Nutrition Therapy in COVID-19 Is Not That Simple.

The commentary by Ochoa and others in a recent issue of the Journal of Parenteral and Enteral Nutrition, based on the experience of clinicians working in Latin America, is timely. Recommendations are suggested based on existing practice for patients without coronavirus disease 2019 (COVID‐19) but are applicable with modifications to patients with severe COVID‐19. There are, however, some areas on which I humbly disagree with the authors.

Capturing disease‐related malnutrition has always been elusive. Documenting a diagnosis of “malnutrition” is important to encourage initiation of early interventions. The authors point out the benefits of Subjective Global Assessment (SGA) but state that this method “demands training.” Urgent training for nonexperts has been initiated in many countries to help them manage patients with COVID‐19, including basic ventilator techniques and advanced hemodynamic monitoring. I submit that SGA, in vogue for decades, can be easily taught online.

The use of laboratory tests to diagnose malnutrition is unnecessary. This has been suggested for many years, but old habits die hard. The authors recommend 3 tests: vitamin D, serum albumin (SA) level, and hemograms. Obtaining vitamin D levels in critically ill patients and attempting to correct low levels by administering even high doses of vitamin D3 have been conclusively shown to have no benefit. In fact, low vitamin D levels obtained after resuscitation may represent hemodilution and not true deficiency. SA level, deeply entrenched in the minds of nutritionists, has no positive or negative predictive values and is not needed to make a diagnosis of malnutrition. The authors do point out that SA levels merely correlate with inflammation, which is anyway detected by measurement of C‐reactive protein levels, which is recommended by the authors. Except for glucose levels, electrolytes (including Mg and P), and a few other tests for metabolic management (eg, coagulation tests), all other tests are unnecessary for nutrition‐related purposes, and none are required specifically for the purpose of making a diagnosis of malnutrition, thus saving resources.

The authors’ opinion, quoting a reference on parenteral nutrition, is to resort to hypocaloric feeding during the first week of intensive care unit stay and recommend that goals are reached only by the end of that period. This controversy aside, their recommendation to continue this practice beyond the first week is more problematic. They quote the European Society for Clinical Nutrition and Metabolism (ESPEN) expert statement specific to COVID‐19 that we should aim to achieve 100% of calculated energy goals, but they give 2 unsubstantiated reasons why they do not agree. The first reason is “ongoing inflammatory response” and the second is “obesity.” Inflammation per se, difficult to identify clinically and quantify, is not a contraindication to nutrition therapy. The metabolic derangements in obesity that they allude to are hyperglycemia and hypertriglyceridemia. Hyperglycemia is easily controlled by judicious use of both oral agents and/or parenteral insulin, even in patients who have COVID‐19 and receive dexamethasone or other corticosteroids. Triglyceride elevation is generally not a problem with enteral feeding.

The authors mention a phase 2 trial using a newer high‐protein formula in which excess energy was avoided, glucose levels were controlled, and there was “a potential” decrease in CO2 production. The reference quoted is not any particular study but the 2016 Society of Critical Care Medicine (SCCM)/American Society for Parenteral and Enteral Nutrition (ASPEN) guidelines. Perturbations of the respiratory quotient, specifically those due to higher CO2 production due to excess carbohydrate energy, do not occur with the current energy goals of 25–35 kcal/kg.

In summary, it is appreciated that the authors have expressed their frank opinions about nutrition therapy during the current virus crisis. However, it is suggested that readers review all available information and society guidelines and make individual choices.

CONFLICT OF INTEREST

None declared.

FUNDING INFORMATION

None declared.