supporting nutrition in copd: sam blamires. plan summer meeting
TRANSCRIPT
Reviewing the latest evidence and
guidelinesSamantha Blamires
16th June 2016
Supporting Nutrition in COPD
Outline Overview of malnutrition in COPD
• Prevalence• Causes• Consequences
NICE Clinical Guidelines• CG32 and CG101
Evidence for nutrition support in COPD• A review of the current evidence base
Putting theory into practice• Managing malnutrition in COPD
1. Overview of malnutrition in COPD
Definition of Malnutrition
“A state of nutrition in which a deficiency, excess (or imbalance) of energy, protein, and other nutrients causes measurable adverse effects on tissue / body form (body shape, size and composition) and function, and clinical outcome” (Elia,2000)
For the purpose of this session we will focus on malnutrition relating to a deficiency of nutrients, inadequate intake, unintentional weight loss.
Malnutrition is common but is often under-recognised1
In the UK, approximately 1/3 of patients with COPD are at risk of malnutrition2
Depends on severity of disease and method of assessment
More common in severe COPD patients and patients with emphysema
In older patients attention should be paid to changes in weight, particularly if the change is more than 3 kg3
1. Ambrosino, et al. Respiratory Medicine; 2007;101:1613-24. 2. Stratton, et al. Disease-related malnutrition: an evidence-based approach to treatment. Oxford: CABI Publishing, 2003. 3. NICE. https://www.nice.org.uk/guidance/cg101[3.2.2016].
Weight Loss in COPD = Loss of Lean Body Mass
Cross-sectional survey
n = 300 COPD outpatients
38% had lean body mass depletion
Whereas only 17% had low BMI (<20 kg/m2)
Cano NJ, et al. Eur Respir J 2002;20:30–7.
Causes of malnutrition in COPD
Malnutrition can occur in COPD due to increased nutritional requirements and decreased oral intake1
Within COPD patients there is a spectrum ranging from those who are very underweight to those who are overweight2
Patients with chronic bronchitis are more
commonly overweight.
Typically emphysematous patients are more commonly underweight.
1. Ezzell, et al. Am J Clin Nutr. 2000;72:1415-6. 2. Ohar, et al. Prim Care Respir J. 2011;20:370-8.
Factors affecting nutritional intake in COPD
Gandy. Manual of Dietetic Practice. Wiley-Blackwell, 2014.
Pharmacological
• Dry mouth• Oral thrush• Taste changes
Physical
• Dyspnoea• Fatigue• Dysphagia
Psychological
• Depression• Anxiety• Loneliness
Social
• Social isolation• Unemployment• Housebound
Consequences of malnutrition in COPD
1. Ezzell L and Jensen GL. Am J Clin Nut 2000;72:1415-1416. 2. Collins PF et al. Clinical Nutrition 2010;5,S2:17 3. Gupta B, Kant S, Mishra R, Verma S. J Clin Med Res, 2010 Mar 20; 2(2): 68-74. 4. Ferreira IM, Brooks D, White J, Goldstein R. Cochrane Database Syst Rev. 2012. 5.Vermeeren MA et al. Respir Med, 2006; 100: 1349-1355, 6. Collins PF, Stratton RJ, Elia M. Proceedings of the Nutrition Society, 2011; 70 (OCE5): E324.
1 year mortality according to BMI
0
5
10
15
20
25
BMI classification (kg/ m2)<20 20-24.9 25-29.9 >30
p<0.001%
mor
talit
y
1-year mortality is four-fold higher in underweight patients compared to those classified as overweight or obese
Collins P. Thorax 2010;65(Suppl.4):A74
underweight 21%, normal weight 15%, overweight 5%, obese 4%; p <0.001
2.Nutritional Screening
Identifying patients at risk of malnutritionMalnutrition in COPD can present as1:
Assessing BMI alone will not pick up all patients who are at riskThe ‘Malnutrition Universal Screening Tool’ (‘MUST’) can help identify adults who are underweight and/or at risk of malnutrition2
Reduction in lean body mass
and/or unintentional weight loss
Low BMI (<20 kg/m2)and/or
1. Managing Malnutrition in COPD. http://malnutritionpathway.co.uk/copd/ 2. BAPEN. http://www.bapen.org.uk/musttoolkit.html[26.2.2016].
3.NICE Clinical Guidelines
NICE CG32: Nutrition Support in AdultsHealthcare professionals should consider oral nutrition support to improve intake for people who can swallow safely and are malnourished or at risk of malnutrition (A GRADE)
NICE CG101
BMI should be calculated in patients with COPD Normal range is 20-25kg/m2
If the BMI is abnormal, or changing over time refer for dietetic advice
If the BMI is low: Give ONS to increase total calorific
intake Encourage patient to take exercise to
augment the effects of ONS
4.Evidence for nutritional support in COPD
Evidence for nutritional support in COPDSystematic reviews and meta-analyses show multiple benefits of nutritional support in COPD1–3
1. Collins, et al. Am J Clin Nutr. 2012;95:1385-95. 2. Collins, et al. Respirology. 2013;18:616-29.3. Ferreira, et al. Cochrane Database Syst Rev. 2012;12:CD000998.
Study Number of trials Statistically significant outcomes
Collins et al. 20121
13 ↑ Nutritional intake↑ Weight gain↑ Hand grip strength
Collins et al. 20132
12 ↑ Inspiratory/expiratory muscle strength ↑ Hand grip strength
Ferreira et al. 20123
17 ↑ Weight gain↑ Fat-free mass/fat-free mass index↑ Fat mass/fat mass index ↑ Exercise capacity ↑ Health-related QoL
NICE CG32 – Evidence Update 46 (2013)
- Oral nutritional supplements appear to improve energy and protein intake, body weight, and functional outcomes in malnourished patients with stable COPD
- Evidence is consistent with the recommendation in NICE CG101 to give nutritional supplements to patients with COPD and a low BMI
- The evidence base now appears to be more robust
European Respiratory Society statement (2014)
Hospital Use of ONS in malnourished COPD patients1
*N.b. A 21.5% reduction in LOS equates to 1.9days (8.8 to 6.9 days)
1. Snider et al. CHEST 2015;147(6):1477 - 1484
• Average length of stay was reduced*
21.5%
• Total hospital costs were lowered
12.5%
• Hospital readmissions (within 30 days) were reduced
13.1%
5.Putting theory into practice
The Respiratory Healthcare Professional’s Nutritional Guideline for COPD PatientsThe original nutritional guideline for COPD patients was launched in 2011 and was supported by ARNS.
Managing Malnutrition in COPD
Coming soon at http://www.malnutritionpathway.co.uk/copd/1. Managing Malnutrition in COPD. http://malnutritionpathway.co.uk/copd/
A pathway for the appropriate use of ONS in the management of malnutrition in COPD
For ‘high risk’ patients and/or those with a BMI<20kg/m2
Guides you through goal setting and the appropriate use of ONS
When to stop ONS prescription
Management plans according to ‘MUST’ score
Re-categorise individuals according to improvement or deterioration
Reassess individuals identified at risk as they move through care settings
Low risk – score 0Routine clinical care
Provide green leaflet toraise awareness of importance of a healthy diet
If BMI>30kg/m2 (obese) treat according to local guidelines
Review / re-screen annually
Medium risk – score 1Observe
Dietary advice to maximise nutritional intake
Provide yellow leaflet to support dietary advice
NICE recommends patients with a BMI <20kg/m2 should be prescribed ONS
Review progress after 1–3 months
High risk – score 2+Treat as appropriate
Dietary advice to maximise nutritional intake
Provide red leaflet to support dietary advice
Prescribe ONS and monitor
Review progress
Refer to dietitian if no improvement
What can you do today to improve the nutritional management of your patients?
• Recognise that malnutrition is prevalent amongst patients with COPD
• Screen your patients! – ‘MUST’ at initial appointment and annually thereafter or more regularly where there is clinical concern
• Set nutritional goals with patient/carer
• Implement appropriate nutritional care plan
• ONS should be provided to patients with a low BMI (NICE CG101)
• Review at agreed intervals
Make nutrition an integral part of COPD care!
Questions
Thank you