To our knowledge, this study is the first reporting the prevalence of malnutrition in patients hospitalized for SARS-CoV-2 pneumonia. It showed a high prevalence (37.5%) of malnutrition in hospitalized patients with 26% of severe malnutrition. Median albuminemia was very low (24 [18–27] g/L) and pectoralis muscle area index was not associated with recent malnutrition. There were no association between recent malnutrition and the need for ICU admission. However, there were more deaths in the malnutrition group. The included population was comparable to recent publications of COVID-19 cohorts in terms of age, sex ratio [14] and comorbidities (BMI, diabetes mellitus, hypertension) [15]. The population of the study was overweight (median BMI 28.5 [25–31] kg/m²) consistent with numerous previous studies [16, 17].
A recent Chinese publication found a high prevalence (52.7%) of malnutrition in 182 elderly patients with COVID-19 [9] diagnosed with the Mini Nutritional Assessment (MNA) [18]. The mean age of the population was 68.5 years old. Interestingly, in this younger cohort (59.5 [49.5–68.5] years old), we described more than one third of malnourished patients (37.5%). The diagnosis of malnutrition was based on international GLIM criteria [19], not specific to an elderly population and easy to use. All hospitalized patients got the etiological criterion (pneumonia), the phenotypic criterion being based solely on a recent weight loss of 5% in our overweight population.
Concerning the weight loss and the importance of fasting, almost forty-six percent (n = 37) of the patients reported decreased food intakes with multiple reasons. They mentioned anorexia (27.5%), asthenia (21.25%), dysgeusia (27.5) and anosmia (20%). Surprisingly, no statistical association was made between the self-reported importance of starvation and the existence of malnutrition. In a recent publication, Bouëtté and al. found an association between oral intakes < 7/10 and the existence of malnutrition according to GLIM criteria in a population of general medicine practice patients [20]. One first explanation of our results could be a lack of power for this criterion. Another explanation could be related to the inflammatory nature of COVID-19 malnutrition. In 97 patients, Hedlund and al. found an association between hypoalbuminemia, inflammation and outcome in patients hospitalized for community-acquired pneumonia [21]. The authors argue that hypoabuminemia is explained by the inflammatory status more than their nutritional status [21].
It should be noted that the nutritional assessment was conducted at admission, with a median onset of COVID-19 symptom of 7 days. Thus, we highlighted an acute malnutrition. The concept of acute malnutrition is described and might need a specific management [22].
Concerning metabolic disorders, hyperlipidemia affects immune functions and could promote COVID-19 susceptibility [23]. Hypercholesterolemia is associated with cholesterol accumulation in immune cells, which participate to inflammatory responses and may affect the response to infections [24]. Our multivariate analysis found an association between malnutrition and dyslipidemia in this context of inflammatory disease. To our knowledge, there is no data that can specifically explain this association.
Pectoralis muscle index has been suggested as a prognostic marker in relation to muscularity in an oncology population [25]. In our population, there was no difference in this index between malnourished and non-malnourished patients. This could be explained by the recent development of this malnutrition. There was no statistical association between the pectoralis muscle index and patients’ outcomes.
The three patients who died (3.75%) were malnourished. One of them died after withdrawal of life-sustaining measures. The others, with extracorporeal life support (ECLS), died from severe intracranial hemorrhage. Our study was not designed to analyze this association. Association between nutritional status and outcome is well known [26, 27]. In contrast, there was no association between malnutrition and the need for ICU admission or hospital length of stay in our study.
Strengths and weaknesses
NUTRICOV strengths are the prospective design of the study, which allowed for an exhaustive collection and the use of international tools (GLIM definition and NRS-2002). Therefore, this is the first study analyzing malnutrition in a general population of COVID-19 inpatients. The limits are the declarative nature of some collected data (basis weight, oral intakes prior to hospitalization). We used GLIM criteria to define malnutrition. GLIM definition may lead to higher prevalence because of requiring fewer criteria in comparison with ESPEN definition. In a recent publication, Clark and al. exhibited a small agreement between GLIM and ESPEN definition for malnutrition [28].