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Updated Guidance to Help Combat Malnutrition in Patients with COPD

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 documents, 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 status.3  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 usage and costs, higher mortality, longer hospital stays, more frequent readmissions, as well as reduced muscle strength and respiratory muscle function.

“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.”   

“I think GPs are becoming aware of the role that good nutrition plays in achieving better disease outcomes but it is not routinely seen as a priority to incorporate nutrition into treatment plans,” says panel member Dr Anita Nathan, General Practitioner/Member of the GPs Interested in Nutrition Group. “With growing numbers of elderly patients and those with multi-morbidities we are going to see a larger group of malnourished patients in our surgeries. We therefore need to work more closely with our dietetic colleagues to ensure nutrition screening and monitoring is integrated into current pathways of care, particularly targeting high risk groups, such as patients with COPD.  I hope that these guidelines will assist GPs and other members of the primary care team to facilitate better care for our patients.”

‘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 National Institute for Health and Care Excellence (NICE) (NG115 Chronic obstructive pulmonary disease in over 16s: diagnosis and management)5 and the Global Initiative for Chronic Obstructive Lung Disease (GOLD) strategy.6 It also includes revised guidance on energy and protein requirements for patients with COPD,7-9 and advice on nutritional intervention alongside pulmonary rehabilitation programmes, which have been found to be associated with improved patient outcomes.

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),  which were launched in 2012.

Patient leaflets

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:

‘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).  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.

References: 1. 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.  2. Collins PF et al. Prevalence of malnutrition in outpatients with chronic obstructive pulmonary disease. Proc Nut Soc. 2010; 69(Issue OCE2): E148.  3. Jones et al. Sarcopenia in COPD: prevalence, clinical correlates and response to pulmonary rehabilitation. Thorax 2015;70 (3).  4. Wagner PD. Possible mechanisms underlying the development of cachexia in COPD. ERJ 2008; 31: 492-501.  5. 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).  6. 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 ).  7. Gandy J. Manual of Dietetic Practice. 6th Ed. Blackwell Publishing; 2019.  8. Parenteral and Enteral Nutrition Group (PENG). Pocket Guide to Clinical Nutrition. British Dietetic Association (BDA). 2019.

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