Nutritional parameters and outcomes in patients admitted to intensive care with COVID-19: a retrospective single-centre service evaluation

DOI record: { "DOI": "10.1136/bmjnph-2021-000270", "ISSN": [ "2516-5542" ], "URL": "http://dx.doi.org/10.1136/bmjnph-2021-000270", "abstract": "<jats:title>Background</jats:title><jats:p>COVID-19 is an inflammatory syndrome caused by novel coronavirus SARS-CoV-2. Symptoms range from mild infection to severe acute respiratory distress syndrome (ARDS) requiring ventilation and intensive care. At the time of data collection, UK cases were around 300 000 with a fatality rate of 13% necessitating over 10 000 critical care admissions; now there have been over 4 million cases. Nutrition is important to immune function and influences metabolic risk factors such as obesity and glycaemic control, as well as recovery from acute illnesses. Poor nutritional status is associated with worse outcomes in ARDS and viral infections, yet limited research has assessed pre-morbid nutritional status and outcomes in patients critically unwell with COVID-19.</jats:p><jats:sec><jats:title>Objectives</jats:title><jats:p>Investigate the effect of body mass index (BMI), glycaemic control and vitamin D status on outcomes in adult patients with COVID-19 admitted to an intensive care unit (ICU).</jats:p></jats:sec><jats:sec><jats:title>Methods</jats:title><jats:p>Retrospective review of all patients admitted to a central London ICU between March and May 2020 with confirmed COVID-19. Electronic patient records data were analysed for patient demographics; comorbidities; admission BMI; and serum vitamin D, zinc, selenium and haemoglobin A1c (HbA1c) concentrations. Serum vitamin D and HbA1c were measured on admission, or within 1 month of admission to ICU. Primary outcome of interest was mortality. Secondary outcomes included time intubated, ICU stay duration and ICU-related morbidity.</jats:p></jats:sec><jats:sec><jats:title>Results</jats:title><jats:p>Seventy-two patients; 54 (75%) men, mean age 57.1 (±9.8) years, were included. Overall, mortality was 24 (33%). No significant association with mortality was observed across BMI categories. In the survival arm admission, HbA1c (mmol/mol) was lower, 50.2 vs 60.8, but this was not statistically significant. Vitamin D status did not significantly associate with mortality (p=0.131). However, 32% of patients with low vitamin D (&lt;25 IU/L) died, compared with 13% of patients with vitamin D levels &gt;26 IU/L. Serum zinc and selenium, and vitamin B<jats:sub>12</jats:sub> and folate levels were measured in 46% and 26% of patients, respectively.</jats:p></jats:sec><jats:sec><jats:title>Discussion/conclusion</jats:title><jats:p>Increased adiposity and deranged glucose homeostasis may potentially increase risk of COVID-19 infection and severity, possibly relating to impaired lung and metabolic function, increased proinflammatory and prothrombotic mechanisms. Vitamin D deficiency may also associate with poorer outcomes and mortality, supporting a possible role of vitamin D in immune function specific to pulmonary inflammation and COVID-19 pathophysiology. There are plausible associations between raised BMI, glycaemic control, vitamin D status and poor prognosis, as seen in wider studies; however, in this service evaluation audit during the first wave of the pandemic in the UK, with a limited data set available for this analysis, the associations did not reach statistical significance. 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ICNARC report on COVID-19 in critical care 31 July 2020, 2020." }, { "DOI": "10.1136/bmjnph-2020-000085", "doi-asserted-by": "publisher", "key": "2021123006401107000_4.2.416.2" }, { "DOI": "10.1016/j.clnu.2020.03.022", "doi-asserted-by": "publisher", "key": "2021123006401107000_4.2.416.3" }, { "DOI": "10.1002/oby.22831", "article-title": "High prevalence of obesity in severe acute respiratory syndrome Coronavirus-2 (SARS-CoV-2) requiring invasive mechanical ventilation", "author": "Simonnet", "doi-asserted-by": "crossref", "first-page": "1195", "journal-title": "Obesity", "key": "2021123006401107000_4.2.416.4", "volume": "28", "year": "2020" }, { "DOI": "10.1038/s41586-020-2521-4", "doi-asserted-by": "publisher", "key": "2021123006401107000_4.2.416.5" }, { "DOI": "10.1038/oby.2008.584", "article-title": "Obesity is associated with altered lung function independently of physical activity and fitness", "author": "Steele", "doi-asserted-by": "crossref", "first-page": "578", "journal-title": "Obesity", "key": "2021123006401107000_4.2.416.6", "volume": "17", "year": "2009" }, { "article-title": "[Clinical characteristics and outcomes of 112 cardiovascular disease patients infected by 2019-nCoV]", "author": "Peng", "first-page": "450", "journal-title": "Zhonghua Xin Xue Guan Bing Za Zhi", "key": "2021123006401107000_4.2.416.7", "volume": "48", "year": "2020" }, { "DOI": "10.1016/S2213-8587(20)30272-2", "article-title": "Associations of type 1 and type 2 diabetes with COVID-19-related mortality in England: a whole-population study", "author": "Barron", "doi-asserted-by": "crossref", "first-page": "813", "journal-title": "Lancet Diabetes Endocrinol", "key": "2021123006401107000_4.2.416.8", "volume": "8", "year": "2020" }, { "DOI": "10.1210/jc.2011-2100", "doi-asserted-by": "publisher", "key": "2021123006401107000_4.2.416.9" }, { "DOI": "10.1186/s40001-016-0208-y", "article-title": "Vitamin D and airway infections: a European perspective", "author": "Zittermann", "doi-asserted-by": "crossref", "first-page": "1", "journal-title": "Eur J Med Res", "key": "2021123006401107000_4.2.416.10", "volume": "21", "year": "2016" }, { "key": "2021123006401107000_4.2.416.11", "unstructured": "NDNS: results from Years 1 to 4 (combined) - GOV.UK [Internet]. PHE and FSA (2014b) Statistical Press Notice: National Diet and Nutrition Survey: results from years 1, 2, 3 and 4 combined (2008/09 – 2011/12). Public Health England and Food Standards Agency. [cited 2021 Jan 24]. Available: https://www.gov.uk/government/statistics/national-diet-and-nutrition-survey-results-from-years-1-to-4-combined-of-the-rolling-programme-for-2008-and-2009-to-2011-and-2012" }, { "DOI": "10.1007/s00508-021-01833-y", "article-title": "Strong correlation between prevalence of severe vitamin D deficiency and population mortality rate from COVID-19 in Europe", "author": "Pugach", "doi-asserted-by": "crossref", "first-page": "403", "journal-title": "Wien Klin Wochenschr", "key": "2021123006401107000_4.2.416.12", "volume": "133", "year": "2021" }, { "DOI": "10.1136/bmj.i6583", "doi-asserted-by": "publisher", "key": "2021123006401107000_4.2.416.13" }, { "DOI": "10.1016/S0140-6736(20)31303-9", "article-title": "Men's health: COVID-19 pandemic highlights need for overdue policy action", "author": "Baker", "doi-asserted-by": "crossref", "first-page": "1886", "journal-title": "Lancet", "key": "2021123006401107000_4.2.416.14", "volume": "395", "year": "2020" }, { "DOI": "10.1186/s12979-018-0117-8", "article-title": "Immune-Inflammatory responses in the elderly: an update", "author": "Accardi", "doi-asserted-by": "crossref", "first-page": "11", "journal-title": "Immun Ageing", "key": "2021123006401107000_4.2.416.15", "volume": "15", "year": "2018" }, { "DOI": "10.1038/s41467-019-13889-6", "doi-asserted-by": "publisher", "key": "2021123006401107000_4.2.416.16" }, { "DOI": "10.5888/pcd17.200247", "doi-asserted-by": "publisher", "key": "2021123006401107000_4.2.416.17" }, { "DOI": "10.1093/eurheartj/ehaa373", "article-title": "Circulating plasma concentrations of angiotensin-converting enzyme 2 in men and women with heart failure and effects of renin-angiotensin-aldosterone inhibitors", "author": "Sama", "doi-asserted-by": "crossref", "first-page": "1810", "journal-title": "Eur Heart J", "key": "2021123006401107000_4.2.416.18", "volume": "41", "year": "2020" }, { "DOI": "10.1016/j.jaccas.2020.04.027", "doi-asserted-by": "publisher", "key": "2021123006401107000_4.2.416.19" }, { "DOI": "10.31234/osf.io/dyxqn", "doi-asserted-by": "crossref", "key": "2021123006401107000_4.2.416.20", "unstructured": "De La Vega R , Barquin RR , Boros S . Could attitudes toward COVID-19 in Spain render men more vulnerable than women? [cited 2020 Oct 25], 2020. Available: https://psyarxiv.com/dyxqn/" }, { "DOI": "10.1097/CCM.0000000000004455", "article-title": "Implications of obesity for the management of severe coronavirus disease 2019 pneumonia", "author": "Lemyze", "doi-asserted-by": "crossref", "first-page": "e761", "journal-title": "Crit Care Med", "key": "2021123006401107000_4.2.416.21", "volume": "48", "year": "2020" }, { "DOI": "10.3389/fpubh.2020.00184", "article-title": "Coronavirus and obesity: could insulin resistance mediate the severity of Covid-19 infection?", "author": "Finucane", "doi-asserted-by": "crossref", "first-page": "184", "journal-title": "Front Public Health", "key": "2021123006401107000_4.2.416.22", "volume": "8", "year": "2020" }, { "DOI": "10.1016/j.cmet.2020.04.021", "doi-asserted-by": "publisher", "key": "2021123006401107000_4.2.416.23" }, { "DOI": "10.1007/s00134-009-1424-5", "doi-asserted-by": "publisher", "key": "2021123006401107000_4.2.416.24" }, { "DOI": "10.1378/chest.12-2115", "doi-asserted-by": "publisher", "key": "2021123006401107000_4.2.416.25" }, { "DOI": "10.1378/chest.11-3302", "doi-asserted-by": "publisher", "key": "2021123006401107000_4.2.416.26" }, { "DOI": "10.1186/s13054-020-03286-7", "article-title": "Persistent hypermetabolism and longitudinal energy expenditure in critically ill patients with COVID-19", "author": "Whittle", "doi-asserted-by": "crossref", "first-page": "581", "journal-title": "Crit Care", "key": "2021123006401107000_4.2.416.27", "volume": "24", "year": "2020" }, { "DOI": "10.1186/s13054-017-1641-1", "article-title": "Mechanical ventilation in obese ICU patients: from intubation to extubation", "author": "De Jong", "doi-asserted-by": "crossref", "first-page": "63", "journal-title": "Crit Care", "key": "2021123006401107000_4.2.416.28", "volume": "21", "year": "2017" }, { "DOI": "10.1016/S2213-8587(20)30238-2", "article-title": "COVID-19 in people with diabetes: understanding the reasons for worse outcomes", "author": "Apicella", "doi-asserted-by": "crossref", "first-page": "782", "journal-title": "Lancet Diabetes Endocrinol", "key": "2021123006401107000_4.2.416.29", "volume": "8", "year": "2020" }, { "DOI": "10.1152/ajpendo.00124.2020", "article-title": "COVID-19 pandemic, coronaviruses, and diabetes mellitus", "author": "Muniyappa", "doi-asserted-by": "crossref", "first-page": "E736", "journal-title": "Am J Physiol Endocrinol Metab", "key": "2021123006401107000_4.2.416.30", "volume": "318", "year": "2020" }, { "DOI": "10.1007/s00394-020-02372-4", "article-title": "Vitamin D and COVID-19 infection and mortality in UK Biobank", "author": "Hastie", "doi-asserted-by": "crossref", "first-page": "545", "journal-title": "Eur J Nutr", "key": "2021123006401107000_4.2.416.31", "volume": "60", "year": "2021" }, { "DOI": "10.1101/2020.10.05.20206706", "doi-asserted-by": "crossref", "key": "2021123006401107000_4.2.416.32", "unstructured": "Faniyi AA , Lugg ST , Faustini SE . Vitamin D status and seroconversion for COVID-19 in UK healthcare workers who isolated for COVID-19 like symptoms during the 2020 pandemic. medRxiv 2020.doi:10.1101/2020.10.05.20206706" }, { "DOI": "10.1101/2020.09.04.20188268", "doi-asserted-by": "crossref", "key": "2021123006401107000_4.2.416.33", "unstructured": "Israel A , Cicurel A , Feldhamer I . The link between vitamin D deficiency and Covid-19 in a large population. medRxiv 2020.doi:10.1101/2020.09.04.20188268" }, { "DOI": "10.1371/journal.pone.0239252", "doi-asserted-by": "publisher", "key": "2021123006401107000_4.2.416.34" }, { "author": "Pourshahidi", "first-page": "115", "key": "2021123006401107000_4.2.416.35", "volume": "74", "volume-title": "Proceedings of the Nutrition Society [Internet", "year": "2015" }, { "DOI": "10.1093/gerona/glaa010", "doi-asserted-by": "crossref", "key": "2021123006401107000_4.2.416.36", "unstructured": "Griffin TP , Wall D , Blake L . Vitamin D status of adults in the community, in outpatient clinics, in hospital, and in nursing homes in the West of Ireland. Journals Gerontol Ser A [Internet] 2020 https://pubmed.ncbi.nlm.nih.gov/31942614/" }, { "DOI": "10.1371/journal.pmed.1001383", "doi-asserted-by": "publisher", "key": "2021123006401107000_4.2.416.37" }, { "DOI": "10.1136/bmjnph-2020-000096", "article-title": "Avoidance of vitamin D deficiency to slow the COVID-19 pandemic", "author": "Kohlmeier", "doi-asserted-by": "crossref", "first-page": "67", "journal-title": "BMJ Nutr Prev Health", "key": "2021123006401107000_4.2.416.38", "volume": "3", "year": "2020" }, { "DOI": "10.1186/s13054-018-2185-8", "article-title": "Vitamin D deficiency and supplementation in critical illness-the known knowns and known unknowns", "author": "Nair", "doi-asserted-by": "crossref", "first-page": "276", "journal-title": "Crit Care", "key": "2021123006401107000_4.2.416.39", "volume": "22", "year": "2018" }, { "DOI": "10.1530/EC-18-0184", "doi-asserted-by": "publisher", "key": "2021123006401107000_4.2.416.40" }, { "DOI": "10.4049/jimmunol.181.10.7090", "doi-asserted-by": "publisher", "key": "2021123006401107000_4.2.416.41" }, { "DOI": "10.1002/jmv.26360", "article-title": "Vitamin D insufficiency as a potential culprit in critical COVID-19 patients", "author": "Munshi", "doi-asserted-by": "crossref", "first-page": "733", "journal-title": "J Med Virol", "key": "2021123006401107000_4.2.416.42", "volume": "93", "year": "2021" }, { "DOI": "10.1007/s40618-020-01370-x", "article-title": "Vitamin D deficiency as a predictor of poor prognosis in patients with acute respiratory failure due to COVID-19", "author": "Carpagnano", "doi-asserted-by": "crossref", "first-page": "765", "journal-title": "J Endocrinol Invest", "key": "2021123006401107000_4.2.416.43", "volume": "44", "year": "2021" }, { "DOI": "10.1016/j.jsbmb.2020.105751", "doi-asserted-by": "publisher", "key": "2021123006401107000_4.2.416.44" }, { "DOI": "10.1002/jpen.2002", "article-title": "Nutrition and micronutrient therapy in critical illness should be individualized", "author": "Berger", "doi-asserted-by": "crossref", "first-page": "1380", "journal-title": "JPEN J Parenter Enteral Nutr", "key": "2021123006401107000_4.2.416.45", "volume": "44", "year": "2020" } ], "reference-count": 45, "references-count": 45, "relation": {}, "resource": { "primary": { "URL": "https://nutrition.bmj.com/lookup/doi/10.1136/bmjnph-2021-000270" } }, "score": 1, "short-title": [], "source": "Crossref", "subject": [ "Nutrition and Dietetics", "Medicine (miscellaneous)", "Health (social science)" ], "subtitle": [], "title": "Nutritional parameters and outcomes in patients admitted to intensive care with COVID-19: a retrospective single-centre service evaluation", "type": "journal-article", "update-policy": "http://dx.doi.org/10.1136/crossmarkpolicy", "volume": "4" }