InSight – A Quarterly Newsletter · 2 IAPEN InSight – Newsletter What is COVID -19? CO Corona...

• President’s Message

• Coronavirus Disease 2019

(COVID-19)

• Understanding Novel Coronavirus

from an epidemiologist’s point of

view.

• Dietitians Perspective – COVID

19?

• Break the fast: why is it important

for children

• IAPEN Malnutrition Week -

Workshops, India

• ASPEN GNP – Global Nutrition

Partnership, India

• IAPEN Malnutrition Week

Workshops Bangladesh, Nepal,

and Bhutan

• Quality Award, Case Studies and

IAPEN-COVID Guidelines 2020

The Indian Association for Parenteral and Enteral Nutrition

(IAPEN) is an organization in the field of parenteral and enteral

nutrition and promotes basic research, clinical research,

advanced education, organization of consensus statements

about clinical care and quality control.

I am extremely pleased and overwhelmingly humbled to see the

current progress of IAPEN in recent years. It shows the

dedication, sincerity and commitment of the team involved in the

developmental activities of IAPEN.

In these unpreceded times of Pandemic, our teams at IAPEN

strove hard to bring out this newsletter to you, so that IAPEN can

reach out to innumerable healthcare professionals and

community at large and support each other as committed

association.

I am deeply proud of how all Healthcare Professionals

associated with IAPEN (The Indian Association for Parenteral

and Enteral Nutrition) are responding to the COVID-19

(Coronavirus Disease - 2019) crisis. Stay aware of the latest

information on the COVID-19 outbreak, available on the WHO

website and through your national and local public health

authority.

Dr C.S. Chamania Hon President The Indian Association for Parenteral and Enteral Nutrition Consultant General Surgeon Department of General Surgery Choithram Hospital and Research Centre Manik Bagh Road, Indore, Madhya Pradesh India

Welcome to the First Edition of

InSight – A Quarterly Newsletter

T O P N E W S I N S I D E

VOL 1 | ISSUE 1 | APR 2020

2 IAPEN InSight – Newsletter

What is COVID -19? CO Corona VI Virus D Disease

19 Year 2019 Origin CAUSED BY SARS C0V-2 VIRUS

Most people (about 80%) recover from the disease

without needing special treatment. Increasing

evidence and news report from WHO, CDC,

MoHFW-India shows that coronavirus infection as

a serious illness is seen in population that are

elderly and patients with existing diseases like

cardiovascular diseases, diabetes, cancers etc due

to probable decreased immunity and loss of lean

body mass. Follow social distancing, hygiene and

other recommendations from WHO (World Health

Organization) and Government of India.

Nutrition and Immunity- A diet rich in whole grains,

proteins, seasonal, coloured vegetables and fruits

can aid lower blood pressure, reduce risk of heart

disease, stroke, some types of cancers, diabetes

and rich fiber content of above foods may help

keep appetite in check thus aid in managing and

lowering the comorbidities too. Healthy immune

response along with other things also requires

regular nourishment with an array of nutrients,

primary among them are the macronutrient

Proteins and micronutrients

An epidemic of Severe Acute Respiratory Syndrome-Corona Virus-2

(SARS-CoV-2) (COVID-19), a new strand of the Coronavirus family

belongs to subfamily Orthocoronavirinae in the group of Coronaviridae

in the order Nidovirales, and this subfamily including α‐coronavirus,

β‐coronavirus, γ‐coronavirus, and deltacoronavirus, originated from

Wuhan (China) in December 2019, and was declared a pandemic by the

World Health Organization (WHO) as of 11th March 2020*

(https://www.who.int/emergencies/diseases/novel-coronavirus-2019),

primarily cause enzootic infections in birds and mammals and, in the

last decades, have shown to be capable of infecting humans as well and

is highly contagious. The most common symptoms of COVID-19 that

begin gradually are fever, tiredness, sore throat, dry cough and

diarrhoea. Some patients may be asymptomatic but severe cases are

predominated with fever, cough, difficulty breathing and respiratory

distress.

Including vitamins, minerals and antioxidants. Broad Range Include

(vitamins A, vitamin E, B6, B9, B12, C and D; iron, selenium, zinc,

magnesium). Also, functional foods like omega 3 fatty acids, honey,

spices like turmeric, garlic, ginger, cardamom, cinnamon, star anise,

mint, tulsi, neem, pepper, tea, nuts and daily dose of probiotics like

curds, buttermilk, fermented foods for healthy respiratory and digestive

system.

Simple tips: Incorporate traditional simple whole grain carbohydrate

preparations like ragi malt, thalipeeth, bhakri, thepla, ambali, daliya, sattu

etc. and including at least a serving of food preparation from protein

source in each meal like dals, pulses, eggs, well-cooked lean meat, low

fat milk and milk products, soya bean etc. Simply squeezing a lemon

over salads, cooked vegetables, dals, snacks ensures supply of vitamin

C. Adding or garnishing with ginger, ajwain, flaxseeds, garden cress

seeds, sesame seeds, nuts like almonds, walnuts, cashew nuts in your

daily meals like soups, salads, cooked vegetables ensures you get

essential fatty acids and zinc. Sip on home-made ginger lemon tea with

mint, tulsi. Sprouting pulses, adding green leafy vegetables like palak,

methi, coriander to dals are good ways to add to nutrient content of

food. Using traditional fermented foods like idli, dosa, dhokla and curds/

buttermilk provide good probiotics.

The above summarize some potential nutritional support at community

level for COVID‐19 infection according to previous treatments of SARS

and MERS that enhances host immune response against RNA viral

infection. It is important to note that Viral Respiratory Tract Infections

spread from droplets of infected person and no one food or superfoods

are a treatment to this illness.

COVID-19 – Coronavirus Disease – 2019

Dr Shilpa Varma, Hon National Secretary, IAPEN

Director, HealthyHey LLP, Mumbai

April 2020 // Issue 1

IAPEN InSight – Newsletter 3

Understanding Novel Coronavirus from an epidemiologist’s point of view

R0 (R-naught) has been defined as the number of cases, on an average

that an infected person will cause during their infectious period.

The year 2020 has seen the

pandemic Novel Coronavirus19

(SARS CoV-2) take the world by a

storm. It has been a trying few

months for all of us with the world

coming to a standstill. Among all

of this, the greatest challenge has

been for the policy makers to take

decisions with knowledge and

information that is incomplete and

yet to be perfected. The scientists

are still trying to understand how

the virus is transmitted, how

virulent it is, the seasonal effects it

shows or what is the best

treatment and prevention strategy.

The impact of an epidemic

depends on the number of persons

infected, the infection’s

transmissibility, and the spectrum

of clinical severity. We can try to

understand this facet of the

disease using a very important

concept in epidemiology which is

also a crucial part of public health

planning during an epidemic

-understanding the R0 of the

disease, i.e., the reproduction

number of the infectious disease.

R0 can be understood in two

different ways, the first is an ideal

scenario where the R0 is

determines as the “Maximum

Epidemic Potential” of pathogen

by modelling on the following

basis – what would happen if an

infectious person were to enter a

fully susceptible community. The

second includes, the “Effective

Reproduction Number” which is a

more realistic measure which

takes into consideration the

current susceptibility of the

population. This value is lower

than the Maximum Epidemic

Potential and is dependent on

various factors like history of

vaccination, prior exposure to the

pathogen or even community

interaction of people (This is the

reason behind lockdown and the

concept of social distancing came in). Thus, the

R0 changes during the outbreak and is an

estimate based on a more realistic situation within

the population. It’s important to realize that both

the basic and effective R0 are situation

dependent.

Is Nutrient Deficiency = High Risk group?

And this gets us to the point that the pre-existing

health condition of the community plays an

important role in determining the R0 of the

pathogen. It thus is important for our country to

assess the high- risk population- which must

include nutritionally deficient individuals. As has

been stated numerous times, Indians have a lower

protein intake among all other nutrients and

proteins have a major immune modulating effect-

thus putting Indians at a higher risk of contracting

this virus. Multiple nutrient deficiencies, low

physical activity levels and unhealthy lifestyles

with increasing unmanaged stress may be an

important deciding factor for a higher R0

(Effective Reproduction Number) for Indians. "If

we take the 'R0' to be 2.5 then one positive person

can infect 406 people in 30 days, if the lockdown

and social distancing measures are not in place,

but if social exposure is reduced by 75 per cent

then that one sick person will only be able to infect

only 2.5 persons," Dr. Agarwal from ICMR had

rightly highlighting the importance of the ongoing

lockdown and social distancing.

It is thus important to invest in the long-term

health of the population of the country- and shift

our focus from individual to community health.

Dr Mansi Patil, (PhD)

National Joint Secretary, IAPEN

Dietitian, Asha Kiran JHC Hospital, Pune



Dietitians Perspective – COVID 19?

As I am a research dietician in a government

hospital, many outsiders (non-medical) ask me,

what is the necessity of going to hospital, as your

only concern is to give diet chart.

I always explain them, a dietitian’s role is not only

giving random diet charts to admitted patients,

our main motto is to help in patients' recovery

with proper nutrition. If one's immunity is already

compromised, then the person may be prone to

the COVID-19. So, still people have the notion

regarding dietician's role. And at least in Kolkata,

there are no appointed dietician in isolation ward

of government hospitals. (As there is no as such

dietician in most of the government set up).

Followed by my first point, people (both medical

and non-medical) think that, medical team only

consists of doctors and nurses.

In my opinion, the medical team has the unique multidisciplinary

approach where dieticians play a commendable role. They should be

considered as an emergency service provider.

As per West Bengal scenario, people are enjoying buying groceries in

market during lockdown. They are thinking that wearing a mask is

everything to protect. Ultimately, they are purchasing unlimited food items

unnecessarily as if they may have picnic at their places.

Panic buying is a recent trend where people can't understand the basic

requirements of them and their families. They are not prioritizing their

economic condition also. So, we, as a dietician or food science expert,

should come forward to make people understand what food budgeting is.

Although we are in health sectors, but the health care professionals are

always neglecting their health due to professional commitments. Same

thing is happened during this phase.

It is our duty is to take care of our colleagues also, give suggestions on

nutrition to other professionals too. Thus, we can build a nourished health

care team. I do it in my hospital, write some blogs, give interviews to

newspaper, just for building awareness. Different sites claim numerous

outcomes, portray their predictions and common people start panicking,

in layman's term, it is called panic attack. These may affect adversely in

their health. In my opinion, we are not only Nutritionist or Dietitian, we are

social worker and counselors too. So, I guess more researches should be

done on stress management with the help of diet. Although our fraternity

is dealing with it and there are many mechanisms which prove that stress

regulates our eating patterns and as well the metabolism.

Koyel Pal Chowdhury

Research Dietician, IPGMER and SSKM HOSPITAL, Kolkata.

Regional Officer, IAPEN Kolkata Chapter

Future Aims of Dietitians

As a dietician we should conduct many health camps ,

community programs for assessing their health and nutrition

status. There should be some brainstorming sessions and life

style management classes for common people to get rid of

the stress. Specifically, this management may help to those

employees who are continuing 'work from home'. Dietitians

should arrange some session in our hospitals for the

refreshment and some scientific discussion on the pandemic

and future precautions.


Internally, if we focus on proceeding some study/clinical

trial/observation of micronutrient deficiency of people during

pandemic, I guess , it will be beneficial for us for future.

I'd like to request IAPEN and its members to take this notes. I

just share my experience and my suggestions.


BREAK THE FAST: WHY IS IT IMPORTANT FOR CHILDREN

parents working in todays urban society

and it may not be practical to prepare an

elaborate breakfast. But the good thing is,

a well-balanced breakfast need not to be

a fancy one. One simple rule is to avoid

packaged food like cereals, bread

(doesn’t matter if the label says it is

“whole wheat” or “Atta bread” as these

also contain preservatives and processed

flour) and canned or packed juices (which

contains high amount of sugars and

preservative irrespective of what the label

says). Remember what we used to have

in breakfast in our childhood? Upma,

poha, stuffed paranthas or simple roti-

sabji. These very common Indian

breakfast menus are rich in nutrients and

far healthier any day compared to

packaged food. You can create an

improvised menu for your children which

includes protein items like paneer, eggs,

curd, cheese, various nuts etc. Nowadays

various unprocessed flour (Atta) made

from whole grains like ragi, jowar, bajra

which are highly nutrient-rich are easily

available and you can use thses to

introduce complex carbohydrates as part

of the breakfast. Choose fruits which are

locally grown and seasonal as the

chances are that they will be fresh and

has not travelled a long distance to reach

your plate. India’s fast growing economy

has affected the urban lifestyle as well as

the food habits. The global food

manufacturing companies have pushed

consumption of packaged food as part of

our daily life through the super market

culture and slew of marketing tactics. As

a result, India is dealing with

undernutrition and hunger in one side and

multi-fold increase in diseases like

obesity, hypertension and diabetes on

other side. Children are not spared from

these diseases. We as parents need to be

more aware to guide them to a healthy

lifestyle.

A I am mother of a 12-year-old son and a nutritionist by profession. Our

generation of parents, who were born in 70s and early 80s have come a

long way. We are the generation that is fortunate enough to witness the

amazingly fast growth of technology and lifestyle from landline to smart

phone, type-writer to tablet and from local grocery store to spanking new

super markets.

We are well educated, doing well in our chosen professions and want to

give our children the best of the world and we try our best to keep them

entertained and happy. As adults in our late 30s and early 40s, we follow

strict diet regimes, invest our time in fitness routines but when it comes

to our precious children we give little thoughts on their food and diet. The

common reaction I receive is that “they are just young and at the best of

their health. They don’t need to worry”. WRONG ! Malnutrition is not only

undernutrition or overnutrition, it is defined as nutrient-deficiency

disorder.

As part of my profession as a child nutritionist, during workshops, I often

enquire about what breakfast the children normally have. As per an

overwhelming number of responders, it seems very common for school-

going children to skip a proper breakfast and have only milk and biscuits

as a replacement. Most of the parents probably know that breakfast is

widely considered to be the most important meal of the day. What many

of us probably don’t know is that considerable number of global studies

conducted by WHO and National Health and Nutrition Examination

Survey (NHANES) have revealed that consumption of a regular breakfast

contributes to improving overall nutritional status in children and

adolescents. In addition, adolescents who consume breakfast have been

shown to have better overall improved cognitive performance and

academic achievement. Concomitantly, studies have linked skipping

breakfast to adverse health outcomes of overweight and obesity (due to

increased snacking and consumption of energy-rich foods of poor

nutrient density), type 2 diabetes mellitus and metabolic syndrome. Most

of the parents are probably aware that India is witnessing an increase in

the burden of childhood obesity, especially among the upper

socioeconomic strata and in urban areas. India specific emerging


Mrs. Jayati Mukherjee Private Nutritional

Consultant, Gurgaon

literatures suggest a link

between childhood obesity and

the diabetes epidemic in India.

The dual epidemic is called

“diabecity” caused by exposer to

an obesogenic environment,

created by rapid urbanization

and nutrition transition in India.

So, now the bigger question is

what should we do as parents

for the wellbeing of our children.

Over time we are getting more

and more busier everyday. It is

more common to have both

6 IAPEN InSight Newsletter

Nationwide IAPEN Malnutrition Week – Second Week of February 2020

.

Dr. C.S Chamania, Hon President IAPEN,

Announced Second Week of February as

IAPEN Malnutrition Week at 7th Annual

Meeting of IAPEN, 7th to 9th February

2020, JIPMER, Puducherry, India.

IAPEN Received Nationwide Response

for its call for IAPEN Malnutrition Week.

About more than 100 Free Malnutrition

Camps were done throughout India,

Bangladesh, Nepal and Bhutan.

Community Event, Rural Karnataka, India

IAPEN Bangalore Chapter

Malnutrition Education to Children,

IAPEN Bhopal Chapter.


Team IAPEN Bhopal Chapter

IAPEN InSight Newsletter 7

Glimpses of Events at Karnataka, India

IAPEN South Delhi Chapter

IAPEN South Delhi Chapter has conducted

Malnutrition Awareness Camp to Police Training

Centre at at Saket on 18th Feburary 2020 under

the guidance of Department of Nutrition, Max

Hospital, Saket.

.

Community Nutrition Programme on 16th February with an objective to

educate pregnant mother's about nutrition and iron rich foods to prevent

anemia. The IAPEN Bangalore team covered 8 rural primary health

centers located at Peresandra, Burugunte, Chelur, Nagarkere,

Pathapalya, Manchinahalli and Irgampalli around the chikballapur

district.



East Delhi Chapter of IAPEN

Promotion of COVID 19 – Health Tips Via Social Media Platforms. A - Z of COVID -19 A – Avoid Handshakes B – Build Immunity C – Cover your face with mask while going out D - Drink adequate quantity of water E – Eat a Balanced diet F – Follow your Doctor’s advise when sick G – Going out of home not suggested (GO CORONA GO) H – Home is the best place (Stay Home Stay Safe) I – Indoor exercises to keep yourself Fit J – Jaan hai toh Jahan hai K – Keep your home and surrounding clean L – Limit online shopping as much as possible M – Maintain Social Distancing N – No to Alcohol & Smoking O – Only Home cooked food P – Personal protection Equipment (PPE) to be used by Doctors treating COVID cases Q – Quality time with family R – Restrict yourself from spreading false news / panic messages

S – Sanitize hands regularly T – Take all necessary precautions U – Use glaves & masks V – Vitamin C rich foods helps build immunity W – Wash your hands X – Xtra precautions for diabetics and heart patients Y – Yoga is the best way to keep healthy Z – Zero gathering

GUWAHATI CHAPTER OF IAPEN

Ms Nomi Mohan, Dietitian, Rahman Hospital Pvt Ltd

and Dr. Ananya Kashyap (PhD), Regional Officer,

IAPEN Guwahati Chapter and Associate Professor


Hyderabad Chapter of IAPEN

Ms. Safia Khanam has conducted free Malnutrition Awareness Camp at

a Government School, Hyderabad on 22nd February 2020. .

Department of

Food, Nutrition

and Dietetics,

Assam Downtown

University,

Guwahati has

conducted various

activities.

Silchar Chapter of IAPEN (Assam) Mr Dibyendu.Sharma had conducted Nutrition Camp for Malnourished Patients at Cachar Cancer Hospital and Research Centre, Silchar Assam.


IAPEN Nashik Chapter

IAPEN is a multidisciplinary society

involving (Doctors, Dietitians, Nursing,

Pharma, patients and other

professionals) devoted to the study of

metabolic problems associated with

acute diseases and their nutritional

implications and management. IAPEN

has developed a toolkit for a cost

effective implementation of Nutrition

Intervention in All Indian Hospitals. There

by help developing Indian Specific BMI.

The open source and free toolkit is

available via Android Play Store (IMW

Toolkit) or Web App or iphone users or

Internet or Web Browser or Any Other

Device (Tablets/Smart TV/Others)

(http://www.iapen.co.in/imw).

Dr Mansi Patil, explained about the

importance of the Toolkit and its

applications in the IAPEN Nashik

Symposium Series. The full video can be

downloaded using the below website link.

http://www.iapen.co.in/imwiapen

/resources.html

IAPEN Malnutrition Week Workshop was conducted at “Interdisciplinary

Approach Towards Better Healthcare, IAPEN Symposium Series at HCG

Manavata Cancer Centre, Mylan Circle, Nashik on 23rd June 2019. The

theme include “Bringing together doctors and Dietitians to improve health

through better nutrition”. The Symposium was organised in association

with the Association of Physicians (Nasik), API Nasik Chapter. The

symposium was also rewarded 2 credit points by Maharashtra Medical

Council. Nutritional support has now come to be recognized to be of

utmost importance and prime in management of critically ill. Its status is

changing from being adjunct in critical care to that of being a definitive

therapy.

Enteral nutrition has been shown to maintain intestinal structure and

function by improving organ function & immune competency may aid the

recovery process & reduce the period required for convalescence.

Initiation of EN early in courses of illness has been recommended to

reduce the stress response and improve feeding tolerance. There are

number of studies suggesting EN being better tolerated within two-three

days of initiation. Nutritional requirement of hospitalized patient has been

neglected for quite a time. Dietitians are uniquely placed to participate in

the nutrition management in primary care, provide support & education to

patients & their cares, evaluate treatment & promotes better outcomes

for patient receiving tube feeding.


The Symposium was scheduled over 9 hours and consisted of

information sessions. The Symposium was attended by 100

participants: Physicians, Gynaecologists, Anaesthetist, Nephrologists,

Oncologists and Dietitians from Nasik, Mumbai, Aurangabad and

Malegaon. There were also student participants who got to know about

the scope & benefits of nutrition. On arrival and in the course of the

Workshop, each participant was provided with a registration kit. It

consisted of leaflets by the sponsors and a 4-page module explaining

the IMW app. Participants were also given pens, note pads and papers

to present the results of case studies and to prepare a nutrition care

plan. Ms Himani Puri coordinated the Entire Event as Organizing

Secretary.

10 IAPEN InSight Newsletter

Dietitian Amruta Bolli explaining importance of nutrition to kidney

disease patients on World kidney day 12th March, 2020, at Mesonic

hall Solapur, in presence with Kidney specialist Dr Sandeep Holkar.

Special thanks to Rotary Club of Solapur North.

.

Pune Chapter has conducted malnutrition screening for our

helpers, mama’s, maushi’s and cooks by using a valid

nutritional screening tool, NRS 2002 at Jehangir Hospital,

Pune on 27th Feb 2020. They also provided free oral nutritional

supplements to the one’s who were at a risk for malnutrition.

Provided diet counselling to all the people indulging in poor

eating habits and making them understand their nutritional

needs and the importance of eating regular meals and not

skipping the meals for a healthy and a fitter body. On February

22nd 2020, Pune Chapter had Conducted an interactive and

interesting session on “ Ahar Sanskar " आहार संस्कार to educate

parents to develop healthy eating habits in primary school

children and identify their needs in a small primary English

medium school in Paud Rural Area. Many Events were

conducted in Pune and surrounding areas.

Malnutrition Education to Children,

IAPEN Bhopal Chapter.


Team IAPEN Pune Chapter

IAPEN Pune Chapter

IAPEN Surat Chapter

IAPEN Surat chapter successfully completed

Malnutrition screening camps in different

hospitals and clinical settings across the city

during the 2nd week of February. As a part of the

activity, the volunteers were trained to get a hands

on training on the IMW tool kit @ Sheth P T Mahila

College of Food Science. In this camp we tried to

cover most of the vulnerable groups like cancer

patients, patients with digestive disorders,

paediatric patients etc.

One more free malnutrition assessment camp was conducted on 9th

February 2020 at Priyam Nutrition Clinic, Surat, Gujarat by Dr Bidita Shah.

IIAPEN Surat Chapter Formation IAPEN Surat Chapter was formed on 15th February 2020 with

a strong team of expert nutrition support clinicians and clinical

nutritionists. The team was headed by Dr. Saumin Shah,

(Gastroenterologist), Hon President and guided by Dr. Bidita

Shah, Hon. Secretary and Ms. Amita Tambekar, Treasurer. Ms

Nirja parekh, Ms Geeta Chandani, Ms .Shilpee Agrawal and

Ms.Meena Hardasani are Executive Directors. The Chapter

also has a strong advisory board including Dr. Jayesh Shah, Dr.

Piyush Desai, Dr. Ankit Dave, Dr. Ronak Nagoria and Prof. Dr.

Manisha vyas. IAPEN Surat Chapter launch aims to recognize

extent of prevalence of malnutrition in clinical setting and

prioritize issues in nutritional care process with the help of it's

diverse multidisciplinary team.



IAPEN Jaipur Chapter

Mumbai Chapter has Conducted IMW Malnutrition

Week Activity on 14th September, 2019 for Navi

Mumbai Dietitian Division. The CNE highlights

were training Dietitian for using MUST tool kit,

Malnutrition assessment, and also presented and

discussed various aspects of Gut Nutrition. The

response of Navi Mumbai dietitians for such

activity was overwhelmed which has initiated the

process of establishing Navi Mumbai as a

separate IAPEN Chapter with the key members of

core team Ms. Shifali Mehra, Ms. Varsha Gorey,

Ms. Fatima Radhanpurwala, Ms. Madhuri Somani

and Ms. Datta Patel.

Name of the Office bearers:

President: Dr. Kailash Jawade

Secretary/ Regional Officer: Ms. Datta Patel

Treasurer: Ms. Fatima Radhanpurwala

Executive Director (Hospital screening

committee): Ms. Shifali Mehra

Executive Director (Research & Publication):

Ms. Varsha Gorey

Member of Executive Council:

Ms. Madhuri Somani

IAPEN Jaipur Chapter under the guidance of Dr Ankita Sharma has

conducted Promotion of Nutri-Garden among Tribal Women of Pindwara

Tehsil of Sirohi District as a part of IAPEN Malnutrition Week.

Medical checkup for Hb and lifestyle diseases and lecture on importance

of diet in management of lifestyle diseases on 23rd February 2020 to

household women at Jalandhar. Jalandhar Chapter under the leadership

of Dr Kanchan Sandhu had conducted many activities for empowering

women with all the nutrition tools in a simple manner. She has also

demonstrated how to prepare proper nutritious recipes and also

explained about growth of various plants.

IAPEN Jalandhar Chapter

Navi Mumbai, India

ICNC-2021 – IAPEN Clinical Nutrition Congress and

8th Annual Meeting of IAPEN, Feb Second Week is

planned to be hosted by IAPEN Navi Mumbai Chapter.

April 2020 // Issue 1 12 IAPEN InSight Newsletter

IAPEN Karad Chapter

. IAPEN Karad Chapter under the

leadership of Komal Sawant, Dietitian,

Krishna Hospital and Medical Research

Centre, Karad had conducted

awareness camp for women related to

anaemia and calcium deficiencies. She

also explained about the importance of

nutrition to mothers and methods to

provide nutritious meals to kids

considering their food choices.

She also conducted nutrition lecture for

relatives of patients (Post-Operative) at

Krishna Hospital & Medical Research

Centre , Karad.

IAPEN Ongole Chapter under the

leadership of Dr Manasa Mane had

conducted Nutrition Assessment using

IMW Toolkit for Patients. This will help in

implementing the nutrition care process at

KIMS Hospitals, Ongole. Andhra Pradesh.

IAPEN Ahmedabad Chapter

IAPEN Ongole Chapter

IAPEN Ahmedabad Chapter under the

leadership of Ms Shruti Bhardwaj had

conducted Continual Nutrition

Education Program and IAPEN

Malnutrition Week for Dietitians and

Healthcare Providers at Hotel Fairfield



IAPEN Chennai Chapter

Hospital Nutrition- Bridging the Gap

Meetings with Physicians and surgeons in

Coimbatore to discuss the issues in Hospital

Nutrition by Dr PC Vijaykumar on 28.02.2020

Malnutrition awarness program-nutrition for

women, at Veg council of India, Anganwadi,

nungambakkam, chennai by Ms.Lekha and Ms.

Sanjula on 5/3/2020.

IAPEN Chennai Chapter under the leadership of Ms Lekha Sreedharan

had conducted Nutritional Screening & Assessment Training to evaluate

and address Malnutrition in hospitalized patients. IAPEN Chennai

chapter educated nurses of Apollo children's Hospital on 19th February

2020 about the importance of nutritional intervention.

Chennai Chapter also conducted

Malnutrition screening & nutritional

assessment at Chennai Model High School,

Shafee Mohd Road by Dietitians Lekha,

Sowmiya, Surabi & Intern Priya & Bhargavi

on 28/2/2020. They also provided

personalised Diet counselling for all

students .

14 IAPEN InSight Newsletter April 2020 // Issue 1

IAPEN Puducherry Chapter

IAPEN Clinical Nutrition Congress - 2020

7th Annual International Conference of IAPEN was

conducted by IAPEN Puducherry Chapter on 7th to

9th February 2020 at JIPMER, Puducherry, India.

According to a JIPMER release on Saturday,

JIPMER Director inaugurated the three day

conference in which three hundred delegates

from different hospitals in and around India and

Nepal participated. The many experts in the field

of Clinical Nutrition shared their knowledge and

experience on topics such as Nutritional Support

in the Perioperative Period, Nutritional Support in

Cancer and Critical Care, Nutritional Support in

Renal Disease and Nutritional Assessment and

Techniques.

IAPEN Mohali Chapter

IAPEN Mohali Chapter under the leadership of Ms

Shivani Thakur had conducted malnutrition

awareness camp at Desmesh Khalasa Public Sr Sec

School, Mohali on 21st February 2020.

Dr Biju Pottakkat is the Chair Person and Ms Uma Sankari is the

Organizing Secretary of the activity. IAPEN-ESPEN lifelong learning

workshop faculty Dr. Remy Meier, Dr. Ashwin Dabhi, Dr. Ramakrishnan,

Dr. Bhuvaneshwari, Dr. P.C. Vijayakumar and Dr. Anita Saxena attended

the conference.

IAPEN InSight Newsletter 15 April 2020 // Issue 1

IAPEN Mumbai chapter succesfully celebrate the launch of the IMW tool

kit at Kokilaben Dhirubai Ambani Hospital on 17th August 2019.

The houseful event was kept engrossed with excellent speakers. The

National Secretary Dr. Shilpa Varma beautifully coverd the use of the IMW

toolkit as a free screening tool for the masses. Mr.Shivshakar, shared the

journey of IAPEN and introduced the entire Mumbai Chapter committee

members. Dr.Rita Patil, Ms.Bhakti Samant, Ms.Purabhi Mahajan shared

their experiences using the IMW tool kit under different settings.

The second part of the program touched on the Gut Story through the

lifecycle presented by Ms.Priya Karkera, Ms.Vibha Hasija, Mr.

Shivshankar and Ms.Jayashree Paranjpe. We are obliged to the

moderators of the sessions Ms.Naaznin Hussein, Ms. Zamrud Patel,

Ms.Datta Patel, Ms.Vaidehi Nawathe. Ms. Anuradha Shekar culminated

the event on a positive note with a interactive game with the audience.

IAPEN Mumbai Chapter look forward to many more such events in the

future.

IAPEN Mumbai Chapter


The corona virus disease (COVID-19) outbreak has disturbed the routine for everybody around the globe. This has also forced

the sports organizations to stop regular training sessions for athletes. Government and health department have advised that all

individual stay indoors as much as possible to avoid getting infected with corona virus. Various nutrition guidelines are circulated

by many health and nutrition authorities to maintain a balanced diet and to boost immunity. Athletes are encouraged to follow

the general safety recommendations by health department. Here are few guidelines for athletes to practice during lockdown:

1. Maintain optimum level of hydration:

● It is important for physiological functions of body and avoid dehydration

● Drink plain water or lemon water

● Avoid all sugary drinks

● Stop recovery drinks/sports drinks/pre-workout drinks if you are not training at home for more than 90 minutes

● Avoid packaged fruit juice

● Add clear soups to your diet (no added starch/corn flour)

● Avoid carbonated drinks like Pepsi, Coke etc.

● Green tea is good to provide antioxidants but drink with no added sugar.

2. Include more fresh fruits like orange, berries, guava etc. in your diet to provide adequate vitamin C to boost immunity.

3. Switch to low fat milk and curd to avoid excess fat in diet when physical activities are less.

4. Maintain good protein intake in diet to ensure good muscle mass. Corona virus is not spreading via meat and eggs so one

can continue eating non-vegetarian food. Vegetarians can include tofu, paneer, soya chunks, sprouts, nuts etc.

5. To avoid excess weight/fat gain during non-training phase include low fat food preparation methods like boiling, baking, grilling

and roasting.

6. Include curd/buttermilk in diet every day.

7. Use more natural herbs in diet like basil, mint, ginger, curry leaves etc.

8. Include at least 3 servings of fruits and 4 servings of vegetables in diet. Include more colors of fruits and vegetables to ensure

more antioxidants in diet.

9. Remember it is important to maintain healthy body composition, due to less physical activity body requires less calories

through diet. Protein intake is important to maintain muscle mass, but overall energy intake can be reduced by reducing the

portion size and avoiding food that are high in fat and sugar. You may resume your regular diet before you return to regular

training.

10. Do not use food to pass time when you are at home. Snack on low calorie nutritious foods like salads, fruits, roasted chana,

sprouts etc.

11. Best way to avoid eating high fat snacks is not buying those in the first place.

12. When not training, a good use of time at home is to learn low fat cooking; a skill that would be useful for you and your family.

NUTRITION RECOMMENDATION FOR ATHLETES DURING TRAINING BREAK DUE TO CORONA VIRUS OUTBREAK

General guidelines for social distancing, personal hygiene and food safety are

publicized by various agencies to curb the spread of corona virus; athletes are

advised to follow those guidelines. Currently there is no evidence that corona

virus can be transmitted through food or food packaging, but the virus can

survive on various surfaces for many hours and that is why it is advised that

athletes avoid sharing food and beverages and follow hygiene practices like

washing hands frequently and prepare food with suggested hygiene guidelines

by authorities.

Stay Healthy, Stay Safe

Aradhana Sharma

Senior Sports Science Consultant Directorate of Sports and Youth Welfare Department

Pune, Maharashtra Adjunct Faculty

Manipal University, Department of Exercise and Sports Sciences



IAPEN Clinical Nutrition Updates Symposium Series, Renal Nutrition

Nutrition in renal diseases, 12th October 2019,

Puducherry, India.

The IAPEN Clinical Nutrition Update Symposium

Series is a part of lifelong learning initiative of

IAPEN to sensitize doctors and dietitians in the

area of Advanced Clinical Nutrition. The aim of this

IAPEN Symposium Series is to promote young

doctors and dietitians to take up advanced

education and lifelong learning in clinical nutrition.

IAPEN Puducherry chapter organized a

Symposium on ‘Nutrition in Renal diseases’ on

12th October 2019. The event was organized by

the team led by of Dr. Biju Pottakkat , Organizing

Chairman and the Hon. President, IAPEN

Puducherry chapter , Dr. Priyamvada, Organizing

Secretary and Ms. Uma Sankari , Hon. Secretary,

IAPEN Puducherry chapter. This is the third

symposium in the IAPEN Clinical Nutrition update

series. The symposium was aimed at providing

critical insights to the nutritional issues across the

entire spectrum of Kidney disorders.

Chronic Kidney disease is reaching epidemic

proportions, with prevalence rates varying from 1-

17% across different parts of the India. More than

half of patients with advanced kidney diseases

suffer from Protein Energy Wasting, which is an

independent contributor of morbidity and adverse

outcomes. There is no single tool to diagnose

malnutrition in Kidney diseases. A comprehensive approach

incorporating Anthropometric, biochemical, clinical and dietary

assessment is imperative to identify PEW at an early stage. The nutritional

requirements of the patients vary considerably across the various

spectrum of renal diseases. An optimal diet is essential for retarding the

progression of kidney disease as well as preventing the complications. In

extreme scenarios where patient is unresponsive to oral nutrition

supplements, the nutritional status needs to be restored by intradialytic

parenteral nutrition.

The program was inaugurated by Dr. Biju Pottakkat, Additional Professor

& head, Dept. of Surgical Gastroenterology, JIPMER, Puducherry . Dr

Pottakkat gave a brief report on activities of IAPEN, Puducherry chapter .

Dr Ashwin Dabhi, Hon.Executive Director IAPEN and Course director

ESPEN LLL discussed the ABCD approach in renal nutrition. Dr Anitha

Saxena, Secretary, Society of renal nutrition and metabolism spoke on

parenteral nutrition in critically ill patients with acute kidney injury.

Practical difficulties in the nutritional assessment and giving dietary

counseling to the patient were also discussed in elaborate manner. Other

speakers included Dr Rajeevalochana Parthasarathy (Consultant

Nephrologist Madras Medical Mission , Chennai), Dr P S Priyamvada

(Additional professor of Nephrology, JIPMER , Puducherry), Dr. N.K.

Ganesh Prasad( Consultant Nephrologist, MIOT International Hospital,

Chennai), Dr.Sriram Krishnamurthy(Additional Professor, Department of

Paediatrics, JIPMER, Puducherry), Ms.Suneetha Rao (Chief Dietitian, NU

Hospital, Bengaluru) and Ms. Meenakshi Bajaj(Dietician, Tamil Nadu Govt.

Multi Super Specialty Hospital,Chennai). In the concluding session . two

different case scenarios were discussed regarding the nutritional

management which paved way for the delegates to have a clear idea on

the treatment progression. On the whole the program, provided a platform

for active discussion and interaction between doctors and practicing

dieticians.


IAPEN - ESPENLLL Workshop, Puducherry, India

IAPEN- ESPEN LifeLong Learning programme in Clinical Nutrition and

Metabolism which is structured by European Society for Parenteral and

Enteral and scientific session. Four different LLL modules such as

Nutritional Support in the Perioperative Period , Nutritional Support in

Cancer and Critical Care, Nutritional Support in Renal Disease and

Nutritional Assessment and Techniques were conducted. The course

Director of the IAPEN-ESPEN lifelong learning courses, Dr. Aswin

Dabhi, and LLL teachers Dr. Remy Meier, Dr. Ramakrishnan and

Dr. Bhuvaneshwari, conducted the workshop successfully along with other faculties. During the Scientific session various topics

such nutritional management in SAM child and nutritional assessment in paediatrics were discussed. Dr. Mathangi Ramakrishnan

from Chennai who has received Padmabhusan award for her dedicated medical care in the field of burns, presented key note

address on “Nutritional management in Pediatric burns patients”. Nutritional management in Oncology and Critically were

discussed. Symposium on IBD and Obesity were also conducted as a part of the main conference. On the whole the program,

provided a very good platform for discussion and interaction between doctors and practicing dieticians.

Next Live Course is Planned in October, 2020 at Ahmedabad. More Details about LLL will be covered in July 2020 Issue.



ESPEN

Now in India

British Association for Parenteral and Enteral Nutrition – BAPEN and IAPEN

British Association of Parenteral and Enteral

Nutrition (BAPEN) is a Charitable Association that

raises awareness of malnutrition and works to

advance the nutritional care of patients and those at

risk from malnutrition in the wider community.

BAPEN brings together the strengths of its Core

Groups to raise awareness and understanding of

malnutrition in all settings and provides education,

advice and resources to advance the nutritional care

of patients and those at risk from malnutrition in the

wider community. BAPEN agreed to issue two years

free license to use MUST in India.

The association with BAPEN dates back from the

inception of the very idea of IAPEN in 2012. In the

year 2019, IAPEN executive committee decided to

adopt two-step process for fight against

malnutrition inside Indian hospitals. IAPEN has

developed IMW Toolkit - IAPEN Malnutrition Week

Toolkit for detecting Malnutrition in hospitals and

community. BAPEN has issued two years free

license to use MUST in India. IAPEN is planning to

develop own guidelines and Indian based toolkit

with the help of nutrition intervention in all Indian

hospitals.

On 29th Jan, 2020, Dr Shilpa Varma, Hon Secretary,

IAPEN has met Dr Andrew Rochford, Consultant

Gastroenterologist, Newham University Hospital,

Barts NHS Trust, BAPEN Executive Committee, UK

and Dr Jeremy Nightingale, Hon Consultant

Gastroenterologist, St Mark's Hospital, Past

Chairman BAPEN and Present Chairman of British

Intestinal Failure Alliance to extend support to

IAPEN for promoting Nutrition Intervention using

MUST.

Dr Sorrel Burden, Senior Clinical Lecturer in Dietetics, School of Health

Sciences, Division of Nursing, Midwifery & Social Work, The University of

Manchester, United Kingdom and BAPEN had issued two years free

license to use MUST for IAPEN Malnutrition Week (Second Week of

February) on 1st May 2019.

IAPEN had developed a Mobile App titled IMW Toolkit and Integrated

MUST Screening Tool along with Subjective Global Assessment for

nutrition screening and thereby intervention inside Indian Hospitals. The

App was launched officially on May 22nd 2019 by Dr. Parmeet Kaur, Chief

Dietitian, All India Institute of Medical Sciences (AIIMS), New Delhi


ASPEN GNP – Global Nutrition Partnership, India

The ASPEN GNP Team, India is happy to inform about the launch of our

new website http://www.aspengnp.in. The American Society for

Parenteral and Enteral Nutrition (ASPEN) was founded in 1975 by 35

dedicated healthcare professionals who met in Chicago to create an

interdisciplinary association. ASPEN was founded for the purpose of

providing optimal nutrition to all people under all conditions at all times.

The pioneers of ASPEN recognized the importance of research, clinical

practice, advocacy, education, and an interdisciplinary approach to

nutrition support therapy.

Global Nutrition Partnership (GNP) Program

Through the Global Nutrition Partnership Program (GNP), international

sister societies from countries classified by the World Bank as low- or

middle-income economies* may have a group of their members join

ASPEN for a reduced membership fee. ASPEN is very excited to offer the

GNP after working for years with many societies that have expressed

interest in this type of partnership. Not only will the program make

membership in ASPEN more affordable and allow for more efficient

payments in U.S. funds, each sister society can tout participation in the

GNP as an additional member benefit to their own members and consider

this program an opportunity to pave the way for future collaborations with

ASPEN.

National Head of ASPEN GNP, India Dr. C.S. Chamania, Hon President, IAPEN ASPEN GNP Chairpersons Dr PC Vijayakumar, ASPEN GNP Mentor Dr Shivshankar Timanpyati, Chairman, IQASC (IAPEN Quality Award Selection Committee) ASPEN GNP Team, India Karnataka - Sreemathy Venkatraman Delhi - Ritika Samaddar Tamil Nadu - Lekha Sreedharan Haryana - Poonam Jaglan Uttar Pradesh - Ranu Singh Gujarat - Bidita Shah

ASPEN GNP – Team India

ASPEN GNP Executive Director Ms Priya Karkare Regional Center, Ground floor, Dadabhai # Road no 2, Andheri West, Mumbai 400058, Maharashtra Email: [email protected] Phone: 9821011462

April 2020 // Issue 1 21 IAPEN InSight – Newsletter

http://www.aspengnp.in/

mailto:[email protected]

IAPEN Quality Award

The Indian Association for Parenteral and Enteral Nutrition (IAPEN) is an

organization in the field of parenteral and enteral nutrition and promotes

basic and clinical research, basic and advanced education, organization

of consensus statements about clinical care and care quality control.

IAPEN - Quality Award for High Value Healthcare will be awarded to the

hospitals and healthcare professionals that were able to achieve top

performance in nutrition care quality control set by the IAPEN Quality

Award Selection Committee (IQASC) under the leadership of

members, and will receive the prestigious Quality Award, which is

expected to generate significant media coverage throughout world. All

participated organizations will get a complementary quality group

membership from IAPEN. IAPEN will also monitor the quality

management system in the participated organization for considering for

the Quality Award.

Dr Shivshankar T,

Chairman. The

organizations or

healthcare professionals

will be selected by the

IAPEN Quality Award

Selection Committee

(IQASC), all of whom will

have the chance to

present a brief outline of

their policies adopted in

care quality control. The

winning team will be

chosen by a vote from

amongst the IAPEN

Applications are Invited for being part of IAPEN Quality Award Selection Committee

Applications are invited from prospective

healthcare experts to be part of IAPEN Quality

Award Selection Committee. The selection

committee is the Apex Body of Individuals, who

can set guidelines and direction for this

prestigious national award. We request healthcare

professional to send their applications for

becoming part of this IAPEN Quality Award

Selection Committee. The committee will be

having a National Advisory Board and Statewide

Working Board. Experts can email their biodata to

[email protected] for more information.

ASPEN Quality Award

https://www.youtube.com/watch?v=-PC19Z1rFkw

American Society for Parenteral and Enteral Nutrition

(ASPEN) recognizes and presents awards to members

who have contributed to the field by showcasing

exceptional expertise in clinical practice, education, and

advocacy. The accomplishments of those selected for an

award improved the quality and efficacy of the profession

and their actions provide a positive example for healthcare

professionals.

The requirements of the Health Care Criteria for Performance Excellence are embodied in

seven categories, including Leadership (120), Strategic Planning (85), Customer Focus (85),

Measurement, Analysis, and Knowledge Management (90), Workforce Focus (85)

Operations Focus (85). Remaining Criteria’s and call for applications for Quality Award will

be launched soon.



https://www.youtube.com/watch?v=-PC19Z1rFkw

Special Mentions

IAPEN Nepal team had conducted free

nutrition camp at Birgunj, Nepal.

IAPEN Bangladesh Chapter under the leadership of Ms Tamanna

Chowdary had conducted a free health camp for about 1200

Bangladeshis at Dhaka, Bangladesh.

Ms Chimi Wangmo from Bhutan had conducted

Malnutrition Week at Eastern Regional Referral Hospital,

Mongar, Bhutan. Ms Chimi Wangmo is planning to

establish an expert group by involving about 30 dietitians

present in Bhutan with the help and support from The

Indian Association for Parenteral and Enteral Nutrition.

Ms Chimi Wangmo was also IAPEN Certified Clinical

Nutritionist.

IAPEN Nepal Team

Ms Nani Shova Shakyaat ICNC 2020



Continual Nutrition Education Program for Healthcare Providers – Nationwide Workshops

A case study of a half-marathon runner

his body weight, activity and exercise cost (2800Kcal, 90g

Protein, 400g (Carb) and 1-3 hrs moderate exercise). His Pre-

Race day intake was even lower than his usual diet and

therefore could not allow adequate glycogen storage. He was

not used to a pre-run snack during practice and marathons

but managed to eat a fruit and an electoral sachet which

together provided carbohydrates of 41g i.e; not even 1g per

kg his body weight. All these facts were presented to him and

he was counselled on the importance of an adequate daily

The Learning Objectives of the workshops is to know the

different approach in Nutrition Intervention Strategies to treat

patients, to know how to evaluate patients during nutrition

assessment, to know how to plan nutrition support in

patients with medical or surgical conditions and to be familiar

with concepts of nutrition support in patients. The workshop

also introduces IMW (IAPEN Malnutrition Week) toolkit as a

free support for Implementing Nutrition Intervention in any

Hospital setting. The workshops were conducted throughout

India in all Major cities for promoting Malnutrition and

Nutrition Intervention Strategies in Indian Hospital Settings.

Dr Ashwin Dabhi, Executive Director, IAPEN has collaborated

with Dialog India Services Pvt. Ltd, India for conducting

series of workshops throughout India.


Sr. No. 138 Balaji Chowk, Chinchwad, Pune, Maharashtra 411019

+91 9986795754 // [email protected] // www.iapen.co.in

Hyderabad

Nashik

Background: The half marathon runner approached Ms.

Meena K. Hardasani, Head, Nutriventure Specialty Nutrition

Clinic, Surat for improving his personal best timing and to

understand all process variables for best performance.

About Client: A 45-year-old half marathon runner, 173 cm tall

weighing 67 kgs has a run experience of 4 years, takes

coaching in the past 2 years along with strength training and

rehabilitation. His coaching includes 40 kms run per week (3-

4 days a week) and alternate days of circuit with strength

training exercise lasting upto 60 mins duration. A 24 hr diet

recall (2090 Kcal, 87g (Protein), 300.6g (Carbs) and 54g

(fats)) was collected along with information on Race Day

intake and pre-race preparations practiced if any. The client‘s

major concern was his race time, as he was unable to reach

close to his PB (Personal Best) for a year now. He

experienced anxiety and a weird feeling in the stomach

before the race, also was unable to eat well before race day.

He does well in practice, but not in the actual race where he

feels a lot of muscle cramps apart from feeling low on

energy. However, he starts the run with a lot of vigor but soon

feels drains out. He has always followed the ritual of

practicing the race 24hrs before the race day.

Assessment and Management: The clients Energy, Protein

and Carbohydrate requirements were calculated considering

calorie-protein-carbohydrate

intake. The revised diet plan

includes 2900Kcal, 93 g

(Protein), 417 (Carb) and 68

g fats. He was also

discouraged from practicing

the run 24-48 hours prior the

actual run for the same

reason and was counselled

about pre-run snack in

boosting glycogen. With

continuous nutrition intervention and monitoring the runner

could able to beat his personal best timing.

Newsletter Team

Editor: Dr Mansi Patil; Publishing Editor – Dr RR Siva Kiran

Members: Ms. Somya Shrivastava, Ms. Shreesha Gijare

Ms. Shivani Thakur, Dr. Ankita Sharma

About IAPEN

The Indian Association for Parenteral and Enteral Nutrition (IAPEN) is an organization in the field of parenteral and enteral nutrition and promotes basic research, clinical research, advanced education, organization of consensus statements about clinical care and quality control.

IAPEN Guidelines Committee

Chairman Dr. Ashwin Dabhi. Consultant Physician in Metabolic and Nutritional Disorders, Sujivan Hospital, Ahmedabad. Member-Executive Council, ESPEN, Hon Executive Director- IAPEN. Email: [email protected] Members Dr. C.S. Chamania, Hon President, IAPEN Dr. P. C Vijayakumar, Hon Executive Director, IAPEN Dr. Suryanarayana S.P, Hon Executive Director, IAPEN Dr. Nihar Ranjan Das, Hon President, New Delhi Chapter Dr. Anoop Kumar A S, Hon President, Calicut Chapter Dr. Biju Pottakkat, Hon President, Puducherry Chapter Dr. Shilpa A Varma, Hon Secretary, IAPEN Dr. Kajal Pandya Yeptho, Hon President, Gurgam Chapter

BEST PRACTICE POSITION PAPER OF IAPEN FOR NUTRITIONAL SUPPORT OF SARS COV- 2 PATIENTS

IAPEN – The Indian Association for Parenteral and Enteral Nutrition

WELCOME NOTE

THURSDAY, 27th MARCH 2020 In wake of the unprecedented crisis in India and the world

due to Coronavirus 2019 (COVID-19) pandemic, the team at


(IAPEN) had decided to prepare “Best Practice Position

Paper for Nutrition Support of SARS–COV-2 Patients” to help

health care professionals in India.

Overview • Coronavirus disease (COVID-19) is a highly contagious

disease caused by a newly discovered coronavirus.

• Most people infected with the COVID-19 virus will

experience mild to moderate respiratory illness and

recover without requiring special treatment. Older

people, obese people and those with underlying

medical problems like cardiovascular disease,

diabetes, chronic respiratory disease, cancer and

immune-compromised patients are more likely to

develop serious illness.

• The best way to prevent and slow down transmission

is be well informed about the COVID-19 virus, the

disease, it causes and how it spreads and the best

possible available treatment.

• Preventive measures like protecting yourself and

others from infection by washing your hands or using

an alcohol-based rub frequently and not touching

your face.

• The COVID-19 virus spreads primarily through

droplets of saliva or discharge from the nose when an

infected person coughs or sneezes, so it’s important

that you also practice respiratory etiquette (for

example, by coughing into a flexed elbow). Avoid

touching/ rubbing your eyes, nose, mouth, face.

At the same time, it is extremely important to maintain

social distance.

C

that you also practice respiratory etiquette (for example, by coughing into a flexed elbow). Avoid touching/rubbing

your eyes, nose, mouth, face.

• At the same time, it is extremely important to maintain social distance.

• Currently, there are no specific vaccines or treatments for COVID-19. However, there are few on-going clinical trials

evaluating potential treatments like SOLIDARITY etc.

• Please use clinical judgment at the bedside, consider local practices and evidence/guidelines for the nutritional

management of critically ill patients.

• The average time of mechanical ventilation in COVID-19 patients is expected to be around 14 days and therefore these

patients are at high nutrition risk.

• This Statement document has been developed by guidelines committee of IAPEN taking into account current scenario

in absence of evidenced based guidance but based on management of patients with acute respiratory distress

syndrome, acute critically ill patients admitted to an ICU setting and medical nutrition recommendations has been

formulated in collaboration with national frontline health care provider, international colleagues, sister PEN

associations, recommendations from ESPEN and WHO and direct and indirect evidence on the same. IAPEN formed

panel of experts from different states of India and identified relevant and recent experience on the statements

presented here.

This document is up to date as of Friday 27th of March, 2020 and we will update in line with new information that

arises. Please contact us at IAPEN if you have any information to share that might be useful for others at email

[email protected]

• There is a lack of acquired immunity in populations

across the globe to COVID-19 & no vaccine is

available as of now.

• Uncertainty about true infections rates within

countries.

• Elderly with poly-morbid illnesses are the most

vulnerable targets. Compromised appetite, dyspnea,

STATEMENT 1 WHEN AND HOW TO SCREEN AFTER DIAGNOSIS: EASY EVALUATION To screen all patients after diagnosis depending on current practices at local level or as scenarios mentioned below but our aim is to identify patients with early and rapid decline in oral intake.

Scenario 1: Tertiary care center where Nutrition Support Team(NST) is established and practiced can continue to do so by using any validated tools like MUST(Malnutrition Universal Screening Tool), NRS2002(Nutrition Risk Screening) OR SGA(Subjective Global Assessment) or to categorize patients by routinely using rapid digital platform like IAPEN IMW Toolkit seems time/life-saving which can be downloaded for free from http://www.iapen.co.in/imwapp/. The App is an open source software available on android and apple platform. For further assistance for same, you can mail at [email protected].

Scenario 2: Centers where Nutrition Support Team doesn’t exist, it is better to categorize patients at risk of malnutrition or malnourished depending on brief and quick clinical assessment and to make aware all the attending healthcare people about importance of NST.

Nutrition assessment can be repeated every 3rd day in ICU and weekly for out of ICU patients admitted in wards or at home.

SARS-COV-2 BACKGROUND C

mechanical ventilation, and disturbance of

consciousness after long-term bedridden can lead to

inadequate intake of patients.

• There are reasonable evidences from animal and

human studies that anti-oxidants and related

nutrients support the immune function*1.

• Nutritional advice is therefore, considered most

appropriate at this point of care.

BEST PRACTICE POSITION PAPER OF IAPEN FOR NUTRITIONAL SUPPORT OF SARS COV- 2 PATIENTS, 27th March, 2020, IAPEN

STATEMENT 2 EASIER AND BETTER WAYS TO OPTIMIZE NUTRITION STATUS OF MALNOURISHED SUBJECTS WITH COVID 19 INFECTIONS Scenario 1: Whenever available diet and nutrition counseling only by experienced professional (RD, EXPERIENCED NUTRITION PROFESSIONAL), PHYSICIAN/INTENSIVIST/ENDOCRINOLOGIST specialized in nutrition intervention. Scenario 2: In a most likely situation in absence of the above-mentioned experts, trained NURSES along with treating physician to lead and support using rule of thumb for nutritional intervention. The critically ill patients with new type of coronavirus pneumonia, respiratory failure and mechanical ventilation required; shock; combined with other organ failures need to be admitted to the intensive care unit treatment. For patients who can eat on their own and have no risk of vomiting or aspiration, oral diet should be given priority as soon as possible and the goal is to meet 70% of nutritional requirements within 3 to 7 days. In all above scenario ready to use or customized Oral Nutritional Supplements to be prescribed in order to treat according to target energy and protein requirements. For any nasogastric feeding route advised for therapeutic management of Covid-19 patients, there will be challenges with respect to continuous versus intermittent bolus feeding due to totally different set of ICU scenario in tertiary care private hospitals versus public hospital set ups in India. Also, to maintain ratio of nurse to ICU beds round the clock will be challenging in view of availability of skilled and trained staff due to minimum of 6 hours of uninterrupted duties without any personal privileges. Continuous infusion can significantly reduce the risk of diarrhea compared to single infusion; hence recommendations support continuous feeding ideally by feeding pumps or gravity feeding through bags with all aseptic precautions and protected timings and monitoring of GRV on demands. And to be mindful of other co-morbidity parameters.

STATEMENT 3 OPTIMUM TARGET FOR ENERGY AND PROTEINS IN SUBJECTS WITH COVID 19 INFECTIONS Recommended Energy targets: 25-30 kcal / ABW in non-obese adults and to start with half the target energy requirements and to reach 70% by day 3 of admission and aim to reach close to 100% by end of first week of admission depending on tolerance. Keep a close check on re-feeding parameters and adjust caloric supply accordingly. Simultaneously correct all potential metabolic and hemodynamic derangements and most of the times investigation protocol should be kept to bare necessity because of logistic reasons of contamination and resources. In overweight and obese adults, it is advisable to use IBW or Adjusted BW respectively to calculate energy needs. Most of the patient on tube feedings whether ventilated or not, to receive commercial polymeric feeds with carbohydrates to fat ratio of 70:30. In centers where there is no insulin infusion protocol and when hyperglycemia seem difficult to control or when weaning seems difficult or in situations where ventilator goals seems difficult to achieve we can adjust ratio to 60:40 or 50:50 and review and reassess to look for improvements in all such parameters. Regular assessment of food intake during hospital stay and 3-day dietary survey/recall in adult undernourished patients or in all those at risk of under nutrition should be carried out. Protein target of 1-1.5 gm/kg body weight per day but adjust depending on clinical background and co-morbidities. The total fat energy supply ratio of the recommended diet and tube feeding nutrition reaches 25% ~ 30% of the total energy. Safer we reach to targets for proteins and energy are probably there may be parallel reductions in LOS, ventilator days and overall morbidity and mortality.


STATEMENT 4 SHOULD WE SUPPLEMENT MULTI VITAMINS AND MULTI-MINERALS AND TRACE ELEMENTS Multivitamin and multi-mineral supplements recommended to be part of enteral and/or parenteral feedings in all patients due to rapid depletion of body stores, in a setting of poor appetite week before admission and later once admitted the demands increases due to complex metabolic and hormonal milieu for regeneration, repair and rehabilitation which many a times increases demands to double or multiple times more than the RDA. Since this pandemic had peaked in winter patients may have the lowest possible levels of Vitamin D. Vitamin D deficiency has been associated with several different viral diseases including influenza *2 Therefore, vitamin D could work as an important therapeutic supplementation option for the treatment or prevention from this novel virus infection. Recommended dosage- Vitamin D 10-100 mcg /day*2. Many centers have tried single large intramuscular dose of 6.0 Lacs unit in ARDS by the end of first week*3. Vitamin A: This vitamin has been called “anti‐infective” vitamin since many of the body's defenses against infection depend on an adequate supply*4 of vitamin A. Therefore, vitamin A supplementation and β‐carotene, its plant‐derived precursor, could be an important promising option for the treatment of COVID-19 infection and the prevention of lung infection. Valuable β‐carotene sources are for examples carrot salad with oil, carrot juice, pumpkin, sweet potato, and spinach. Specific advice in relation to elderly is to increase the intake of Vitamin E (134-800 mg/day), Vitamin C (200 mg – 2 gm/day), Zinc (30-220 mg/day) *5. These nutrients have been shown to increase T cell and B cell (antibody) immunity in human studies including in elderly*6 SHOULD WE USE TRADITIONAL SUPPLEMENTS AS CONCURRENT TO THERAPEUTIC MANAGEMENT IN COVID-19 PATIENTS. Traditional Indian approaches of AYUSH 64 complimentary and Ayurveda cocktail developed by ministry of Ayurveda , Yoga and Naturopathy which is made up of 29 herbs and elements including holy basil- Ocimum tenuiflorum (Tulsi) in the family Lamiaceae, Ginger, Turmeric and Guduchi (Tinspora Cordifolia) may be used at discretion of the local practices protocol of treating physician as an add on to therapeutic medical intervention of necessary conventional care as suggested by CCRAS (Central Council for Research in Ayurveda Science), India.

STATEMENT 5

SHOULD PATIENT CONTINUE REGULAR PHYSICAL ACTIVITIES ESPECIALLY THOSE IN QUARANTINE ON CASE PER CASE BASIS? Regular exercise to be incorporated depending on whether patients are in quarantine at home or in dedicated rooms / wards. Exercise should be for 30 min a day for > 50 years and one hour for < 50 years. Chest physiotherapy we should be careful as it might increase aerosols and simple breathing exercise can be undertaken on case to case basis. Leisure walking, simple stretching exercises will maintain muscle protein synthesis and immune competency and also relieves disease and confinement related stress. Physical activities of any nature will improve overall wellbeing. Avoid lying down except 8 hours of sleep. Intermittent walking is also encouraged.


STATEMENT 6 WHEN AND HOW SHOULD WE USE ORAL NUTRITIONAL SUPPLEMENTS Oral nutritional supplements (ONS) should be used whenever possible to meet patients’ nutrition needs, when dietary counseling and food fortification are not sufficient to increase dietary intake to reach nutritional goals. ONS shall provide at least 400-600 kcal/day including 30 g or more of protein/day and shall be continued for at least one month. Efficacy and expected benefit of ONS/food intake shall be assessed every 3rd day and once a week in hospitalized cases and in rest of the cases weekly after discharge and then monthly after successful recovery.

STATEMENT 8 THE APPROPRIATE ROUTES TO FEED INTUBATED COVID 19 ICU PATIENT’S In COVID-19 intubated and ventilated ICU patient’s enteral nutrition (EN) should be started through a nasogastric tube. Since we mostly use rule of thumb ( 25-30 kcal/kg/D) or energy equations, it’s safe to start with lower energy needs and to aim for 70% of energy targets by end of 1st week failing which we may use post- pyloric routes after all attempts to optimize nasogastric feeds are exhausted. Post-pyloric feeding should be advised in patients with gastric intolerance after prokinetic treatment or in patients at high-risk for aspiration.


STATEMENT 7 HOW OFTEN SHOULD WE TAKE DIET RECALL AND REVIEW AND REASSESS WHEN NUTRITION TARGETS ARE NOT ACHIEVED IN NON-INTUBATED PATIENTS All admitted patients on oral feeds and ONS to be reviewed and reassessed at least every 3rd day. All patients on artificial EN or PN or both should be reviewed and reassessed every day. Transition may be followed between Oral>>Enteral>>PN alone or combined depending on the clinical and disease parameters. If there are limitations for the enteral route it could be advised to prescribe peripheral parenteral nutrition in the population not reaching energy-protein target by oral or enteral nutrition.

STATEMENT 9 HOW TO OVERCOME DYSPHAGIA FOLLOWING EXTUBATION? Patients no longer needing mechanical ventilation have high incidence of swallowing problems and consequent dysphagia which may strongly limit oral nutrient intake, even at a time of general improvement of clinical condition. The following recommendations therefore can be applied also to the COVID-19 patient population after extubation. In ICU patients with dysphagia, texture-modified food can be considered after extubation. If swallowing is proven unsafe, EN should be administered.

STATEMENT 9 In cases with very high aspiration risk, post-pyloric EN or, if not possible, temporary PN during swallowing training with removed Nasoenteral tube can be performed. Swallowing assessment and evaluation to be done and active and passive physiotherapy to be optimized.

STATEMENT 10 FOOD SERVICE MANAGEMENT Food should be provided to patients in separate plates, cups and utensils in case of non-availability of disposables. Food distributers should deliver food/meals to the relevant/ quarantined area of the hospital and the patients’ assigned nurse should transfer the meal tray to the patient in his room. Left-over meals by the patients be treated as medical waste. Separate food trolleys to be designated for delivery and collection of used/unused containers/utensils and everything to be decontaminated before next usage. All staff handling food service management should be provided with Personal Protective Equipment.


STATEMENT 11 WHAT NUTRITION ADVISE SHOULD BE GIVEN ON DISCHARGE AND SUBSEQUENT FOLLOW-UP? All patients should receive diet and nutrition counseling on discharge with special emphasis on compliance to meals plans and ONS prescribed. Energy intakes in convalescence can be 25-35 kcal/kg/day depending on the clinical back ground with co-morbid medical conditions. Protein target to continue same as what was continued during hospitalization. Regular physical activities including breathing exercises up to their individual tolerance to continue as advised. As all the patients will return back to the respective hospital set up after 1 week for COVID 19 lab checks as follow up protocol, nutrition assessment too should be carried out at the same time which can include advised dietary recall and then nutrition counselling and required meal plan to be individualized accordingly. All patients to be gently informed for benefits of exercise and to be physically active. At the same time check the compliance for nutrition and ONS intakes. There is a general advice to eat diverse and well-balanced foods rich in colored fruits and vegetables to increase the intake of anti-oxidants and associated nutrients to support immune functions. There is no specific evidence as of now that these nutritional measures can help protect against COVID 19 infections or even lessen the effects of the same but can aid general health and immunity.

(WHO Official Facebook Page: https://www.facebook.com/WHO/posts/2851434531568578)

EAT WELL PLATE The Indian Association for Parenteral and Enteral Nutrition is happy to adopt, The Eatwell Plate suggested by the Department of Health, issued officially by the government of the United Kingdom. The Eatwell Plate is a pictorial summary of the main food groups and their recommended proportions for a healthy diet. https://www.gov.uk/government/publications/the-eatwell-guide


IAPEN GUIDELINES COMMITTEE MEMBERS

Chairman and Principal Author and IAPEN Guidelines Committee Correspondent

Dr. Ashwin Dabhi, Consultant Physician in Metabolic and Nutritional Disorders, Sujivan Hospital Ahmedabad. Hon Executive Director, IAPEN, India

Members Dr. C.S. Chamania, Head of Department, Surgery and Renal Transplant, Choithram Hospital and Research Center, Indore Hon President, IAPEN, India Dr. P.C. Vijayakumar, Chief Anaesthesiologist and Critical Care Physician, Sooriya Hospital, Chennai Hon Executive Director, IAPEN, India Dr. S.P. Suryanarayana, Head Of Department, Community Medicine, Dr. B.R Ambedkar Medical College, Bangaluru Hon Executive Director, IAPEN, India Dr. Nihar Ranjan Das, Professor Gi Surgery and Liver Transplant, AIIMS, New Delhi Hon President, New Delhi Chapter Dr. Anoop Kumar A S, Consultant and Chief of Critical Care Medicine, Baby Memorial Hospital, Kerala Hon President, Calicut Chapter Dr. Biju Pottakkat, Professor and Head Surgical Gastroenetrology, JIPMER, Puducherry Hon President, Puducherry Chapter Dr. Shilpa A Varma, Consultant Nutritionist, Bellevue Multispeciality Hospital, Child Hormone Foundation, Mothercare Clinic, Mumbai, Hon Secretary, IAPEN, India Dr. Kajal Pandya Yeptho, General Manager-Dietetics, Medanta Hospital, Gurgam, Haryana Hon President, Gurgam Chapter

BIBLIOGRAPHY

1. Wu, D., Lewis, E. D., Pae, M., & Meydani, S. N. (2019). Nutritional modulation of immune function: analysis of evidence,

mechanisms, and clinical relevance. Frontiers in immunology, 9, 3160.

2 Gruber-Bzura, B. M. (2018). Vitamin D and Influenza—Prevention or Therapy?. Int journal of molecular sciences, 19(8), 2419.

2 Dancer, R. C., Parekh, D., Lax, S., D'Souza et al. (2015). Vitamin D deficiency contributes directly to the acute respiratory

distress syndrome (ARDS). Thorax, 70(7), 617-624.

3. Han, J. E., Jones, J. L., Tangpricha, V. et al (2016). High dose vitamin D administration in ventilated intensive care unit

patients: a pilot double blind randomized controlled trial. Journal of clinical & translational endocrinology, 4, 59-65.

4. McCullough, F. S. W., Northrop-Clewes, C. A., & Thurnham, D. I. (1999). The effect of vitamin A on epithelial integrity.

Proceedings of the Nutrition Society, 58(2), 289-293.

5. Maares, M., & Haase, H. (2016). Zinc and immunity: An essential interrelation. Archives of biochemistry and biophysics,

611, 58-65.

6. International Society for Immunonutrition (ISIN), March 2020) Position Statement on Nutrition, Immunity and Covid 19/

[Online] http://www.immunonutrition-isin.org/docs/isinComunicadoCovid19.pdf

7. Vitamin C Fact Sheet for Health Professionals [0nline] https://ods.od.nih.gov/factsheets/VitaminC-HealthProfessional/

Other IAPEN Recommendations 1. ESPEN Guideline on clinical nutrition in the intensive care unit 2. WHO- CORONAVIRUS https://www.who.int/health-topics/coronavirus#tab=tab_1 3. CDC- Coronavirus (Covid-19) https://www.cdc.gov/coronavirus/2019-ncov/index.html

4. https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(20)30185-9/fulltext 5. Government of India- Covid-19 https://www.mygov.in/covid-19 6. Early enteral nutrition in critically ill patients: ESICM clinical practice guidelines 7. Guidelines for the provision and assessment of nutrition support therapy in the adult critically ill patient: Society of Critical Care Medicine (SCCM) and American Society for Parenteral and Enteral Nutrition (ASPEN) 8. Surviving Sepsis Campaign Rapid Guidelines on the Management of Critically Ill Adults with Coronavirus Disease 2019 https://www.esicm.org/ssc-covid19-guidelines/ 9. Food Safety and the Coronavirus Disease 2019 (COVID-19) https://www.fda.gov/food/food-safety-during-emergencies/food-safety-and-coronavirus-disease-2019-covid-19

S


http://www.immunonutrition-isin.org/docs/isinComunicadoCovid19.pdf

https://ods.od.nih.gov/factsheets/VitaminC-HealthProfessional/

https://www.who.int/health-topics/coronavirus#tab=tab_1

https://www.cdc.gov/coronavirus/2019-ncov/index.html

https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(20)30185-9/fulltext

https://www.mygov.in/covid-19

https://www.esicm.org/ssc-covid19-guidelines/

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