Nutritional Guideline for COPD Patients

Supporting Slide Deck

The objectives of the guideline:

To raise the awareness of nutrition with respiratory healthcare professionals and their patients

To provide a simple tool to aid first line nutritional management of this group

To improve the nutritional status of COPD patients

Nutritional Screening NICE recommends that all patients, whether in the community or in

hospital, should be regularly screened using a tool like “MUST”. In some centres a nutritional screening tool may be being regularly used with your COPD patients. In other centres this is not the case

The Nutritional Guideline for COPD is not designed to replace a more formal screening tool but is designed to be something you can use either along side the results from nutritional screening (see the colour coding on the guideline), or as a first line approach to tackling nutritional issues in this group

If you have up to date screening information you can use this to understand where your patient fits on the guideline. If your team are not using a formal screening process you can make a simple assessment using a Body Mass Index and by asking some key questions that you can incorporate into your patient’s appointment

Simple Steps:1. Obtain patient’s weight (if possible review weight

history)

2. Calculate Body Mass Index (BMI)

3. Understand current nutritional situation

4. Identify your patient’s position on the guideline

5. Take appropriate action

6. Review and monitor: build a quick check regarding diet and nutrition into every appointment

Note your patients weight:

Start to regularly keep a check on your patients weight

Weigh the patient if possible every time they are in clinic

Look at a weight history if available◦If their weight has been changing this

can indicate a cause for concern

Calculate BMI (Body Mass Index)

Body Mass index or BMI is the patients weight in kg divided by their height in meters squared:

Weight (kg) Height2 (m2)

Alternatively, use the BMI chart found on the back of the guideline

Once you have a BMI, categorise your patient as:◦ Underweight <20 ◦ Normal weight 20-25◦ Overweight 25-30◦ Obese >30

Understand your patients nutritional status

Poor nutritional status in COPD is not always easy to identify

There should be cause for concern if your patient has:◦ A low Body Mass Index (<20 kg/m2)◦ Unintentional weight loss (your patient is losing weight without deliberately

trying to) – they may have what appears on the surface to have perfectly healthy BMI but if they are losing weight without trying, this needs to be monitored

◦ Muscle wasting – this is often the hardest to spot, there are complicated techniques to identify this, but your patient should be able to tell you that they have noticed changes in their body shape, loss of muscle in arms and legs and loss of muscle strength

Although not always considered as a cause for concern, it is also important to think about those patients who are:◦ Very overweight, i.e. obese (>30 kg/m2), their weight can be affecting their

breathing and mobility◦ Eating well and have a stable body weight but have very poor quality diet

The 5 Key Open Questions to Ask1. How is your appetite?

2. Are you managing to eat as well as you usually do?

3. Have you noticed any changes in your weight? Useful prompts: ◦ Clothes and jewellery becoming looser◦ Have friends/family made comments

4. Have you noticed any other changes to your body shape? Useful prompts:◦ Changes to arms and legs◦ Muscle strength

5. Do you have any concerns about your food intake and diet?

Use the GuidelineOnce you have a BMI

for your patient and have had a short discussion around food, diet and weight, you should be able to use the colour coded guideline to identify the appropriate course of action for them

Resources Guidance around prescription of Oral Nutritional Supplements in disease related

malnutrition & COPD: NICE Clinical Guide CG 32 Nutrition Support in Adults NICE Clinical Guideline CG 101 Chronic Obstructive Pulmonary Disease (update) Evidence and support for the use of Oral Nutritional Supplements in COPD

patients: Stratton RJ, Green CJ, Elia M. Evidence base for Oral Nutritional Support. In Disease Related

Malnutrition: An Evidence based Approach to Treatment Stratton RJ, Green CJ, Elia M.(eds). CABI Publishing , Wallingford, Oxon pp168-236, 2003.

NICE Clinical Guideline CG 101 Chronic Obstructive Pulmonary Disease (update)Collins PF, Stratton RJ and Elia M (2011) Nutritional support in chronic obstructive pulmonary

disease (COPD): a systematic review and meta-analysis. Clinical Nutrition, 6 (Suppl. 1): 153.

Collins PF, Stratton RJ and Elia M (2011) Nutritional support and functional capacity in chronic obstructive pulmonary disease (COPD): a systematic review and meta-analysis. Clinical Nutrition, 6 (Suppl. 1): 153-154.

 Evidence in support of COPD patient’s having an energy gap of around 600kcal: Baarends EM et al. Total Free Living Energy Expenditure in Patients with Severe Chronic

Obstructive Pulmonary Disease. Am J RespirCrit Care Med 1997; 155: 549-544.Schols AMWJ et al. Energy Balance in Chronic Obstructive Pulmonary Disease. Am

RevRespirDis 1991; 143: 1248-1252 

Resources

 Guidelines in support of combining nutritional intervention and exercise to

improve outcomes: NICE Clinical Guideline CG 101 Chronic Obstructive Pulmonary Disease (update)Anker SD et al. ESPEN Guidelines on EnteralNutrition:Cardiology and Pulmonology

Clinical Nutrition 2006; 25:311-31 Evidence in support of COPD patients having better outcomes if they are

overweight:Landbo C, Prescott E, Lange P, Vestbo J, Almdal TP Prognostic value of nutritional status

in chronic obstructive pulmonary disease. Am J RespirCrit Care Med. 1999; Dec;160(6):1856-61.

Schols AM, Broekhuizen R, Weling-Scheepers CA, Wouters EF Body composition and mortality in chronic obstructive pulmonary disease. Am J ClinNutr. 2005; Jul;82(1):53-9.

 Guideline that suggests nutritional issues should be addressed as part of a PR

programme: Nici et al.ATS/ERS Statement on Pulmonary Rehabilitation. Am J RespirCrit Care Med

2006;173:1390-1413 (Pulmonary Rehabilitation programs should address body composition abnormalities, which are frequently present and under recognised in chronic lung disease)