Letter to the Editor: Challenges Providing Nutrition Care during the COVID-19 Pandemic: Canadian Dietitian Perspectives.

Dear Editor,

The coronavirus disease-2019 (COVID-19) is an infectious disease that causes a variety of symptoms, including cough, fatigue, sore throat, and in some cases, impaired taste and smell (1, 2). Each of these symptoms can impact a person’s desire and ability to eat, which prevents the body from acquiring the vitamins, minerals, and macronutrients needed to protect itself and recover from illness (3, 4). COVID-19 has also restricted access to healthcare appointments, community services, grocery shopping, and social visits with family and friends. Consequently, patients are at increased risk of developing malnutrition (3–5). As part of a larger survey about nutrition care practices as patients leave the hospital or are cared for in primary and community care, we investigated the challenges that Canadian dietitians have experienced while providing care to their patients during the COVID-19 pandemic.

COVID-19 survey questions were available via an online platform (QualtricsXM) from April 25–May 31, 2020. Dietitians were asked two questions about COVID-19: i) their perception of nutrition-related challenges for patients returning to the community post-hospital discharge; and ii) how the pandemic had affected their practice. For these questions, the dietitians submitted their qualitative responses via an open comment box. Two hundred and fifty-five dietitians participated in this survey with 23.5% (n= 60) and 16.9% (n= 43) providing responses for COVID-19 questions one and two, respectively. These responses were analyzed using qualitative description with minimal interpretation (6).

Decreased access to healthcare professionals and nutrition care services due to limited in-person contact and service cancellations was the most common challenge that dietitians reported for discharged patients. Nutrition counselling, education, and meal delivery programs have been shown to improve energy and protein intake as well as prevent rehospitalization (7–9). Hence, dietitians felt that barriers to accessing these resources could cause or exacerbate nutrition problems since patients would be unable to receive the nutritional supports that they required. Additionally, dietitians reported that many patients were experiencing food insecurity due to decreased income and increased anxiety regarding grocery shopping during the pandemic. This was most evident amongst populations that are at high risk of poor outcomes with COVID-19, such as older adults and individuals with comorbidities (10). Food insecurity is a known risk factor for malnutrition, as it reduces food and nutrient intake (10, 11). Similarly, dietitians were concerned that the social isolation and mental distress caused by shelter-in-place requirements would reduce appetite and the desire to eat healthy, nutritious foods, thereby increasing nutrition risk (3, 4, 10).

In terms of changes to practice, dietitians indicated that COVID-19 made it necessary for them to conduct appointments with their patients by phone or online. While the increased availability of virtual services may work well for some patients, others do not have access to reliable phone or internet connection and/or they may not have the capacity to use this technology. Furthermore, patients who are deaf or hard of hearing may have difficulties participating in virtual appointments, thereby restricting their access to high-quality healthcare. This creates health disparities for patients who are already at high risk of malnutrition: older adults, patients with low socioeconomic status, and patients with disabilities (3, 4, 10). Dietitians also experienced many barriers to performing nutrition-focused assessments using virtual methods, including limited-to-no ability to conduct physical exams and reliance on subjective, patient-reported measures (e.g., weight, appetite, or food intake). Moreover, there was impaired communication and coordination efforts between different healthcare settings, professionals, and disciplines. In fact, this group of dietitians reported receiving fewer referrals since the pandemic began in Canada, despite the established nutrition risks associated with COVID-19 (3–5, 10, 11). This prevents early intervention, which can cause progression of malnutrition, development of frailty, and rehospitalization (3, 4).

COVID-19 has made patients more vulnerable to malnutrition and highlighted many health disparities embedded within our society. Although virtual services do not replace the need for in-person healthcare, such services must be made more accessible and intuitive for individuals of diverse backgrounds. Moreover, nutrition care must be prioritized within hospital, primary care, and community settings to prevent, detect, and treat malnutrition. Nutrition screening and assessment must continue, even for patients with suspected or confirmed COVID-19, to identify individuals experiencing low appetite, food insecurity, social isolation, or other nutrition risk factors. This will facilitate early intervention by helping healthcare professionals recognize when a dietitian referral and/or support from community services are needed. COVID-19 has uncovered the nutritional vulnerability of key subgroups within the population, such as socially isolated older adults. Healthcare and social service providers within primary care and community sectors must rise to the challenge of supporting these nutritionally vulnerable groups during the COVID-19 pandemic and afterward.