Table 4.
A Priori Critical PICO-T Questions on COVID-19 and Nutrition and Mapping to Heat Map Nutrition Topics.a
| COVID-19 stage and issue | Critical PICO-T question | Heat map nutrition topic |
|---|---|---|
|
| ||
| Pre–COVID-19 | ||
| Risk mitigation Malnutrition | 1. In the adult and pediatric populations, are there any specific foods vs no specific foods that affect the risk of COVID-19 severity? | NONE |
| 2. In the adult population, what is the effect of micronutrient supplementation vs no supplementation on immune function–mediated risk for COVID-19 severity? | NONE | |
| 3. In adults with type 2 diabetes, does the use of nutraceuticals for those with poorly controlled blood glucose, compared with nonuse, confer any benefit on glycemic control during and after acute COVID-19? | MALNUTRITION | |
| 4. In patients aged >65 years with decreased activities of daily living (eg, isolation and decreased mobility), what is the effect of poor vs adequate nutrition intake and/or nutrition status on increased COVID-19 severity? | MALNUTRITION | |
| 5. What challenges do hospital organizations face regarding the safe handling and administration of expressed human milk, compared with use of standard commercial formulas, during the COVID-19 pandemic? | BREASTFEEDING CONSIDERATIONS | |
| 6. In neonates born to mothers with SARS-CoV-2 infection, does breastfeeding vs formula feeding increase neonatal risk for SARS-CoV-2 infection? | BREASTFEEDING CONSIDERATIONS | |
| 7. In infants born to mothers with SARS-CoV-2 infection, is donated human milk a safe source of nutrition, compared with mother’s breast milk, to mitigate risk for infection transmission and meet growth and development milestones? | BREASTFEEDING CONSIDERATIONS | |
| 8. In new breastfeeding mothers not infected with SARS-CoV-2, will infection mitigation procedures of mask wearing and hand and breast hygiene, compared with no mitigation procedures, offer sufficient protection from infection for newborns? | BREASTFEEDING CONSIDERATIONS | |
| Cardiometabolic | 9. In the adult population, does the presence vs absence or control vs noncontrol of any cardiometabolic risk factor (abnormal adiposity, dysglycemia, hypertension, cardiovascular disease, etc) alter the immune system, adversely affect nutrition status, and/or increase the risk of COVID-19 severity? | CARDIOMETABOLIC DISEASES |
| 10. In the adult population with obesity, does a change, vs no change, to a healthy diet reduce the risk of COVID-19 severity? | CARDIOMETABOLIC DISEASES | |
| 11. In the adult population with obesity, does having vs not having a history of bariatric procedure(s) increase the risk of COVID-19 severity? | NONE | |
| Social determinants of health Lifestyle | 12. In the adult population, do interventions that address food insecurity, vs no actions, affect the risk of increased COVID-19 severity? | FOOD INSECURITY/SOCIETAL INFRASTRUCTURE |
| 13. In school age children, does aggressive case finding for malnutrition and food insecurity in underserved populations, compared with not case finding, improve the clinical course of COVID-19? | FOOD INSECURITY/SOCIETAL INFRASTRUCTURE | |
| Transcultural | 14. In patients >65 years of age in the US, does being an ethnic minority vs Caucasian increase the negative effect of malnutrition on increased COVID-19 severity? | FOOD INSECURITY/SOCIETAL INFRASTRUCTURE |
| 15. Among high-risk ethnic minorities (eg, aged >60–65 years), do modifications in the nutrition assessment need to be performed, vs using standard protocols, to decrease the risk for COVID-19 severity? | MALNUTRITION | |
| 16. In the adult population, does accommodation of regional and cultural differences in food and lifestyle, compared with no accommodation, decrease the risk of COVID-19 severity? | NONE | |
| 17. In the adult population of uninfected new mothers in diverse geographic regions, does the presence vs absence of culturally sensitive recommendations for breastfeeding contribute to optimal neonatal outcomes and neonatal risk for COVID-19? | BREASTFEEDING CONSIDERATIONS | |
| Acute COVID-19 | ||
| Outpatient | 18. In patients with acute but nonsevere COVID-19 managed as an outpatient, does a formal nutrition assessment and counseling, with or without enteral supplements, vs no nutrition intervention, hasten recovery time and/or decrease the likelihood of severe COVID-19. | NONE |
| Inpatient: Non-ICU or ICU Nutrition assessment | 19. In patients hospitalized with COVID-19, does prehospitalization weight loss > 5% vs no weight loss modify the decision-making on timing, modality, and/or dosing of nutrition support, with respect to effects on clinical outcomes? | NUTRITION ASSESSMENT |
| Nutrition therapy | 20. In patients hospitalized with COVID-19 on high-flow nasal cannula and inadequate oral intake (<50% of estimated needs), does supplemental EN vs continued attempts with standard oral nutrition improve clinical outcomes (reduce infections, mortality, ICU days, ventilator days, and nosocomial infections)? | NUTRITION THERAPY |
| 21. In patients hospitalized with COVID-19 receiving EN, will increasing the head of bed to ≥10–25 degrees, compared with a supine position, be adequate to decrease aspirated gastric contents with intra-abdominal hypertension? | NUTRITION THERAPY | |
| 22. In patients hospitalized with COVID-19 and with obesity, does hypocaloric, high-protein nutrition, compared with standard care, improve clinical outcomes? | NUTRITION THERAPY | |
| 23. In patients hospitalized with COVID-19, does micronutrient supplementation (eg, vitamin A, B-complex, C, D, selenium, chromium, and/or zinc) vs no supplementation improve clinical outcomes (eg, reduce mortality, ICU days, and ventilator days)? | NUTRITION THERAPY | |
| 24. In patients hospitalized with COVID-19 and with severe hyperglycemia, does the infusion of IV chromium > 5 mcg/d, with or without PN, vs no or lower chromium (≤5 mcg/d) improve glycemic status? | NUTRITION THERAPY | |
| Infrastructure | 25. In patients hospitalized with COVID-19, does having an RDN and/or nutrition support team vs standard care on acute-care floors, or present in team rounds, increase adequacy of nutrition intake (standard/enteral/parenteral)? | HOSPITAL INFRASTRUCTURE |
| Inpatient: ICU only Nutrition assessment | 26. In patients with critical illness and receiving EN and/or PN, with vs without COVID-19, is there a higher risk for refeeding syndrome? | NUTRITION ASSESSMENT |
| 27. In patients with critical illness and COVID-19, is an energy deficit of <4000 kcal vs >4000 kcal by day 7 associated with improved clinical outcomes (eg, reduce infections, mortality, ICU days, ventilator days, and nosocomial infection)? | NUTRITION ASSESSMENT | |
| Nutrition support | 28. In patients with critical illness and COVID-19, does probiotic supplementation vs no supplementation improve clinical outcomes (eg, reduce infections, mortality, ICU days, and ventilator days)? | NUTRITION SUPPORT |
| 29. In patients on mechanical ventilation with COVID-19, does initiation of early EN (within 48 hours of ICU admission) compared with either not receiving EN, initiation of EN >48 hours, or early PN (within 48 hours of ICU admission) improve outcomes (eg, reduce infections, mortality, ICU days, ventilator days, and nosocomial infections)? | NUTRITION SUPPORT | |
| 30. In patients on mechanical ventilation with high nutrition risk (mNUTRIC ≥5 or NRS ≥3) and COVID-19, does full-dose early EN vs <70% prescribed EN improve clinical outcomes (eg, reduce infections, mortality, ICU days, and ventilator days)? | NUTRITION SUPPORT | |
| 31. In patients with critical illness and COVID-19, with or without prehospitalization sarcopenia, does higher (>1.2 g/kg/d ABW) vs lower (<1.2 g/kg/d ABW) protein delivery improve clinical outcomes (eg, reduce infections, mortality, ICU days, and ventilator days, and nosocomial infection)? | NUTRITION SUPPORT | |
| 32. In patients with critical illness and COVID-19 undergoing prone positioning with gastric delivery of EN, does monitoring vs not monitoring gastric residual volume increase enteral feeding tolerance and reduce adverse events, such as aspiration pneumonia? | NUTRITION SUPPORT | |
| 33. In patients with critical illness and COVID-19 undergoing prone positioning with gastric delivery of EN, does prokinetic use vs nonuse improve enteral feeding tolerance? | NUTRITION SUPPORT | |
| 34. In patients with critical illness and COVID-19 undergoing ECMO or VAD placement, is early EN vs no nutrition safe (eg, no nonocclusive bowel necrosis) and tolerated (eg, no vomiting, ileus, or diarrhea)? | NUTRITION SUPPORT | |
| 35. In patients with critical illness and COVID-19 receiving multiple vasopressor agents, does trophic or hypocaloric dosing of EN vs no EN increase the risk of nonocclusive bowel necrosis? | NUTRITION SUPPORT | |
| 36. In patients who are malnourished and critically ill with COVID-19, and also unable to tolerate early EN, does intervention with early PN (within 24–48 hours of demonstrated enteral intolerance), compared with either late or no PN, improve clinical outcomes (eg, reduce ICU mortality, ICU days, and ventilator days)? | NUTRITION SUPPORT | |
| 37. In patients with critical illness and COVID-19, do volume-based bolus feeds incidental to healthcare personnel at the patient’s bedside (due to enteral pump shortages) vs standard rate–based EN via enteral pump (when available) lead to more enteral feeding delivered and/or more feed intolerance (eg, diarrhea, vomiting, ileus) or complications (eg, pneumonia)? | NUTRITION SUPPORT | |
| 38. In patients with critical illness, COVID-19, and PN use, do fish oil–containing lipids, compared with pure soybean oil lipids or no lipids, improve viral clearance and/or clinical outcomes (eg, reduce infections, mortality, ICU days, and ventilator days)? | NUTRITION SUPPORT | |
| 39. In patients with critical illness, COVID-19, high nutrition risk (NUTRIC ≥5 or NRS ≥3), severe hyperglycemia (>300 mg/dl), and insulin resistance (>25 units/h), does permissive underfeeding with EN or PN to prioritize glycemic targets, vs continuing standard nutrition dosing, improve clinical outcomes (eg, reduce infections, mortality, ICU days, and ventilator days)? | NUTRITION SUPPORT | |
| 40. In patients with critical illness, COVID-19, and hyperglycemia (blood glucose > 180 mg/dL), does glycemic control to blood glucose 140–180 mg/dL, compared with other glycemic targets, improve clinical outcomes (eg, reduce infections, mortality, ICU days, and ventilator days)? | NUTRITION SUPPORT | |
| Infrastructure | 41. In patients on mechanical ventilation with COVID-19, does the presence of a feeding/nutrition protocol increase the number of patients receiving early EN? | HOSPITAL INFRASTRUCTURE |
| Chronic/Post–COVID-19 | ||
| Outpatient Nutrition assessment | 42. In patients who have had severe COVID-19, does the performance vs nonperformance of a nutrition risk assessment improve clinical outcomes? | DIET ADVICE |
| 43. In adults aged >65 years, with or without having had COVID-19, does poor mobility and isolation, when compared with socially active and mobile counterparts, result in poorer nutrition that leads to increased risk for COVID-19–related morbidity or mortality? | MALNUTRITION | |
| 44. In the general population during the COVID pandemic, what is the impact of stay-at-home quarantine schedules on weight and nutrition-related comorbidities? | QUARANTINE DEPRESSIONS/STRESS EATING, UNHEALTHY FOOD CHOICES, WEIGHT GAIN | |
| Nutrition therapy | 45. In patients with obesity who have had severe COVID-19, does weight loss vs weight maintenance or weight gain improve metrics of recovery? | DIET ADVICE |
| 46. In children recovering from COVID-19, does supplemental nutrition vs an ad lib diet, improve growth and weight parameters? | DIET ADVICE | |
| 47. In patients who have had severe COVID-19, does subsequent supplementation with micronutrients or other nutrition products vs no supplementation result in improved recovery? | DIET ADVICE | |
| 48. In patients who have had severe COVID-19, does nutrition management that achieves a priori protein-energy goals, vs standard care without goal-directed nutrition, decrease the risk of complications (eg, renal, pulmonary, cardiac, hematological, and neurological)? | DIET ADVICE AND MALNUTRITION | |
| 49. In patients who have had severe COVID-19, does nutrition supplementation (oral, EN, and/or PN) vs no supplementation improve achievement of rehabilitation goals? | DIET ADVICE AND MALNUTRITION | |
| Infrastructure | 50. In patients who have had severe COVID-19, does MNT provided by an RDN vs no MNT result in improved outcomes? | NUTRITION COUNSELING |
| 51. In patients who have had COVID-19, do outpatient nutrition follow-up protocols vs no protocols improve clinical outcomes? | NUTRITION COUNSELING | |
| 52. In patients receiving home PN and/or EN during the COVID-19 pandemic, does having access to care management by an RDN and/or nutrition support team impact nutrition adequacy and hospitalization due to COVID-19? | NUTRITION COUNSELING AND TELEHEALTH | |
| 53. In pediatric patients receiving home PN, do COVID-19–altered caregiver routines and schedules impact feeding and bodyweight? | DIET ADVICE AND NUTRITION COUNSELING | |
| 54. In patients who have had severe COVID-19, does subsequent food insecurity vs no food insecurity result in impaired recovery? | FOOD INSECURITY/SOCIETAL INFRASTRUCTURE | |
| Inpatient Nutrition support | 55. In patients who have had severe COVID-19 and remain in the ICU with a tracheostomy, do adjustments in nutrition care goals, vs continuing the same goals as with acute critical illness, improve clinical outcomes? | MALNUTRITION AND NUTRITION COUNSELING |
| 56. In patients who have had acute COVID-19 and discharged from the ICU, does meeting indirect calorimetry–determined nutrition goals vs standard care improve metrics of recovery and reduce rehospitalization due to COVID-19? | MALNUTRITION AND NUTRITION COUNSELING | |
ABW, adjusted body weight; CDC, Centers for Disease Control and Prevention; COVID-19, coronavirus disease 2019; ECMO, extracorporeal membrane oxygenation; EN, enteral nutrition; ICU, intensive care unit; MNT, medical nutrition therapy; mNUTRIC, modified nutrition risk in critically ill (score); NRS, nutrition risk screening; PICO-T, Population, Intervention, Comparator, Outcome, and Time; PN, parenteral nutrition; RDN, registered dietitian nutritionist; VAD, ventricular assist device.
a
PICO-T questions are based on nutrition issues with COVID-19 (Table 1) and the clinical experience of the expert writing group prior to analysis of the scoping results. PICO-T questions confer relevance to research and knowledge gaps and provide specific topics for systematic reviews to address practice gaps. Critical PICO-T questions are sorted by COVID-19 stage (pre-, acute, and post-/chronic) and deemed highly relevant to clinical nutrition practice and vetted by the primary authors and a member of the community. Each critical PICO-T question has a numerical designation to assist identification of the most relevant research and knowledge gaps discovered by this scoping review. Heat maps (Figure 3) are interpretable in terms of the PICO-T questions that map to the nutrition topics on the y-axes. PICO-T questions that do not map to nutrition topics (labeled as “NONE”) automatically qualify as research and knowledge gaps.