key: cord-0914615-6o3c1ho3 authors: Larrazabal, Ramon B.; Perez, Blessie Marie; Masamayor, Ella Mae; Chiu, Harold Henrison; Palileo-Villanueva, Lia M. title: The Prevalence of Malnutrition and Analysis of Related Factors among Adult Patients with the Coronavirus Disease 2019 (COVID 19) in a Tertiary Government Hospital: The MalnutriCoV Study date: 2021-02-23 journal: Clin Nutr ESPEN DOI: 10.1016/j.clnesp.2021.02.009 sha: ea22303124d03707ef5bd595e76bfb9e978047c4 doc_id: 914615 cord_uid: 6o3c1ho3 Background and Aims As of November 2020, the Coronavirus Disease 2019 (COVID 19) has infected more than 396,000 people in the Philippines. Although no study has been done on malnutrition among a general cohort of patients with COVID 19, it has long been associated with increased mortality and poor long-term outcomes. We aimed to determine the prevalence of malnutrition among patients with COVID 19 admitted in a tertiary government hospital. Methods Cross-sectional study on COVID 19-confirmed patients admitted to the COVID 19 wards from July 15 to September 15, 2020. Nutritional status was assessed using the Philippine Society for Parenteral and Enteral Nutrition (PhilSPEN) modified Subjective Global Assessment Grade (SGA) tool. Malnutrition was defined as those with SGA grades B and C. Chi-square test or Fisher exact test of association, as appropriate, was used to identify factors that have a significant association with malnutrition. Furthermore, logistic regression was done on factors with significant association. Results Among the 355 adult patients in the study, 71.83% (255/355) were malnourished [SGA B: 48.73% (173/255); SGA C: 23.10% (82/255)]. The following were shown to have significant association with malnutrition: community-acquired pneumonia (CAP) [p-value < 0.001], hospital-acquired pneumonia (HAP) [p-value 0.002], and chronic kidney disease (p-value 0.033). Multivariable logistic regression revealed that age [OR 1.02, CI 95% 1.00, 1.04, p-value 0.027] and CAP-Moderate Risk (MR) [OR 3.02, CI 95% 1.73, 5.27, p-value < 0.001] are significant predictors of malnutrition. All patients with CAP- High Risk and HAP were malnourished. Conclusion The prevalence of malnutrition was high (71.83%) in a general cohort of COVID 19 patients as measured by the modified SGA tool. The following are risk factors of malnutrition among patients with COVID 19: age, CAP, and HAP. Nutritional support and management of comorbidities are of paramount importance in the care of patients with COVID 19. As of November 2020, the COVID-19 has affected more than 50.4 million people and resulted in more than 1.26 million deaths worldwide, with numbers continuously increasing daily (1) . In the Philippines, the disease has infected more than 396,000 people and resulted in almost seven thousand deaths (2) . This current pandemic has been declared by the World Health Organization as a global public health emergency (3) . Older adults and people of any age who have underlying medical conditions, especially if uncontrolled, are at a higher risk for acquiring severe illness from COVID-19 (4) . A cross-sectional study by Li et al. from Wuhan, China reported that 27.5% of patients aged 65 years and above were at risk for malnutrition and at least 52.7% were malnourished (5) . These figures were higher than the global incidence of malnutrition in the elderly signifying that there was a higher prevalence of malnutrition among COVID-19 patients (6) . The investigators attributed these findings to the following: first, protein consumption was increased from the acute inflammatory response from the coronavirus infection; second, the comorbid diseases of these patients, such as diabetes, may increase the risk for malnutrition; third, gastrointestinal symptoms such as diarrhea, vomiting, and poor appetite; and fourth, the patient's anxiety of having the disease may further aggravate poor appetite (5, 7, 8, 9) . While there has been no study yet on malnutrition and mortality among patients with COVID-19, malnutrition has long been associated with increased mortality and poor long-term outcomes among patients with community acquired pneumonia. This may be due to the increased propensity of malnourished patients to develop impaired muscle and respiratory function (10) . Numerous tools have been employed to assess nutritional status and risks. One of the most widely used tool is the Subjective Global Assessment (SGA). It uses medical history which includes history of weight loss, food intake, gastrointestinal symptoms, functional capacity, disease and relation to nutritional requirements, combined with a brief physical examination suggestive of muscle wasting, alternations in fluid balance to assess nutritional status (11) . The tool is inexpensive, rapid to conduct and can be effectively used by nurses, dieticians and physicians (12, 13) . In the Philippines, the modified SGA, developed by the Philippine Society of Enteral and Parenteral Nutrition (PhilSPEN), has been validated for use in the Filipino population. In addition to the standard SGA, the modified SGA tool also includes measurement of the Body Mass Index, serum albumin and total lymphocyte count. (14) . This tool has been found to have a sensitivity of 94.7%, specificity of 96.2% and Positive Predictive Value of 95.7% in determining malnutrition in adults in both inpatient and outpatient settings (15) . This study aimed to determine the prevalence of malnutrition among COVID-19 patients admitted in a tertiary government hospital and explore its association with various demographic and clinical factors. This was a cross sectional study on the prevalence of malnutrition among COVID All adult patients aged 19 years and older with COVID-19 confirmed by a positive nasopharyngeal swab RT-PCR test and admitted to the COVID wards were recruited to the study. Patients who were unable to follow commands, answer when asked questions, stand to be weighed, needed maternity or psychiatric care, had missing data from their medical charts (e.g. no total lymphocyte count or serum albumin results), or did not consent were excluded. Nutritional status and risk were assessed using the Philippine Society of Enteral and Parenteral Nutrition (Phil-SPEN) developed Modified Subjective Global Assessment (SGA) Grade (14) . An SGA grade of A is normal/not malnourished, J o u r n a l P r e -p r o o f Grade B will show mild/moderate (if with +1/+2 subcutaneous fat or muscle loss) malnutrition and Grade C will show severe malnutrition. Nutritional risk score of 0-2 corresponds to low risk, a score of 3-5 corresponds to moderate risk while a score equal to 6 or greater corresponds to a high risk for malnutrition. The prevalence of malnutrition in this study was defined as participants with modified SGA scores B (mild/moderate) and C (severe). The study was conducted from July 15 to September 15, 2020. All ward admissions within the last 24 hours were checked in the hospital's electronic database daily. Eligible patients were invited to participate in the study. Those who gave their written informed consent were enrolled and interviewed regarding weight loss, food intake, gastrointestinal symptoms, and functional capacity. The following information were obtained from their medical charts: birthdate, sex, nationality, educational attainment, employment status, city of residence, comorbidities, contact number, admission diagnoses, and latest available laboratory values of not more than 6 months for Serum Albumin and Total Lymphocyte count (TLC), physical examination on admission (i.e. edema/ascites). The height (rounded off to the nearest millimeter) and weight (rounded off to the nearest 100 grams) on admission were also extracted from the medical charts. In the instances where the height and weight were not recorded on admission, the investigators measured them using the weighing scale with built-in height rod (Detecto 339) located in the wards. All data were recorded in electronic data collection forms using the Google Form application. The body mass index (BMI) was calculated by dividing the weight in kilograms with the height in meters squared. The WHO BMI cut-offs for the general population J o u r n a l P r e -p r o o f were used instead of the Asian-cut offs because it correlated better in predicting malnutrition among the Filipino population. BMI less than 18.5kg/m 2 is underweight, BMI between 18.5 to 24.9kg/m 2 is ideal, BMI between 25.0 to 29.9kg/m 2 is overweight and BMI more than 30kg/m 2 is considered obese. Study participants were classified according to their risk for death using the A-DROP tool, which has been shown to be a reliable tool for risk stratification in hospitalized COVID-19 patients at point of admission, with a specificity and a sensitivity of 86% and 94%, respectively (16) . The PhilSPEN-formed modified SGA tool was used to assess and rate the nutritional status of the participants based on the information obtained from the chart and the interviews. The data were organized in MS Excel software and analyzed in STATA 15.1 (Stata corp, College Station, TX, USA). Categorical variables were summarized using frequencies and percentages. The continuous variable in the study (i.e. age) was reported in mean and standard deviation. The prevalence of malnutrition and nutrition risk were expressed in percent. Chi-square test or Fisher exact test of association, as appropriate (parametric or non-parametric data) , were used to identify significant association between malnutrition and nutrition risk with the different clinical factors. Post-hoc univariable and multivariable logistic regression were performed to identify factors significantly associated with malnutrition. The confidence interval used is 95% (p-value cut-off of 0.05). The Table 1 shows the characteristics of the participants in the study. There were more males (56.06%) in the study than females (43.94%). As to educational attainment, there were more who completed secondary education (45.63%) than any other group. However, almost half of the participants were unemployed (49.86%) with some of them being retired (5.07%). Table 2 shows the comparison between the malnourished and not malnourished groups. Malnutrition was found to be more common in patients with Community-Acquired Pneumonia (p-value <0.001), Hospital-Acquired Pneumonia (pvalue 0.002), and Chronic Kidney Disease (p-value 0.033). There were more obese than underweight (13 vs 19) . Furthermore, majority (77%) of the underweight were classified as malnourished, while only 15% of those who were obese were classified as malnourished. The investigators did an analysis between underweight and obese with COVID-19 pneumonia severity. Our analysis showed that there is no sufficient evidence to conclude that either factors are associated with COVID-19 pneumonia severity (Table 5 ). The profiles of the patients included in the study grouped according to nutrition risk are shown in Table 3 . Malnutrition Risk was increased in patients with age above 65 years old (p-value 0.036), CAP (p-value <0.001), and Bronchial Asthma (p-value 0.003). There were no significant associations between malnutrition and other sociodemographic factors such as educational attainment, place of residence, or employment status. Individual (Univariable) logistic regression showed that age, CAP, and CKD are significant predictors of malnutrition among COVID-19 patients admitted in PGH ( with alterations in the lung's ability to resist invading pathogens that lead to increased incidence, more virulent and prolonged respiratory infection that ultimately lead to poor long-term outcome in these patients (10, 20) . Our study has also shown that patients with COVID 19 and Chronic Kidney disease had approximately twice (OR 1.97) the risk of being malnourished. Malnutrition in CKD is caused by an interplay of several factors, such as decreased appetite and nutrient uptake, metabolic imbalances, hormonal derangements, inflammation, dialysis-related abnormalities, and increased catabolism (21) . Aside from nutritional status, the investigators also looked into nutrition risk. This study has several limitations. First, it is a single-center study done in a tertiary government hospital located in the National Capital Region that was designated as a COVID-19 referral center. This may have caused some selection bias--the admitted patients were mostly from within the vicinity, or may have had more severe disease, hence may not be representative of COVID 19 patients in general. Second, other factors that may affect the nutrition status and/or severity of their diseases and comorbidities were not analyzed in the study, such as lifestyle habits, physical activity, and social support. Third, some of the collected data (e.g. weight loss prior to hospitalization, food intake) were subjective and may have been subject to recall bias. Fourth, the relatively small sample size may have limited the study's ability to demonstrate significant associations between malnutrition and other variables. We recommend that larger multi-center studies be done in different COVID-19 referral centers or hospitals throughout the country to better reflect the burden of malnutrition among those with COVID-19. We also recommend that more objective measurements of malnutrition be taken (i.e. mid upper arm circumference and triceps skin fold). The prevalence of malnutrition among hospitalized patients with COVID-19 was high (71.83%). Risk factors for malnutrition among these patients include older age, severity of pneumonia and chronic kidney disease. Routine nutrition screening and assessment for all patients admitted in the COVID wards and management of malnourished patients by a nutrition support team are recommended. Larger, multicenter studies that use more objective measures of malnutrition are also recommended. Malnutrition is associated with poorer outcomes among admitted patients. Therefore, screening for malnutrition (by using a tool validated for Filipinos such as the modified SGA tool) and also addressing it is critical in treating and preventing further adverse health outcomes. This is important especially in the context of the current pandemic where different modes of therapy are still currently under investigation. Table 2 . Comparison between patients with malnutrition or not. Table 4 . Factors predicting malnutrition among COVID-19 patients admitted in PGH. • The severity of pneumonia is directly proportional to the risk of malnutrition. • Age and Chronic Kidney Disease and associated with malnutrition. COVID 19 Case tracker COVID-19) Outbreak Prevalence of malnutrition and analysis of related factors in elderly patients with COVID-19 in Wuhan, China Frequency of malnutrition in older adults: a multinational perspective using the mini nutritional assessment Pulmonary angiotensin-converting enzyme 2 (ACE2) and inflammatory lung disease Type 2 diabetes mellitus and skeletal muscle metabolic function Clinical characteristics of Coronavirus disease 2019 in China Prognostic significance of malnutrition for long-term mortality in community-acquired pneumonia: a propensity score matched analysis. The Korean journal of internal medicine Subjective Global Assessment in chronic kidney disease: A review Reliability of the 7-point subjective global assessment scale in assessing nutritional status of dialysis patients Is subjective global assessment a reliable measure of nutritional status in hemodialysis The Prognostic Capacity of the Nutrition Risk Score and Subjective Global Assessment (SGA) Grade of the PhilSPEN The results of the validation process of a Modified SGA (Subjective Global Assessment) Nutrition Assessment and Risk Level Tool designed by the Clinical Nutrition Service of St. Luke's Medical Center, a tertiary care hospital in the Philippines Comparison of severity scores for COVID-19 patients with pneumonia: a retrospective study Prevalence of malnutrition in COVID-19 inpatients: the Nutricov study Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: A retrospective cohort study Nutrition support in the time of SARS-CoV-2 (COVID-19) Malnutrition and Lung Host Defenses: Implications for the Pathogenesis and Prevention of Pneumonia Malnutrition in Chronic Kidney Disease Hospital malnutrition: the Brazilian National Survey (IBRANUTRI): a study of 4000 patients Prevalence of malnutiriton in nonsurgical hospitalized patients and its association with disease coplications The 2020 Global Nutrition Report in the context of COVID-19 The investigators would like to acknowledge the expert advice by Dr. Joyce B.Bernardino. We would also like to acknowledge the unwavering support of the administration of the Philippine General Hospital in the conduct of this study in the COVID 19 wards of the hospital.