Weight Loss in COVID-19–Positive Nursing Home Residents

To the Editor:

Coronavirus Disease 2019 (COVID-19) has had an impact on nutrition at individual, community, national, and global levels.¹ COVID-19 has been associated with weight loss and also has been linked to cachexia and sarcopenia.² Anorexia was the most common symptom during COVID-19 infection among patients at an academic long-term chronic care facility, with 70.8% of residents developing anorexia during the illness course.³ In addition to effects of the disease itself, there are potential unintended consequences of infection control measures. A study of residents in a nursing home without a COVID-19 outbreak in the month following implementation of restrictions on visitors and group dining designed to mitigate the spread of COVID-19 showed significant weight loss among residents.⁴

We conducted a retrospective chart review assessing the outcome of a COVID-19 outbreak on resident weights in a >200-bed skilled nursing facility (SNF) in Chicago, IL. The medical charts of each resident in the facility between March 1, 2020, and May 31, 2020, were reviewed in the electronic medical record (EMR) (PointClickCare) at the SNF and the affiliated academic medical center (Epic, 2020 Epic Systems Corporation). Among the residents included in the sample (n = 209), the average age was 75.3 years (SD = 11.9 years); residents were predominantly Black (93.3%) and women (56.0%). Hypertension (89.5%) and cognitive impairment (67.9%) were the most common chronic conditions present, followed by cardiac disease (43.5%) and diabetes (39.2%).There was no significant difference in age, race, gender, or comorbidities between the COVID-positive (n = 172) and COVID-negative groups (n = 32). Prevalence testing was completed for all residents in the facility twice at 7-day intervals in addition to as-needed testing based on symptoms and exposure.⁵ The results of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) polymerase chain reaction (Roche, Basel, Switzerland) nasopharyngeal swab testing were recorded. The first weight after March 1, 2020, and the last weight on or before May 31, 2020, were recorded along with the duration between the 2 weights. Of the 209 residents in the SNF during the study period, 194 residents had both a starting weight and an end weight recorded within this 3-month period. Weight change was stratified by COVID-19 result status.

Mean starting weight for the COVID-positive group was 161.4 lb (n = 169) and mean starting weight for the COVID-negative group was 146.7 lb (n = 32) (P = .20) (Table 1 ). Mean time between weight measurements was similar for both groups (COVID-positive = 2.1 months, COVID-negative = 2.0 months, P = .52). Both groups experienced a decrease in weight during the study period. COVID-positive residents with both a start and end weight (n = 162) experienced a mean weight loss of 7.8 lb and residents in the COVID-negative group (n = 32) experienced a mean weight loss of 3.6 lb (P < .05). Adjusted for percent weight change over the study period, the COVID-positive group experienced weight loss of 4.6% from starting weight and the COVID-negative group experienced weight loss of 2.4% (P = .06).

Table 1.

Weight Change in COVID-Positive and COVID-Negative Groups

	COVID-19 Positive	COVID-19 Negative	P Value
	Mean (SD) Median n	Mean (SD) Median n
Starting weight (lb)	161.4 (53.4) 153.0 n = 169	146.7 (38.3) 141.6 n = 32	.20
Weight change (end to start; lb)	−7.8 (12.1) −5.8 n = 162	−3.6 (5.9) −3.3 n = 32	.048
% weight change	−4.6 (7.1) −3.8 n = 162	−2.4 (3.7) −2.2 n = 32	.06
% weight change per month	−2.4 (4.4) −1.8 n = 162	−1.9 (3.5) −1.3 n = 32	.20
Time between 2 weight measurements (mo)	2.1 (0.6) 2.2 n = 162	2.0 (0.7) 2.0 n = 32	.52

This study found weight loss among both COVID-positive and COVID-negative residents in a nursing home population after a widespread COVID-19 outbreak. Residents who were COVID-positive had both a larger absolute weight loss and trended toward a larger percentage weight loss. This is the first study, to our knowledge, that shows clinical evidence of a consistent weight loss trend in an SNF population during and after a COVID-19 infection that is distinct from weight loss related to restrictive infection control measures. The etiology of weight loss in this population is likely multifactorial. In addition to previously proposed theories of increased metabolic demand associated with the inflammatory process of SARS-CoV-2 viral infection,² the COVID-19 associated symptoms of anorexia, fatigue, delirium, nausea/vomiting, and sore throat³ likely further exacerbate dementia, dysphagia, and poor oral intake that are common in a multimorbid nursing home population. Furthermore, increased isolation and decreased activity levels due to infection control restrictions, such as visitor restriction and dining hall closure likely also contribute to increased weight loss.

Weight loss in older adults has been associated with mortality overall⁶ and is a common feature of other geriatric syndromes. These findings support the call to proactively address COVID-19–associated weight loss as part of a COVID-19 management strategy at SNFs. Creative strategies and policies are needed to ensure residents receive adequate mealtime support, symptom management, weight monitoring, and comprehensive nutrition assessments. Limitations of this study include a single site and a relatively small number of individuals in the COVID-negative group, which may have limited the ability to detect significant differences between the 2 groups. Further research is needed on the mechanism of COVID-19–associated weight loss as well optimal strategies for identification, prevention, and treatment of COVID-19–associated weight loss.

Supplementary Methods. Setting

This study took place in a single >200-bed SNF in Chicago, IL, that experienced a COVID-19 outbreak between March 1 and May 31, 2020. The cohort included both sub-acute and long-term care residents (n = 209) living at the SNF during the study period. There were no new admissions during this time due to facility restrictions in the setting of the outbreak.

Demographics

Demographics were collected, and included age (as of March 1, 2020), gender, and race/ethnicity as recorded in the EMR.

Statistical Analysis

Simple summary statistics were used to quantify the degree of weight change experienced by residents during the COVID-19 lockdown time period. To compare weight change between COVID-19–positive and COVID-19–negative residents, we used Wilcoxon rank-sum tests. All analyses were conducted in Stata Version 16 (StataCorp LLC, College Station, TX). This study was approved by the affiliated academic medical center Institutional Review Board.