What supplements are recommended for COVID-19 patients?

Nutritional Supplements for COVID-19 Patients

For COVID-19 patients, a high-protein diet with adequate micronutrient supplementation is recommended, particularly focusing on vitamins A, D, B vitamins, C, zinc, and selenium to support immune function and improve clinical outcomes. 1

Assessment of Nutritional Status

• Screen all COVID-19 patients for malnutrition using validated tools:
  • Use MUST criteria for outpatients
  • Use NRS-2002 criteria for hospitalized patients 1
• Monitor serum albumin levels as an inflammatory marker associated with nutritional risk 1
• Be aware that COVID-19 patients are at high nutritional risk due to:
  • Hypermetabolism
  • Decreased nutrient intake from reduced appetite
  • Dyspnea
  • Gastrointestinal symptoms 1

Nutritional Recommendations by Patient Setting

For Non-Hospitalized COVID-19 Patients

1. Macronutrients:

   • Energy: 27-30 kcal/kg body weight/day 1
   • Protein: 1 g/kg body weight/day 1
   • Fat and carbohydrates: Adapt to energy needs with ratio between 30:70 (no respiratory deficiency) to 50:50 (with respiratory issues) 1

2. Micronutrients:

   • Ensure sufficient supplementation of vitamins and minerals 1
   • Key micronutrients:
     • Vitamin D (associated with reduced risk of viral infections)
     • Vitamin A (supports immune defense against infection)
     • B vitamins
     • Vitamin C
     • Zinc and selenium 1

3. Oral Nutrition Supplements (ONS):

   • Use when dietary counseling and food fortification are insufficient 1
   • Continue regular physical activity while taking precautions 1

For Hospitalized Non-ICU COVID-19 Patients

1. Nutritional Support:

   • Oral feeding is preferred when possible 1
   • If oral intake is insufficient, use ONS 1
   • If ONS is insufficient, initiate enteral nutrition (EN) 1
   • Use parenteral nutrition (PN) only when EN is contraindicated or insufficient 1

2. Specific Recommendations:

   • Energy requirements: 27-30 kcal/kg/day 1
   • Protein requirements: 1 g/kg/day 1
   • Monitor electrolytes closely, especially in patients at risk of refeeding syndrome 1

For ICU COVID-19 Patients

1. Enteral Nutrition Protocol:

   • Start EN through nasogastric tube within 24-48 hours of ICU admission 1
   • Use post-pyloric feeding in patients with gastric intolerance after prokinetic treatment 1
   • Prone positioning is not a contraindication for EN 1

2. Energy and Protein Goals:

   • Initial phase: Hypocaloric nutrition (not exceeding 70% of energy expenditure) 1
   • Progressive increase: Reach 80-100% after day 3 1
   • Protein target: 1.3 g/kg/day, reached by day 3-5 1
   • For obesity: Use 1.3 g/kg "adjusted body weight" 1

3. Formula Selection:

   • Standard, high protein (20%), polymeric isosmotic EN formula 1
   • Consider energy-dense formula (>1.25 kcal/ml) for fluid restriction 1
   • Formulas enriched with EPA and DHA (omega-3 fatty acids) may provide immunomodulatory benefits 1

4. Monitoring:

   • Monitor gastric residual volumes (though guidelines differ on this practice) 1
   • Monitor serum triglycerides when patients are receiving propofol and/or PN 1
   • Monitor electrolytes closely, especially potassium, phosphate, and magnesium 1
   • Maintain blood glucose between 6-8 mmol/l 1

Post-Ventilation Nutritional Support

• Assess for dysphagia after extubation 1
• If swallowing is safe, use texture-adapted food 1
• If swallowing is unsafe, continue EN 1
• For high aspiration risk, use post-pyloric EN or temporary PN during swallowing training 1
• Be aware that post-extubation swallowing disorders may persist for up to 21 days 1

Important Considerations

• Early nutritional intervention is associated with better survival outcomes in COVID-19 patients 1
• Continuous EN is preferred over bolus feeding to reduce diarrhea and staff exposure 1
• Cluster care is recommended to minimize exposure to SARS-CoV-2 1
• For patients with COVID-19 recovering at home, ensure adequate hydration, protein, and energy intake 2

Pitfalls to Avoid

• Don't delay nutritional assessment and intervention - early nutrition support within 48 hours is associated with better outcomes 1
• Don't rely on albumin levels alone to assess nutritional status, as they are primarily markers of inflammation in COVID-19 1
• Don't overlook the risk of refeeding syndrome, especially when initiating PN 3
• Don't abruptly increase nutritional support - use a ramp protocol for increasing supply 3
• Don't discontinue breastfeeding for mothers with COVID-19 - it is still encouraged 2, 4