From my point of view, the main challenge lies in making decisions on the management of COVID-19 in a scenario characterized by uncertainty. According to the Real Academia Española de la Lengua (Royal Academy of the Spanish Language), uncertainty is defined as “the lack of certainty, of assurance”. Certainty is “the firm conviction and clear knowledge of something; the firm adherence of the mind to something knowable, without fear of erring”. In other words, decisions concerning the life and death of thousands of sick people are made without solid knowledge and under the constant fear of causing harm. Decisions made in this way jeopardize the ethical principles and values of beneficence, non-maleficence, justice, equity, and respect for human dignity. Given the uncertainty about the course of the COVID-19 pandemic, in an article published in Nutrition in Clinical Practice, Barrocas et al. propose an ethical framework for decision-making in a context of scarce resources, and emphasize the importance of ethical protocols and a multidisciplinary decision-making approach(8).

In this context, there has been a worrying influx of scientific articles. A search conducted in PUBMED shows shows that from January 1 to November 15 2020, 34,462 articles have been published on COVID-19 and 18,834 on SARS-CoV-2. Publishing this number of articles in such a short period of time means that they have been published hastily, and sometimes probably evading the requirements to meet editorial standards. An expression of this is the not inconsiderable number of articles retracted from prestigious journals. As of November 2020, 38 articles had been permanently retracted and 3 temporarily retracted(9).

For example, an article that erroneously stated that Vitamin D sufficiency (serum 25-hydroxyvitamin D of at least 30 ng/mL) reduced the risk of adverse clinical outcomes in patients with COVID-19 infection was retracted. Also, the retraction of controversial articles published in The Lancet and The New England Journal of Medicine draws attention to a deep trust issue in research and fuels the controversy over economic and political interests in science. However, even if it was the editorial process of these publications which failed, most probably during the peer review process, the scrutiny of the scientific community, probably driven by the media attention on coronavirus research, allowed the faults to be detected in record time. These retractions and the controversy generated are not an exceptional case. According to Ivan Oransky, some 1500 articles are retracted each year due to lack of scientific solidity(9), but the COVID-19 crisis brought this serious problem to light.

The nutritional management of patients with COVID-19 does not escape this scenario. There is no certainty about the metabolic impact of the virus on the patient and, therefore, there is also no clarity on the best way to address nutritional challenges or the nutritional needs of patients with COVID-19 requiring mechanical ventilation. According to expert opinion, their nutritional needs are similar to those of any patient with acute respiratory distress syndrome (ARDS)(10). In this context there, an influx of scientific articles has not been observed, on the contrary, the shortage of articles is disturbing. A search in PUBMED yielded 1200 articles on “COVID-19 and nutrition” and 766 articles on “SARS-CoV-2 and nutrition”, which is equivalent to 1.6 % and 1.7 % of the total number of published articles, respectively.

Undoubtedly, it is not a matter of quantity of information but of quality of the scientific evidence. In other words, to evade uncertainty, knowledge arising from a high-quality scientific method that follows a rigorous editorial process is required. Expert opinion is essential, but it must be rebutted or confirmed under the standards of science through randomized controlled studies.

In the field of clinical nutrition, the main concern is the scarcity and poor quality of published research. An example of this and of the danger of poor quality of nutrition research is the article by Yu PJ et al. published in the Journal of Parenteral and Enteral Nutrition where they suggest that critically ill patients with COVID-19 are in an extreme hypermetabolic state. The study involving 7 critically ill patients with COVID-19 showed a median resting energy expenditure (REE) of 4044 Kcal/day obtained by indirect calorimetry. The authors conclude that it is necessary to “enhance nutritional requirements for these patients”(11). This article is surprising not only because of the high REE values, but also because of the poor methodological description and the lack of information on the cases studied, which prevents an accurate analysis of the results. We will never know if the high REE values obtained were the result of technical failures, to specific clinical situations (severe pulmonary shunt) or if this is the genuine metabolic profile of patients with COVID-19. These types of articles generate more uncertainty than certainty and put the lives of patients at risk.

These concerns are also shared by Dr. M. Isabel T.D. Correia in her article Nutrition in times of Covid-19, how to trust the deluge of scientific information. She highlights the high number of articles published on COVID-19 from countries initially affected by the disease, which additionally are mostly epidemiological observations or opinion articles that do not meet research quality standards. Furthermore, she highlights that nutritional therapy for patients with COVID-19 is a topic that is not frequently addressed in published studies despite being of utmost relevance in the holistic approach of any individual(12).

Thus, I share with Dr. Correia that “the best patient care must combine clinical reasoning with scientific knowledge. The massive deluge of publications is not necessarily indicative of scientific quality.”

Acknowledgments

The conversations and communication exchange with M. Isabel T.D. Correia, Serrana Tihista, Juan B. Ochoa and Fernando Carrasco have motivated and enriched the topic of this editorial.

Diana Cárdenas, MD, PhD

Faculty of Medicine, Research Institute on Nutrition, Genetics and Metabolism. Universidad El Bosque, Bogota, Colombia.

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