Human Nutrition and Dietetics
QUESTIONS WE HAVE ANSWERED
What is the impact of achieving adequate nutrition in the rehabilitation phase post COVID-19 infection?
At this time, there is no evidence on the impact of adequate nutrition in the rehabilitation phase post COVID-19. There is also limited evidence for the impact of adequate nutrition in the prevention and treatment of COVID-19. However, given the broader evidence on the impact of nutrition on recovery from infectious diseases, guidelines highlight the need to assess malnutrition in COVID-19 patients and to develop an appropriate plan to ensure necessary energy, protein, vitamin and mineral intakes.
How long do taste changes or loss remain post COVID-19? What is the impact of same?
Research indicates that about 1 in 3 COVID-19 patients will experience taste changes or loss and that for the majority this dysfunction will last 7 to 14 days. It is not yet clear how long it will take those patients with persistent taste dysfunction to recover. Research to date has included only short-term follow-up protocols, following patients for four to eight weeks. As with everything in the COVID-19 era evidence is constantly accruing and more research is needed to determine both the average length of recovery time for persistent taste dysfunction as well as the impact of such a dysfunction overtime on the patient. Existing literature on taste dysfunction (unrelated to COVID-19) has found that loss of taste can be detrimental to both the physical and mental health of a patient. There are currently no treatments recommended by researchers for loss of taste produced by the COVID-19 virus.
When cleaning areas between patients are detergent wipes (e.g. Sanicloths) required or will a general detergent spray and disposable tissue suffice?
When disinfecting areas between patients are disinfectant wipes required or can we use disinfectant spray and disposable tissues?
The HSE Health Protection Surveillance Centre guidelines do not stipulate that wipes are required to clean or disinfect areas between patients. Disposable tissues, cloth, or paper towels are sufficient to use in conjunction with the appropriate detergent solution and disinfectant.
The content of this document is correct as of 06/11/2020.
This response was based on HSE Health Protection Surveillance Centre Interim Guidance on Infection Prevention and Control for the Health Service Executive 2020 v1.2. Available here.
Is there sufficient evidence to warrant a change in the established position (i.e. NICE guidelines of June 2020) regarding vitamin D for the prevention or treatment of COVID-19?
No, there is insufficient evidence to warrant a change in the established position (i.e. NICE guidelines of June 2020) regarding vitamin D for the prevention or treatment of COVID-19. Best practice remains maintaining recommended levels of Vitamin D, which may include supplementation of vitamin D in groups at high-risk of deficiency.
The content of this document is correct as of 17/09/2020.
- To what degree are people with Long COVID presenting with dysphagia and/or voice difficulties?
- To what degree are mildly symptomatic / asymptomatic patients post COVID presenting with dysphagia and/or voice difficulties?
Long COVID has not yet been well-studied and research is underway in this area. Many of the studies of dysphagia and voice difficulties are observational or prospective with small sample sizes and varying lengths of follow-up. Furthermore, the evidence for dysphagia/voice disorders in long-COVID is limited at this point. Studies mainly focus on dysphagia and voice difficulties following acute respiratory distress syndrome (ARDS) and/or the associated respiratory support interventions such as intubation and tracheostomy. The limited evidence suggests people with who have been hospitalised for COVID-19 and particularly, those who have experienced ARDS and undergone associated medical interventions, are at increased risk of dysphagia and/or voice difficulties. There is also preliminary evidence that dysphagia can be addressed through rehabilitation, therefore, reducing long-term effects. In addition, there is insufficient evidence to assess the degree to which mildly symptomatic or asymptomatic patients present with dysphagia and/or voice difficulties post COVID-19.
The content of this document is correct as of 05/02/2021.
Could you please provide clarity on the proper disposal of PPE?
What type of bin should be used? Can certain types of PPE be disposed in domestic bins (e.g. masks)?
If PPE is worn with a person who is known or suspected to have COVID-19 then it should be disposed of in a healthcare risk waste bin (yellow). If a healthcare risk waste bin is unavailable, the following procedure should be followed:
- All items of PPE should be disposed of into a plastic bag
- The bag should not be filled more than three quarters full
- The bag should be securely tied and placed inside another second, plastic bag (double bag)
- The bag should be stored securely for 72 hours and can then be disposed of with general domestic waste
If PPE is worn in the absence of a specific known risk of COVID-19 it can be discarded immediately as general domestic waste. There is no distinction made between different types of PPE in terms of disposal procedures.
The content of this document is correct as of 11/12/20.
1.Can a Classroom Feeding Observation for Dysphagia take place within a Pod?
2.When conducting a Classroom Feeding Observation for Dysphagia do parents of children in the same Pod as the patient need to be informed of, and consent to, the observation?
1.Yes, assuming local and national COVID-19 guidelines are followed including PPE and social distancing, a Classroom Feeding Observation for Dysphagia can take place within a Pod.
2.Yes, assuming local and national COVID-19 guidelines are followed including PPE and social distancing, a Classroom Feeding Observation for Dysphagia can take place within a Pod.
The content of this document is correct as of 18/09/2020.
This response was based on the Department of Education COVID-19 Response Plan for Reopening our Primary and Special Schools, version 2, published in August 2020. Access this document here.
- What is the evidence to support high flow nasal oxygen in COVID-19 management?
- Does high flow nasal oxygen result in increased droplet dispersion and aerosol generation in COVID-19 patients?
High flow nasal oxygen for the management of COVID-19 is a controversial topic due to a lack of high-quality research into its efficacy and its potential as an aerosol-generating procedure. Systematic reviews commissioned by the World Health Organization found that high-flow nasal cannulas may reduce the need for invasive ventilation and the escalation of treatments over conventional oxygen therapy in COVID-19 patients. However, they caution that this potential advantage must be weighed against the currently unknown risk of droplet and aerosol transmission: there is currently no research evidence directly examining the consequent dispersion of COVID-19 virus for this procedure. A number of actions can reduce any potential risk: deliver HFNO in negative-pressure rooms and/or ensure proper ventilation; use an increased area of precaution; ensure staff have protective PPE; and place surgical masks on patients receiving the HFNO.
The content of this document is correct as of 04/12/20.
- Is there any evidence to suggest chest physiotherapy is an aerosol-generating procedure?
- Does the evidence compare different types of chest physiotherapy treatment techniques – and whether certain treatments may be more aerosol generating than others? (i.e. positive pressure devices, oscillating devices, cough assist, breathing techniques, patient coughing, suction etc).
There is insufficient evidence to state that chest physiotherapy is an aerosol-generating procedure. However, absence of evidence is not evidence of absence. International and national professional physiotherapy bodies have endorsed guidelines for physiotherapy management during COVID-19 which state that chest physiotherapy interventions are potentially aerosol-generating procedures and strongly recommend using airborne precautions when delivering these interventions. Furthermore, a recent systematic review classified chest physiotherapy interventions as potentially aerosol-generating and recommended, for the purposes of selecting personal protective equipment, that such procedures be treated as aerosol-generating.
The content of this document is correct as of 04/12/20.
What is the latest evidence regarding conscious proning of COVID-19 patients?
At what level of oxygen is it best to commence proning?
When should you stop proning as the patient is improving?
The current evidence for conscious proning is of poor quality and fails to answer several key questions required to inform clinical practice, including the optimum conditions for commencing and ceasing proning. There are multiple RCTs underway that will address these gaps in knowledge over the coming months.
The content of this document is correct as of 27/11/2020.
1.What is current guidance for cleaning a room after a hands-on physiotherapy session?
2.What are the current recommended products for effectively cleaning surfaces?
3.Do I have to wait a certain amount of time to clean my treatment room after a session?
1.Clean with detergent and water followed by rinsing and drying. If a surface is suspected or known to have been contaminated by infectious material a disinfected should be used after cleaning.
2.A neutral detergent with water for cleaning and a chlorine-based product, such as sodium hypochlorite, for disinfecting.
3.HSPC cleaning protocols do not stipulate that a certain amount of time should be left between seeing a patient and cleaning. HSPC guidelines state that COVID-19 virus droplets produced by an infected patient will land on surfaces “within minutes” of production. They do not state how many minutes precisely. Research has found that large droplets fall within 1 second while smaller droplets can take up to 9 minutes to fall to the ground.
The content of this answer is correct as of 02/10/2020
What is the current guidance for Occupational Therapists practicing telehealth?
There are a number of best practice guidance documents currently available. We have summarised the information and guidance from the Irish COVID-19 Occupational Therapy in Acute Hospitals Interest Group, the Association of Occupational Therapists of Ireland, the World Federation of Occupational Therapists, the American Occupational Therapy Association and Occupational Therapy Australia (OTA).
Can the below tests be administered via telepractice?
- Beery-Buktenica Developmental Test of Visual-Motor Integration
- Detailed assessment of speed of handwriting (DASH)
Yes, both Beery and the DASH have publisher recommendations for administration via telepractice. Detailed instructions for the DASH can be found here and detailed instructions for the Beery can be found here.
Both tests are published by Pearson. The DASH telepractice information is available on the Pearson UK website but it does not appear on their US website. For the Beery, vice versa, the telepractice information is available on the Pearson US website and does not appear on their UK website.
What is the impact on return to work for patients with COVID-19 who have been hospitalised?
In Ireland, 3,676 people have been hospitalised because of COVID-19. There is no information on the consequent work status of these individuals. This is also the case on the global stage. There are indications from small scale studies and research on similar diseases (SARS & MERS) that some individuals hospitalised with COVID-19 will experience delayed return to work. Fatigue and breathlessness are the most common post-discharge symptoms. Scientists and professional bodies are calling for occupational therapists and other allied health professionals to prepare for the surge in demand for services but more research is needed to determine the long-term consequences of a COVID-19 hospitalisation and its impact on return to work.
The content of this document is correct as of 08/10/2020.
- What is the current best practice when working as a CBT therapist in primary care?
- In light of the new strains of Covid 19 and the most recent information, is it still recommended to wear a face shield and maintain 2 metres distance from the patient?
- What is a safe session duration?
Recent updates of Irish guidance have reiterated that masks must be worn in healthcare facilities when a distance of 2 metres cannot be maintained. However, the guidance does not specifically address if masks need to be worn if persons are greater than 2 metres apart. Surgical masks are recommended for health workers within primary care practices while face coverings are recommended for patients entering a primary care practice. An updated rapid evidence summary by the HSPC indicates that face coverings are preferable to visors/shields to reduce transmission of COVID-19, though the evidence is of low quality. However, there are circumstances where a face covering may not be appropriate and may affect quality of care. In these circumstances a visor/shield may be used provided that it extends from above the eyes to below the chin and from ear-to-ear. The role of room ventilation is increasingly acknowledged and some guidance exists on increasing ventilation though this is dependent on context. Recommendations are not made about safe session duration.
The content of this document is correct as of 02/02/2021.
How can a person who is a ‘close contact’ without their own transport safely travel to a COVID-19 testing centre? Are there any specific arrangements for students or healthcare workers? Can they use public transport, taxi or is there any arrangement with the ambulance centre to support this?
A person who is a ‘close contact’, without their own car, should ask one person that they live with to drive them to the testing centre. If the ‘close contact’ does not live with anyone who has a car they should ask someone who they have been in close contact with very recently to drive them. They should follow the HSE guidance on how to safely travel in a car in such a circumstance. A person who is a close contact should not use public transport, this includes using a taxi service. There are no special arrangements in place for students or healthcare workers.
The content of this document is correct as of 10/11/2020.
Do I need to wear a mask if maintaining a 2m distance in a treatment room while delivering face-to-face CBT in Primary Care?
The National Public Health Emergency Team (NPHET) has recommended that healthcare workers use a surgical mask for all patient care activities when a safe distance (2m) cannot be maintained. This implies that when a 2m distance can be maintained a mask is not necessary. However, the NPHET guidance does not state this explicitly and does not address the issues of room size/occupancy or duration of contact. The European Centre for Disease Prevention and Control considers maintaining a 2m distance in a closed environment, such as a treatment room, as low-risk for exposure to COVID-19. The HSE Health Protection Surveillance Centre state that in low-risk circumstances, where wearing a mask may impact on patient care, a clear face visor is an acceptable alternative.
The content of this document is correct as of 30/09/2020.
These documents were used to answer this question:
- Health Protection Surveillance Centre (2020). Interim Guidance on Infection Prevention and Control for the Health Service Executive 2020 v1.2. HSE: September 2020.
- Health Protection Surveillance Centre (2020). Guiding principles for Infection Prevention and Control when returning to routine General Practice during pandemic COVID-19 v2.1. HSE: July 2020.
- European Centre for Disease Prevention and Control (2020). Public health management of persons having had contact with cases of novel coronavirus in the European Union. ECDC: February 2020.
Dr Liz Kingston, member of the RapidInfo4U Panel of Experienced Clinicians and Lecturer at the University of Limerick, with a clinical speciality in infection prevention and control, was consulted to answer this question.
Essential oils have been use for decades for the treatment of minor ailments. Each particular essential oil has their specific properties from antiviral, antimicrobial, anti-fungicide, antibacterial and so on. Is there any evidence that essential oils ease respiratory symptoms or respiratory distress for patients with COVID-19 if used alongside or in conjunction with medical treatment?
Research on the antiviral properties of essential oils are at the early stages. Recent reviews have found no trials that evaluated the clinical efficacy of essential oils on respiratory symptoms caused by coronavirus in humans. Additionally, current studies fail to provide adequate information on the toxicity of essential oils and safe dose information.
The content of this document is correct as of 28/01/2021.
Is there a mandatory requirement to set aside vacant rooms to be utilised in the event of a COVID-19 outbreak in a residential care facility?
Will there be financial provision or grant to the centre to cover the cost of having vacant rooms for this purpose?
This document has been prepared on behalf of the British Dietetic Association Critical Care Specialist Group by the following working group of Critical Care Dietitians from various NHS Trusts, Addenbrookes Hospital Cambridge and Kings College Hospital London.
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Bear, D., Terblanche, E., Davies, C., Duff, S., & Fixter, L. (2020). Critical Care Specialist Group (CCSG) of the BDA Guidance on management of nutrition and dietetic services during the COVID 19 pandemic. The Association of UK Dietitians, 1, 8.
This document has been developed by members from the Critical Care Dietitians Specialist Group of the British Dietetic Association taking into account current recommendations for planning and local experiences to date. In the absence of evidence-based guidance in this area, this document draws on experiences and knowledge obtained from those already working with critically ill patients with COVID-19, including international colleagues.
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Barazzoni, R., Bischoff, S. C., Breda, J., Wickramasinghe, K., Krznaric, Z., Nitzan, D., … & Singer, P. (2020). ESPEN expert statements and practical guidance for nutritional management of individuals with SARS-CoV-2 infection.
ESPEN is the European Society for Clinical Nutrition and Metabolism. This editorial discusses the acute respiratory complications that require intensive care unit (ICU) management that are a major cause of morbidity and mortality in COVID-19 patients. Patients with worst outcomes and higher mortality are reported to include immunocompromised subjects, namely older adults and polymorbid individuals and malnourished people in general. ICU stay, polymorbidity and older age are all commonly associated with high risk for malnutrition, representing per se a relevant risk factor for higher morbidity and mortality in chronic and acute disease. Also importantly, prolonged ICU stays are reported to be required for COVID-19 patients stabilization, and longer ICU stay may per se directly worsen or cause malnutrition, with severe loss of skeletal muscle mass and function which may lead to disability, poor quality of life and additional morbidity. Prevention, diagnosis and treatment of malnutrition should therefore be routinely included in the management of COVID-19 patients. In the current document, the European Society for Clinical Nutrition and Metabolism (ESPEN) aims at providing concise guidance for nutritional management of COVID-19 patients by proposing 10 practical recommendations. The practical guidance is focused to those in the ICU setting or in the presence of older age and polymorbidity, which are independently associated with malnutrition and its negative impact on patient survival.
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CONTENT FROM SCIENTIFIC JOURNALS
This article proposes a flow chart and ten key issues for optimizing the nutrition management of COVID-19 patients in the ICU.
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Optimal nutrition can improve well-being and might mitigate the risk and morbidity associated with coronavirus disease 2019 (COVID-19), caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). This review summarizes nutritional guidelines to support dietary counseling provided by dietitians and health-related professionals.
The majority of documents encouraged the consumption of fruits, vegetables, and whole-grain foods. Thirty-one percent of the guidelines highlighted the importance of minerals and vitamins such as zinc and vitamins C, A, and D to maintain a well-functioning immune system.
Dietary supplementation has not been linked to COVID-19 prevention. However, supplementation with vitamins C and D, as well as with zinc and selenium, was highlighted as potentially beneficial for individuals with, or at risk of, respiratory viral infections or for those in whom nutrient deficiency is detected.
There was no convincing evidence that food or food packaging is associated with the transmission of COVID-19, but good hygiene practices for handling and preparing foods were recommended. No changes to breastfeeding recommendations have been made, even in women diagnosed with COVID-19.
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This article discusses the health disparities in nutrition and obesity which correlate closely with the alarming racial and ethnic disparities related to Covid-19.
Black, Latinx, and Native Americans are experiencing disproportionate burdens of infections, hospitalizations, and deaths from SARS-CoV-2 (Covid-19). Similar disparities are observed in other countries where minority groups face hurdles in accessing health, education, and social services as well as affordable, healthy food. These stark manifestations of health inequities have emerged in the wake of a body of evidence linking obesity and obesity-related chronic diseases, such as hypertension, diabetes, and cardiovascular disease — conditions that disproportionately affect disadvantaged populations — with severe outcomes from Covid-19.
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Robinson, E., Boyland, E., Chisholm, A., Harrold, J., Maloney, N. G., Marty, L., … & Hardman, C. A. (2020). Obesity, eating behavior and physical activity during COVID-19 lockdown: A study of UK adults. Appetite, 104853.
This study examined weight-related behaviours and weight management barriers among UK adults (n = 2002) during April–May of the 2020 COVID-19 social lockdown.
UK adults completed an online survey including measures relating to physical activity, diet quality, overeating and how mental/physical health had been affected by lockdown. Participants also reported on perceived changes in weight-related behaviours and whether they had experienced barriers to weight management, compared to before the lockdown.
The study reports that many participants reported negative changes in eating and physical activity behaviour (e.g. 56% reported snacking more frequently) and experiencing barriers to weight management (e.g. problems with motivation and control around food) compared to before lockdown. These trends were particularly pronounced among participants with higher BMI. During lockdown, in this study sample, higher BMI was associated with lower levels of physical activity and diet quality, and a greater reported frequency of overeating.
This study found that reporting a decline in mental health because of the COVID-19 crisis was predictive of greater overeating and lower physical activity in lockdown.
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High Level of Food Insecurity among Families with Children Seeking Routine Care during the Pandemic
Abrams, S. A., Avalos, A., Gray, M., & Hawthorne, K. M. (2020). High Level of Food Insecurity among Families with Children Seeking Routine Care at Federally Qualified Health Centers during the COVID-19 Pandemic. The journal of pediatrics: X, 100044.
Clinicians in two federally qualified health centers in the US state of Texas assessed food insecurity during pediatric visits during the COVID-19 pandemic using the validated American Academy of Pediatrics 2-question food security screen. Interviews of 200 families found approximately half of families reported food insecurity. 94% of the food insecure families indicated worsening of food insecurity during the pandemic. The findings strongly suggest screening of food security be part of routine pediatric care.
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OTHER REPUTABLE REPOSITORIES & USEFUL CONTENT
The Irish Nutrition & Dietetic Institute (INDI) is the professional organisation for dietitians in Ireland representing almost 800 Dietitians and Student Dietitians nationwide.
INDI has formed a task and finish group to develop resources to support practice druing the pandemmic. They are available for you in the INDI E-Learning centre.
There are two areas in the E-learning centre – one for clinical dietetic practice and one as a signpost for general information which may be useful (non-urgent, non-acute, general healthy eating).
These documents have been developed and/or collated by Dr Anne Griffin, Ruth Kilcawley, Carmel O Hanlon, Jennifer Feighan, Ruth Reidy, Mairead Aherne and Lisa Shanahan using material from a variety of sources.
The INDI E-Learning centre also contains a forum to share experience, provide support and seek knowledge. This forum is private and is not moderated.
To access the E-Learning Centre: Please follow this link https://learning.indi.ie/course/index.php?categoryid=8 then click on the ‘Resources for Dietitians’ course and click LOG IN AS GUEST from the login screen.
Fresenius Kabi is a global healthcare company that specializes in lifesaving medicines and technologies for infusion, transfusion and clinical nutrition. They have compiled COVID-19 updates and useful documents here.
RapidInfo4U is part of the Irish Government’s national coordinated research and innovation response to the COVID-19 pandemic. RapidInfo4U is funded by a Health Research Board COVID-19 Pandemic – Rapid response funding award and managed by the Health Implementation Science and Technology cluster at the University of Limerick.