This information was written by Harriet Smith, Registered Dietitian, in October 2019.
We've gathered relevant information and resources on a variety of disease areas to support healthcare professionals.
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Chronic Obstructive Pulmonary Disease (COPD)
Chronic obstructive pulmonary disease (COPD) is a common, preventable and treatable respiratory disease.
COPD is the third most common cause of death in the world
More than 90% of COPD deaths occur in low and middle income countries (LMICs)
The prevalence of COPD amongst men and women is almost equal.
COPD is characterised by persistent respiratory symptoms and airflow limitation. This is due to airway and/or alveolar abnormalities, usually caused by significant exposure to noxious (harmful) particles or gases. 2
Signs and Symptoms
Common signs and symptoms of COPD include3:
Shortness of breath, particularly on exertion
Ongoing or chronic cough
Regular sputum production
Frequent bronchitis/lower respiratory infections
Tobacco smoking is a leading cause of COPD. 4 However, incidences of COPD also occur in non- smokers. 5
External risk factors associated with COPD in non-smokers include :
Passive smoking (being in close proximity to other smokers)
Occupational exposure to substances e.g. coal and silica
Noxious fumes and vapours
Indoor air pollution from the burning of biomass fuels
Outdoor air pollution in urban areas
Internal risk factors include genetic predisposition, damaged airways due to prenatal maternal smoke exposure and childhood respiratory infection. 6
A small percentage of patients with a genetically inherited disorder known as alpha-1 antitrypsin deficiency will develop COPD. It often affects younger individuals, and usually results in the development of emphysema in the lower lobes of the lungs. It can sometimes be associated with bronchiectasis, asthma and liver involvement. 7 8
A diagnosis of COPD should be considered in patients displaying clinical signs and symptoms. This is especially important for individuals who have experienced prolonged exposure to the external risk factors mentioned above.
A diagnosis of COPD is confirmed by spirometry tests.
Spirometry is a standard procedure used to measure lung function; specifically, it measures the amount and/or speed of air inhaled and exhaled. 9
A spirometer provides the following readings: 10
FEV1: Forced Expiratory Volume in One Second. This is the volume of air exhaled in the first second and is frequently utilized as an index measure of airway obstruction. FEV1 enables the severity of the disease to be classified and the progression of obstructive lung disease to be followed over time
FVC: Forced Vital Capacity. This is the amount of air that can be forcibly exhaled from the lungs after taking the deepest breath possible. A reduced FVC value implies restrictive ventilatory defect and serves as an independent and reliable mortality predictor in the human population.
The FEV1/FVC ratio is used in the diagnosis of COPD. A normal ratio is above 0.75-85, though this is age dependent. Values less than 0.70 are suggestive of airflow limitation with an obstructive pattern and results in a diagnosis of COPD. 11
Section 2 Impact of COPD
COPD significantly impacts on the patients themselves12 and the wider healthy economy; in the United Kingdom, COPD costs the NHS around £1.9 billion each year. 13
Specifically, COPD has been associated with anxiety, depression and sleep problems. 17 18
In a 2014 systematic review, depression was a predictor of poor quality of life in people with COPD.19 Depression in COPD patients has also been found to be associated with an increased risk of hospital admission. 20 21
COPD is a progressively disabling condition which is associated with impaired health‐related quality of life. 14 15 16
NICE guidelines for depression in adults with a chronic physical health problem such as COPD recommend that healthcare professionals monitor for anxiety and depression amongst patients and signpost them towards relevant treatment services if necessary.
In addition to respiratory symptoms, physical incapacity and mental health problems, COPD patients often have comorbidities such as: 22
Obstructive sleep apnoea syndrome
Dysfunctional skeletal myopathies
Impaired health status and health-related quality of life is an independent predictor of hospitalisations and mortality. 23 24
Healthcare professionals working with COPD patients should work together in order to provide a multidisciplinary approach to managing multiple comorbidities.
Nutritional Implications of COPD
The prevalence of obesity amongst the COPD population is 42%. An interesting paradox can be seen in COPD, with overweight and mild obesity (BMI 25-30 kg/m2) being associated with improved survival rate and a slower decline in lung function. 25
On the contrary, the prevalence of disease-related malnutrition amongst the COPD community is estimated to be between 20% and 45%. 26
This article focuses on managing malnutrition in COPD since poor nutritional status is associated with negative outcomes in this patient group.
These may include: 27 28
Decreased muscle strength
More rapid deterioration in lung function
Decrease in exercise capacity
Worsening quality of life indices 29
Increased length of hospital stay
More frequent exacerbations
Increased mortality rates
Malnutrition is a significant and independent predictor of mortality in COPD patients, with malnourished patients having a threefold increased risk of dying within a year. 30
Inadequate dietary intake is the most commonly cited reason for malnutrition in COPD patients. 31
32 Poor dietary intake can be affected by many different factors, including loss of appetite, depression and anxiety and physical limitations such as difficulty breathing while eating, problems chewing, taste alterations and coughing. 33
Other causes of malnutrition in COPD include:
An imbalance between energy intake and expenditure; it has been demonstrated that resting energy expenditure (REE) is increased in COPD patients 34
Systemic inflammation 35
Hypoxia (when the blood does not deliver enough oxygen to the air sacs in the lungs)
Effect of medications
Changes in body composition. 36 Around a third (35%) of COPD patients have a fat free mass
(FFM) which is significantly lower than normal. 37
Screening for Malnutrition in COPD Patients
BAPEN, the British Association for Parenteral and Enteral Nutrition, recommends routine nutritional screening with a validated screening tool such as the Malnutrition Universal Screening Tool
(MUST) for all COPD patients. 38
This should be done on first contact with a patient and after any changes in condition (such as recent exacerbations or changes in social or psychological status).
Repeat screening should take place at least annually and more frequently if risk of malnutrition is identified.
NICE guidelines recommend that Body Mass Index (BMI) should be calculated in all patients with COPD and that they should be referred to a dietitian for advice if they have a BMI which has changed significantly over time or is outside the range of 20 to 25 kg/m2. 39
NICE also state that special attention must be paid to unintentional weight changes, particularly if the change is more than 3kg in the elderly.
Nutritional Strategies for COPD Patients
Identifying and addressing malnutrition in COPD patients can improve nutritional status, clinical outcomes and reduce healthcare costs. 40
If patients are deemed to be ‘at risk of malnutrition’, nutritional goals should be agreed and appropriate steps taken to correct malnutrition and optimise nutritional status.
Dietetic strategies may include provision of dietary information (i.e. food-first advice), special diets (i.e. texture-modified), eating assistance and oral nutrition supplements.
The nutrition advice given should aim to increase intake of all micro- and macronutrients. However, it’s important to note that nutritional requirements (particularly for energy and protein) may vary depending on whether the patient has stable COPD or an acute exacerbation. 41
For patients who have lost weight, a weight gain of 2kg should be used as a therapeutic target as this amount has been associated with a number of functional improvements in COPD patients. 42
Pulmonary rehabilitation is often used in COPD patients and nutrition should be implemented as part of this treatment plan. 43
The Managing Malnutrition in COPD Pathway
“The Managing Malnutrition in COPD Pathway is a practical guide to assist healthcare professionals in identifying and managing people with COPD who are malnourished or at risk of disease-related malnutrition.” (Malnutrition Pathway, 2019)
It is based on clinical evidence alongside accepted best practice and includes guidance to assist in the appropriate use of oral nutritional supplements (ONS).
The pathway recommends a treatment algorithm for COPD patients based on MUST screening tool scores. It is accompanied by a series of colour-coded information booklets for use with patients, which include dietary advice for the three malnutrition risk categories (low risk, medium risk, high risk).
Identifying Malnutrition According to Risk Category Using 'MUST' - First Line Management Pathway
MUST Score 0 Low Risk - routine clinical care
Provide green information leaflet: Eating Well For Your Lungs to raise awareness of the importance of a healthy diet
If BMI >30 (obese) treat according to local guidelines
Review / re-screen annually.
MUST Score 1 Medium Risk - observe
Dietary advice to maximise nutritional intake. This includes encouraging small frequent meals and snacks, with high energy and protein food and fluids
Provide yellow leaflet: Improving Your Nutrition In COPD to support dietary advice
NICE recommends COPD patients with a BMI <20kg/m2 should be prescribed oral nutritional
Review progress after 1-3 months
If improving continue until ‘low risk’ - if deteriorating, consider treating as ‘high risk’.
MUST Score 2 + High Risk - treat
Dietary advice to maximise nutritional intake. This includes encouraging small frequent meals and snacks, with high energy and protein food and fluids
Provide red leaflet: Nutrition Support In COPD to support dietary advice
Prescribe oral nutritional supplements (ONS) and monitor
On improvement, consider managing as ‘medium risk’
Oral Nutritional Support and COPD
A growing number of studies supports the use of Oral Nutritional Supplements (ONS) in malnourished patients with COPD.
A Cochrane Review of 17 studies44 found that nutritional supplementation promoted an average weight gain of 1.65 Kg over a 24 week period and improved respiratory muscle strength, walking and quality of life in malnourished COPD patients.
Further systematic reviews and meta-analyses of nutritional support45 found that taking ONS for 8 weeks significantly improved respiratory muscle strength, handgrip strength, weight gain (≥2 kg), exercise performance, and quality of life. 46
The use of ONS in COPD patients whilst in hospital has also been associated with a 22% decreased length of hospital stay, a 13% reduction in hospitalisation costs and a 13% decrease in the probability of readmission within 30 days. 47
Appropriate Usage of ONS
The Managing Malnutrition in COPD Pathway recommends the following for the appropriate use of ONS for patients with a low BMI or at risk of malnutrition:
Clinical benefits of ONS are often seen with 300-900kcal/day, typically within 2-3 months of supplementation. 48 49 Prescribe 1-3 ONS bottles/sachets per day in addition to oral intake.
Review for compliance and adjust for flavour (if needed) after 6 weeks.
Patients may benefit from a low volume, high energy/high protein ONS in addition to dietary
advice due to symptoms of COPD.
If following a pulmonary rehabilitation programme consider increased energy and protein
Continue ONS for a 12 week duration according to clinical condition/nutritional needs.
After 12 weeks, patients should be reviewed. ONS should be reduced and eventually stopped
if nutritional and weight goals have been met. If goals have not been met, adjust the ONS to
suit the patient’s requirements
Thereafter, patients should be reviewed every 3-6 months or upon change in clinical
Stop ONS prescription if goals of intervention have been met and individual is no longer at
risk of malnutrition.
Further Resources on COPD
NICE guidelines for COPD diagnosis and management
British Lung Foundation - What is COPD?
Managing Malnutrition in COPD Pathway
Nursing Times - Nutrition Screening in Patients with COPD
COPD Foundation - Nutrition for Someone with COPD
Nutritional support and functional capacity in chronic obstructive pulmonary disease: a systematic review and meta-analysis.
The influence of deprivation on malnutrition risk in outpatients with chronic obstructive pulmonary disease (COPD).
Cochrane Review: Nutritional Supplementation for Stable COPD
Nutritional Support in COPD: a systematic review and meta-analysis
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