malnutrition in copd: meeting patients’ nutritional needs · and is defined as an imbalance of...

Impact of copD on nutrItIonal status

EnergyThe resting energy expenditure of patients with COPD is reported to be 15–20% above normal. This, combined with a decreased oral intake, puts patients at increasing risk of malnutrition (Ezzell et al, 2000). Symptoms such as difficulty swallowing or chewing due to dyspnoea (shortness of breath); chronic ‘mouth breathing’; chronic mucous production; coughing; depression; and fatigue can all contribute to a poor nutritional intake in this patient group (Gandy, 2014).

proteinProteins are the body’s building blocks, essential for growth, repair, and immunity. They help to maintain muscle mass, including those required for breathing, and it is therefore important to ensure that patients consume adequate protein. Current guidelines recommend a daily protein intake of at least 1.5g/kg body weight to allow for optimal protein synthesis (Ferreira, 2008). When feasible, patients should also be encouraged to participate in an exercise programme to stimulate the anabolic response, e.g. pulmonary rehabilitation (Ferreira, 2008).

micronutrientsMicronutrient (vitamins and minerals) intake is likely to be compromised in individuals who have a diet deficient in energy and protein. Micronutrients are important to help regulate numerous body processes and are essential in the body for the optimal use of macronutrients (protein, fat and carbohydrate). Any form of nutritional support should consider the provision of adequate micronutrients (Gandy, 2014).

common among COPD patients, with an estimated 30–60% of inpatients and 10–45% of outpatients thought to be at risk (Stratton et al, 2003).

consEquEncEs of malnutrItIon

Malnutrition has been linked to poor outcomes, with body weight and body mass index (BMI) identified as independent risk factors for mortality in patients with COPD (Ezzell et al, 2000). Those at risk of malnutrition have a higher risk of being admitted to hospital and requiring a longer length of stay (Collins et al, 2010). Poor nutritional status is further associated with adverse effects, such as decreased muscle strength (including those required for breathing), more rapid deterioration in lung function, and a decrease in exercise capacity, all of which contribute to: Increased complications Increased use of

healthcare services Decreased quality of life

(Ezzell et al, 2000; Collins et al, 2011; Ferreira et al, 2012; Collins et al, 2013).

Thus, clinicians need to understand the importance of good nutrition and identify and manage malnutrition appropriately.

Malnutrition in COPD: meeting patients’ nutritional needs

GPN 2015, Vol 1, No 4

Chronic obstructive pulmonary disease (COPD) is an umbrella term for a number of lung diseases, including emphysema and chronic bronchitis. There are an estimated three million people living with the condition in the UK, however only 900,000 are currently diagnosed (National Institute for Health and Care Excellence [NICE], 2010). COPD is a major cause of morbidity and mortality, accounting for more than 28,000 deaths, 130,000 emergency admissions and 1.4 million GP consultations every year (NICE, 2010). Weight loss and being underweight are associated with poor prognosis and increased mortality, independent of disease severity (Ezzell et al, 2000), yet malnutrition is largely under-recognised and undertreated.

prEvalEncE of malnutrItIon

The term malnutrition refers to both over- and undernutrition, and is defined as an imbalance of energy, protein and nutrients which cause measurable adverse effects on body form, function and clinical outcome (Brotherton et al, 2012). Patients with COPD can experience malnutrition in the form of both under- and overnutrition. However, for the purposes of this feature, malnutrition refers to the problem of undernutrition. Malnutrition is

Identifying and managing malnutrition in patients with copD is vital

Matthew Hodson and Samantha Blamires explore how nutritional screening and appropriate management of malnutrition can improve outcomes for patients with COPD

Editorial this piece was sponsored by an educational grant from nutricia advanced medical nutrition

Matthew Hodson (left), chair of ARNS; respiratory nurse consultant, Homerton University Hospital NHS Foundation Trust; Samantha Blamires (right), senior medical affairs advisor, Nutricia Advanced Medical

Nutrition

GPN 2015, Vol 1, No 4

Editorial

› practice points

use a validated screening tool (e.g. ‘must’) to identify those at risk of malnutrition.

Document and act upon nutritional risk score — always investigate underlying cause of unintentional weight loss.

Discuss nutritional goals with the patient and implement appropriate care pathway. remember, there are resources available to support you in providing appropriate nutritional advice. refer to a dietitian for further advice if required.

commence prescription of oral nutritional supplements (ons) if BmI is low (<20kg/m2); two bottles per day for 12 weeks.(nIcE, 2010; Brotherton et al, 2012)

scrEEnIng

Malnutrition in COPD can present as a low BMI (<20 kg/m2), a reduction in lean body mass and/or unintentional weight loss. Current guidelines published by NICE (2010), the Department of Health (DH, 2010) and the Care Quality Commission (CQC, 2010) recognise the value of screening for malnutrition in COPD. Managing Adult Malnutrition in the Community (Brotherton et al, 2012; Figure 1), provides a practical pathway to support healthcare professionals in primary care to identify and manage individuals at risk of disease-related malnutrition. The pathway begins with nutritional screening using the ‘Malnutrition Universal Screening Tool’ (‘MUST’) — a validated tool for use in all care settings, which calculates a malnutrition risk score based on the assessment of BMI and percentage of unintentional weight loss in the last 3–6 months.

The NICE clinical guideline for COPD (2010) recommends: BMI should be calculated If BMI is abnormal (high or low),

or changing over time, the patient should be referred for dietetic advice

If BMI is low (<20kg/m2) patients should be given oral nutritional supplements (ONS) to increase their total calorific intake and be encouraged to take exercise to augment the effects of ONS.

It is important to consider that BMI may be less reliable as an index of nutritional status in older patients because of age-related changes in height, posture and ratio of fat to muscle (NICE, 2010). In these patients, changes in weight, particularly if

conclusIon

Healthcare professionals working with patients with COPD acknowledge that they often find it difficult to provide nutritional support (Association of Respiratory Nurse Specialists [ARNS], 2010). With World COPD Day highlighting the condition, it is timely that clinicians should familiarise themselves with resources that are currently available (see ‘Resources’ box; Figures 1 and 2).

greater than 3kg, should be noted and acted upon (NICE, 2010).

managEmEnt of malnutrItIon

When identified as ‘at risk of malnutrition’, nutritional goals should be agreed with patients and appropriate steps taken to support their nutritional status. Until recently, weight loss was thought to be an inevitable part of the disease process, however we now know that weight loss can be reversed in patients with COPD (Collins, 2013). Weight gain of 2kg has been associated with a number of functional improvements, and it is therefore recommended that this level of weight gain is used as a therapeutic target (Collins et al, 2013).

NICE (2006) recommends the use of various nutrition support strategies to improve dietary intake, including dietary counselling, food fortification and ONS, otherwise known as sip feeds. Many patients with COPD struggle to consume the volume of food required to meet their nutritional requirements and therefore NICE (2010) recommends that patients with a low BMI (<20kg/m2) receive ONS to support their nutritional intake. ONS are a balanced mix of energy, protein and micronutrients, which typically contain approximately 300kcal per bottle. They are designed to be taken in addition to normal dietary intake and are ideal for use in patients with COPD who have a poor appetite, as they improve total nutritional intake with little suppression of voluntary food intake (Stratton and Elia, 2007).

ONS have been shown to significantly improve outcomes including quality of life, exercise performance, respiratory muscle strength and hand-grip strength (Collins et al, 2012; Ferreira et al, 2012; Collins et al, 2013). Additionally, they have been associated with a 22% decreased length of hospital stay, 13% reduction in hospitalisation costs and a 13% decrease in the probability of 30-day hospital readmission (Snider et al, 2015).

Red Flag Indicators of malnutrition

Low BMI (<20kg/m2) Unintentional weight loss over

past 3–6 months Loose fitting clothes/rings/

dentures Reduced appetite/ability to eatNote: Always investigate the patient for underlying cause of weight loss.

fIgurE 1.Guidelines for the assessment and management of malnutrition.

Malnutrition is prevalent among patients with COPD and may contribute to the morbidity and mortality associated with this disease. Malnutrition is currently under-recognised and undertreated, however general practice nurses play a pivotal role in the identification and management of this largely manageable condition. Nutritional support within COPD can be a challenging aspect of care, however evidence demonstrates that good nutritional status is associated with improved outcomes (Ferreira, 2012; Collins, 2013). This should therefore should form an important part of the integrated care pathway for these patients.

rEfErEncEs

Association of Respiratory Nurse Specialists (2010) COPD Nutrition Survey. Data on file

Brotherton A, Holdoway A, Mason P, McGregor I, Parsons B, Pryke R (2012). Managing Adult Malnutrition in the Community. Available online: www.malnutritionpathway.co.uk

Care Quality Commission (2010) Guidance about compliance – Summary of regulations, outcomes and judgement framework. CQC, London. Available online: www.cqc.org.uk.

Collins PF, Elia M, Smith TR, et al (2010) The impact of malnutrition on hospitalisation and mortality in outpatients with chronic obstructive pulmonary disease. Proc Nutr Soc 69(OCE2): E148

Collins PF, Stratton RJ, Elia M (2011) An economic analysis of the costs associated with malnutrition in chronic obstructive pulmonary disease (COPD). Proc Nutr Soc 70(OCE5): E324

› resources

Malnutrition: general advice/practical pathway for managing malnutrition can be found in Managing Adult Malnutrition in the Community. Available online: www.malnutritionpathway.co.uk.

COPD: information from the malnutrition pathway has been reflected in Respiratory Healthcare Professionals — Nutritional Guideline for COPD Patients — an independent pathway developed by clinicians working in the field of COPD (Figure 2). Available online: www.arns.co.uk.

Both documents recommend prescribing ONS (two bottles [2 x 300kcal] per day for three months) for patients with a low BMI and/or unintentional weight/muscle loss. The COPD guideline also contains colour-coded diet sheets, written by specialist respiratory dietitians, that help to support clinicians when giving appropriate nutritional advice.

Collins PF, Stratton RJ, Elia M (2012) Nutritional support in chronic obstructive pulmonary disease: a systematic review and meta-analysis. Am J Clin Nutr 95(6): 1385–95

Collins PF, Elia M, Stratton RJ (2013) Nutritional support and functional capacity in chronic obstructive pulmonary disease: a systematic review and meta-analysis. Respirology 18(4): 616–29

Department of Health (2010) Essence of Care 2010. Benchmarks for food and drink. DH, London

Ezzell L, Jensen GL (2000) Malnutrition in chronic obstructive pulmonary disease. Am J Clin Nutr 72(6): 1415–6

Ferreira IM (2008) Update: nutritional support for patients with COPD. Respir Med 4(4): 127–31

Ferreira IM, Brooks D, White J, Goldstein R (2012) Nutritional supplementation for stable chronic obstructive pulmonary disease. Cochrane Database Syst Rev 2012;12:CD000998

Gandy J, ed (2014) Manual of Dietetic Practice. 5th edn. Wiley Blackwell Publishing, Oxford

National Institute for Health and Care Excellence (2006) Nutrition support in adults: oral nutrition support, enteral tube feeding and parenteral nutrition. CG32. NICE, London. Available online: www.nice.org .uk/guidance/cg32

National Institute for Health and Care Excellence (2010) Chronic obstructive pulmonary disease: Management of chronic obstructive pulmonary disease in adults in primary and secondary care. CG 101. NICE, London. Available online: www.nice.org.uk/guidance/cg101/resources/guidance-chronic-obstructive-pulmonary-disease-pdf

Snider JT, Jena AB, Linthicum MT, et al (2015) Effect of hospital use of oral nutritional

fIgurE 2.The Respiratory Healthcare Professionals — Nutritional Guideline for COPD Patients, created by an expert working group.

High BMI >25kg/m2 Normal BMI 20-25kg/m2 Low BMI <20kg/m2

Weight stable

Food intake normal

Advise patient to eat a healthy and varied diet.

Give patient ‘Eating Well for Your Lungs’ leaflet.

If planning to reduce weight, discuss the need to cut back on high-energy foods and aim for gradual weight loss - do not consider unless BMI >30kg/m2.



Advise patient to eat a healthy and varied diet - monitor and review at next appointment.

Give patient ‘COPD Improving Your Nutrition’ leaflet.

If following an activity programme, advise your patient to increase their energy intake and consider prescribing oral nutritional supplement: 600kcal daily for 3 months.

Review at end of 3 months.

Unintentional weight or muscle loss

Food intake not compromised

Advise patient to eat a healthy and varied diet and the need to boost energy and protein intake, and make changes to their diet if appetite is poor.


Monitor and review if possible within 2 months or at next appointment.




Advise patient to increase energy and protein intake, and make changes to their diet if appetite is poor.

Give patient ‘Nutrition Support in COPD’ leaflet.

Prescribe oral nutritional supplement: 600kcal daily for 3 months, review monthly if possible. If no improvement seek advice of the dietitian.

If following an activity programme, ensure your patient understands the need to increase their energy intake.


Food intake compromised

Advise patient to increase energy and protein intake, and make changes to manage with poor appetite.












Work with all patients to increase awareness of changes in weight, body shape and food intake, and when to seek help If concerned about diet and co-morbidity, for example diabetes, seek advice from the Dietitian Two standard bottles of oral nutritional supplements provide 600kcal Malnutrition risk: Low Medium High

For a copy of the guideline plus accompanying patient leaflets contact the Nutricia Resource Centre on 01225 751098 or for electronic copies go to www.copdeducation.org.uk Sponsored by an educational grant from Nutricia Ltd and supported by the Respiratory Dietitians Network

Respiratory Healthcare Professionals – Nutritional Guideline for COPD Patients 5 Key QuestionsUse the following questions to help understand your patient’s food intake and current nutritional status.

This information, together with their BMI, will help you establish the position on the guideline to identify the appropriate course of action for your patient.

1. 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?

Are clothes and jewellery becoming looser, have friends/family made comments?

4. Have you noticed any other changes to your body shape?

Any changes to arms and legs, muscle strength?

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

Wei

ght

(kg

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Height (m)

Calculate BMIHeight (feet and inches)

For a copy of the guideline plus accompanying patient leaflets contact the Nutricia Resource Centre on 01225 751098 or for electronic copies go to www.copdeducation.org.uk

Sponsored by an educational grant from Nutricia Ltd and supported by the Respiratory Dietitians Network

4’10 1/2 4’11 5’0 5’01/2 5’11/2 5’2 5’3 5’4 5’41/2 5’51/2 5’6 5’7 5’71/2 5’81/2 5’91/2 5’10 5’11 5’111/2 6’01/2 6’1 6’2 6’3

100 46 44 43 42 41 40 39 38 37 36 35 35 34 33 32 32 31 30 30 29 28 28 15 1099 45 44 43 42 41 40 39 38 37 36 35 34 33 33 32 31 31 30 29 29 28 27 15 898 45 44 42 41 40 39 38 37 36 36 35 34 33 32 32 31 30 30 29 28 28 27 15 697 44 43 42 41 40 39 38 37 36 35 34 34 33 32 31 31 30 29 29 28 27 27 15 496 44 43 42 40 39 38 38 37 36 35 34 33 32 32 31 30 30 29 28 28 27 27 15 295 43 42 41 40 39 38 37 36 35 34 34 33 32 31 31 30 29 29 28 27 27 26 15 094 43 42 41 40 39 38 37 36 35 34 33 33 32 31 30 30 29 28 28 27 27 26 14 1193 42 41 40 39 38 37 36 35 35 34 33 32 31 31 30 29 29 28 27 27 26 26 14 992 42 41 40 39 38 37 36 35 34 33 33 32 31 30 30 29 28 28 27 27 26 25 14 791 42 40 39 38 37 36 36 35 34 33 32 31 31 30 29 29 28 27 27 26 26 25 14 590 41 40 39 38 37 36 35 34 33 33 32 31 30 30 29 28 28 27 27 26 25 25 14 289 41 40 39 38 37 36 35 34 33 32 32 31 30 29 29 28 27 27 26 26 25 25 14 088 40 39 38 37 36 35 34 34 33 32 31 30 30 29 28 28 27 27 26 25 25 24 13 1287 40 39 38 37 36 35 34 33 32 32 31 30 29 29 28 27 27 26 26 25 25 24 13 1086 39 38 37 36 35 34 34 33 32 31 30 30 29 28 28 27 27 26 25 25 24 24 13 885 39 38 37 36 35 34 33 32 32 31 30 29 29 28 27 27 26 26 25 25 24 24 13 684 38 37 36 35 35 34 33 32 31 30 30 29 28 28 27 27 26 25 25 24 24 23 13 383 38 37 36 35 34 33 32 32 31 30 29 29 28 27 27 26 26 25 25 24 23 23 13 182 37 36 35 35 34 33 32 31 30 30 29 28 28 27 26 26 25 25 24 24 23 23 12 1381 37 36 35 34 33 32 32 31 30 29 29 28 27 27 26 26 25 24 24 23 23 22 12 1180 37 36 35 34 33 32 31 30 30 29 28 28 27 26 26 25 25 24 24 23 23 22 12 879 36 35 34 33 32 32 31 30 29 29 28 27 27 26 26 25 24 24 23 23 22 22 12 678 36 35 34 33 32 31 30 30 29 28 28 27 26 26 25 25 24 24 23 23 22 22 12 477 35 34 33 32 32 31 30 29 29 28 27 27 26 25 25 24 24 23 23 22 22 21 12 176 35 34 33 32 31 30 30 29 28 28 27 26 26 25 25 24 23 23 22 22 22 21 11 1375 34 33 32 32 31 30 29 29 28 27 27 26 25 25 24 24 23 23 22 22 21 21 11 1174 34 33 32 31 30 30 29 28 28 27 26 26 25 24 24 23 23 22 22 21 21 20 11 973 33 32 32 31 30 29 29 28 27 26 26 25 25 24 24 23 23 22 22 21 21 20 11 772 33 32 31 30 30 29 28 27 27 26 26 25 24 24 23 23 22 22 21 21 20 20 11 471 32 32 31 30 29 28 28 27 26 26 25 25 24 23 23 22 22 21 21 21 20 20 11 370 32 31 30 30 29 28 27 27 26 25 25 24 24 23 23 22 22 21 21 20 20 19 11 069 32 31 30 29 28 28 27 26 26 25 24 24 23 23 22 22 21 21 20 20 20 19 10 1168 31 30 29 29 28 27 27 26 25 25 24 24 23 22 22 21 21 21 20 20 19 19 10 1067 31 30 29 28 28 27 26 26 25 24 24 23 23 22 22 21 21 20 20 19 19 19 10 766 30 29 29 28 27 26 26 25 25 24 23 23 22 22 21 21 20 20 19 19 19 18 10 665 30 29 28 27 27 26 25 25 24 24 23 22 22 21 21 21 20 20 19 19 18 18 10 364 29 28 28 27 26 26 25 24 24 23 23 22 22 21 21 20 20 19 19 18 18 18 10 163 29 28 27 27 26 25 25 24 23 23 22 22 21 21 20 20 19 19 19 18 18 17 9 1362 28 28 27 26 25 25 24 24 23 22 22 21 21 20 20 20 19 19 18 18 18 17 9 1061 28 27 26 26 25 24 24 23 23 22 22 21 21 20 20 19 19 18 18 18 17 17 9 860 27 27 26 25 25 24 23 23 22 22 21 21 20 20 19 19 19 18 18 17 17 17 9 659 27 26 26 25 24 24 23 22 22 21 21 20 20 19 19 19 18 18 17 17 17 16 9 458 26 26 25 24 24 23 23 22 22 21 21 20 20 19 19 18 18 18 17 17 16 16 9 157 26 25 25 24 23 23 22 22 21 21 20 20 19 19 18 18 18 17 17 16 16 16 9 056 26 25 24 24 23 22 22 21 21 20 20 19 19 18 18 18 17 17 17 16 16 16 8 1155 25 24 24 23 23 22 21 21 20 20 19 19 19 18 18 17 17 17 16 16 16 15 8 854 25 24 23 23 22 22 21 21 20 20 19 19 18 18 17 17 17 16 16 16 15 15 8 753 24 24 23 22 22 21 21 20 20 19 19 18 18 18 17 17 16 16 16 15 15 15 8 452 24 23 23 22 21 21 20 20 19 19 18 18 18 17 17 16 16 16 15 15 15 14 8 351 23 23 22 22 21 20 20 19 19 19 18 18 17 17 16 16 16 15 15 15 14 14 8 050 23 22 22 21 21 20 20 19 19 18 18 17 17 17 16 16 15 15 15 14 14 14 7 1349 22 22 21 21 20 20 19 19 18 18 17 17 17 16 16 15 15 15 14 14 14 14 7 1048 22 21 21 20 20 19 19 18 18 17 17 17 16 16 15 15 15 14 14 14 14 13 7 747 21 21 20 20 19 19 18 18 17 17 17 16 16 16 15 15 15 14 14 14 13 13 7 646 21 20 20 19 19 18 18 18 17 17 16 16 16 15 15 15 14 14 14 13 13 13 7 345 21 20 19 19 18 18 18 17 17 16 16 16 15 15 15 14 14 14 13 13 13 12 7 144 20 20 19 19 18 18 17 17 16 16 16 15 15 15 14 14 14 13 13 13 12 12 6 1343 20 19 19 18 18 17 17 16 16 16 15 15 15 14 14 14 13 13 13 12 12 12 6 1142 19 19 18 18 17 17 16 16 16 15 15 15 14 14 14 13 13 13 12 12 12 12 6 841 19 18 18 17 17 16 16 16 15 15 15 14 14 14 13 13 13 12 12 12 12 11 6 640 18 18 17 17 16 16 16 15 15 15 14 14 14 13 13 13 12 12 12 12 11 11 6 439 18 17 17 16 16 16 15 15 15 14 14 13 13 13 13 12 12 12 12 11 11 11 6 138 17 17 16 16 16 15 15 14 14 14 13 13 13 13 12 12 12 11 11 11 11 11 6 037 17 16 16 16 15 15 14 14 14 13 13 13 13 12 12 12 11 11 11 11 10 10 5 1136 16 16 16 15 15 14 14 14 13 13 13 12 12 12 12 11 11 11 11 10 10 10 5 935 16 16 15 15 14 14 14 13 13 13 12 12 12 12 11 11 11 11 10 10 10 10 5 734 16 15 15 14 14 14 13 13 13 12 12 12 11 11 11 11 10 10 10 10 10 9 5 5

1.48 1.50 1.52 1.54 1.56 1.58 1.60 1.62 1.64 1.66 1.68 1.70 1.72 1.74 1.76 1.78 1.80 1.82 1.84 1.86 1.88 1.90

Version 1, Published Nov. 2011

High BMI >25kg/m2 Normal BMI 20-25kg/m2 Low BMI <20kg/m2

Weight stable

Food intake normal



If planning to reduce weight, discuss the need to cut back on high-energy foods and aim for gradual weight loss - do not consider unless BMI >30kg/m2.



Advise patient to eat a healthy and varied diet - monitor and review at next appointment.


If following an activity programme, advise your patient to increase their energy intake and consider prescribing oral nutritional supplement: 600kcal daily for 3 months.

Review at end of 3 months.


Food intake not compromised







Advise patient to increase energy and protein intake, and make changes to their diet if appetite is poor.





Food intake compromised













Work with all patients to increase awareness of changes in weight, body shape and food intake, and when to seek help If concerned about diet and co-morbidity, for example diabetes, seek advice from the Dietitian Two standard bottles of oral nutritional supplements provide 600kcal Malnutrition risk: Low Medium High

For a copy of the guideline plus accompanying patient leaflets contact the Nutricia Resource Centre on 01225 751098 or for electronic copies go to www.copdeducation.org.uk Sponsored by an educational grant from Nutricia Ltd and supported by the Respiratory Dietitians Network

Respiratory Healthcare Professionals – Nutritional Guideline for COPD Patients

GPN

supplementation on length of stay, hospital cost, and 30-day readmissions among Medicare patients with COPD. Chest 147(6):1477–84

Stratton RJ, Green CJ, Elia M (2003) Disease-related malnutrition: an evidence based approach to treatment. Cabi publishing, Oxford

Stratton RJ, Elia M (2007) A review of reviews: a new look at the evidence for oral nutritional supplements in clinical practice. Clin Nutr Supp 2(1): 5–23

GPN 2015, Vol 1, No 4

My COPD means my appetite hasn’t been very good...

• Low 125ml volume and easy to take

• The most protein-rich, energy-dense nutritional supplement on the market

• Better compliance1*

Why change to anything else?

...so I started taking Fortisip Compact Protein. It’s very easy to take and I feel like I’m getting better. Ron; Camden ”

“

Right patient, right product, right outcomes

Nutricia Ltd., White Horse Business Park, Trowbridge, Wiltshire BA14 0XQ. Tel: 01225 751098. www.nutriciaONS.co.uk

03/15

* Greater compliance (91%) has been shown with more energy dense supplements (≥2kcal/ml) such as Fortisip Compact Protein when compared to standard oral nutritional supplements.

Reference: 1. Hubbard GP et al. Clin Nutr 2012:31;293–312.

malnutrition in copd: meeting patients’ nutritional needs · and is defined as an imbalance of...

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