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NUTRITION

The role of nutrition in the management of COPD patients

Edel McGinley

This article examines the role of m alnutrition in chronic obstructive pulmonary disease (COPD). Until recently, weight loss was considered an inevitable consequence of COPD, however, modern research has dem onstrated that weight gain is in fact achievable and can result in functional improvements. It is im portant that community nurses are aware of the importance of nutrition in COPD, both in screening for m alnutrition and developing appropriate treatm ent plans, including the use of oral nutritional supplem ents alongside dietary advice and counselling. The current NHS policy of moving care 'closer to home' is resulting in more complex COPD patients being managed in the community and with this comes the challenge of managing reduced weight and low oral intake. It is, therefore, essential that community nurses develop the necessary skills and resources to deal with this growing group of patients.

KEYWORDS: Malnutrition ■ COPD ■ Nutritional supplements ■ Diet

An estimated 835,000 people are affected by chronic obstructive pulmonary disease (COPD) in the UK, with a further two million remaining undiagnosed (Shahab et al, 2006). COPD is a chronic progressive lung disease, which makes breathing difficult due to partially obstructed airflow into and out of the lungs. It results from inflammation stimulated by exposure to toxins, primarily due to a history of smoking. It is the fifth largest cause of respiratory deaths in the UK (British Thoracic Society, 2006).

Edel McGinley, lead specialist community nutrition support dietitian, Ealing Hospital NHS Trust, London

'In pa tien ts w ith COPD, lo w bo dy w e ig h t a n d s ig n ifican t w e ig h t loss a re assoc ia ted w ith a redu ced overa ll prognosis a n d increased m orta lity , in d e p e n d e n t o f th e severity o f th e d isea se 1

COPD is an umbrella term that includes both emphysema and chronic bronchitis. Patients with emphysema experience shortness of breath due to a reduction in the elasticity and eventual damage to the air sac walls in the lungs. This leads to impaired exhalation and a resultant build-up of carbon dioxide in the lungs. These patients typically present as underweight, often exhibiting significant weight loss due to the increased energy output associated with laboured breathing (Wouters, 2000).

In contrast, in the author's experience, patients with chronic

bronchitis typically present as normal weight or overweight, but have a persistent cough, increased mucous production and shortness of breath due to inflammation, scarring, and eventual narrowing of the airways.

Compared to those who are undernourished, obese and overweight COPD patients can experience: ► Improved survival (Landbo

et al, 1999) ► Fewer early readmissions (Steer

et al, 2010) ► Fewer emergency hospital

admissions and shorter lengths of stay (Collins et al, 2011).

ROLE OF NUTRITION IN COPD

In patients with COPD, low body weight and significant weight loss are associated with a reduced overall prognosis and increased mortality, independent of the severity of the disease (Landbo et al, 1999). Therefore, dietary

Table 1: Reasons for poor nutritional intake

Difficulty swallowing or chewing due to dyspnoea (shortness of breath)

Chronic 'mouth breathing', which can alter the taste of food

Chronic mucous production

Coughing

Fatigue

Morning headache or confusion due to hypercapnia (increased carbon dioxide in the blood)

Anorexia

Depression

Side-effects of medications

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education and intervention play important roles in the management of patients with COPD.

Malnutrition is a significant problem in patients with COPD, with several factors contributing to

a lowered body weight and weight loss, including (Congleton, 1999; Slinde et al, 2002): ► Increased resting

energy expenditure ► Increased energy expenditure

during activity ► Reduced dietary intake.

'M U ST' Tool

a Add scores together to calculate overall risk of malnutrition.

Score 0: Low risk

Score 1: Medium risk

Score 2 or more: High risk

* ------------------------------1

0 Low risk

i 1 M edium risk

r---------------------------- 1 2 or m ore H igh risk

R o u t in e c l in ic a l O b s e r v e T re a t*

c a r e • Follow'MUSTT care • Follow action plan for

• Ensure appropriate food pathway on page 10 medium risk

and drink choices of guidelines booklet • Refer to dietitian* • Repeat screening every (available at: www. • Re-weigh weekly

3-6 months, unless there bapen.org.uk/screening- • Document action taken

are clinical concerns for-malnutrition/must/

• Document action taken must-toolkit/the-must- *unless 'detrimental1 or 'no' explanatory-booklet) benefit is expected from

nutritional support, i.e. end o f life care pathway

----------- ■ ■ J S 1 ^ J This tool is to assist your assessment.

If in doubt, use your professional judgement

British Assodation for Parenteral and Enteral Nutrition (BAPEN) Malnutrition Universal Screening Tool BAPEN (2004)

Available from: www.bapen.org.uk/pdfs/must/must_full.pdf

Figure 1. The MUST malnutrition assessment tool.

R e d F la g S u d d e n s h o rtn e s s

o f b r e a th

S u d d e n u n e x p e c t e d b r e a t h l e s s n e s s c a n b e a c lu e t o a n u m b e r o f p o t e n t i a l l y d a n g e r o u s h e a l t h p r o b l e m s , i n c l u d i n g :

► C O P D : i f a p a t i e n t h a s C O P D , s u d d e n b r e a t h l e s s n e s s i s a s i g n t h a t t h e i r c o n d i t i o n h a s s u d d e n l y w o r s e n e d a n d m e d i c a l h e l p s h o u l d b e s o u g h t i m m e d i a t e l y

► A s t h m a a t t a c k : t h i s w i l l c a u s e t h e a i r w a y s t o n a r r o w a n d p r o d u c e i n c r e a s e d p h l e g m r e s u l t i n g in w h e e z i n g a n d c o u g h i n g — a g a i n m e d i c a l a t t e n t i o n

s h o u l d b e s o u g h t

► P n e u m o n i a ( l u n g i n f l a m m a t i o n ) c a n a l s o c a u s e s h o r t n e s s o f b r e a t h , u s u a l l y a s a r e s u l t o f a n i n f e c t i o n . T h e p a t i e n t m a y n e e d a c o u r s e o f a n t i b i o t i c s .

Other factors that contribute to a reduced nutritional intake include: ► Increased shortness of breath ► Chronic 'mouth breathing' ► Coughing ► Loss of appetite ► Difficulty swallowing or chewing

due to dyspnoea (shortness of breath) (Table T).

Other factors that can affect nutritional intake in COPD include anorexia and early satiety (where a person feels full after eating a small amount of food) (Cochrane and Afolabi, 2004).

Those patients identified as malnourished or at risk of malnutrition are more likely to be admitted to hospital, experience increased length of hospital stay, have earlier readmission rates and have a poorer prognosis. In particular to COPD, malnutrition can impair pulmonary function, increase susceptibility to infection, lower exercise capacity, and increase the risk for mortality and morbidity (Ferreira et al, 2000).

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Five-minute test

Answer the following questions about this article, either to test the

new knowledge you have gained or to form part of your ongoing practice

development portfolio.

1 - What is a common definition of malnutrition?

2 - Name some of the causes of malnutrition.

3 - How does malnutrition affect the patient with COPD?

4 - How can community nurses best assess people's risk of malnutrition?

5 - List five practical ways in which community nurses can help to treat malnutrition in patients with COPD.v__ ;____

When addressing the nutritional status of COPD patients who present as underweight (body mass index [BMI] of less than 18.5kg/m2), and/or with significant weight loss (greater than 10% in six months), the main focus is to increase total calorie intake thus maintaining a stable weight, or to promote weight gain to improve clinical and functional outcomes (Ferreira et al, 2012).

IDENTIFYING MALNUTRITION

It is essential that community nurses understand how to undertake regular nutritional screening to identify and develop appropriate care plans in all patients, but specifically in those with COPD. To do this they should know how to use a validated nutritional screening tool.

The tool most commonly used in the UK is MUST (malnutrition universal screening tool) developed by BAPEN (British Association of Parenteral and Enteral Nutrition, 2004) — this is recommended in the National Institute for Health and Care Excellence (NICE) (2006) guidelines for nutritional support.

MUST is a validated tool for use within the primary care setting and involves three steps: ► BMI score ► Percentage weight loss score ► Disease effect score (likely

decrease in oral intake for more than five days) (Figure 1).

It is vital that community nurses screen all new patients and continue to regularly screen current patients as per local guidelines — only in this way will they be able to spot any deterioration in the patient's nutritional status.

Patients with a MUST score of '2' or more should be referred directly

to a dietitian for further assessment and support. Those patients who score '1', have a medium risk of malnutrition and, in the case of COPD, it is essential that dietary advice is provided to prevent further weight loss.

DIETETIC INTERVENTION

In the management of malnutrition, the dietitian may use one or a combination of the following approaches in a patient with COPD: ► Dietary advice and support to

increase dietary intake, focusing on the frequency of meals and the types of food/fluid consumed

► Food fortification — aimed at improving the energy 'density' of meals and snacks

► Prescription of oral nutrition support supplements.

Dietary advice should include the following: ► Eat meals when energy levels

are at their highest, which is usually in the morning

► Eat several small energy dense meals to avoid becoming breathless while eating

► Eat slowly and chew foods thoroughly to avoid 'swallowing air' while eating

► Choose foods that are easy to chew or change the food consistency if the patient reports fatigue on eating. This can be done by using energy dense liquids to create a softer texture, e.g. adding full-fat milk and butter to mashed potato or meat- based gravy to cottage pie. Avoid the use of water or clear fluids such as stock and broth as these will increase the volume of food but decrease the energy content further, thereby increasing the risk of decreased calorie intake

► Choose foods that are easy to prepare — this conserves energy for eating

► Eat while sitting up to ease pressure on the lungs

► Drink fluids at the end of the meal rather than during — this will lessen the likelihood of the patient 'feeling full' while eating.

Stratton et al (2003) have demonstrated the benefit of

nJ THE SCIENCE — UNDERSTANDING MALNUTRITION ^ Malnutrition develops when an individual's diet does not contain

the right amount of nutrients. It is commonly used to mean 'undernutrition' — where people do not take in enough nutrients — however, it can also mean 'overnutrition', where the individual takes in more nutrients than required. It is estimated there are about three million malnourished people in the UK at any one time and up to one-in-three people admitted to hospital are malnourished or at risk of malnourishment. Malnutrition results from either an inadequate diet or a problem that prevents a person from absorbing enough nutrients from food, including reduced mobility, long-term health conditions or low income. By far the most obvious sign of undernutrition is unplanned weight loss, however, other signs include weakened muscles, persistent tiredness, low mood, and a rise in illnesses or infections.

Source: NHS Choices: www.nhs.uk/conditions/malnutrition

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oral nutrition supplements in malnourished patients with stable COPD, including: ► Improved energy and

protein intake ► Improved body weight ► Improved functional

outcomes (such as peripheral muscle strength, and maximum inspiratory and expiratory pressure).

However, oral nutrition supplements are not effective as a sole treatment option in all patients and reported compliance rates can be as low as 50%, especially in the elderly (Payette et al, 2002; Bonnefoy et al, 2003). Poor compliance can be influenced by: ► Taste fatigue (where patients

who have been taking oral nutrition supplements for a long time become bored with the lack of flavour or similar flavours)

► Gastrointestinal symptoms ► Individual preference.

As discussed above, other factors that can affect patients' tolerance of oral nutrition supplements include early satiety and anorexia. Anker et al (2006) recommended energy dense (high in calorie and protein) and small volume oral nutrition supplements, and/or small energy dense and frequent meals to help alleviate these problems. The author's recent practice also shows that poor compliance can be improved with the use of energy dense oral nutrition supplements, which are now readily available on prescription for disease-related malnutrition, including in COPD patients.

Weight gain Stratton et al (2003) reported that a weight gain of at least 2kg is required in COPD patients in order to achieve any benefit from nutritional intervention.

This was similarly reported in a study by Weekes et al (2008), which demonstrated that dietary counselling resulted in significant benefits for dietary intake, body composition and quality of life in a COPD patient group who achieved weight gain of at least

2kg. The researchers focused on dietary education and counselling for a period of at least six months and advice was tailored and individualised for each patient (Weekes et al, 2008). It was also noted that some beneficial effects persisted for at least six months after the intervention period, in contrast to the use of oral nutrition supplements as a sole treatment option.

These results were backed up in research by Efthimiou et al (1988), which demonstrated decreased oral intake and further weight loss when nutrition supplements were discontinued, particularly in patients with COPD.

'W hen addressing nutritional intake and status with COPD patients, it is im portant for community nurses to rem em ber that not all symptoms can be tackled by nutritional intervention alone — often a multidisciplinary approach needs to be considered1

Counselling The kind of dietary counselling mentioned in the above studies can consist of: ► Taking a detailed dietary history,

which gathers information on frequency of meals, snacks and drinks, portion sizes, cooking methods, and the patient's support network

► The drawing up of personalised dietary goals to increase calorie and protein intake based on the dietary history. These goals can include food fortification (adding extra calories to meals or snacks using high-calorie, high-protein foods, e.g. butter, cream, yogurt, milk); manipulating meal patterns (increasing frequency of energy dense snacks between meals); and/or recommending energy dense drinks (e.g. full-fat milk; making coffee/tea with half milk/half water; and malt or hot chocolate drinks).

KEY POINTS

ntil recently, weight loss was considered an inevitable consequence of COPD, however, modern research has demonstrated that weight gain is in fact achievable.

It is important that community nurses are aware of the importance of nutrition in COPD, both in screening for malnutrition and developing appropriate treatment plans.

The current NHS policy of moving care 'closer to home' is resulting in more complex COPD patients being managed in the community, and with this comes the challenge of managing reduced weight and low oral intake.

It is essential that community nurses develop the necessary skills to deal with this growing group of patients, including knowledge of therapies such as oral nutritional supplements and dietary advice.

The above studies suggest that with the use of tailored advice based on a patient's dietary preferences, symptoms, support network and lifestyle, it may be possible to achieve compliance for longer periods, even in the absence of long-term direct dietetic intervention and monitoring. For example, Weekes et al (2008) demonstrated that in stable COPD outpatients, dietary advice plus a six-month supply of whole milk powder had beneficial effects, including: ► Significant improvements in

nutritional intake, body weight, functional status and quality of life

► Effects lasting for six months beyond the intervention period.

Leaflets Weekes et al (2008) also examined the use of dietary advice leaflets versus nutritional counselling (with or without oral nutrition

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supplements) and found that providing literature is ineffective in achieving weight gain and functional benefits in COPD patients.

It is important to stress the importance of education and counselling alongside oral nutrition supplements as, in the author's experience, it is common in primary and secondary care for patients to be prescribed oral nutrition supplements as a sole treatment for weight loss without referral to a dietitian for specialist input or dietary advice.

The combination of education and counselling alongside oral nutrition supplements provides the patient with greater choice and results in long-term changes, ultimately supporting improvements in nutritional status and weight gain beyond the initial intervention period.

MULTIDISCIPLINARY APPROACH

When addressing nutritional intake and status with COPD patients, it is important for community nurses to remember that not all symptoms can be tackled by nutritional intervention alone — often a multidisciplinary approach needs to be considered. An example would be a patient whose dyspnoea (shortness of breath) causes problems when eating — this could be discussed with a respiratory nurse specialist, who might suggest the use of oxygen therapy alongside small easy- to-prepare energy dense meals, thereby minimising the burden of eating on the patient's breathing.

CONCLUSION

In the author's opinion, the way that nutrition in COPD patients is managed within the community needs more thought, particularly as nutritional interventions often extend no further than the provision of dietary leaflets.

Although many community nurses already educate and

support patients, initiating changes where possible, it is vital that all community staff are aware of the range of interventions available.

This article highlights the need for a multidisciplinary approach to pulmonary rehabilitation and management of COPD patients, including timely referral to the dietitian for specialist input.

It is also crucial that community nurses do not simply provide oral nutrition support to patients with COPD, but also consider the use of dietary counselling in order to maintain any improvements over a longer period of time. jcn

REFERENCES

Anker SD, John M, Pederson PU, et al (2006) ESPEN Guidelines on enteral nutrition; cardiology and pulmonology. Clin Nutr 25: 311-18

BAPEN (2004) Malnutrition Universal Screening Tool. Available at: www. bapen.org.uk/must_tool.html (accessed 4 July, 2014)

Bonnefoy M, Cornu C, Normand S, et al (2003) The effects of exercise and protein-energy supplements on body composition and muscle function in frail elderly individuals: a long term controlled randomised study. Br J Nutr 89: 731-38

British Thoracic Society (2006) The Burden of Lung Disease. 2nd edn. British Thoracic Society, London

Cochrane WJ, Afolabi OA (2004) Investigations into the nutritional status, dietary intake and smoking habits of patients with chronic obstructive pulmonary disease./ Human Nutr Diet 17: 3-11

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

Congleton J (1999) The pulmonary cachexia syndrome: aspects of energy balance. Proc Nutr Soc 58: 321-28

Efthimiou J, Feming J, Gomes C, et al (1988) The effect of supplementary oral nutrition in poorly nourished patients

with chronic obstructive pulmonary disease. Am J Resp Dis 137: 1075-82

Ferreira IM, Brooks D, Lacasse T, Goldstein RS (2000) Nutritional support for individuals with COPD: A meta-analysis. Chest 117(3): 672-78

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

Landbo C, Prescott E, Lange P, Vestbo J, AlmdalTP (1999) Prognostic value of nutritional status in chronic obstructive pulmonary disease. Am ] Resp Crit Care Med 160: 1856-61

NICE (2006) Nutrition Support in Adults: oral nutrition support, enteral tube feeding and parenteral nutrition. Clinical Guideline 32. NICE, London

Payette H, BoutierV, Coulombe C, et al (2002) Benefits of nutritional supplementation on free living, frail, undernourished elderly people: a prospective randomised community trial. J Am Diet Assoc 102: 1088-95

Shahab L, Jarvis M J, Britton J, West R (2006) Prevalence, diagnosis and relation to tobacco dependence of chronic obstructive pulmonary disease in a nationally representative population sample. Thorax 61(12): 1043-47

Slinde F, Gronberg AM, Engstrom CP, Rossander-Hulthen L, Larrson S (2002) Individual dietary intervention in patients with COPD during MDT rehabilitation. Resp Med 96: 330-36

Steer J, Gibson GJ, Bourke SC. Stratton RF (2010) Predicting outcomes following hospitalization for acute exacerbations of COPD. QJM 103(11): 817-29

Green CJ, Elia M (2003) Disease-related Malnutrition: an evidence-based approach to treatment. CAB International Wallingford, Oxon

Weekes CE, Emery PW, Elia M (2008) Dietary counselling and food fortification in stable COPD: a randomised trial. Thorax 64: 326-31

Wouters EFM (2000) Nutrition and metabolism in COPD Chest 117(5 Suppl): 274-80

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