September/October 2021

COVID & Nutrition — How the Pandemic Has Changed Practice
By Michelle Johnson, PhD, RDN, LDN, and Julia Barroso, BS
Today’s Geriatric Medicine
Vol. 14 No. 5 P. 18

The COVID-19 pandemic has had major implications in the field of nutrition. Emerging literature has outlined strategies for identifying and treating those in acute care and as they transition to outpatient settings, but there’s been limited discussion about how the pandemic has affected daily nutrition practice in postacute care, long term care, and assisted living settings, and implications for future practice.1

Malnutrition is of continued interest in geriatrics, as its prevalence increases with age and level of dependence. It has been reported to occur in as many as 29% of individuals in long term care and rehabilitation/subacute care settings, and the prevalence has been reported to be as high as 50% among all older adults.2-4 Malnutrition is characterized by nutrient imbalances; it can be a result of a number of factors, but age coupled with chronic disease, decreased taste and smell, and declines in oral, physical and cognitive function affect intake, increasing the likelihood of nutrient deficiency and resulting muscle loss.3 Acute illness compounds these challenges. Furthermore, immune function can be diminished as a result of poor nutrition status, increasing vulnerability to infection and illness.4,5

In the months since the World Health Organization declared COVID-19 a pandemic, few have felt the impact more than those in postacute care, long term care, and assisted living settings. While the long-term consequences of COVID-19 infection are still emerging, evidence indicates that symptoms affecting nutrition—including fatigue, muscle weakness, sleep difficulties, anxiety and/or depression—are persistent, suggesting that the implications of the virus will continue for some time.6

It’s been reported that more than 2 million adults reside in long term care facilities in the United States alone.7 The prevention and treatment of malnutrition in this population are influenced by complex medical and psychosocial factors including mealtime environments and quality of foods provided.4 It’s the priority of nutrition and dietetics professionals to provide individualized nutrition care and play an active role among interprofessional teams to ensure adequacy of nutrients and enhance the quality of life of residents.8 Nutrition care was significantly influenced during the first year of the COVID-19 pandemic, and there were unavoidable barriers that had to be addressed to meet the needs of this vulnerable population. This study identifies and summarizes COVID-19–related effects on nutrition practice in these settings and recognizes general trends in nutrition practice that emerged and would be beneficial to encourage in the future, with the goal of optimizing outcomes.

Study approval was obtained through East Tennessee State University’s Institutional Review Board. A focus group of six registered dietitian nutritionists (RDNs) with content expertise assisted with survey development. Pilot testing and revision resulted in a 47-question, online (Qualtrics) survey, including quantitative and qualitative items related to clinical nutrition job tasks, resident feeding practices, and barriers to providing care. Twelve months after the COVID-19 pandemic was declared a public health emergency, the survey was distributed to a convenience sample of 86 RDNs and 14 certified dietary managers (CDMs) across 20 states, employed by two national companies providing services in postacute care, long term care, and assisted living settings. Participants were asked to consider their nutrition-related practice and resident outcomes over the previous 12 months. Survey response rate was 47%; 78.7% (n=37) of respondents were RDNs, and 21.2% (n=10) were CDMs; 51% held their job title for longer than 10 years. The majority of respondents described working in long term care with at least one rehabilitation unit (51.6%), long term care (28%), and assisted living (17%). The total reported number of residents served at the onset of COVID-19 was 4,616 and the mean facility census was 94.2 residents.

One of the greatest challenges during the pandemic has been prioritizing individualized nutrition care for residents while managing the risks of this highly contagious virus in facilities with residents in close quarters and limited opportunities for social distancing.7-9 Additionally, while patient census numbers and budgets decreased during the pandemic, for many dietetic professionals, their job roles changed, and in some instances their responsibilities increased (25.5%). Ensuring adequate, quality nutrition is essential, but with increased infection control measures, staff illnesses, school closures, and limited recruiting opportunities for hiring, nutrition care of patients required a significant shift in procedures. One aspect affected was the ability to complete job tasks in the physical building served. While 80% of participating CDMs continued to practice in their facilities, 51.4% of RDNs were required to complete at least some of their work remotely, and 37.8% completed all work remotely. The most common tasks included completion of comprehensive nutrition assessments (51%), care plan and Minimum Data Set documentation (25.5%), and participating in high risk meetings for residents who were nutritionally compromised (21.2%).

Nutrient Intake and Weight Loss
Adequate nutrient intake is required to maintain health and quality of life and is closely monitored in long term care settings.4 The provision of oral nutrition supplements and modified foods are common approaches to ensuring that nutrition needs are met. All respondents reported declines in appetite and food and fluid intake among residents during this period (significant decrease: 59.5%; some decrease: 40.5%). For those infected with COVID-19, barriers to intake included related symptoms: gastrointestinal distress, fatigue, and loss of taste and smell. Changes in policies and feeding practices were required. For all residents, infection control required alterations to communal dining (34%) and decreased access to restorative feeding programs (68%), feeding therapies (38.2%), and cueing with meals (46.8%), which negatively influenced intake. In the majority of facilities, dining in group settings had to be discontinued (66%), and 97.9% of respondents reported meals were required to be served in resident rooms some or all of the time. Related declines in psychological well-being of residents were also suspected to affect appetite (74.4%), with visitors not allowed (100%), a lack of social activities (96%), and eating alone (93.6%). Despite limitations, therapies including speech and language pathology (95.7%) and occupational therapy (93.6%) continued with precautions.

Obtaining individual food preferences can improve perceived quality and intake, but with infection control requirements, it was often more challenging to get preferences (84% infection risk, 42% staffing shortage, and 42% family unable to be present). While 100% of CDMs continued to participate in this task, 15.8% of RDNs reported they assisted with obtaining food preferences more often during COVID-19 and at times communicated with residents through calls and offsite (8.5%). Prescribed nutrition interventions were also affected. Staffing (49%) and product shortages (10.1%) as well as illness-related intolerance of nutrition supplements (36%) further decreased the intake of oral nutrition supplements. Participants observed longer-term effects on appetite and resident nutrition status in residents who had COVID-19 infections within the previous 12 months. These included slow regain of appetite and sense of taste and smell, fatigue affecting self-feeding ability, and increased dysphagia and related increases in the use of mechanically altered foods. Interestingly, 76% reported increased prescriptions for mood/appetite stimulants, as well as increased perceived depression among residents.

Accurate measures of weight and nutrition are key to assessing patient status, and some barriers made obtaining weights more difficult, including staffing shortages (72.3%), sanitation concerns with obtaining multiple patient weights (46.8%), and the inability to transport scales between units due to infection control concerns (61.7%). As expected, the majority of respondents (97.4%) observed moderate to significant increases in the incidence of weight loss among residents (70% significant and 27.4% moderate); 67% reported increased coding of malnutrition or at risk for malnutrition.

Hydration
Hydration maintenance is also a key aspect of ensuring quality of life and is often a challenge in long term care settings; dehydration can be predictive of morbidity and mortality in the geriatric population.10 Dehydration is of particular concern associated with infection and fever. Of respondents, 48.9% reported necessary changes to hydration policies and practices during the pandemic, and typical hydration approaches were limited due to infection control precautions. Strategies included increasing the variety and times of hydration passes, providing additional fluids on meal trays and with medication passes, close monitoring of fluid intake by nursing staff, and the addition of oral rehydration solutions for those with COVID-19 infection. Increased education about hydration maintenance was a priority, and most felt these new, more aggressive hydration policies (as shown in the accompanying figure) should continue after the pandemic.

Resident Feeding Practices and Budgets
COVID-19 also has presented large-scale food systems challenges that have affected health care facilities and their budgets. Supply chain disruptions decreased availability of foods and needed supplies.11 As a result, while 21.2% of respondents reported they were able to continue preparing menus as initially written in the facilities they served, unavoidable changes to resident menus were required for the majority, influenced by product availability (68%) as well as adjustments related to changes in delivery to COVID units (57.8%). Initially, due to concerns related to foods and food packaging as potential carriers of the virus, strict infection control measures were implemented. This drove the purchase of disposable wares, personal protective equipment, and cleaning supplies, which were not initially included in budgets. Providing adaptive feeding utensils for residents who were COVID positive also presented challenges. Increased food cost and food shortages required purchases of higher-cost items at times, and a decline in census required staffing decreases, despite little change in staff workload. Food delivery was altered during the COVID-19 outbreak, and as a result, food temperatures at delivery were more challenging to manage.

Qualitative data identified similar concerns across facilities: Residents who had tested positive for the virus required disposable dishes, which cannot maintain temperatures as long as traditional service equipment and plates can. With residents required to eat in their rooms and sanitation protocols in place, meals were held longer on carts prior to delivery, causing temperature issues. Staffing shortages affected meal delivery times, with limited staffing for feeding residents efficiently in their rooms, which also influenced food temperatures. Creative delivery solutions were identified to manage proper delivery temperature, including the following:

• Fewer meals were delivered on each cart to reduce service to delivery delay.
• Facilities ensured “all hands on deck” for tray delivery.
• Disposables were provided only to those with active infections.
• Isolation trays were delivered first.
• When possible, facilities set up satellite kitchens in units to decrease time from service to delivery.

Foodservice operations adjusted sanitation procedures due to increased precautions; carts required sanitizing between deliveries, and COVID-19–unit meal carts were the last to be returned for cleaning.

Strengths and Opportunities
While 79% of respondents reported experiencing increased personal stress during the pandemic, they had the opportunity to advocate for the field of nutrition and dietetics. RDNs reported increased awareness of the value of nutrition professionals as facilities relied heavily on them to come up with creative solutions for patient care. They were quick to recognize the foodservice employees as well, stating that those who were able to continue to work through the pandemic were very dedicated, working extra hours to ensure the residents received high-quality meals. Participants also reported feeling supported, having access to training by employers (52%) despite limited time and resources. In the face of budgetary restrictions, most said facility administrators were proactive in purchasing products and equipment to improve food quality.

Future Practice
Novel nutrition policies participants would like to see continue after the COVID-19 pandemic include those addressing a greater focus on hydration management (particularly during acute illness) and enhanced infection control in the kitchen and within the tray delivery process. They valued the development of convenience menus for emergency staffing shortages and would like to see increased focus on emergency stock and preparedness. The pandemic identified limitations in approaches to weighing residents. Policies for families, including virtual opportunities for visits and telehealth, were recommended as well.

Ongoing training needs include stress management techniques, preparing for future pandemic needs, understanding how major changes affect residents’ well-being and health, ongoing teambuilding and the importance of teamwork, sanitation training for nursing and foodservice staff, the importance of hydration, and how to create a customized weighing policy. As health officials have a clearer picture of the efficacy of specific guidelines for food safety for COVID-19, newer policies can be designed as we continue to manage and recover and plan for the future.11

Best practices have been identified in the ESPEN guidelines for managing malnutrition.12 Moving forward, it will be important to focus on malnutrition risk in those previously diagnosed with COVID-19 and increase the frequency of nutrition screenings, utilizing tools such as the Mini Nutrition Assessment.2,4 This would be an efficient method of identifying ongoing risk for malnutrition alongside regularly scheduled assessments. It may also be beneficial to include COVID-specific clinical symptoms on nutrition assessment forms and in monthly high-risk patient evaluations, including diminished taste and smell, and alterations in physical and neuro-cognitive function. Understanding the role of specific nutrients in the treatment of COVID-19 and its variants will assist with the development of pandemic-specific guidelines for nutrition intake and emergency menu planning to ensure optimal outcomes for individuals.11 Additional resources can be found from the American Society for Parenteral and Enteral Nutrition on its Malnutrition Awareness Week page at nutritioncare.org/MAW.

Conclusion
COVID-19 vaccines have been made available to residents and staff of care facilities nationwide and declines in infection rates lead to hope that a new normal will be established. Reflecting on the lessons learned during the pandemic will improve practice in the field of nutrition and dietetics, and continuing to incorporate updated policies and procedures will better meet the needs of the geriatric population.

— Michelle Johnson, PhD, RDN, LDN, is an associate professor and the director of the Dietetic Internship program in the College of Clinical and Rehabilitative Health Sciences at East Tennessee State University. She has 20 years of experience in adult and pediatric nutrition.

— Julia Barroso, BS, is a graduate of Auburn University and a graduate student and dietetic intern in the clinical nutrition graduate program in the College of Clinical and Rehabilitative Health Sciences at East Tennessee State University.

References
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