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Identification of malnutrition—nutritional screening

  • Identifying and managing malnutrition (in the general population and in individuals with chronic obstructive pulmonary disease (COPD)) can improve nutritional status, clinical outcomes, and reduce healthcare use
  • Routine nutritional risk screening with a validated screening tool should be performed in all COPD patients across settings
  • NICE guidelines recommend body mass index (BMI) is calculated in all patients with COPD
  • Screening should take place on first contact with a patient and/or upon clinical concern e.g. recent exacerbation, change in social or psychological status. A review should take place at least annually and more frequently if risk of malnutrition is identified
  • ‘MUST’ is a simple 5 step screening tool that can be used across care settings to identify adults who are at risk of malnutrition (see Figure 1). It combines assessment of BMI, recent weight loss, and presence of acute illness
  • Unintentional weight loss of 5–10 % over 3–6 months indicates risk of malnutrition irrespective of BMI

Considerations

  • Weight loss may be a sign of other conditions, e.g. malignancy. These conditions should be excluded before it is assumed that weight loss is COPD related
  • Care should be taken when interpreting BMI or percentage weight loss if oedema is present
  • Mid upper arm circumference (MUAC) can be used in the presence of severe oedema, or in the absence of weight measurement, to estimate BMI (MUAC of <23 cm often indicates a BMI <20 kg/m2)

Principles of the management of malnutrition in COPD

  • Once identified as at risk of malnutrition, individuals with COPD can be managed using the pathways in this summary (see Figures 1 and 2). The principles of the management strategies in the pathways are detailed below
  • Management of malnutrition should be linked to the risk category (low, medium, or high risk)
  • For all individuals:
    • record risk
    • agree goals of intervention
    • monitor

Goal setting—agree goals of intervention with individual/carer

  • Set goals to assess the effectiveness of intervention, taking into account the disease stage and prognosis
  • Goals could include: increase lean body mass, improve nutritional status e.g. minimise weight loss and loss of function (e.g. in palliative care or advanced illness)
  • Stable COPD: it may be appropriate to aim for an increase in body weight and fat-free mass. Amongst those who are malnourished a 2 kg increase is suggested as a threshold at which functional improvements are seen, timescales will depend on the individual’s condition
  • Acute Exacerbations: minimising the loss of weight and fat free mass through nutritional intervention may be an appropriate goal
  • Pulmonary Rehabilitation: is recommended as part of the management of individuals with COPD, and nutrition should be incorporated as part of the intervention. Nutritional intervention is likely to support the effectiveness of exercise programmes in malnourished COPD patients
    • consideration should be given to optimising nutritional status during pulmonary rehabilitation as energy requirements may increase with increased physical activity. Dietary advice and ONS should be considered for those at risk of malnutrition to ensure further weight loss is prevented

Management of malnutrition

  • Follow guidance in the management pathway (see Figure 1). This includes different strategies depending on the malnutrition risk category
  • Management options can include: dietary advice, assistance with eating, texture modified diets, and ONS where indicated
  • Dietary advice should aim to increase intake of all nutrients including energy, protein, and micronutrients (vitamins and minerals)
  • Consideration should be given to issues which may impact on food intake and the practicalities of dietary advice, such as mobility and access to food, particularly in patients on home oxygen therapy
  • Smoking cessation is an important strategy to support the management of malnutrition and may increase appetite and support weight gain. Patients may also find their senses of smell and taste are enhanced if smoking is stopped; making food more pleasurable

Monitoring progress

  • Monitor progress against goals and modify intervention appropriately
  • Consider weight change, strength e.g. ability to perform activities of daily living, physical appearance, appetite, and disease progression
  • Frequency of monitoring depends on the risk category and intervention
  • Further information on nutritional monitoring can be found in insert NICE Clinical Guideline 32 (CG32) Nutrition support for adults: oral nutrition support, enteral tube feeding, and parenteral nutrition

Figure 1: Identifying malnutrition according to risk category using ’MUST’—first-line management pathway

identifying malnutrition according to risk category using must first line management pathway 1280

Figure 2: Pathway for using ONS in the management of malnutrition in COPD

pathway for using oral nutritional supplements ons in the mangement of malnutrition in copd open

Optimising nutritional intake-an evidence based approach to managing malnutrition

NICE Guidance (CG32 and CG101)

  • NICE Clinical Guideline 101 (CG101) Chronic Obstructive pulmonary disease in over 16s: diagnosis and management recommends ONS are provided for individuals with COPD with a low BMI (<20 kg/m2). NICE CG32 recommends considering oral nutrition support to improve nutritional intake for people who can swallow safely and are malnourished or at risk of malnutrition

Dietary advice to optimise nutritional intake

  • Dietary advice should be used with care, as it may supplement energy and/or protein without providing adequate additional micronutrients and minerals
  • Dietary advice forms an important component of the management pathway, and should be used alongside ONS where indicated, i.e. where BMI is low (<20 kg/m2) or in high risk individuals
  • Individuals with COPD may also have concerns which affect the acceptability of dietary advice e.g. reservations about weight gain. Clear communication of the goals of nutritional interventions is important, e.g. to preserve or improve lean body mass, maintain lung strength, overcome infection, improve ability to perform activities of daily living etc
  • Consideration should be given to the practicalities of implementing dietary advice strategies in all individuals

ONS to optimise nutritional intake

  • Evidence from systematic reviews show ONS in COPD can:
    • significantly improve hand-grip strength
    • significantly improve respiratory muscle strength
    • significantly improve exercise performance
    • significantly improve patients’ nutritional intake
    • significantly improve weight
    • improve quality of life
  • ONS increase energy and protein without affecting dietary intake
  • Higher energy ONS (≥2 kcal/ml) or low volume high energy ONS may aid compliance and be easier to manage for individuals with early satiety and/or breathlessness
  • Increased requirements for protein and other nutrients in COPD may be managed with a low volume, high energy/high protein ONS
  • Maximise oral intake by recommending low volume, energy dense ONS to be taken in small, frequent doses, e.g. between meals
  • Clinical benefits of ONS are often seen with 300–900 kcal/day (1–3 bottles), typically within 2–3 months of supplementation

 

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Full guideline and patient leaflets available to download for free from…www.malnutritionpathway.co.uk/copd/

ARNS, BAPEN, NNNG. Managing malnutrition in COPD. June 2016 (publication).

First included: June 2017.