at www.malnutritionpathway.co.uk/covid19 and an interactive tool has been developed on the website to enable people who have or have had COVID-19 to identify the nutritional advice leaflet that is most suitable to their needs www.malnutritionpathway.co.uk/covid19-resourcetool. The leaflets and the website include advice on how patients can monitor their own weight and understand about their risk of malnutrition using the BAPEN malnutrition self-screening tool www.malnutritionselfscreening.org/.
Nutritional information for people during and after COVID-19 illness
The three leaflets include tips on for coping with symptoms related to COVID-19 illness and encouraging activity combined with good nutrition:
- Green leaflet - ‘Eating Well During and After COVID-19 Illness’
An information leaflet about eating a balanced diet to help maintain your strength and fitness, as well as help your body fight infection - Yellow leaflet - ‘Improving your Nutrition During and After COVID-19 Illness’
An information leaflet for those with a poor appetite and/or recent unintentional weight loss, including tips to help get the most from their food. - Red leaflet - ‘Nutrition Support During and After COVID-19 Illness’
An information leaflet for those who have been very unwell. Aimed at those who have recently been discharged from hospital after COVID-19 illness or who are struggling to eat enough and are underweight and/or have lost quite a bit of weight due to their illness. This information leaflet gives advice on increasing nutritional intake and how to incorporate oral nutritional supplements into the diet if they are prescribed.
The Malnutrition Pathway team has also developed resources for community healthcare professionals who are dealing with patients with COVID-19 in the community. These aim to highlight the importance of nutritional screening and the provision of good nutritional care during this pandemic whilst guiding professionals how to assess malnutrition risk remotely and link to the consumer resources developed – www.malnutritionpathway.co.uk/covid19-community-hcp
References: 1. European Centre for Disease Prevention and Control. Rapid Risk Assessment: Coronavirus disease 2019 (COVID-19) in the EU/EEA and the UK – eighth update. 2020. [Online]. Available from: www.ecdc.europa.eu/sites/default/files/documents/covid-19-rapid-risk-assessment-coronavirus-disease-2019-eighth-update-8-april-2020.pdf [15.04.20].; 2. Holdoway et al. A Guide to Managing Adult Malnutrition in the Community. 2017. [Online]. Available from: www.malnutritionpathway.co.uk/library/managing_malnutrition.pdf [17.04.20].; 3. Stratton RJ et al. Disease-related malnutrition: an evidence-based approach to treatment. Oxford: CABI publishing. 2003.; 4. Barazzoni R, Bischoff SC, Krznaric Z, Pirlich M, Singer P, endorsed by the ESPEN Council, Espen expert statements and practical guidance for nutritional management of individuals with sars-cov-2 infection, Clinical Nutrition, https://doi.org/10.1016/j.clnu.2020.03.022.
The Nutrition Society’s Training Academy is Offering COVID-19 Webinars
With appreciation for the extensive efforts of all NHS colleagues and all frontline workers, webinar registrations are available to accommodate all of those wishing to participate.
Both webinars, Nutrition, immunity and COVID-19 and COVID-19: Why the interest in Vitamin-D, are endorsed by the Association for Nutrition.
Please email training@nutritionsociety.org from your NHS email address, alternatively list your work email address.
Gut Research Delves Deeper into Obesity Problems
By delving deeper into metabolism problems, the research team has found that the nutrient sensing capacity of Enterochromaffin (EC) cells - which line the gastrointestinal tract and are the source of almost all serotonin in the body - have changed in mice under the influence of high-fat diet-induced obesity and metabolic disease.
Dr Alyce Martin is part of a Flinders University research group under the supervision of Professor Damien Keating that made this discovery, and their recently published paper in the journal Neurogastroenterology & Motility has been chosen as the stand-out article for the August issue and is the monthly feature for the journal's podcast.
"Our newly published work builds upon previous work from our lab published during my PhD, showing that the EC cells which produce serotonin in the gut act as important sensory cells within their environment." says Dr Martin. "It also builds upon our work in humans showing that circulating serotonin and duodenal EC cell numbers are increased in obese humans."
Despite the known metabolic roles of gut-derived serotonin, the underlying causes of increased serotonin with obesity and diabetes remains unknown.
However, Dr Martin says the new research offers novel insights into the mechanisms by which functional changes to EC cells occur, which may contribute to the altered circulating serotonin seen with obesity and metabolic disease, and associated gastrointestinal disorders including gastroparesis and nausea.
"We've already shown that these cells have the ability to sense and release serotonin in response to select nutrients under healthy conditions, which is dependent upon their location within the gut," says Dr Martin. "Now we have shown that nutrient sensing by these cells, as well as the number of cells, is impacted by diet in an obese, diabetic model."
The study – Diet differentially regulates enterochromaffin cell serotonin content, density and nutrient sensitivity in the mouse small and large intestine, by Alyce Martin, Lauren Jones, Claire Jessup, Emily Sun and Damien Keating – has been published by the Wiley journal Neurogastroenterology & Motility.
The new paper also builds on a significant study by Flinders researchers published in the Proceedings of the National Academy of Science in 2019, which showed that gut bacteria communicate with EC cells, to impact metabolism even under healthy conditions. This was the first evidence to highlight gut-derived serotonin as a pathway by which bacteria impact metabolism.
The activity of gut-derived serotonin in these metabolic processes has direct implications of such metabolic disorders as obesity and type 2 diabetes.
Current additional work by the Flinders researchers involves looking at how serotonin from EC cells influences gut motility - also examining how these EC cells respond to mechanical stimulation and communicate with neurons in the gut as part of the gut-brain-axis.
"We are progressing on several fronts to understand the dynamic relationship that serotonin-producing EC cells have with their gut environment, to ultimately impact physiological processes such as gut function and metabolism," says Dr Martin.
High Doses of Vitamin D Supplementation has No Current Benefit in Preventing or Treating COVID-19
Scientists from the UK, Europe and the USA, including experts from the University of Birmingham, have published a vitamin D consensus paper warning against high doses of vitamin D supplementation.
According to the study, there is currently insufficient scientific evidence to show vitamin D can be beneficial in preventing or treating Covid-19. Its authors advise that the population adhere to Public Health England guidance on supplementation. Following unverified reports that high doses of vitamin D (higher than 4000IU/d) could reduce the risk of contracting Covid-19 and be used to successfully treat the virus, the new report published in the journal BMJ, Nutrition, Prevention and Health, investigated the current scientific evidence base on the vitamin and its use in treating infections. Vitamin D is a hormone, produced in the skin during exposure to sunlight, and helps regulate the amount of calcium and phosphate in the body, which are needed to keep bones, teeth and muscles healthy.
Professor Sue Lanham-New, Head of the Department of Nutritional Sciences at the University of Surrey and lead author of the study, said: "An adequate level of vitamin D in the body is crucial to our overall health, too little can lead to rickets or the development of osteoporosis but too much can lead to an increase in calcium levels in the blood which could be particularly harmful."
Examining previous studies in this field scientists found no evidence of a link between high dose supplementation of vitamin D in helping to prevent or successfully treat Covid-19 and cautioned against over supplementation of the vitamin, without medical supervision, due to health risks. Scientists concluded that assertions about the benefit of the vitamin in treating the virus are not currently supported by adequate human studies and are based on findings from studies that did not specifically examine this area. Claims of a link between vitamin D levels and respiratory tract infections were also examined by scientists. Previous studies in this area have found that lower vitamin D status is associated with acute respiratory tract infections however limitations of the findings of these studies were identified. Findings from the majority of studies were based on data gathered from population groups in developing countries and cannot be extrapolated to populations from more developed countries due to external factors. Scientists believe that there is currently no firm link between vitamin D intake and resistance to respiratory tract infections.
Professors Carolyn Greig and Martin Hewison from Birmingham University, are co-authors on the paper. Professor Greig says: "Most of our vitamin D comes from exposure to sunlight, however for many people, particularly those who are self-isolating with limited access to sunlight during the current pandemic, getting enough vitamin D may be a real challenge. Supplementing with vitamin D is recommended but should be done under the current UK guidance.
Although there is some evidence that low vitamin D is associated with acute respiratory tract infections, there is currently insufficient evidence for vitamin D as a treatment for COVID-19 and over-supplementing must be avoided as it could be harmful." Professor Judy Buttriss, Director General British Nutrition Foundation and also a co-author of the paper said: "In line with the latest Public Health England guidance on vitamin D, we recommend that people consider taking a vitamin D supplement of 10 micrograms a day during the winter months (from October to March), and all year round if their time outside is limited.
Levels of the vitamin in the body can also be supplemented through a nutritionally balanced diet including foods that provide the vitamin, such as oily fish, red meat, egg yolk and fortified foods such as breakfast cereals, and safe sunlight exposure to boost vitamin D status."
Altered Sense of Taste Present in Half of COVID-19 Cases
Nearly half of individuals who contract COVID-19 experience changes in their sense of taste, a new analysis led by a University of Toledo researcher has found.
The systematic review, published in the journal Gastroenterology, could provide yet another diagnostic hint for clinicians who suspect their patients might have the disease.
"Earlier studies didn't note this symptom, and that was probably because of the severity of other symptoms like cough, fever and trouble breathing," said Dr Muhammad Aziz, chief internal medicine resident at the University of Toledo and the paper's lead author. "We were beginning to note that altered or lost sense of taste were also present, not just here and there, but in a significant proportion."
Aziz and his research collaborators analysed data from five studies conducted between mid-January and the end of March. Of the 817 patients studied, 49.8% experienced changes to their sense of taste. Researchers suspect the true prevalence could be even higher because some of the studies were based on reviews of patient charts, which may not have noted every symptom.
"We propose that this symptom should be one of the screening symptoms in addition to the fever, shortness of breath and productive cough. Not just for suspected COVID patients, but also for the general population to identify healthy carriers of the virus," Aziz said.
Prior research has found that a significant number of people who have COVID-19 don't know they've been infected and may be spreading the virus.
Aziz and his research collaborators suspect an altered sense of taste is more prevalent in patients with minor symptoms, though more studies are needed to validate that suspicion. Even so, changes in an individual's sense of taste could be a valuable way to identify carriers who are otherwise mostly asymptomatic.
Taste disorders are tied to a variety of viral illnesses. The review did not attempt to identify the reason that COVID-19 is causing changes in patients' sense of taste; however, researchers theorize it could be COVID-19's ability to bind to what's known as the ACE-2 receptor, which is expressed in epithelial cells on the tongue and mouth.
Because the novel coronavirus was unknown prior to its emergence in January, scientists have been moving rapidly to learn more about both the virus and the disease it causes.
Aziz said the drip of new information shows the need for more scientists to dig into the impacts of COVID-19.
"A lot of things are being missed, which is why I think researchers from every field should try to look into this and see if it's affecting their specialty in one way or another," he said. "Who knows what systems this virus is affecting. If we can catch it earlier in the disease course, we can prevent the spread of the virus and potentially have ways of managing it."