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Tabitha Ward RD
Tabitha is a Senior Dietitian in Weight Management. She is also a freelance health writer.
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VEGANUARY 2021 HITS RECORD
Veganuary has had its biggest sign up ever this year since launching in 2014. In January, 500,000 people signed up to take part in the month-long vegan challenge, double that of 2019. 125,000 of those sign-ups were in the UK, with supermarkets getting right behind it by releasing new vegan lines and creating dedicated online Veganuary pages providing information all about veganism.
Toni Vernelli, Veganuary’s Head of Communications, said, “While new vegan product launches from big name brands are exciting, the way British supermarkets have embraced Veganuary this year is truly game changing. They are not simply using it as a marketing opportunity, but are promoting the many benefits of plant-based eating and encouraging people to give it a try.”
It’s not just the supermarkets who got enthusiastic. Many celebrities joined in too, with the likes of Ricky Gervais and Paul McCartney going plant-based for the month to help reduce environmental impact.
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EATING DISORDER HOSPITAL ADMISSIONS RISE SHARPLY
Hospital admissions for eating disorders have risen by 37% across all age groups in the last two years, according to NHS Digital data for England obtained by PA news agency. The data shows that in 2018/19, there were 19,040 admissions for eating disorders, up from 13,855 in 2016/17. Of those admissions, 25% were children under the age of 18.1 The Royal College of Paediatrics and Child Health (RCPCH) reported that several factors in the pandemic may have contributed to this, including, isolation from peers during school closures, exam cancellations, loss of extra-curricular activities, and an increase in social media usage with a focus on unrealistic ideas of body image.2
Dr Karen Street, a Consultant Paediatrician at the Royal Devon and Exeter Hospital and Officer for Child Mental Health at the RCPCH said, “We are extremely concerned about many children and teenagers’ wellbeing because of the pandemic. Many of them are just not coping. Eating disorders are often related to a need for control – something many young people feel they have lost during the pandemic. Many have described needing a focus which, in the absence of anything else, has, for some, centred around eating and exercise.”2
The RCPCH is now warning parents and guardians to look out for signs of eating disorders at home so problems can be caught as early as possible.
Turn to page 19 for more on acute eating disorders. References 1 https://www.bbc.co.uk/news/uk-50969174 2 https://www.rcpch.ac.uk/news-events/news/ paediatricians-warn-parents-be-alert-signs-eating-disorders-over-holidays
NATURE MEDICINE PUBLISHES LATEST DISCOVERIES ON THE GUT MICROBIOME AND HEALTH
New research suggests a strong link between specific gut microbes, diet quality and health. The study published in Nature Medicine, used metagenomics and blood chemical profiling to look at these factors.
PREDICT 1 (Personalised Responses to Dietary Composition Trial 1), found links between diet, microbiome and health outcomes. The researchers identified microbes that were classified as ‘good’ or ‘bad’ based on whether they positively or negatively affected health markers, including factors such as inflammation, blood sugar control and weight. For example, having a microbiome rich in Prevotella copri and Blastocystis was associated with a healthier blood sugar response after eating a meal.
Results showed those who ate a diet rich in less processed ‘healthy’ plant-based foods were more likely to have high levels of the so-called ‘good’ gut microbes. But the ‘good’ microbes were also seen in those with diets rich in ‘healthy’ animal-based foods. In contrast, those consuming a highly processed diet were more likely to be associated with the ‘bad’ gut microbes.
This study highlights the importance of the microbiome and that it may even have a greater association to health markers compared with other factors, such as genetics.
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NEW DATA REVEALS HOW OUR DIETS ARE CHANGING OVER TIME
Public Health England recently posted the results of the National Diet and Nutrition Survey for the years 2016-17 to 2018-19, providing detailed information on food and nutrition intake within the UK population for both adults and children.
What did they find? • A steady decline in sugar intake in both children and adults since 2008, partly to do with a reduction in sugar-sweetened beverages. • No decline in sweet confectionary and chocolate consumption. Intake went up in some groups. • A fall in red and processed meat intake over the last decade. • Saturated fat intake is increasing in some groups, possibly due to a rise in lower carbohydrate diets. • Average intakes of fibre are still well below the recommended daily amount, with little change since 2008. • For adults, salt intake was higher than the recommended intake. Salt intake is slowly decreasing, but the decrease has slowed since 2014. • Most people are still not getting enough vitamin D.
Overall, whilst some people’s diets are improving, there is still a lot of room for improvement in others.
Emma Berry ANutr
Emma is a freelance nutrition writer interested in Public Health nutrition. She is also a PhD Student in Health Services Research and works in NHS Research and Development at the University of Aberdeen.
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REFERENCES Please visit: nhdmag.com/ references.html
OBESITY: THE IMPACT OF COVID-19
How has the pandemic influenced our eating behaviours and food insecurity in general? This article takes a look at some of the latest research into obesity during COVID-19.
Obesity hit the headlines in 2020 during the COVID-19 pandemic. Boris Johnson announced that he was “too fat” when he was hospitalised with the virus, and his experience was used as part of the marketing for the new Public Health England obesity strategy, Better Health.1 The policy paper for the strategy has a section on the links between COVID-19 and obesity, and why the new campaign is important for reducing the risk of not only the virus, but also for specific dietrelated conditions.2
The paper outlines several measures that the UK government will be taking to support people in making healthier choices. It discusses factors that can influence food choices and which could help to shape our food environment for the better, such as advertising, food promotions and nutritional labelling.2
Although these plans appear to be evidence based, many people’s lives have changed dramatically due to the pandemic. It could be worth asking what the impact has been on our food and exercise choices and how these could influence our weight. Below are some of the areas which may be influenced by the pandemic in terms of obesity.
EATING HABITS DURING THE PANDEMIC COVID-19 has presented numerous challenges for people. Many individuals have struggled with increased levels of anxiety, increased isolation and reduced access to coping mechanisms. The constant changes and uncertainty can be very difficult to deal with. The increased mental burden, alongside more time spent in the house, has meant that many people have changed their eating habits and their weight. One UK study looked at the changes before and during lockdown.3 A sample of UK adults were asked to complete a questionnaire, which included questions on self-reported weight and height, medical history and whether they had COVID-19. The results showed that many participants reported the following:3 • an increased level of anxiety during lockdown; • feeling bad about their weight; • eating more because of their feelings; • eating larger portions; • drinking more alcohol; • snacking more; • spending more time sitting down.
Several factors, including age, gender, education level, BMI, health status, ethnicity and education, were seen to be related to lockdown behaviours that could contribute to weight gain, such as increased eating or reduced physical activity.3 However, there have also been numerous positive changes that have been made possible during lockdown, such as being more active and doing more exercise.3 Many people reported still having access to healthy food as well as having time to eat healthily and exercise.
This study provides only a snapshot of the changes during the pandemic, as it was carried out during April and May 2020. It is possible that as the pandemic response has developed, and with more services re-opening (and then having to close again), our eating and exercise habits may continue to change.
There have been other studies published outside the UK, exploring the impact of the pandemic on obesity levels. One such example is a study in Italy, which observed the changes in patients who attended an Obesity Unit after one month of lockdown.4 These patients reported an average weight gain of 1.5kg. The researchers explain that although there was an increase in sedentary behaviours, there was also a reduced chance to consume meals in cafes/restaurants and a reduced need for ready meals, as there was more time to cook at home.4
Despite this, many patients reported an increase in the amount of food they ate, consuming more sweets, snacks and reduced fruit and vegetables.4 Again, as also discussed in the UK study, certain factors increased the likelihood of weight gain, such as education level and anxiety or depression.4 This shows that many of the nutritional impacts from COVID-19 can be seen across multiple different countries.
Much of the research is still emerging in this area, and it will be interesting to see how it develops over both the near future and in the longer term.
CHILDHOOD OBESITY AND COVID-19 In 2020, Marcus Rashford led an important campaign to provide free school meals to children while schools were closed.5 This was an important opportunity to reduce food insecurity for children who were at risk during the holidays. Research, based on the findings of previous studies carried out during school summer holidays, has suggested that increased school closures may contribute to childhood obesity levels, as there will be a reduction in the level of physical activity that children will undertake at home compared with the school environment.6 In preparing for a COVID-19 lockdown or self-isolation, households may also choose to buy foods that are more calorie dense and will last for a longer period of time.6 Food insecurity, therefore, is linked to an increased risk of weight gain and obesity, which means that the provision of free school meals will hopefully help children in need.6
Rising unemployment and reduced income from furlough – all due to COVID-19 – could lead to a longer-lasting impact on children. There may well be more research to be published in this area in the future.
PUBLIC UNDERSTANDING AND VIEWS OF OBESITY In Scotland, research was carried out to investigate the public’s understanding and views of obesity. This research was carried out in 2016 using a sample of the population, with the report being released in January 2018. This report includes how well people recognise obesity, the health consequences, barriers and responsibility for obesity reduction.7
There were numerous findings in this report, including that many people did not identify the overweight or obese persons correctly on the options given, often selecting those of a much higher BMI as the first identifiable overweight person.7 When self-identifying, many people did not describe themselves as obese or very overweight. The report suggests that this might be because people do not recognise their own body weight. It could also be suggested that perhaps people did not want to identify themselves as being very overweight due to the negative perceptions associated with being of a higher BMI – many individuals might feel uncomfortable identifying themselves as the highest weight category on surveys discussing obesity.7
The section discussing who is responsible for reducing obesity offers a selection of options, including the individual who is overweight, healthcare professionals, food and drink manufacturers and the media, to name but a few.7 Unsurprisingly, the highest scoring option was the individuals themselves. The second highest scoring was healthcare professionals, followed by food and drink manufacturers. The report says that many people selected multiple options, with a mixture of groups (eg, organisations) and individuals (eg, friends, family, person who is overweight). Many people in the survey
seemed to be aware of the complex situation that can impact weight.7 It’s good that people understand this complex relationship, as body size can be influenced by numerous factors. For example, weight gain can be a common side effect from many long-term medications and can also be caused by some medical conditions.8
Although many people think that losing weight is something which is up to an individual, it’s not necessarily an easy thing to do and many people may not easily be able to change their lifestyles. A review carried out by Serrano Fuentes et al (2019) captured this when they explored how the social network influences obesity-related behaviours.9 This study showed that there can be an impact from various factors, such as relationships, the time of social process and environmental factors. These can be complex though; for example, friends can either be a positive or a negative influence, depending on the situation.
CONCLUSIONS Although it is too early to know the full impact of COVID-19 on obesity levels and body weight in the UK, there are already a few ways in which it has had a negative influence. On a positive note, however, it may have helped more people to realise that weight is a very complex issue, and it is not necessarily an individual’s fault alone. Weight gain can happen for numerous reasons and is not always unhealthy.
Many people have been struggling with food insecurity due to, or made worse by, the pandemic. More people have been using foodbanks and eating food past the use-bydates because of the affordability of food.10 So, although many people may have reported snacking more or eating larger meals, this will not be the situation for everyone. 2020 proved challenging for everyone and has had an impact on our nutrition and weight in a way that we may not have seen before. Many people may have struggled with their nutrition, weight and exercise due to pandemic lockdowns. Some people could have also experienced different reactions entirely to COVID-19 stress or lockdown. The studies I have mentioned throughout this article only capture a small piece of what is happening. Over time, more studies will help to give us a better understanding of the whole picture.
THE IMMUNE SYSTEM AND NUTRITION
This article will summarise the salient points in relation to antiviral immune function and nutrition, within a backdrop of COVID-19.
Nutrition and immunity together have become a seminal topic, particularly at the current time with the coronavirus pandemic continuing to affect everyone worldwide. The year 2020 was difficult for misinformation in science and epidemiology, but especially for nutrition. How many times did you read that specific nutrients could help to “boost your immune system”?
First off, here’s a whistle-stop refresher tour of the immune system and its function and how nutrition fits into it all. The points and information summarised here were taken from the British Nutrition Foundation’s annual seminar in November 2020, entitled ‘Nutrition and COVID-19’. Dr Philip Calder presented on this and has published an excellent piece in the BMJ entitled ‘Nutrition, immunity and COVID-19’.1
HOW THE IMMUNE SYSTEM FUNCTIONS There are four lines of defence that the body has in reducing infection/ pathogen invasion:
1 Barrier function
This prevents pathogens from entering the body. • Physical barriers include skin,
GI tract, respiratory tract and genitourinary tract. • Chemical barriers include the acid pH of the stomach. • Biological barriers include: – beneficial bacteria in GI tract or on skin; – secretions like secretory IgA in the GI tract, antimicrobial proteins in saliva and tears; – complement system.
2 Identifying pathogens if they breech a barrier
Pathogens are recognised by the innate immune system and possibly by memory cells of the adaptive immune system if there has been an infection before or vaccination.
3 Eliminating pathogens
The immune system uses different approaches to different pathogens in the body. For example, bacteria (which don’t typically invade host cells) will be engulfed and killed by phagocytic cells from the innate immune system, digesting the bacteria and displaying their remnants, known as antigens, on their surface. These antigens are recognised by the adaptive immune system, which is triggered by CD4+ T helper lymphocytes to coordinate the response. The response involves both T and B lymphocytes, which are involved in producing antigen-specific antibodies, and the further communication with and activation of the innate immune system.
Viral infection response (for example as in coronavirus which is a single-strand RNA virus) is slightly different in that the adaptive immune system is more involved, with CD8+ T lymphocytes and Natural Killer Cells recognising the virus and killing the infected host cells. The virus escapes once the host cell is killed and continues to infect other host cells – the battle continues until the virus is destroyed. This can take days to weeks.
Judy Paterson RD
Judy is a Freelance Paediatric Dietitian with 10 years’ clinical experience in the NHS. She is a Nutrition writer and Founder of Judicious Nutrition.
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REFERENCES Please visit: nhdmag.com/ references.html
Both types of infection need to have a coordinated response and there is much cell communication, cell proliferation and hormonal/ cytokine response impacted by nutrition.
4 Generating an immunological memory
Antibodies can remain in circulation for many months to years, protecting against reinfection. After an active immune response to viral/ bacterial infection, a small number of memory T and B lymphocytes remain in a resting state until the same pathogen is identified. They can then rapidly kill the pathogen. Memory cells have a long life – this is the basis of vaccination.
NUTRITION IS INTEGRAL TO THE IMMUNE SYSTEM Once the immune system is activated, a vast amount of energy and nutrients are needed to support the immune response adequately.3 • Fuel is needed for energy, which comes from our diet. • Biosynthesis – building blocks are needed for cell proliferation and cytokine and protein production, eg, amino acids for immunoglobulins and nucleic acids, cytokines, receptors and acute phase proteins. • Regulators of molecular and cellular components of immune responses, eg, zinc and vitamin A. • Substrates for the synthesis of metabolites involved in the immune response, eg, arginine and nitric oxide which is toxic to bacteria. • Specific anti-infection roles such as zinc. • Protection of the host tissues against oxidative stress, eg, vitamins C, E, cysteine, zinc, copper, selenium and phytochemicals are involved in this protection. • Regulation of the immune response via the gut microbiota.
IMPORTANT NUTRIENTS IN THE CONTEXT OF VIRAL INFECTIONS The nutrients vitamin D, selenium and zinc, are well studied and thought to be most important in terms of their roles in antiviral protection.3
Vitamin D
Vitamin D receptors have been identified in most immune cells, and some cells of the immune system (such as dendritic cells) can activate 25-OH vitamin D. It has been shown to impact widely on both the adaptive and innate immune system. There is a great deal of
Nutrient Good dietary sources
Vitamin A (or equivalents)
Martineau et al demonstrated Milk and cheese, eggs, liver, oily fish, fortified cereals, dark the likely effect of vitamin D on orange or green vegetables (eg, carrots, sweet potatoes, pumpkin, squash, kale, spinach, broccoli), orange fruits (eg, respiratory tract infections with apricots, peaches, papaya, mango, cantaloupe melon), a well-considered meta-analysis tomato juice from 2017.7 This looked at 25
Vitamin B6 Fish, poultry, meat, eggs, wholegrain cereals, fortified cereals, many vegetables (especially green leafy) and placebo RCT trials, n=11,321, with fruits, soya beans, tofu, yeast extract both adults and children included
Vitamin B12 Fish, meat, some shellfish, milk and cheese, eggs, fortified breakfast cereals, yeast extract in the analysis. There were different doses used over different time
Folate Broccoli, Brussels sprouts, green leafy vegetables (spinach, kale, cabbage), peas, chickpeas, fortified cereals periods (weeks to months). Studies with daily dosing used 7.5 to
Vitamin C Oranges and orange juice, red and green peppers, strawberries, blackcurrants, kiwi, broccoli, Brussels 100mcg. The results clearly showed sprouts, potatoes a significant effect of vitamin D
Vitamin D Oily fish, liver, eggs, fortified foods (spreads and some breakfast cereals) supplementation on reducing respiratory tract infection over placebo.
Vitamin E Many vegetable oils, nuts and seeds, wheatgerm (in cereals) Effects were greatest in those who
Zinc Shellfish, meat, cheese, some grains and seeds, cereals, seeded or wholegrain breads were vitamin D deficient. Research published earlier this
Selenium Fish, shellfish, meat, eggs, some nuts (especially Brazil nuts) year by Merzon et al8 has pointed
Iron Meat, liver, beans, nuts, dried fruit (eg, apricots), wholegrains (eg, brown rice), fortified cereals, most dark towards vitamin D status as being green leafy vegetables (spinach, kale) likely to affect risk of COVID-19
Copper Shellfish, nuts, liver, some vegetables infection. Suboptimal vitamin
Essential Meat, poultry, fish, eggs, milk and cheese, soya, nuts and D levels were identified as one amino acids seeds, pulses of four independent risk factors
Essential fatty acids Many seeds, nuts and vegetable oils for contracting the virus, and possibly independent risk factors
Long-chain omega-3 fatty acids (EPA and Oily fish for hospitalisation with COVID-19 (thus increased severity). However,
DHA*) with adjustment to this regression *EPA, eicosapentaenoic acid; DHA, docosahexaenoic acid data, vitamin D was no longer complexity in the way it works in the immune significant; nevertheless, the trend remained system, both ‘boosting’ responses from the important. innate immune system and inhibiting those Vitamin D is highly likely to be an important from the adaptive immune system’s T and nutrient in the antiviral immune response, but B lymphocytes.4 This is but one example of is usually at suboptimal levels over the winter why the message about boosting the immune months in most UK residents, particularly in system is incorrect, and why the immune those who are housebound or who are from system needs to be in balance. ethnic minorities. Therefore, the announcement
An interesting example of the importance of that care home residents and clinically vulnerable vitamin D, particularly in relation to viruses, is patients will receive free prescriptions of vitamin its production of an antimicrobial peptide LL- D in the UK has been a welcome addition to the 37, cathelicidin, which is important in antiviral UK Government’s pandemic response. defences.5
A study on vitamin D status and lung infection Zinc across the seasons in British adults showed Zinc has a myriad of important integral roles in an inverse dose response association between the immune system and has been well studied.9 vitamin D status and respiratory infection, with It is integral to metalloenzymes and proteases the highest infection risk seen in those with serum making it essential to their function. Zinc levels of 25-OH vitamin D at <25nmol/l.6 deficiency has a marked impact on bone marrow,
decreasing the number of immune precursor cells, and causes thymic atrophy.1-4 Zinc is important in maintaining T and B lymphocyte numbers.4
In research trials, markers of immune response can be increased with zinc supplementation, particularly in older people and those with low zinc status.4 It is important to note, however, that high doses of zinc have been shown to impair lymphocyte proliferation and response; therefore, the therapeutic window is yet to be established.4
Zinc’s therapeutic effects in severe infection have been demonstrated. In a study of patients with severe pneumonia, for example, zinc was shown to reduce risk of mortality.10
In terms of COVID-19 infection, as coronavirus is a single-strand RNA virus, zinc is likely to be directly involved in inhibiting the replication process of its genome, as zinc acts to inhibit RNAdependent RNA polymerase.11
Selenium
Selenium supports antigen presenting cells, T cells and B cells, to function. Deficiency has been shown extensively in mice studies to increase susceptibility to viral infections, permitting viruses to mutate, or allowing viruses to become more virulent.3
In a trial conducted in Liverpool in 2004, adults with low selenium status were randomised to receive selenium of 50mcg/d, 100mcg/d, or placebo for three weeks, after they received live poliovirus vaccination. Results showed that the ability of the immune system to produce interferon-gamma (an important cytokine in antiviral protection) improved seven days after vaccination, increasing in a dose-response manner after polio vaccination.12 Researchers also showed supplementation may have resulted in better clearance of the virus and prevention of viral mutations, as these occurred in the control group, but not in the group that received the higher doses of selenium.12
An interesting association was also shown between selenium status and COVID-19 cure rate in China.13 In a population with the highest selenium status, the cure rate of COVID-19 was highest.13
Recently, German researchers showed deficiency of selenium may have an impact on COVID-19 mortality. The selenium status was significantly higher in samples from surviving COVID patients as compared with non-survivors, recovering with time in survivors while remaining low, or even declining in non-survivors.14
PROBIOTICS AND THE GUT MICROBIOME The gut microbiota are understood to play a role in host immune defence by creating a barrier against colonisation by pathogens. There is now evidence that probiotics, in particular some lactobacilli and bifidobacteria, can contribute to maintenance of the host’s gastrointestinal barrier and reduce the incidence and severity of respiratory infections in humans.15-18
Dietary fibre and phytochemicals are fuel for beneficial bacteria and help them to grow in number. A recent American Gut study suggests including over 30 different plant-based foods per week, although portion size has not been elucidated.19 This would also serve to increase vitamin C intake with diet.
OTHER IMPORTANT EFFECTS TO CONSIDER We have not had space here to discuss the important effects of ageing on the immune system (known as immunosenescence) and obesity. These are vital considerations for nutrition professionals in providing individualised advice to patients.
CONCLUSION A healthy balanced diet with a plentiful supply of a variety of fruit and vegetables, is likely to be best to support the immune system, much like the current dietary guidelines. There are a number of other lifestyle factors to consider in addition when thinking about optimising immune health, alongside nutrition.
The problem with misinformation online and statements like “immune-boosting” if used by healthcare professionals, is that this legitimises bogus health claims used to advertise supplements, where there is little evidence to support these in reality.20
There is evidence to support the additional supplementation of vitamin D over the winter months, and perhaps zinc and selenium during infection. However, the best dose and time of supplementation is not yet known, and high doses are best avoided due to possible negative effects on the immune system.
Julie Harris RDN, LDN, CPT
Julie currently works as a dietitian at a health technology company, Welldoc. She has a wide range of dietetic experience and is a specialist in behavioural health, diabetes and eating disorders.
www. mykokoronutrition.com
kokoronutrition
REFERENCES Please visit: nhdmag.com/ references.html
TIREDNESS AND FATIGUE: CHALLENGES ASSOCIATED WITH COVID-19
This article focuses on how COVID-19 has affected people’s tiredness and fatigue levels and how best to support your clients and patients who are dealing with these symptoms.
For months, we’ve been dealing with the constant threat of the virus, deaths, financial hits and school closures, while our normal emotional coping methods, like social support, feel non-existent. It has led to widespread emotional exhaustion, some calling it COVID fatigue. Then, there are the early symptoms of fatigue and the lingering fatigue that is plaguing those who have contracted COVID-19.
Trying to figure out what’s causing a client’s fatigue is the first step to creating the right treatment plan. In addition, addressing these symptoms often improves other areas of health, like nutrition choices and lifestyle behaviours.
FATIGUE – A MULTIDIMENSIONAL SYMPTOM Fatigue is described in different ways. It can be characterised as a subjective feeling or difficulty in participating in or completing daily activities.8 Fatigue can be caused by a variety of factors, which may not always be easily identifiable. The body triggers fatigue and tiredness as a way of slowing us down in order to regain health.
Fatigue often involves more than one dimension of health (see Figure 1). A person can be physically fatigued and lack the ability to engage in physical activities, while another person can be mentally and emotionally tired. The dimensions can be, and often are, associated with one another, but do not always coexist.8 Thus, the feelings of fatigue can differ significantly from one person to another.
Fatigue is very common in both the general population and in various medical conditions (see Table 1).1,6,11 In 2011, researchers used a few instruments
Figure 1: Three dimensions of health relating to fatigue
Population
General population12
Outpatients5
Cancer patients1
Prevalence
30-50%
80%
25-99%
to analyse fatigue ratings in the United States general population.5 They found that women reported higher levels of fatigue than men. In addition, younger age, not being married and lower educational attainment were each associated with increased fatigue and tiredness.5
CAUSES OF FATIGUE One of the most common symptoms associated with an infection is fatigue. When the immune system is activated, cytokines – small proteins – are released to signal the immune system to do its job.14 Cytokines also act on the central nervous system to induce changes in our desires and behaviours, like reducing appetite, often referred to as sickness behaviour.3 Fatigue is a core sickness behaviour and very sensitive to the effects of cytokines.
Cytokines is a general term and includes several types of protein cells. They can act on the cells that secrete them, on nearby cells or on distant cells.14 The anti-inflammatory cytokines help the immune system get rid of the infection, and this can cause fatigue, as the body is working overtime to fight off invader cells. The fatigue is eased as the immune system fights off the infection, and with rest and sleep.
There are also cytokines that are considered pro-inflammatory, which are produced by certain white blood cells. There is abundant evidence that these types of cytokines are involved in long-term fatigue and pain.14 Currently, research is being conducted to understand the influence that cytokines have on patients who have COVID-19.7 Initial studies have reported elevated levels of inflammatory cytokines.7 It has been reported that a small percentage of severely ill COVID patients have experienced ‘cytokine storms’, whereby the body starts to attack its own cells and tissues rather than just fighting off the virus.15 Thus, the effect that cytokines have on fatigue is still being discovered.
CHALLENGES AFFECTING THOSE RECOVERING FROM COVID-19 Tiredness and fatigue are common symptoms in those who have contracted COVID-19,10 with as high as 72% reporting fatigue as an early symptom.4 In addition, a recent study showed that more than half of those who have recovered from the acute phase of COVID-19 reported persistent fatigue 10 weeks after their initial symptoms.9 A particular challenge is that COVID-19 has the potential to trigger a post-viral fatigue syndrome.9 Researchers also reported that there was no association between the severity of the patient’s condition and the fatigue levels during recovery.9
For patients who spend time in the ICU because of COVID-19, it’s important to note that one of the most commonly occurring symptoms following an ICU stay is fatigue.11 In addition, patients may experience muscle weakness, nerve pain, shortness of breath, joint discomfort and a weakened immune system.11 These additional symptoms may make it difficult for patients to return to their normal activities, thus intensifying the feelings of fatigue and tiredness.
Patients recovering from COVID-19 often have higher energy requirements. Yet, clinical symptoms that patients with COVID-19 have, like fatigue, create difficulties in obtaining an adequate nutritional intake. Higher energy needs, coupled with inadequate nutritional intake, may lead to feelings of fatigue.
INTERVENTIONS ADDRESSING COVID-19 FATIGUE Registered dietitians are trained to help address chronic disease by creating nutrition treatment plans. Based on nutritional assessments, dietitians can make recommendations for healthful foods and particular dietary supplements that can help address these COVID-19 symptoms.
Adequate nutrition is required for a healthy immune system, as poor nutrition can lead to a poor immune defence.2
Studies have demonstrated that deficiencies in micronutrients, including thiamine, selenium, zinc and vitamin B6, in patients who have been hospitalised with an infectious disease, are associated with adverse clinical outcomes.2 Early detection and treatment of micronutrient deficiencies after being exposed to COVID-19 may help decrease the inflammatory response and alleviate long-term symptoms.2
Socioeconomic conditions need to be considered too, such as mental status, age and social support, when reviewing why a person may feel fatigued.13 Certain populations may be at higher risk of malnourishment and nutritional deficiencies. The elderly may be more susceptible to deficiencies of calcium, vitamin C, vitamin D, folate and zinc.13 Therefore, healthy dietary patterns are beneficial against inflammatory responses that may occur during a viral infection.13
CONCLUSION Fatigue is a common symptom of various medical conditions, including chronic heart disease, cancer, depression and now COVID-19.1,6,10,11 It is a common reason for seeking medical care. Yet, adequate treatment of fatigue has been challenging, as the cause varies significantly from person to person.
A multidisciplinary approach to understanding the root cause of fatigue is important. Registered dietitians have a key role to play in the treatment of fatigue. Based on a full evaluation of the patient, registered dietitians can make recommendations for healthful foods and dietary supplements that may help lessen fatigue.
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NHD CPD eArticle Figure 1: ONS as nutrition pathway NHD CPD eArticle Volume 10.05 28th May 2020
NHD CPD eArticle Volume 10.05 - May 28th 2020 Copyright © 2020 NH Publishing Ltd - All rights reserved. Available for printing and sharing for the use of CPD activities for personal use. Not for reproduction for publishing purposes without written permission from NH Publishing Ltd. Questions relating to: Oral nutritional support in eating disorders Type your answers below, download and save or print for your records, or print and complete by hand.Q.1 Outline the challenges in employing the food-first model to those with eating disorders.Q.2 What factors contribute to calculating the volume and quantity of sip feeds?A Q.3 Describe the different circumstances under which you might consider the ONS nutrition pathway and what action this would lead to. Q.4 In what circumstances might bolus nasogastric feeding be considered?A Q.5 How does the BDA recommend dealing with veganism in eating disorder treatment?A Q.6 How might sip feeds be best prescribed to out-patients?A Q.7 What are some of the concerns with using sip feeds to treat those with eating disorders?A Q.8 How would you mitigate against some of these concerns?A Please type additional notes here . . . Volume 10.05 - May 28th 2020 NHD CPD eArticle Copyright © 2020 NH Publishing Ltd - All rights reserved. Available for printing and sharing for the use of CPD activities for personal use. Not for reproduction for publishing purposes without written permission from NH Publishing Ltd. Volume 10.05 - May 28th 2020 BOLUS NASOGASTRIC FEEDING For some, managing their prescribed meal plan and the oral sip feed is not tolerable. At this point multidisciplinary team discussion can be in support of bolus nasogastric feeding to minimise medical complications. Whilst this is an intervention that involves significant discussion with the client, often including their next of kin and which may involve the use of a legal framework like the Mental Health Act, it can also involve sip feeds. In this instance, the same sip feed, which is offered in the dining room to replace food not managed, can be placed down the nasogastric tube when required. This can support the journey back to normalised eating, providing a transparent nutrition pathway for the individual to understand and follow. VEGAN OPTIONS With the global shift towards more plantbased eating, veganism has never been more mainstream. Veganism in eating disorders is still approached with caution, as it is often enmeshed with the eating disorder. The British Dietetic Association (BDA) Mental Health Group has a peer paper: Practice guidance: veganism and eating disorders, 4 which provides information on how veganism within this client group should be managed. At the time of writing, there are currently no completely vegan ONS on the market, with the closest still containing vitamin D from sheep’s wool. For some time now, SEDU’s have been making their own concentrated lipid emulsion A ONS like Calogen and Polycal, often using a plant-based milk like Soya. The BDA peer paper suggests using a ‘SlimFast Vitality’ product or ‘Huel’. However, these are advertised as diet products and have added elements like green tea extract, so should be considered with caution and only used under medical supervision.4OUT-PATIENT SERVICES Where individuals are in outpatient services, they are often making food choices that are more tolerable and, therefore, are closer to meeting their nutritional needs. However, for some, the use of sip feeds can be supportive as a back-up when emotional distress is high and solid food cannot be tolerated, but also for medicalised weight gain. For some, using a supplement is preferable to eating food as a snack, for example, and can be stopped when the individual reaches a healthy or safe weight. Caution should be exercised, as this can create reliance on sip feeds, with the individual not receiving the same level of support as offered by inpatient units and, so, increasing the risk of dependency on this source of nutrition. A TALE OF CAUTION Whilst oral nutritional sip feeds can offer a practical and supportive solution, they can lead to individuals with eating disorders becoming stuck and unable to move back to eating real food. They can encourage patients away from the experience of food, reinforce avoidance of foods and can foster dependency on artificial food sources.1 A . . . the same sip feed, which is offered in the dining room to replace food not managed, can be placed down the nasogastric tube when required. Copyright © 2020 NH Publishing Ltd - All rights reserved. Available for printing and sharing for the use of CPD activities for personal use. Not for reproduction for publishing purposes without written permission from NH Publishing Ltd. of sip feeds becomes important. Alongside refeeding risk, long- and short-term poor health outcomes, rigidity of thinking patterns and behaviours and decreased emotional resilience become more prevalent following significant restriction and weight loss. So, it is important to support the individual to meet their nutritional requirements and start weight restoration.3 There is no consensus on how sip feeds should be calculated, with units having their own protocol dependant on staff experience. Some units will replace calorie for calorie; some will offer a set amount of replacement for that meal (i.e. a quarter of lunch not eaten is equal to x amount of mls of sip feed); and some will offer in fractions of completed meal (i.e. if less than half is managed, the whole meal will be replaced using sip feed). VOLUME AND QUANTITY The tolerance of sip feeds will be client specific and the types used will come down to a specific service and the individual receiving treatment. For the individual who has been significantly restricting their dietary intake in quantity, they may experience heightened sensitivity to fullness, which could result in increased anxiety, distress and gastrointestinal disturbance, or perceived gastrointestinal disturbance post meal. So, a high-energy low-volume feed may be tolerated better. For an individual struggling to meet fluid requirements, a higher-volume lower-energy supplement may be preferred. The use of sip feeds including fibre can be helpful for some individuals, to minimise gastrointestinal complications brought about by refeeding and laxative misuse. Copyright © 2020 NH Publishing Ltd - All rights reserved. Available for printing and sharing for the use of CPD activities for personal use. Not for reproduction for publishing purposes without written permission from NH Publishing Ltd. Alexia Dempsey Specialist Dietitian and Cognitive Behavioural Therapist Alexia has nine years’ experience as a dietitian in eating disorders. She currently works at the Schoen Clinic and Priory Group, as well as in CAMHS clinics for ED inpatients and adult outpatient.Eating Disorders are complex mental health illnesses, with the individual often experiencing anxiety, low mood, low self-worth and weight and shape concerns. This is coupled with behaviours around food, including restrictive eating and/or binge eating and compensatory activities. Eating disorder services commonly treat a variety of diagnoses, including anorexia nervosa, bulimia nervosa, other specified feeding or eating disorders and Avoidant Restrictive Food Intake Disorder (ARFID). It is common practice in a specialist eating disorder unit (SEDU) setting for clients to be offered sip feeds to support managing their prescribed diet if they are struggling to either eat a specific meal or snack, or are finding the volume of food required too difficult. A FOOD-FIRST MODEL Specialist eating disorder units will have a clear prescribed meal plan for every individual being treated. This is often based around average portion sizes, with snacks and puddings included to promote weight gain. These meals are often offered for a set period of time, where the individual who has an eating disorder is supported by staff from the unit to complete the food. The expectation is that the client finishes their prescribed meal plan every day. This food-first model is important, as individuals with eating disorders have a complex relationship with food and have often practiced restrictive behaviours and avoidance with their dietary habits. This food-first model is designed to offer exposure to food that might have been avoided for some time due to the eating disorder rules. It also aims to provide normalisation of regular dietary intake and improved eating patterns, to help create success at discharge.1 However, for some individuals, managing the meal might not be possible. This could be due to a mixture of complex psychological and physiological reasons, for example: high level emotional distress like anxiety, long-term avoidance of solid food and significant gastrointestinal discomfort.2 Given the high risk of medical complications that eating disorders pose, meeting nutritional requirements for refeeding and weight restoration is essential. This is where the use ORAL NUTRITIONAL SUPPORT IN EATING DISORDERS Oral nutritional support in the form of sip feeds is an integral part of dietetic practice, used to supplement dietary intake and support weight gain in individuals who struggle to meet their nutritional requirements. This article provides an overview of the use of sip feeds and the considerations required.
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