Post-Covid Rehabilitation: Recommendations for Nutrition Management

From 22 to 24 September 2022, the Brazilian Congress of Dietetics (CBN 2022) took place in São Paulo, where one of the discussion tables took up the current and necessary topic of rehabilitation after infection with the Coronavirus. Four lectures were presented that dealt with the nuances of the process of rehabilitating the patient with the disease.

In the first lecture, the difficulties encountered in the different stages of the feeding process for this patient were discussed, which includes from the beginning of nutritional therapy (when and how do you start the diet of a critical patient?), the transition to nutritional care until the final stage – how to rehabilitate the patient after discharge from the hospital. In the most severe forms of the disease, patients develop acute respiratory syndrome, with instability of blood circulation and metabolism, and often with the need to use mechanical ventilation.

Acute inflammation also leads to high blood sugar and increased lactate, which causes great difficulty in stabilizing the patient’s condition. This encouraged the use of high doses of anesthetics, vasoactive drugs, and neuromuscular depressants, many of which were placed in the prone position for prolonged periods as well as dialysis, all of which contributed to the delayed initiation of nutritional therapy.

Volumetric fluid control

Controlling the volume of fluids injected, high use of substances containing non-food calories, such as propofol, and careful management of water-electrolyte disturbances were also challenges encountered during the diet’s progression phase. The transitional phase of nutritional therapy care begins with the replacement of parenteral nutrition, when used, and from enteral nutrition to rehabilitation to oral nutrition, which will sometimes not be possible within a hospital setting.

The high rates of readmission to hospital in patients infected with COVID-19, which were illustrated in the studies presented during the lecture, may indicate poor discharge planning, as the patient receives a flood of information at the moment of returning home, which indicates the importance of developing a program Assists in the discharge process and gives heroism to the patient and caregivers, resolving doubts and implementing training when possible.

Motor rehabilitation and early mobilization

As for motor rehabilitation, the speakers touched on the care of critically ill patients in hospitals in intensive care units due to COVID-19. Several studies have been presented showing that these patients were mobilized too late, and mobilization often began only after sedation was suspended or mechanical ventilation withdrawn, which can be prolonged in this pathology.

In these studies, it was shown that in some services, mobilization of patients began from September to 14 days after admission to the ICU. Early mobilization is known to contribute to the maintenance of lean mass and the prevention of sarcopenia in critically ill patients, and the experience of hospital services that adopted early mobilization and muscle preservation strategies such as active contraction, electrically stimulated contraction and resistance exercise as per patient capabilities has been reported.

High or low intensity exercise?

There are a few good studies looking at patients’ recovery after hospital discharge, but those in existence showed that low-intensity exercise showed increases in strength when compared to high-intensity exercise.

Maximum oxygen consumption (VO2 max) can be influenced by many factors in patients with covid-19, who develop with loss of lean mass, muscle tightness and decreased physical strength, demonstrating that another challenge must be overcome in patients with covid-19 cardiopulmonary rehabilitation, highlights the importance of physical training programs, the ability to adapt activities and the use of strategies such as the FITT principle: Repetition (number of days of the week), intensity (workload completed), time (duration of each session), Writes (Exercise mode).

Supplementation in Post-Covid Syndrome

The third lecture dealt with the use of oral nutritional supplements in COVID-19, and showed the importance of critical analysis of the scientific literature, as it was found that many articles showed promising results in the nutritional rehabilitation process, but little works. Statistical fit. Poor study design, few systematic reviews on the topic.

The most promising studies have shown that adequate protein, calorie and mineral support, associated with physical activity and muscle rehabilitation is effective in preventing and improving sarcopenia, and the use of vitamin D, minerals and immunomodulators has shown promising potential in restoring the immune response..

There are promising studies using polyphenols. Vitamin E, C and A; Glutathione and carbohydrates with a low glycemic index contribute to reducing the oxidative stress that these patients undergo in different stages and forms of the syndrome, as well as the use of various substances in reducing inflammation, such as omega-3 fatty acids, monounsaturated fatty acids, dietary fiber, palmitoylethanolamide, N -acetylcysteine and inositol.

Considerations

It is important It should also be noted that post-Covid syndrome is multifactorial and includes many aspects that can affect an individual in the most diverse ways, such as inflammation, traumatic stress, microcoagulation, oxidative stress, impaired immune response, hormonal deficits, drug use, malnutrition, Sarcopenia, a critical polyneuropathy of patients.

All the lectures illustrate the current difficulties of not having an exclusive therapeutic consensus for patients with COVID-19, a disease that has challenged scientific production as it requires immediate solutions, without sufficient time to accomplish all the necessary stages in establishing protocols and the long term. search. For now, the disease is no longer a pandemic, but post-Covid syndrome is a reality that all health professionals must face. Several substances are being tested to reduce acute effects and mitigate the effects and consequences of such a heterogeneous syndrome, but studies have shown that adequate nutrition and physical activity are the most effective tools.

Practical message

There is a recommendation that a patient with hypogonadism and Covid-19 should be treated with testosterone replacement, but there is no clear scientific evidence or consensus on the best time to start this treatment, what is the most appropriate form of treatment and the dose to use.

Many substances have been shown to be effective in different stages of the disease, but there is no strong scientific evidence to suggest the use of any substance as a specific recommendation for the treatment and prevention of post-Covid syndrome, and the final message is that nothing replaces lifestyle.