Since January 2020 Elsevier has created a COVID-19 resource centre with free information in English and Mandarin on the novel coronavirus COVID- 19. The COVID-19 resource centre is hosted on Elsevier Connect, the company's public news and information website. Elsevier hereby grants permission to make all its COVID-19-related research that is available on the COVID-19 resource centre - including this research content - immediately available in PubMed Central and other publicly funded repositories, such as the WHO COVID database with rights for unrestricted research re-use and analyses in any form or by any means with acknowledgement of the original source. These permissions are granted for free by Elsevier for as long as the COVID-19 resource centre remains active. Clinical Nutrition xxx (xxxx) xxx Contents lists available at ScienceDirect Clinical Nutrition journal homepage: http://www.elsevier.com/locate/clnu Covid-19 Impact of COVID-19 on nutritional status during the first wave of the pandemic Analía Ramos a, b, 1, Clara Joaquin a, b, 1, Mireia Ros a, Mariona Martin a, Montserrat Cachero a, María Sospedra a, Eva Martínez a, Jose  Manuel Sa nchez Migallo  n a,  Sendro  s , Berta Soldevila a a, b a, b, * María-Jose , Manel Puig-Domingo a Endocrinology and Nutrition Service, Hospital Universitari Germans Trias i Pujol, Badalona, Spain b Autonomous University of Barcelona, Barcelona, Spain a r t i c l e i n f o s u m m a r y Article history: Background & aims: Patients affected by COVID-19 may develop disease related malnutrition (DRM) due Received 15 December 2020 to the catabolic situation, symptoms that interfere with intake and prolonged hospital stay. This study Accepted 4 May 2021 aims to know the percentage of patients admitted for COVID-19 who required artificial nutrition (AN), their clinical characteristics, as well as the prevalence of DRM and the risk of sarcopenia at hospital Keywords: discharge and after 6 months. COVID-19 Material and methods: Observational, prospective study, with successive inclusion of adult patients Nutritional support admitted for COVID-19 in whom institutional nutritional support (NS) care protocol was applied. Those Disease related malnutrition Artificial nutrition who received AN underwent a nutritional screening by Short Nutritional Assessment Questionnaire Sarcopenia (SNAQ) and an assessment by Subjective Global Assessment (SGA) at hospital discharge, as well as a screening for sarcopenia (SARC-F test) and SNAQ re-test 15 days and 6 months after by a phone call. Symptoms related to food intake, anthropometric and analytical data were also collected. Results: We evaluated 936 patients with a mean age of 63.7 ± 15.3 years; predominantly male (59.7%), overweight 41%, obesity 40.4%; hypertension 52.9%; diabetes mellitus 26.6% and cancer 10.4%. The stay hospital length was 17.3 ± 13.8 days and 13.6% patients died during hospitalization. The modality of nutritional support was: 86.1% dietary adaptation þ oral nutritional supplements (ONS); 12.4% enteral nutrition (EN) by nasogastric (NG) tube; 0.9% parenteral nutrition (PN) and 0.6% EN plus PN. Focusing on patients who received AN, follow-up post discharge was possible in 62 out of 87 who survived. Of these, at the time of hospital discharge, 96.7% presented nutritional risk by SNAQ and 100% malnutrition by SGA (20% B; 80% C). During admission, 82.3% presented intense anorexia and the mean weight loss was 10.9 ± 6 Kg (p < 0.001). Fifteen days after being discharged, 12.9% still had anorexia, while hyperphagia appeared in 85.5% of the patients and risk of sarcopenia by SARC-F was present in 87.1% of them. Six months after discharge, 6.8% still had anorexia and 3.4% hyperphagia, with a global weight gain of 4.03 ± 6.2 Kg (p¼<0.0001). Risk of malnutrition was present in only 1.7% of the patients, although risk of sarcopenia persisted in 49.2%. Conclusion: All patients admitted by COVID-19 for whom EN or PN were indicated following an insti- tutional protocol still presented malnutrition at hospital discharge, and almost all showed risk of sar- copenia, that persisted in almost half of them at 6 months. These findings suggest that nutritional and functional problems persist in these patients after discharge, indicating that they require prolonged nutritional support and monitoring. © 2021 Elsevier Ltd and European Society for Clinical Nutrition and Metabolism. All rights reserved. 1. Introduction The novel coronavirus disease 2019 (COVID-19) is caused by * Corresponding author. Endocrinology and Nutrition Service, Hospital Uni- infection from the newly emerged coronavirus SARS-CoV-2 [1,2] versitari Germans Trias i Pujol, Ctra. Canyet s / n, 08916, Badalona, Barcelona, Spain. E-mail address: mpuigd@igtp.cat (M. Puig-Domingo). and the COVID-19 pandemic has posed an unprecedented chal- 1 Both authors contributed equally to this work. lenge for healthcare systems around the world. The disease mainly https://doi.org/10.1016/j.clnu.2021.05.001 0261-5614/© 2021 Elsevier Ltd and European Society for Clinical Nutrition and Metabolism. All rights reserved. Please cite this article as: A. Ramos, C. Joaquin, M. Ros et al., Impact of COVID-19 on nutritional status during the first wave of the pandemic, Clinical Nutrition, https://doi.org/10.1016/j.clnu.2021.05.001 A. Ramos, C. Joaquin, M. Ros et al. Clinical Nutrition xxx (xxxx) xxx affects the respiratory tract, but in severe cases it can cause mul- Dysphagia was assessed by Eating Assessment Tool-10 (EAT-10) test tiorgan dysfunction and may be fatal [3e5]. Elderly individuals, [16]. When risk of dysphagia or malnutrition were detected, along with those with pre-existing co-morbid conditions, such as nutritional counseling was provided. A sarcopenia screening was hypertension, cancer, cardiovascular diseases, obesity, diabetes also performed by SARC-F test [17]. At 15 days and 6 months after mellitus, and acute kidney injury, have worse outcomes and higher discharge, patients were re-evaluated by a phone call and asked mortality [2,4,6,7]. about symptoms related to intake including an EAT-10 test. At 6 Patients with COVID-19 may develop, according to the classifi- months, a SNAQ and SARC-F test were also administered. cation of the ESPEN guidelines, acute DRM for different reasons, but The study was approved by the local Ethics Committee, and the mainly because of increased energy requirements related to severe investigation conformed to the principles outlined in the Declara- inflammation with difficulty to achieve them due to hyporexia and tion of Helsinki. coexistence of eating difficulties [8]. In particular, COVID-19 infec- tion may be accompanied by gastrointestinal disturbances like 2.1. Statistical analysis nausea, vomiting, and diarrhea that affect both, food intake and absorption [5]. All statistical analyses were performed in line with the statistical In the context of COVID infection, patients may present loss of program SPSS V22. We performed descriptive statistics using fre- muscle mass and functionality due to the catabolic state caused by quencies to summarize categorical variables (percentage) and the viral infection, aggravated by a situation of immobilization and expressing quantitative variables as mean ± standard deviation prolonged hospital stay, especially in those patients requiring (SD). Normal distribution of quantitative data was assessed. The intensive care unit (ICU) admission. univariate tests used were Chi-square for categorical variables and In addition, it should be borne in mind that many of these pa- Student's test for quantitative variables. A p value of <0.05 was set tients already have a high risk of malnutrition due to ongoing as statistically significant. chronic diseases or aging that is associated to adverse changes in body composition, such as the gradual loss of skeletal muscle mass 3. Results and impaired muscle function (sarcopenia) [9,10]. Recently, a multicenter, randomized, controlled trial in medical Nine hundred and thirty-two patients consecutively admitted to inpatients at nutritional risk (EFFORT trial), observed that nutri- our institution were included in the analysis. Briefly, patients had a tional support during the hospital stay improved important clinical mean age of 63.7 ± 15.2 years and were predominantly overweight outcomes, including survival [11]. For all the above, an adequate (41%) or obese (40.4%). According to clinical judgement and stan- assessment of nutritional status in COVID-19 patients, as well as the dard care defined in the institutional protocol, the type of nutri- prescription of a nutritional treatment adapted to their needs, is tional support required during hospitalization was in 86.1% dietary essential to achieve a better nutrition status, which will certainly adaptation þ ONS and in 13.9% (130 patients) AN. Table 1 shows improve clinical outcomes. baseline demographic and clinical data for the total cohort studied Only few studies, performed in Chinese population, have eval- and those in which AN was required. Patients requiring AN were uated nutritional status in COVID-19 patients, finding a risk of younger (61 ± 10.2 vs. 63.7 ± 15.3 years; p ¼ 0.003), predominantly malnutrition in approximately 80% of them during hospitalization male (76.4 vs. 59.7%; p < 0,001), obesity was present in 44.6% of [12,13]. To the best of our knowledge, there are no studies reporting them, had longer length of hospital stay (41.1 ± 17.9 vs. 17.3 ± 13.8 nutritional status at discharge, and no studies evaluating nutri- days; p¼<0,001), and higher mortality (33.1% vs. 13.6%; p¼<0,001). tional support in this type of subjects. Moreover, they had lower albumin levels (31.4 ± 5 vs 36 ± 4.8; Our study aims to assess the nutritional status of patients p < 0.001), lower lymphocyte count (0.6 [0.4e0.8] vs. 0.9 [0.6e1.2] admitted for COVID-19 and to evaluate those who have required AN x109/L) and higher inflammatory markers at hospital admission. (EN or/and PN), their clinical characteristics, as well as the preva- Results are shown in Table 2. Focusing on patients who received AN, lence of DRM and risk of sarcopenia after hospital discharge. follow-up post discharge at 2 weeks and 6 months was possible in 62 out of 87 who survived. Those subjects presented a BMI at 2. Methods admission of 30.9 ± 6.4 kg/m2 and 87% (54 patients) required ICU admission with a length of stay of 20.7 ± 11.9 days. Tube feeding We performed a prospective observational study of adult pa- was required in 92.1% during 20.5 ± 13.3 days. . During hospitali- tients with SARS-CoV-2 infection who were admitted to conven- zation, a mean weight loss of 10,9 ± 6 Kg was observed, and al- tional hospitalization units and/or ICU from April to June 2020 at bumin levels decreased significantly (31.5 ± 4.8 vs. 26.8 ± 4.2, Germans Trias i Pujol Hospital in Badalona (Barcelona), Spain. All p < 0.001). At the time of hospital discharge, 96.7% presented COVID-19 patients admitted in our institution were considered to nutritional risk by SNAQ and 100% malnutrition by SGA (20% B; 80% be at high nutritional risk, given the acute inflammatory situation C) and risk of sarcopenia evaluated by SARC-F was detected in 87.1% with high nutritional requirements of this type of patients. There- of subjects. Figure 2 shows the prevalence of symptoms related to fore, all of them received nutritional support following an institu- food intake. Anorexia was reported in 82.3% and dysphagia by EAT- tional protocol based on ESPEN recommendations. The energy and 10 was detected in 25.8% of patients during hospitalization. Fifteen protein targets were: 25e30 kcal per kg body weight/day and 1.5 g days after discharge anorexia persisted in 12.9% and dysphagia in protein per kg body weight/day. The first step was dietary coun- 4.9% of the patients, highlighting the appearance of hyperphagia in selling and food fortification plus hypercaloric high-protein ONS. 85.5% of them. After 6 months of discharge, 10.2% still presented EN by NG was initiated, if possible, when food intake was less than disorexic symptoms, with 6.8% still having anorexia and 3.4% hy- 50% during more than 48 h despite dietary counselling and ONS perphagia. Only 3 patients of the 62 evaluated (4.9%) persisted with (Fig. 1). When EN was not possible or when nutritional re- dysphagia at 6 months. None of them presented risk of malnutri- quirements could not be met with EN, PN was started. Clinical and tion at the end of follow-up, but all them were at risk of sarcopenia. laboratory data were collected from the hospital's electronic No complications related to dysphagia were observed. For these medical records. At hospital discharge, surviving patients who patients requiring AN, a global weight gain of 4.03 ± 6.2 Kg received AN were asked for symptoms related to intake and a (p¼<0.0001) was observed at 6 months of discharge. Risk of nutritional evaluation by SNAQ and SGA was performed [14,15]. malnutrition was present in only 1.7% of the patients, although risk 2 A. Ramos, C. Joaquin, M. Ros et al. Clinical Nutrition xxx (xxxx) xxx Fig. 1. Nutritional management of COVID-19 patients at Germans Trias i Pujol Hospital. Table 1 Baseline demographic and clinical data. Variable All patients (n ¼ 936) Patients with AN (n ¼ 130) Patients without AN (n ¼ 806) p Age (years) 63.7 ± 15.3 61 ± 10.2 64.2 ± 15.9 0.003a Sex (% male) 59.7 76.4 57 <0.001a BMI (kg/m2) 29.8 ± 5.8 30.2 ± 6.4 29.4 ± 5.8 NS Overweight (%) 41 43.8 40.3 NS Obesity (%) 40.4 44.6 39.4 NS Hypertension (%) 52.9 59.2 52 NS Diabetes mellitus (%) 26.6 26.9 26.6 NS Cancer patient (%) 10.4 4.6 11.3 0.02a Length of stay (days) 17.3 ± 13.8 41.1 ± 17.9 14.9 ± 10.7 <0.001a Exitus (%) 13.6 33.1 10.4 <0.001a Type of nutritional support (%) - Dietary adaptation þ Oral Supplements 86.1 e 100 - Enteral Nutrition 12.4 91.3 - Enteral and parenteral nutrition 0.6 0.8 - Total parenteral nutrition 0.9 7.9 Data are presented as mean ± SD. a P values represent significant comparisons among patients with and without Artificial Nutrition (AN). Table 2 Laboratory measures. Variable Patients without AN (n ¼ 806) Patients with AN (n ¼ 130) p Albumin (g/L) 36.1 ± 4,8 31.4 ± 5.1 <0.001a Lymplocyte count (x 109/L) 0.9 (0.6e1.2) 0.6 (0.4e0.8) <0.001a C-reactive protein (mg/L) 90.7 ± 79 165.7 ± 113.5 <0.001a D-dimer (ng/mL) 742.5 (429.7e1361.7) 1191 (580e2424) 0.002a Interleukin-6 (pg/mL) 37.7 (17.2e78.7) 116.7 (43.8e239.5) <0.001a Ferritin (ng/mL) 494 (255e944) 1292 (670e2107) <0.001a Data are presented as mean ± SD or median (P25eP75). a P values represent significant comparisons among patients with and without Artificial Nutrition (AN). of sarcopenia persisted in 49.2%. Figure 3 shows the evolution of the at hospital discharge and almost all showed risk of sarcopenia, that risk of malnutrition and sarcopenia after hospital discharge. persisted in half of them at 6 months. Moreover, disorexic symp- toms were still present at 6 months in about 10% of cases. In our 4. Discussion cohort of COVID patients at Germans Trias hospital, a university tertiary center covering about 800,000 people in Northern Barce- This observational prospective study shows that all patients lona area, it is remarkable that more than 80% of admitted patients admitted with COVID-19 who received AN presented malnutrition had either obesity or overweight. 3 A. Ramos, C. Joaquin, M. Ros et al. Clinical Nutrition xxx (xxxx) xxx Fig. 2. Symptoms related to food intake. Fig. 3. Risk of malnutrition and sarcopenia during follow-up. Until the present we have not found other studies that evaluate patients has been recently described [12]. Nevertheless, in this the need of artificial nutritional in COVID-19 patients, which in our latter series, patients with milder forms of the disease were series is 13.9%. Although all subjects underwent daily sessions of included and nutritional assessment was performed during prone position, we observed that tube feeding could be imple- hospitalization and not at discharge, which could explain the mented and tolerated in these COVID-19 patients. This finding differences with the out study. confirms and supports ESPEN guidelines recommendations that Anorexia was very prevalent in our patients with AN during prone position does not represent a limitation for EN in COVID-19 admission. Other authors reported less prevalence of this symptom patients [8]. The overall prognosis of patients with AN was worse probably because they included mainly mild-to-moderate COVID-19 than those without this type of support, probably in relation to the patients, without need of intensive care [18]. Nevertheless, it was severity of the disease, as practically all of the patients with AN surprising that most of our patients experienced hyperphagia after required ICU admission. This is further supported by the fact that discharge. No data reporting this finding have been published yet. not just clinical characteristics but also biological factors such as The profound anorectic feeling accompanying COVID-19 infection lymphocytes count and proinflammatory markers were worse in and inflammatory disease is quite impressive. It develops very this subset of patients. rapidly and also disappears at about two weeks after discharge in DRM was present in all patients that required AN at hospital most, although not in all patients. The intensity of this symptom and discharge. Lower prevalence of malnutrition in COVID-19 its rapid disappearance in the recovery phase clearly suggests that 4 A. Ramos, C. Joaquin, M. Ros et al. Clinical Nutrition xxx (xxxx) xxx not just the infective disease state plays a role. It has been described prolonged ICU stay for other diseases [32,33]. One of the reasons that angiotensin converting enzyme 2 (ACE2), the only confirmed could be a direct infection of the digestive epithelial cells by the cellular receptor for SARS-CoV-2, it is expressed in the human hy- virus [34]. The presence of severe post-extubating dysphagia has pothalamus and a case report confirmed viral invasion and repli- been associated with severe outcomes including pneumonia, cation in the hypothalamus in a post-mortem brain of a patient reintubation and hospital mortality [35]. Taking this into account, it affected with COVID-19 [19,20]. One hypothesis could be that some seems necessary that all patients hospitalized for SARS-CoV-2 must component of the viral particles bind to specific areas of the hypo- be screened for dysphagia, and if detected, they must undergo a thalamus leading to the profound effect upon orexigenic state. The swallowing evaluation, in order to prevent nutritional complica- clearance of the viral particles from the hypothalamus would tions and bronchial aspiration. explain the reactive hyperphagic and increased hunger observed in There were several limitations in our study. Firstly, there was the majority of patients. The negative effect conferred by the pro- some lack of data about nutritional status at admission. Chronic found anorectic state of these patients together with the catabolic comorbidities were present in a non-negligible percentage of pa- state induced by COVID-19 inflammatory disease contributes to the tients of the study, which could confer itself an important high prevalence of DRM observed in these patients. Moreover, this component of malnutrition risk and sarcopenia prior to SARS-CoV- disorectic situation doesn't disappear completely at 6 months, as 2 infection. Secondly, we lack of body composition measurements. about 10% of cases in our series still presented symptoms at 6 It has been described that a low lean body mass is an independent months after discharge. Therefore, there is a need to develop risk factor for mortality at 6 months in critically ill patients with tailored anabolic nutrition strategies for those patients entering the mechanical ventilation. Thus, it is important also for clinical care in recovery phase. Furthermore, according to our data it is evident that COVID-19 patients to systematically evaluate body composition, there is a need of an earlier detection and initiation of intensive which will allow a better nutritional support for a given patient. nutritional support during the first days after admission. Furthermore, considering the high prevalence of obesity in COVID- On the other hand, risk of sarcopenia was highly prevalent at 19 patients in our series, it is important to monitor fat mass during discharge and persisted in almost half of the patients at 6 months, the recovery period, and also identify sarcopenic obesity for pre- although risk of malnutrition was only present in few of them at vention of worsening of the metabolic condition in those surviving that time. In our cohort, in whom the vast majority of subjects had COVID-19 diseases. either overweight or obesity, the serious weight loss of more than In conclusion, all patients admitted by COVID-19 who received 10 kg together with the high prevalence of sarcopenia risk could AN presented malnutrition at hospital discharge and almost all of indicate that weight loss is focused on muscle mass loss. Further- them showed a high risk of sarcopenia, that persisted in half of the more, hyperphagic rebound situation would lead consequently to cases after 6 months of discharge. This finding indicates that an increase in adipose reservoir. The net consequence, for these nutritional support must be more intensive and ideally associated obese/overweight convalescent patients, could be an increment in to exercise rehabilitation therapy to prevent or reverse sarcopenia. the previously perturbed body composition and the possibility of Nutritional intervention should be considered as part of the increasing sarcopenic obesity at mid-term, which is a very con- comprehensive care of all patients with SARS-CoV-2 infection who cerning consequence of post-COVID health status. Emerging evi- require hospital admission, to improve hospital outcomes and the dence indicates that low muscle mass and its quality have a strong medium-term health status of survivors. negative prognostic impact in obese individuals and may lead to frailty, disability, and increased morbidity and mortality, unless the Funding situation is reverted with appropriate nutritional and functional intervention [21]. No funding or sponsorship was received for this study or pub- There is evidence that people with severe COVID-19 need a lication of this article. specific program of exercise therapy to prevent or reverse muscle disability [22,23]. Patients who develop sarcopenia as a conse- Authorship quence of a stressful event often require even lifetime exercise and nutrition therapy. More research regarding the incidence and All authors had full access to all of the data in this study and take impact of sarcopenia in post-COVID-19 cases is required and also complete responsibility for the integrity of the data and accuracy of more attention to rehabilitation programs during the recovery the data analysis. All named authors meet the International Com- phase is necessary [24,25]. All these considerations indicate that mittee of Medical Journal Editors (ICMJE) criteria for authorship for integrated follow-up programs for post-COVID clinics should this manuscript, take responsibility for the integrity of the work as a include dietary counseling and functional rehabilitation. In whole, and have given final approval for the version to be concordance with other studies, and as previously highlighted, we published. found a high prevalence of obesity in our SARS-Cov-2 hospitalized patients (40,4%) [26,27]. Nevertheless, this data does not represent Conflict of interest the prevalence of obesity in the general Spanish population, which overall is of 17.4%, which indicates that obese individuals who suffer The authors declare that there are no conflicts of interest. COVID-19 are more prone to a higher risk of hospitalization, as also reported by other authors [28,29]. References Despite overweight, all our patients requiring AN were under- nourished, which confirms that BMI is not a good indicator of [1] Wu Z, McGoogan JM. Characteristics of and important lessons from the nutritional status [30]. Since malnutrition is defined not only by coronavirus disease 2019 (COVID-19) outbreak in China: summary of a report of 72 314 cases from the Chinese center for disease control and prevention. low BMI but also by inability to preserve a healthy body composi- J Am Med Assoc 2020 Apr 7;323(13):1239e42. tion, obese subjects should be screened and investigated by sys- [2] Zhou F, Yu T, Du R, Fan G, Liu Y, Liu Z, et al. Clinical course and risk factors for tematic measurement of body composition. mortality of adult inpatients with COVID-19 in Wuhan, China: a retrospective We observed a high prevalence of dysphagia at discharge in our cohort study. Lancet 2020 Mar 28;395(10229):1054e62. [3] Zhu N, Zhang D, Wang W, Li X, Yang B, Song J, et al. A novel coronavirus study population, as also reported by other authors in COVID-19 from patients with pneumonia in China, 2019. N Engl J Med 2020 Feb patients [31] and similar to swallowing disorders described after 20;382(8):727e33. 5 A. Ramos, C. Joaquin, M. Ros et al. Clinical Nutrition xxx (xxxx) xxx [4] Guan W, Ni Z, Hu Y, Liang W, Ou C, He J, et al. Clinical characteristics of coro- [20] Nampoothiri S, Sauve F, Ternier G, Fernandois D, Coelho C, Imbernon M, et al. navirus disease 2019 in China [Internet] N Engl J Med 2020 Feb 28 [cited 2020 The hypothalamus as a hub for SARS-CoV-2 brain infection and pathogenesis. Aug 13]; Available from: https://www.nejm.org/doi/10.1056/NEJMoa2002032. bioRxiv; 2020 Jun 19. 2020.06.08.139329. [5] Huang C, Wang Y, Li X, Ren L, Zhao J, Hu Y, et al. Clinical features of patients [21] Barazzoni R, Bischoff SC, Boirie Y, Busetto L, Cederholm T, Dicker D, et al. infected with 2019 novel coronavirus in Wuhan, China. Lancet 2020 Feb Sarcopenic obesity: time to meet the challenge. Clin Nutr Edinb Scotl 2018 15;395(10223):497e506. Dec;37(6 Pt A):1787e93. [6] Bouadma L, Lescure F-X, Lucet J-C, Yazdanpanah Y, Timsit J-F. Severe SARS- [22] Li J. Effect and enlightenment of rehabilitation medicine in COVID-19 man- CoV-2 infections: practical considerations and management strategy for agement. Eur J Phys Rehabil Med 2020 Apr 24:56. intensivists. Intensive Care Med 2020;46(4):579e82. [23] Morley JE, Kalantar-Zadeh K, Anker SD. COVID-19: a major cause of cachexia [7] Xu X-W, Wu X-X, Jiang X-G, Xu K-J, Ying L-J, Ma C-L, et al. Clinical findings in a and sarcopenia? J Cach Sarcop Muscle 2020;11(4):863e5. group of patients infected with the 2019 novel coronavirus (SARS-Cov-2) [24] Brugliera L, Spina A, Castellazzi P, Cimino P, Tettamanti A, Houdayer E, et al. outside of Wuhan, China: retrospective case series. BMJ 2020 Feb 19:368 Rehabilitation of COVID-19 patients. J Rehabil Med 2020 15;52(4):jrm00046. [cited 2020 Aug 13] [Internet] Available from: https://www.bmj.com/content/ [25] Kirwan R, McCullough D, Butler T, Perez de Heredia F, Davies IG, Stewart C. 368/bmj.m606. Sarcopenia during COVID-19 lockdown restrictions: long-term health effects [8] Barazzoni R, Bischoff SC, Breda J, Wickramasinghe K, Krznaric Z, Nitzan D, et al. of short-term muscle loss. GeroScience 2020 Oct 1. https://doi.org/10.1007/ ESPEN expert statements and practical guidance for nutritional management s11357-020-00272-3 [Internet] [cited 2020 Oct 13]; Available from:. of individuals with SARS-CoV-2 infection. Clin Nutr 2020 Jun 1;39(6):1631e8. [26] Lighter J, Phillips M, Hochman S, Sterling S, Johnson D, Francois F, et al. [9] Gomes F, Schuetz P, Bounoure L, Austin P, Ballesteros-Pomar M, Cederholm T, Obesity in patients younger than 60 Years is a risk factor for COVID-19 hos- et al. ESPEN guidelines on nutritional support for polymorbid internal medi- pital admission. Clin Infect Dis 2020 Jul 28;71(15):896e7. cine patients. Clin Nutr Edinb Scotl 2018;37(1):336e53. [27] Killerby ME. Characteristics associated with hospitalization among patients [10] Volkert D, Beck AM, Cederholm T, Cruz-Jentoft A, Goisser S, Hooper L, et al. with COVID-19 d metropolitan Atlanta, Georgia, marcheApril 2020. MMWR ESPEN guideline on clinical nutrition and hydration in geriatrics. Clin Nutr Morb Mortal Wkly Rep 2020:69 [Internet] [cited 2020 Oct 9] Available from: Edinb Scotl 2019;38(1):10e47. https://www.cdc.gov/mmwr/volumes/69/wr/mm6925e1.htm. [11] Schuetz P, Fehr R, Baechli V, Geiser M, Deiss M, Gomes F, et al. Individualised [28] Petrilli CM, Jones SA, Yang J, Rajagopalan H, O'Donnell L, Chernyak Y, et al. nutritional support in medical inpatients at nutritional risk: a randomised Factors associated with hospital admission and critical illness among 5279 clinical trial. Lancet 2019 Jun 8;393(10188):2312e21. people with coronavirus disease 2019 in New York City: prospective cohort [12] Li T, Zhang Y, Gong C, Wang J, Liu B, Shi L, et al. Prevalence of malnutrition and study. BMJ 2020 May 22:369 [Internet] [cited 2020 Oct 9] Available from: analysis of related factors in elderly patients with COVID-19 in Wuhan, China. https://www.bmj.com/content/369/bmj.m1966. Eur J Clin Nutr 2020 Jun;74(6):871e5. [29] Popkin BM, Du S, Green WD, Beck MA, Algaith T, Herbst CH, et al. Individuals [13] Liu G, Zhang S, Mao Z, Wang W, Hu H. Clinical significance of nutritional risk with obesity and COVID-19: a global perspective on the epidemiology and screening for older adult patients with COVID-19. Eur J Clin Nutr 2020 biological relationships. Obes Rev 2020;21(11):e13128. Jun;74(6):876e83. [30] Gomez-Ambrosi J, Silva C, Galofre  J, Escalada F, Santos S, Milla n D, et al. Body [14] Detsky AS, McLaughlin JR, Baker JP, Johnston N, Whittaker S, Mendelson RA, mass index classification misses subjects with increased cardiometabolic et al. What is subjective global assessment of nutritional status? JPEN - J risk factors related to elevated adiposity. Int J Obes 2011 May 17;36: Parenter Enter Nutr 1987 Feb;11(1):8e13. 286e94. [15] Screening. Fight malnutrition [internet][cited 2020 Oct 9]. Available from: € [31] Ozçelik Korkmaz M, Eg € ilmez OK, Ozçelik MA, Güven M. Otolaryngological https://www.fightmalnutrition.eu/toolkits/hospital-screening. manifestations of hospitalised patients with confirmed COVID-19 infection. [16] Burgos R, Sarto B, Segurola H, Romagosa A, Puiggro  s C, V azquez C, et al. Eur Arch Oto-Rhino-Laryngol 2020 Oct 3. https://doi.org/10.1007/s00405- Traduccio  n y Validacio n de la Version en Espan ~ ol de la Escala EAT-10. Nutr 020-06396-8 [Internet] [cited 2020 Oct 9]; Available from:. Hosp 2012 Nov 1;(6):2048e54. [32] Peterson SJ, Tsai AA, Scala CM, Sowa DC, Sheean PM, Braunschweig CL. Ade- [17] Parra-Rodríguez L, Szlejf C, García-Gonza lez AI, Malmstrom TK, Cruz-Arenas E, quacy of oral intake in critically ill patients 1 week after extubation. J Am Diet Rosas-Carrasco O. Cross-cultural adaptation and validation of the Spanish- Assoc 2010 Mar;110(3):427e33. language version of the SARC-F to assess sarcopenia in Mexican community- [33] Skoretz SA, Flowers HL, Martino R. The incidence of dysphagia following dwelling older adults. J Am Med Dir Assoc 2016 01;17(12):1142e6. endotracheal intubation: a systematic review. Chest 2010 Mar;137(3):665e73. [18] Lechien JR, Chiesa-Estomba CM, De Siati DR, Horoi M, Le Bon SD, Rodriguez A, [34] Eder P, Łodyga M, Dobrowolska A, Rydzewska G, Kamhieh-Milz J. Addressing et al. Olfactory and gustatory dysfunctions as a clinical presentation of mild- multiple gastroenterological aspects of coronavirus disease 2019. Pol Arch to-moderate forms of the coronavirus disease (COVID-19): a multicenter Intern Med 2020 29;130(5):420e30. European study. Eur Arch Oto-Rhino-Laryngol 2020 Aug 1;277(8):2251e61. [35] Macht M, Wimbish T, Clark BJ, Benson AB, Burnham EL, Williams A, et al. [19] Iadecola C, Anrather J, Kamel H. Effects of COVID-19 on the nervous system. Postextubation dysphagia is persistent and associated with poor outcomes in Cell 2020 Oct 1;183(1):16e27.e1. survivors of critical illness. Crit Care Lond Engl 2011;15(5):R231. 6