Hospitalization for COVID-19 is associated with significant changes in body composition

In critically ill adult patients with COVID-19, lower energy and higher protein intake are associated with fewer mechanical ventilation and antibiotic days but not with ICU length of stay

BACKGROUND

Coronavirus disease 2019 (COVID-19) nutrition management guidelines recommend hypocaloric, high-protein feeding in the acute phase of critical illness. This study aimed to determine, among critically ill adults with COVID-19, whether nutrition support affects outcomes in nonobese patients when providing a mean energy intake of ≥20 kcal/kg/day vs <20 kcal/kg/day and protein intake of ≥1.2 g/kg/day vs <1.2 g/kg/day, using actual body weight, and in patients with obesity when providing ≥20 kcal/kg/day vs <20 kcal/kg/day and a protein intake of ≥2 g/kg/day vs <2 g/kg/day using ideal body weight.

METHODS

This retrospective study included adults with COVID-19 on mechanical ventilation (MV) admitted to the intensive care unit (ICU) from 2020 to 2021. Clinical and nutrition parameters were recorded the first 14 days of ICU stay.

RESULTS

One hundred four patients were included: 79 (75.96%) were male and had a median age of 51 years and body mass index of 29.65 kg/m2 . ICU length of stay (LOS) was not affected by nutrition intake, but patients receiving <20 kcal/kg/day had fewer MV days (P = 0.029). In a subgroup analysis, MV days were lower in the nonobese group receiving <20 kcal/kg/day (P = 0.012). In the obese group, those receiving higher protein intake had fewer antibiotic days (P = 0.013).

CONCLUSION

In critically ill patients with COVID-19, lower energy and higher protein intake were respectively associated with fewer MV days and, in patients with obesity, fewer antibiotic days, but they had no effect on ICU LOS.

Impact of Preparticipation Hypohydration on Cognitive Performance and Concussion-like Symptoms in Recreational Athletes

BACKGROUND

Sports-related concussion is a relevant risk of contact sports, with several million cases per year worldwide. Prompt identification is crucial to prevent complications and late effects but may be impeded by an overlap with dehydration-associated impairment of cognitive function. Researchers have extensively studied the effects of pronounced dehydration in endurance sports, especially in the heat. However, little is known about the effects of isolated and mild dehydration.

METHODS

Healthy recreational athletes underwent a standardized fluid deprivation test. Hypohydration was assessed by bioelectrical impedance analysis (BIA) and laboratory testing of electrolytes and retention parameters. Participants underwent cardiopulmonary exercise testing (CPET) with a cycle ramp protocol. Each participant served as their own control undergoing CPET in a hypohydrated [HYH] and a euhydrated [EUH] state. Effects were assessed using a shortened version of Sport Concussion Assessment Tool 3 (SCAT3).

RESULTS

Fluid deprivation caused a mild (2%) reduction in body water, resulting in a calculated body mass loss of 0.8% without alterations of electrolytes, serum-osmolality, or hematocrit. Athletes reported significantly more (1.8 ± 2.2 vs. 0.4 ± 0.7; p < 0.01) and more severe (4.4 ± 6.2 vs. 1.0 ± 1.9; p < 0.01) concussion-like symptoms in a hypohydrated state. Balance was worse in HYH by trend with a significant difference for tandem stance (1.1 ± 1.3 vs. 0.6 ± 1.1; p = 0.02). No relevant differences were presented for items of memory and concentration.

CONCLUSIONS

Mild dehydration caused relevant alterations of concussion-like symptoms and balance in healthy recreational athletes in the absence of endurance exercise or heat. Further research is needed to clarify the real-life relevance of these findings and to strengthen the differential diagnosis of concussion.

Assessment of body composition in adults hospitalized with acute COVID-19: a scoping review

Introduction

Body composition (BC) assessment can supply accurate information for in-hospital nutritional evaluation. The aim of this study was to explore in the literature how the studies assessed BC, for what purpose, and investigate the role of BC findings in COVID-19 hospitalized patients' outcomes.

Methods

A scoping review was conducted according to the methodology available on the Joanna Briggs Institute website. We used the PCC acronym for the systematic search (population: adults with COVID-19, concept: assessment of BC, context: hospital setting) and performed it on PubMed, Scopus, and the Web of Science on 16 September 2022. Eligibility criteria consisted of the utilization of BC assessment tools in COVID-19 patients. Studies in which BC was solely measured with anthropometry (perimeters and skinfolds) were excluded. No language restriction was applied.

Results

Fifty-five studies were eligible for the review. Out of the 55 studies, 36 used computed tomography (CT), 13 used bioelectrical impedance (BIA), and 6 used ultrasound (US). No studies with D3-creatinine, 24  h urine excretion, dual-energy X-ray absorptiometry, or magnetic resonance were retrieved. BC was mainly assessed to test associations with adverse outcomes such as disease severity and mortality.

Discussion

Studies assessing BC in hospitalized patients with COVID-19 used mainly CT and BIA and associated the parameters with severity and mortality. There is little evidence of BC being assessed by other methods, as well as studies on BC changes during hospitalization.

Impact of Preparticipating Hypohydration on Cardiopulmonary Exercise Capacity in Ambitious Recreational Athletes

BACKGROUND

Heat induces a thermoregulatory strain that impairs cardiopulmonary exercise capacity. The aim of the current study is to elucidate the effect of isolated dehydration on cardiopulmonary exercise capacity in a model of preparticipating hypohydration.

METHODS

Healthy recreational athletes underwent a standardised fluid deprivation test. Hypohydration was assessed by bioelectrical impedance analysis (BIA) and laboratory testing of electrolytes and retention parameters in the blood and urine. The participants underwent cardiopulmonary exercise testing (CPET) with a cycle ramp protocol. Each participant served as their own control undergoing CPET in a hypohydrated [HYH] and euhydrated [EUH] state.

RESULTS

Fluid deprivation caused a mild (2%) but significant reduction of body water (38.6 [36.6; 40.7] vs. 39.4 [37.4; 41.5] %; p < 0.01) and an increase of urine osmolality (767 [694; 839] vs. 537 [445; 629] mosm/kg; p < 0.01). Hypohydration was without alterations of electrolytes, serum osmolality or hematocrit. The oxygen uptake was significantly lower after hypohydration (-4.8%; p = 0.02 at ventilatory threshold1; -2.0%; p < 0.01 at maximum power), with a corresponding decrease of minute ventilation (-4% at ventilatory threshold1; p = 0.01, -3.3% at maximum power; p < 0.01). The power output was lower in hypohydration (-6.8%; p < 0.01 at ventilatory threshold1; -2.2%; p = 0.01 at maximum power).

CONCLUSION

Isolated hypohydration causes impairment of workload as well as peak oxygen uptake in recreational athletes. Our findings might indicate an important role of hypohydration in the heat-induced reduction of exercise capacity.

Prevalence and clinical implications of abnormal body composition phenotypes in patients with COVID-19: a systematic review

BACKGROUND

The impact of body composition (BC) abnormalities on coronavirus disease 2019 (COVID-19) outcomes remains to be determined.

OBJECTIVE

We summarized the evidence on BC abnormalities and their relationship with adverse clinical outcomes in patients with COVID-19.

METHODS

A systematic search was conducted up until September 26, 2022 for observational studies using BC techniques to quantify skeletal muscle mass (or related compartments), muscle radiodensity or echo intensity, adipose tissue (AT, or related compartments), and phase angle (PhA) in adults with COVID-19. Methodological quality of studies was assessed using the Newcastle-Ottawa Scale. A synthesis without meta-analysis was conducted to summarize the prevalence of BC abnormalities and their significant associations with clinical outcomes.

RESULTS

We included 62 studies (69.4% low risk of bias) with 12 to 1,138 participants, except three with up to 490,301 participants. Using computed tomography and different cut-offs, prevalence ranged approximately from 22-90% for low muscle mass, 12-85% for low muscle radiodensity, 16-70% for high visceral AT. Using bioelectrical impedance analysis (BIA), prevalence of high fat mass was 51% and low PhA was 22-88%. Mortality was inversely related to PhA (3/4 studies) and positively related to intramuscular AT (4/5 studies), muscle echo intensity (2/2 studies), and BIA-estimated fat mass (2/2 studies). Intensive care unit admission was positively related to visceral AT (6/7 studies) and total AT (2/3 studies). Disease severity and hospitalization outcomes were positively related to intramuscular AT (2/2 studies). Inconsistent associations were found for the rest of BC measures and hospitalization outcomes.

CONCLUSIONS

Abnormalities in BC were prevalent in patients with COVID-19. Although conflicting associations were observed among certain BC abnormalities and clinical outcomes, higher muscle echo intensity (reflective of myosteatosis) and lower PhA were more consistently associated with greater mortality risk. Likewise, high IMAT and VAT were associated with mortality and ICU admission, respectively.

Phase Angle and Handgrip Strength as Predictors of Clinical Outcomes in Hospitalized COVID-19 Patients

Phase angle (PhA) and muscle strength are predictors of clinical outcomes in critically ill patients. Malnutrition may affect body composition measurements. The aim of this prospective study was to investigate the association between PhA and handgrip strength (HGS), and clinical outcomes in hospitalized COVID-19 patients. The study included a total of 102 patients. Both PhA and HGS were measured twice, within 48 h of hospital admission and on the 7th day of hospitalization. The primary outcome was the clinical status on the 28th day of hospitalization. Secondary outcomes included the hospital length of stay (LOS), the concentrations of ferritin, C-reactive protein and albumin, oxygen requirements and the severity of pneumonia. A one-way analysis of variance (ANOVA) test and Spearman rS correlation coefficient were used for statistical analysis. No differences were found for PhA [on day 1 (p = 0.769) and day 7 (p = 0.807)] and the primary outcome. A difference was found between HGS on day 1 and the primary outcome (p = 0.008), while no difference was found for HGS on day 7 (p = 0.476). Body mass index was found to be associated with the oxygen requirement on day 7 (p = 0.005). LOS was correlated neither with PhA (rs = −0.081, p = 0.422) nor with HGS (rs = 0.137, p = 0.177) on the first day. HGS could be a useful indicator of clinical outcomes in COVID-19 patients, while PhA does not seem to have a clinical impact. However, further research is needed to validate the results of our study.

COVID-19 in older adult residents in nursing homes: factors associated with mortality and impact on functional capacity

Objective

To verify if the functional capacity prior to COVID-19 infection was different between Survivor and Non-survivor older adults. Also, to verify the effect of the isolation period after COVID-19 infection on the functional capacity of the Survivors residing in nursing homes.

Materials and methods

Older adults residing in nursing homes were evaluated 30 days before the COVID-19 outbreak at the site for (i) general health characteristics (obtained from medical records); (ii) gait speed, handgrip strength and 30-s sit-to-stand; (iii) sarcopenia and (iv) estimated muscle mass. Comparisons were made between Survivors and Non-survivors of COVID-19. After the isolation, the Survivors performed the assessments again.

Results

Twenty-one (81 ± 9.3 years) participants tested positive for COVID-19 and participated in the study, 12 survivors. No difference was observed between Survivors and Non-survivors in any of the outcomes evaluated. However, a moderate effect size was observed for handgrip strength, with lower values for the Non-survivors group (- 16%; d = 0.53). The isolation period reduced the number of sit-to-stand repetitions with moderate effect size in the Survivors (p = 0.046, gav = 0.66).

Conclusion

Although the null hypothesis analysis did not find significant differences between the groups, the effect size suggests that older adults residing in nursing homes who died from COVID-19 had lower handgrip strength. In the survivors, the isolation period after COVID-19 infection only negatively impacted the sit-to-stand performance.

COVID-19: Lessons on malnutrition, nutritional care and public health from the ESPEN-WHO Europe call for papers

With prolonged pandemic conditions, and emerging evidence but persisting low awareness of the importance of nutritional derangements, ESPEN has promoted in close collaboration with World Health Organization-Europe a call for papers on all aspects relating COVID-19 and nutrition as well as nutritional care, in the Society Journals Clinical Nutrition and Clinical Nutrition ESPEN. Although more COVID-related papers are being submitted and continue to be evaluated, ESPEN and WHO present the current editorial to summarize the many published findings supporting major interactions between nutritional status and COVID-19. These include 1) high risk of developing the disease and high risk of severe disease in the presence of pre-existing undernutrition (malnutrition) including micronutrient deficiencies; 2) high risk of developing malnutrition during the course of COVID-19, with substantial impact on long-term sequelae and risk of long COVID; 3) persons with obesity are also prone to develop or worsen malnutrition and its negative consequences during the course of COVID-19; 4) malnutrition screening and implementation of nutritional care may improve disease outcomes; 5) social and public health determinants contribute to the interaction between nutritional status and COVID-19, including negative impact of lockdown and social limitations on nutrition quality and nutritional status. We believe the evidence supports the need to consider COVID-19 as (also) a case of malnutrition-enhanced disease and disease-related malnutrition, with added risk for persons both with and without obesity. Similarities with many other disease conditions further support recommendations to implement standard nutritional screening and care in COVID-19 patients, and they underscore the relevance of appropriate nutritional and lifestyle prevention policies to limit infection risk and mitigate the negative health impact of acute pandemic bouts.

Estimating 3-D whole-body composition from a chest CT scan

BACKGROUND

Estimating whole-body composition from limited region-computed tomography (CT) scans has many potential applications in clinical medicine; however, it is challenging.

PURPOSE

To investigate if whole-body composition based on several tissue types (visceral adipose tissue [VAT], subcutaneous adipose tissue [SAT], intermuscular adipose tissue [IMAT], skeletal muscle [SM], and bone) can be reliably estimated from a chest CT scan only.

METHODS

A cohort of 97 lung cancer subjects who underwent both chest CT scans and whole-body positron emission tomography-CT scans at our institution were collected. We used our in-house software to automatically segment and quantify VAT, SAT, IMAT, SM, and bone on the CT images. The field-of-views of the chest CT scans and the whole-body CT scans were standardized, namely, from vertebra T1 to L1 and from C1 to the bottom of the pelvis, respectively. Multivariate linear regression was used to develop the computer models for estimating the volumes of whole-body tissues from chest CT scans. Subject demographics (e.g., gender and age) and lung volume were included in the modeling analysis. Ten-fold cross-validation was used to validate the performance of the prediction models. Mean absolute difference (MAD) and R-squared (R² ) were used as the performance metrics to assess the model performance.

RESULTS

The R² values when estimating volumes of whole-body SAT, VAT, IMAT, total fat, SM, and bone from the regular chest CT scans were 0.901, 0.929, 0.900, 0.933, 0.928, and 0.918, respectively. The corresponding MADs (percentage difference) were 1.44 ± 1.21 L (12.21% ± 11.70%), 0.63 ± 0.49 L (29.68% ± 61.99%), 0.12 ± 0.09 L (16.20% ± 18.42%), 1.65 ± 1.40 L (10.43% ± 10.79%), 0.71 ± 0.68 L (5.14% ± 4.75%), and 0.17 ± 0.15 L (4.32% ± 3.38%), respectively.

CONCLUSION

Our algorithm shows promise in its ability to estimate whole-body compositions from chest CT scans. Body composition measures based on chest CT scans are more accurate than those based on vertebra third lumbar.

Poor Nutritional Status and Dynapenia Are Highly Prevalent in Post-Acute COVID-19

Poor nutritional status is common (estimated prevalence 5–69%) in acute coronavirus disease-2019 (COVID-19), and has been associated with hospitalization, the need for intensive care, and mortality. Body composition (BC) and muscle function have also been related in such patients to poor disease outcomes.

As the evidence in the literature is limited, a cross-sectional study was carried out to determine the frequency of malnutrition in a cohort of post-acute COVID-19 patients referred to a rehabilitation center after hospital discharge. BC and muscle strength were assessed and the differences between bedridden and not bedridden patients were specifically evaluated.

The study sample was composed of 144 post-acute COVID-19 patients (mean age 64.8 years; males = 95), 37% of whom were bedridden (males = 60%). Nutritional status was evaluated with Mini-Nutritional Assessment (MNA) and Controlling Nutritional status (CONUT). Fat-free mass (FFM) and skeletal muscle mass (SM) were estimated using bioelectrical impedance analysis (BIA). Raw BIA variables (phase angle = PhA and impedance ratios = IRs) were also determined and handgrip strength (HGS) was measured. Dynapenia was identified according to the 2019 EWGSOP criteria.

According to MNA, 18% (n. 26) of patients were malnourished and 62% (n. 89) were at risk of malnutrition. As for CONUT, 21% (n. 31) of cases had moderate–severe malnutrition and 58% (n. 83) had light malnutrition. Abnormalities of raw BIA variables (low PhA and high IRs) and low HGS were more common in bedridden patients, in those who were malnourished, or had low FFM or SM. Dynapenic patients were 65% men and 47% women.

In conclusion, malnutrition, BC alterations, and low HGS occur in post-acute COVID-19 patients and are more common in bedridden patients. Further studies are needed to identify reliable algorithms for assessing nutritional status in post-acute COVID-19 patients undergoing rehabilitation.

What should a family physician know about nutrition and physical exercise rehabilitation' advices to communicate to "long-term COVID-19" patients?

In real practice, there is a paradox in the management of patients with "long-term Covid-19". Indeed, Family physicians (FPs) are on the front line in the management process of these patients. For "long-term Covid-19" patients, and according to the World Health Organization guideline, the cardiopulmonary rehabilitation (CPR) should be provided not only at tertiary- or secondary- care, but mainly at primary-care with a real implication of FPs. However, specific guidelines/recommendations were addressed for FPs. Therefore, an alternative including the CPR minimal advice that a FP should provide to "long-term Covid-19" patients, seems to be necessary to respond to the needs of FPs to face their involvement with "long-term Covid-19" patients. Thus, this paper aimed to report the CPR "minimal advice" that should be provided by FPs managing "long-term Covid-19" patients with incapacity (i.e.; alteration of the cardiorespiratory and muscular chain). According to the authors, FPs should be more cautious in the prescription of exercise and nutrition program and informed about the minimal advices related to nutritional and physical exercise rehabilitation guidelines when taking care of "long-term Covid-19" patients, and how these guidelines can relieve the mental and physical problems, improve immunity, and accelerate the recovery process of the patients. With the occurrence of new variants of the severe acute respiratory syndrome coronavirus 2, the nutritional and exercise rehabilitation guidelines implemented by FPs become indispensable to promote the recovery of Covid-19 patients and support a return to normal life.