Nutritional management of adult patients hospitalised with covid-19 by dietitians in KwaZulu-Natal.

Abstract

Background: The outbreak of a novel coronavirus disease (COVID-19) in December 2019, led to a worldwide pandemic. Over the past three years, over 4 million people in South Africa (SA) have been infected with COVID-19, which mainly affects the respiratory system. The presence of existing co-morbidities influences the severity of the illness, and the long-term prognosis. Patients who require hospitalisation for respiratory support are often critically ill and, in most cases, cannot consume enough nutrients. Although dietitians have been involved in the nutritional management of patients hospitalised with COVID-19, there were no guidelines on the nutritional management of COVID-19 available for them to use and they were not trained on its management. There is no consensus on how dietitians managed COVID-19 and which nutritional management guidelines they consulted. Aim: This study aimed to determine how dietitians managed adult patients hospitalised with COVID-19 in KwaZulu-Natal (KZN). Objectives: (i) to determine which nutritional guidelines dietitians used in the management of adult COVID-19 patients; (ii) to identify the challenges that dietitians faced when nutritionally managing adult COVID-19 patients; (iii) to determine whether dietitians took or estimated anthropometric measurements in bed-bound and mobile adult COVID-19 patients; (iv) to determine whether dietitians assessed malnutrition risk in adult COVID-19 patients, and if so, which nutrition screening tools were used; (v) to determine if dietitians recommended unconventional mega-doses of micro- and immunonutrient supplements for the management of adult COVID-19 patients and the reasons for use. Method: A cross-sectional descriptive study, which included dietitians employed in the public and private sectors in KZN was conducted. An electronic self-administered questionnaire was developed and used to collect data via the online platform Google Forms. Initially, the KZN Department of Health (DOH) and the Association for Dietetics in South Africa (ADSA) assisted with distributing the link to the study to dietitians in KZN. However, after an initial poor response, the data collection period was extended and the researcher was granted permission to directly contact and invite dietitians to participate, using publicly-available contact details. Data were collected between 14 August 2022 and 31 March 2023 and analysed using the Statistical Package for Social Sciences (SPSS) version 25. Results: Of the forty-two dietitians who participated in this study, 52.4% (n=22) were KZN DOH-employed dietitians and 31% (n=13) were ADSA members. Seven-percent (n=3) of the dietitians were both KZN DOH-employed dietitians and ADSA members and approximately 10% (n=4) of the dietitians were neither KZN DOH-employed dietitians nor ADSA members. An equal number of dietitians worked in private hospitals (n=16; 38.1%) and in public districtlevel hospitals (n=16; 38.1%). A significant number of dietitians began treating COVID-19 patients from the start of the pandemic or during and/or after the first wave of infection (p=0.001). Just over half of the dietitians were no longer treating any COVID-19 patients at the time of data collection (n=22; 52.4%) (p<0.001). Sixty-nine percent (n=29) of dietitians consulted a nutrition society for recommendations on the nutritional management of COVID-19 patients. The European Society for Parenteral and Enteral Nutrition (ESPEN) expert statements and practical guidance for nutritional management of individuals with SARS-CoV-2 infection were most used in the current study. The most frequently used values for calculating macronutrient requirements were: 25-30 kCal/kg/day for energy, 1.2-1.5 g/kg/day for protein, 30% of the total energy requirement (TER) for fat and 50-60% of TER for carbohydrates. Dietitians also reported using actual body weight (ABW) (n=13; 31.0%) or estimated body weight (n=19; 45.2%) to calculate nutritional requirements (p=0.004). Individual challenges faced by the dietitians were similarly grouped. There was significant disagreement among the dietitians that a lack of support and resources (p<0.001) and nutrition-related external factors were challenges they experienced (p<0.001). Anthropometry was assessed in all patient groups, with the main methods used being estimated weight, height and body mass index (BMI) for patients who were bed-bound and unconscious (n=31; 73.8%) (p=0.003). Actual weight, height and BMI were assessed in patients who were fully mobile (n=35; 83.3%) (p<0.001). There was also a significant agreement amongst the dietitians that COVID-19 patients did not feel well enough to have their anthropometric measurements taken. Half of the dietitians reported using a nutrition screening tool to screen for malnutrition (n=21; 50%) and a significant number of dietitians (n=13; 61.9%) used the Nutrition Risk Screening 2002 (NRS-2002) tool (p<0.001). Only 12 dietitians (28.6%) recommended the use of mega-doses of micro- and immunonutrient supplements in their COVID-19 patients, with an overall significant agreement that mega-doses could benefit the patient (p=0.012). All 12 dietitians who recommended mega-doses of micro and immunonutrient supplements did not report any adverse side-effects in their patients (p<0.001), and most (n=10; 83.3%) noticed an improvement in the condition of their COVID-19 patients (p=0.039). Conclusion: This was one of the first studies in SA to investigate the nutritional management of adult patients hospitalised with COVID-19. Although dietitians were involved in treating COVID-19 patients from the onset of the pandemic, most were not treating any COVID-19 patients at the time of data collection. Most dietitians consulted the ESPEN practical recommendations on the nutritional management of critically ill patients to manage their COVID-19 patients. There was no significant consensus amongst the dietitians that medical conditions and complications were challenges faced by the dietitians. Depending on the degree of mobility of the COVID-19 patient, anthropometry was assessed in COVID-19 patients, either by estimation or actual measurements. The most common malnutrition screening tools used by dietitians were the NRS-2002 and the Malnutrition Universal Screening Tool (MUST). Megadosing of micro- and immunonutrient supplements was not popular among the dietitians in the current study and further studies are needed in this area.