Table 1.

Symptom, metabolic, nutritional status and nutritional intake factors contributing to malnutrition and impaired/delayed recovery across the continuum of care.

Pre-Acute Illness	Acute Illness	Recovery Phase
Pre-existing noncommunicable disease (NCD): Obesity CVD Diabetes COPD Where chronic inflammation ± reduced cardiometabolic fitness 1 contribute to the stress inflammatory response in acute illness Pre-existing loss of body tissue/wasting: Malnutrition Frailty Sarcopenia/Sarcopenic obesity Cachexia (wasting and inflammation)	Effects of acute illness: Stress/inflammatory response Hypermetabolism (increased REE) Increased protein catabolism Bed rest/sedation Oropharyngeal dysphagia GI disturbances disrupting ability to feed Disuse atrophy	Recovery phase complicated by persistent symptoms: Post-intensive care syndrome Functional impairment e.g., fatigue, muscle weakness Oropharyngeal dysphagia Altered appetite and chemosensory dysfunction
Symptom, Metabolic and Nutritional Status Factors ↓
MALNUTRITION, LOSS OF LEAN BODY MASS AND PHYSICAL FUNCTION CONTRIBUTING TO IMPAIRED/DELAYED RECOVERY
↑ Nutritional Intake Factors
Suboptimal dietary quality may already be a concern before onset of acute illness Suboptimal food and nutrient intake linked to NCD [30] Poor diet quality linked to frailty in old age [31] Poor appetite/ability to eat affects physical function [32] Low protein intake linked to reduced strength and physical performance [33]	Nutrient deficits accumulate during hospital stay More than half of patients do not finish their meals in the ward [34] Only 56% of ICU patients meet their requirement for energy 2 and 52% for protein [35] Up to 60% of post ICU patients on oral nutrition alone do not meet their energy requirements and up to 70% do not meet their protein targets [36,37,38] Suboptimal use of thickening agents and texture-modified foods for dysphagic patients Patients on texture modified diets have lower energy and protein intake than patients on a normal hospital diet and fail to meet requirements [39]	Ongoing nutritional needs frequently not addressed at discharge Forty-five percent of malnourished patients received inappropriate advice to limit caloric intake [40] Forty-seven percent received general advice that did not address malnutrition [40] Eighty-eight percent received ONS in hospital, but only 6.6% scripted post-discharge [40] Only 11% of HCPs estimated that all patients with COVID-19 were ‘discharged from hospital with a clear nutrition plan’ [41] Suboptimal use of thickening agents and texture-modified foods for dysphagic patients

¹ The term ‘cardiometabolic fitness’ refers to the presence of insulin resistance, obesity and hypertriglyceridemia rather than physical performance. ² Includes enteral nutrition, parenteral nutrition and propofol. Data presented in the lower part of the table is not specific to COVID-19 patients unless specified. CVD, cardiovascular disease; COPD, chronic obstructive pulmonary disease; REE, resting energy expenditure; ONS, oral nutritional supplements; HCPs, healthcare professionals.