With research showing that around 1 in 3 inpatients1 and 1 in 5 outpatients2 with Chronic Obstructive Pulmonary Disease (COPD) are at risk of malnutrition the ‘Managing Malnutrition in COPD’ multi-professional panel has updated its guidance for healthcare professionals and supporting patient information leaflets. It is hoped that the document based on clinical evidence, clinical experience and best practice will raise awareness amongst the multi-disciplinary team of incorporating nutrition screening and nutritional care into management pathways for patients with COPD.
The causes of malnutrition in patients with COPD are varied and include not only the physiological effects of the disease such as breathlessness and fatigue interfering with appetite and the ability to eat but also psychological, social and environmental factors such as depression, social isolation and living conditions. In addition, individuals with COPD may have increased energy requirements arising from systemic inflammation and increased effort associated with breathing. Malnutrition can develop over several years or be precipitated and continue following an acute exacerbation. Sarcopenia (loss of skeletal muscle mass and strength) affects 15% of patients with stable COPD and impairs function and health status3. In addition nearly a quarter of all individuals with COPD will develop cachexia (loss of lean tissue mass due to chronic illness) 4.
The consequences of malnutrition in COPD are significant and contribute to increased healthcare useage and costs, higher mortality, longer hospital stays, more frequent readmissions as well as reduced muscle strength and respiratory muscle function5-14.
“Patients with COPD are particularly susceptible to loss of muscle mass so dietary advice is paramount and in many cases nutritional interventions may be necessary to ensure loss of weight and muscle mass are minimised particularly when patients are undergoing acute exacerbations,” says panel member Dr Peter Collins, Registered Dietitian and Senior Lecturer in Nutrition & Dietetics. “By working closely with the multi-professional team we can make sure that patients at risk of malnutrition are identified and that an appropriate nutritional care plan is put in place whilst ensuring and that those who require a more detailed dietetic assessment are referred on to the Dietitian. I hope that these guidelines will raise awareness of the importance of nutritional intervention in patients with COPD and assist healthcare professionals in incorporating nutrition screening and management advice into the care pathway of patients with COPD.”
‘Managing Malnutrition in COPD’
‘Managing Malnutrition in COPD’ is a practical guide that aims to assist healthcare professionals in identifying and managing people with COPD who are at risk of disease-related malnutrition and includes a pathway for the appropriate use of Oral Nutritional Supplements (ONS) to support community healthcare professionals. The second edition has been updated to include guidance from NICE NG115 Chronic obstructive pulmonary disease in over 16s: diagnosis and management)15 and the Global Initiative for Chronic Obstructive Lung Disease (GOLD) strategy16 as well as including revised guidance on energy and protein requirements for patients with COPD17-19 and advice on nutritional intervention alongside pulmonary rehabilitation programmes which have been found to be associated with improved patient outcomes15, 20-23.
The first edition of the guidance was launched in 2016 and it complements the ‘Managing Adult Malnutrition in the Community’ guidelines (www.malnutritionpathway.co.uk)24 which were launched in 2012.
The guidance is accompanied by three complementary colour-coded patient leaflets all of which contain dietary advice, advice on eating and physical activity. They also contain tips on coping with common symptoms of COPD including dry mouth, taste changes and shortness of breath. In addition the red (high risk) leaflet includes advice for patients on incorporating oral nutritional supplements into their diet. The three leaflets are:
Green Leaflet – ‘Eating Well for Your Lungs’ – for patients at low risk of malnutrition
Yellow Leaflet – ‘Improving Your Nutrition in COPD’ – for patients at medium risk of malnutrition
Red Leaflet – ‘Nutrition Support in COPD’ – for patients at high risk of malnutrition
Managing Malnutrition in COPD
‘Managing Malnutrition in COPD’ and the complimentary patient leaflets have been developed by a multi-professional panel, with expertise and an interest in malnutrition and COPD, and is endorsed by ten key professional and patient organisations including the British Dietetic Association (BDA), The British Association For Parenteral And Enteral Nutrition (BAPEN), the Association of Respiratory Nurse Specialists (ARNS), the British Lung Foundation (BLF), the Royal College of Nursing (RCN) and the Royal College of General Practitioners (RCGP)25. The document is based on clinical experience and evidence alongside accepted best practice. All materials can be downloaded for free via www.malnutritionpathway.co.uk/copd
NB: Production of the ‘Managing Malnutrition in COPD’ materials was made possible by an unrestricted educational grant from Nutricia Advanced Medical Nutrition.
For further information please contact:
Hilary Franklin Healthcare Communications
Tel: 020 8398 8551
Mobile: 07958 607898
- Steer J et al. P117 Comparison of indices of nutritional status in prediction of in-hospital mortality and early readmission of patients with acute exacerbations of COPD. Thorax. 2010; 65(4): A127-A.
- Collins PF et al. Prevalence of malnutrition in outpatients with chronic obstructive pulmonary disease. Proc Nut Soc. 2010; 69(Issue OCE2): E148
- Jones et al. Sarcopenia in COPD: prevalence, clinical correlates and response to pulmonary rehabilitation. Thorax 2015;70 (3).
- Wagner PD. Possible mechanisms underlying the development of cachexia in COPD. ERJ 2008; 31: 492-501
- Collins PF et al. An economic analysis of the costs associated with weight status in chronic obstructive pulmonary disease (COPD). Proc Nut Soc. 2011; 70(OCE5): E324
- Ezzell L and Jensen GL. Malnutrition in chronic obstructive pulmonary disease. Am J Clin Nut. 2000;72(6):1415-16
- Gupta B et al. Nutritional status of chronic obstructive pulmonary disease patients admitted in hospital with acute exacerbation. J Clin Med Res 2010 Mar 20;2(2):68-74
- Collins PF et al. ‘MUST’ predicts 1-year survival in outpatients with chronic obstructive pulmonary disease. Clin Nutr. 2010;5(2): 17.
- Collins PF et al. The impact of malnutrition on hospitalisation and mortality in outpatients with chronic obstructive pulmonary disease. Proc Nutr Soc 2010; 69(OCE2)
- Landbo C et al. Prognostic value of nutritional status in chronic obstructive pulmonary disease. Am J Respir Crit Care Med 1999; 160(6):1856-1861.
- Vestbo J et al. Body mass, fat-free body mass, and prognosis in patients with chronic obstructive pulmonary disease from a random population sample: findings from the Copenhagen City Heart Study. Am J Respir Crit Care Med 2006; 173(1):79-83.
- Vermeeren MA et al. Prevalence of nutritional depletion in a large outpatient population of patients with COPD. Respir Med, 2006 Aug;100(8):1349-55
- Ingadottir AR et al. Two components of the new ESPEN diagnostic criteria for malnutrition are independent predictors of lung function in hospitalized patients with chronic obstructive pulmonary disease (COPD). Clinical Nutr 2018; 37(4): 1323-1331
- Ingadottir AR et al. Association of energy and protein intakes with length of stay, readmission and mortality in hospitalised patients with chronic obstructive pulmonary disease. Br J Nutr 2018; 119(05): 543-551
- National Institute for Health and Clinical Excellence (NICE) Chronic obstructive pulmonary disease in over 16s: diagnosis and management. NICE Guideline NG115. Dec 2018 https://www.nice.org.uk/guidance/ng115/chapter/Context)
- Global Initiative for Chronic Obstructive Lung Disease (GOLD). Global Strategy for the Diagnosis, Management and Prevention of Chronic Obstructive Pulmonary Disease. 2019. https://goldcopd.org/wp-content/uploads/2018/11/GOLD-2019-v1.7-FINAL-14Nov2018-WMS.pdf")
- Gandy J. Manual of Dietetic Practice. 6th Ed. Blackwell Publishing; 2019.
- Parenteral and Enteral Nutrition Group (PENG). Pocket Guide to Clinical Nutrition. British Dietetic Association (BDA). 2019.
- Bauer J et al. Evidence-based recommendations for optimal dietary protein intake in older people: A position paper from the PROT-AGE study group.J Am Med Dir Assoc. 2013; 14(8): 542–559.
- Collins PF et al. Nutritional support and functional capacity in chronic obstructive pulmonary disease: a systematic review and meta-analysis.Respirology 2013; 18:616-629.
- Sugawara K et al. Effects of nutritional supplementation combined with low intensity exercise in malnourished patients with COPD. Resp Med. 2010 Dec;104(12):1883-9
- Van Wetering CR et al. Efficacy and costs of nutritional rehabilitation in muscle-wasted patients with chronic obstructive pulmonary disease in a community-based setting: a pre-specified subgroup analysis of the INTERCOM trial. J Am Med Dir Assoc. 2010 Mar;11(3):179-87
- Schols AM et al. Nutritional assessment and therapy in COPD: a European Respiratory Society statement. Eur Respir J 2014; 44:1504-1520
- Managing Adult Malnutrition in the Community. Holdoway A. (panel chair). 2012. United Kingdom. www.malnutritionpathway.co.uk
- The ‘Managing Malnutrition in COPD’ document and supporting patient materials have been supported by 10 key professional and patient associations:
- The Association of Chartered Physiotherapists in Respiratory Care (ACPRC)
- The Association of Respiratory Nurse Specialists (ARNS)
- The British Association For Parenteral And Enteral Nutrition (BAPEN)
- The British Dietetic Association (BDA)
- The British Lung Foundation (BLF)
- Education for Health
- The National Nurses Nutrition Group (NNNG)
- The Primary Care Respiratory Society (PCRS)
- The Royal College Of General Practitioners (RCGP)
- The Royal College Of Nursing (RCN)
In addition the guidance also includes the following NICE endorsement statement:
‘This guide (www.malnutritionpathway.co.uk/copd) accurately reflects some of the recommendations on malnutrition in the NICE guidelines on nutrition support in adults (www.nice.org.uk/Guidance/CG32) and chronic obstructive pulmonary disease in over 16s (www.nice.org.uk/guidance/ng115). It also supports statements 1,3 and 5 in the NICE quality standard for nutrition support in adults (www.nice.org.uk/guidance/qs24). This resource is intended for use with adults and not children.
National Institute for Health and Care Excellence. Renewed, December 2019’