Presentation by Sam Blamires, registered dietician and Senior Medical Affairs Advisor at Nutricia. Part of the PLAN Summer meeting 2016. A review of the latest evidence and guidelines on supporting nutrition in COPD, including the causes and consequences of malnutrition in COPD, the use of screening tools, the NICE guidelines on supplementation, and putting theory into practice.

1. Reviewing the latest
evidence and guidelines
Samantha Blamires
16th June 2016
Supporting Nutrition
in COPD

2. Who Am I?
Samantha Blamires
Registered Dietitian
Senior Medical Affairs Advisor
Samantha.blamires@nutricia.com

3. 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

4. 1.
Overview of
malnutrition in
COPD

5. 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.

6. 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].

7. 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.

8. 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.

9. 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

10. 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.

11. 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
%mortality
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

12. 2.
Nutritional
Screening

13. Identifying patients at risk of malnutrition
Malnutrition in COPD can present as1:
Assessing BMI alone will not pick
up all patients who are at risk
The ‘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].

14. 3.
NICE Clinical
Guidelines

15. NICE CG32: Nutrition Support in Adults
Healthcare 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)

16. 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

17. 4.
Evidence for
nutritional
support in COPD

18. Evidence for nutritional support in COPD
Systematic 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

19. 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

20. European Respiratory Society statement (2014)

21. 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
lowered12.5%
• Hospital readmissions (within
30 days) were reduced13.1%

22. 5.
Putting theory
into practice

23. The Respiratory Healthcare Professional’s
Nutritional Guideline for COPD Patients
The original nutritional guideline for COPD patients was launched in 2011 and
was supported by ARNS.

24. Managing Malnutrition in COPD
Coming soon at http://www.malnutritionpathway.co.uk/copd/
1. Managing Malnutrition in COPD. http://malnutritionpathway.co.uk/copd/

25. 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

26. 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 0
Routine clinical care
Provide green leaflet to
raise awareness of
importance of a healthy
diet
If BMI>30kg/m2 (obese)
treat according to local
guidelines
Review / re-screen
annually
Medium risk – score 1
Observe
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

27. 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!

28. Questions
samantha.blamires@nutricia.co
m

29. Thank you