Supporting Nutrition in COPD: Sam Blamires. PLAN Summer meeting

Reviewing the latest evidence and

guidelinesSamantha Blamires

16th June 2016

Supporting Nutrition in COPD

Who Am I?

Samantha Blamires

Registered DietitianSenior Medical Affairs Advisor

Samantha.blamires@nutricia.com

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

samantha.blamires@nutricia.com

Thank you