It is well-documented that nutrition plays an important role in prevention of several common diseases. Nutritional status and the role of diet is known to affect patient outcomes in severe infections and immune responses.⁵ Over the years, zinc and vitamin C have taken the spotlight in immunity enhancement and infection prevention.
With the new incidences of COVID-19, a familiar macronutrient has gained recognition: protein. More specifically, the protein in our blood, albumin. Recent retrospective studies on COVID-19 patients have found that there is an inverse relationship between the level of albumin and the risk of death in COVID-19 patients, independent of age and comorbidity.¹
As clinicians, we know that albumin is also an inflammation marker and not exclusively dependent on nutritional status. According to a recent study from The European Society for Clinical Nutrition and Metabolism (ESPEN), lower albumin (hypoalbuminemia) levels still remain a marker of weight loss and malnutrition, despite a high inflammatory context.²
Recent research shows the prevalence of malnutrition in COVID-19 patients hospitalized in non-intensive medical units was observed to be as high as 42% and even higher (67%) when patients are admitted from an ICU.² Despite our current awareness of this inflammatory marker, hypoalbuminemia has shown to predict the outcome of COVID-19 including the chances of being transferred to the ICU during that hospital stay.
A retrospective study importantly revealed that serum albumin <3.5 g/dL increased the risk of death in COVID-19 patients by at least 600%.¹ The same study found that lower albumin levels on admission can also predict the outcome of COVID‐19, independent of other known indicators.¹ These significant findings help us explain how a balanced diet consisting of adequate amounts of protein positively impacts overall nutritional status and our ability to fight off disease, not only for those who are critically ill, but for all populations.
Low-grade chronic inflammation related to chronic diseases such as obesity, diabetes, autoimmune, and cardiovascular disease can decrease albumin and put an individual at risk for nutritional deficiencies. Maintaining optimal nutritional status through diet may improve immune response in infection phases.
A diet that positively impacts immune function consists of adequate amounts of protein, particularly including glutamine, arginine and branched-chain amino acids (BCAAs); high omega-3 versus lower saturated, trans fat, and omega-6 fatty acids, low refined sugars, high-fiber content such as whole grains, and micronutrients including vitamin A, vitamin D, vitamin C, vitamin E, B vitamins, zinc, selenium and iron, as well as phytochemicals.⁴ A balanced diet is an essential part of disease prevention and recovery.
As we can see, protein is an important component when it comes to prevention of disease. Protein needs are to be sustained and even increased with a critically ill COVID-19 patient due to protein catabolism, which is driven by an inflammatory response. In order to prevent muscle loss and to strengthen respiratory muscles, an estimated 1-1.5g protein/kg body weight per day is recommended.⁴ These recommendations should be individualized to account for disease progression, nutritional status, and GI tolerance.
Historically, we look to albumin and prealbumin to determine a patient's nutritional status and protein intake, however, clinicians should also consider other signs to determine if individual consumption is adequate for protein repletion and albumin improvement. More direct indicators of protein malnutrition may include: muscle wasting, thinning hair, brittle nails, swelling of the extremities, slow healing wounds, fatigue and compromised immune function. In order to prevent protein malnutrition, catabolic, and immune responses related to COVID-19, ESPEN recommends oral nutrition supplementation (ONS) of at least 400 kcal and 30g or more of protein per day, and should be continued for at least one month.³ Improved survival has been shown in critical illness with this increased protein intake.
As recommendations for COVID-19 continue to emerge, it is clear that nutrition therapy, especially protein supplementation such as Vidafuel Wellness Protein, can support the recovery from and prevention of critical illness such as COVID-19. Since low albumin levels upon admission are a predictive marker of more severe outcome of disease, clinicians can continue to remain vigilant in utilizing albumin as a malnourishment marker.
Further research is needed to assess the impact of nutritional care on longer-term prognoses in these patients, however, the emerging evidence and ESPEN recommendations should reinforce the value and need of early nutritional intervention in COVID-19 patients.
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Huang J, Cheng A, Kumar R, et al. Hypoalbuminemia Predicts the Outcome of COVID-19 Independent of Age and Co-Morbidity. Retrieved March, 2021 from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7273060/
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Bedock D, Bel Lassen P, Mathian A, et al. Prevalence and Severity of Malnutrition in Hospitalized COVID-19 Patients. Retrieved March, 2021 from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7500887/
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Barazzoni R, Bischoff SC, Breda J, et al. ESPEN Expert Statements and Practical Guidance for Nutritional Management of Individuals with SARS-CoV-2 Infection. Retrieved March, 2021 from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7138149/
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Iddir M, Brito A, Dingeo G, et al. Strengthening the Immune System and Reducing Inflammation and Oxidative Stress through Diet and Nutrition: Considerations during the COVID-19 Crisis. Retrieved March, 2021 from
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7352291/
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Zabetakis I, Lordan R, Norton C, Tsoupras A. COVID-19: The Inflammation Link and the Role of Nutrition in Potential Mitigation. Retrieved March, 2021 from
https://www.mdpi.com/2072-6643/12/5/1466/pdf