Dr Anita Nathan identifies key learning points for primary care from a best-practice guide to managing malnutrition in COPD
Read this article to learn more about:
- the clinical impact of malnutrition for people with chronic obstructive pulmonary disease (COPD)
- updated guidance on preventing, identifying, and managing malnutrition in people with COPD in the community
- a best-practice pathway for using oral nutritional supplements in people with COPD who are at high risk of malnutrition.
After reading this article, ‘Test and reflect’ on your updated knowledge with our multiple-choice questions. We estimate that this activity will take you 30 minutes—worth 0.5 CPD credits.
Chronic obstructive pulmonary disease (COPD) is a progressive lung disease caused by chronic inflammation and damage to the respiratory system. It results in restricted airflow causing breathing difficulties.1 Around one in three inpatients2 and one in five outpatients3 with COPD are at risk of malnutrition. Malnutrition is an imbalance of energy, protein, and other nutrients that causes adverse effects on the body (shape, size, and composition), its functions, and clinical outcomes.4
Malnutrition can develop over several years or be precipitated by an acute exacerbation of COPD. The causes of malnutrition in patients with COPD are varied and include:1
- psychological, social, and environmental factors e.g. depression, social isolation, and poverty
- medication e.g. taste changes and dry mouth secondary to oxygen therapy
- physiological effects of the disease e.g. breathlessness and fatigue that reduce appetite and the ability to eat
- increased nutritional requirements e.g. energy and protein.
Individuals with COPD may have increased nutritional requirements arising from systemic inflammation and the increased effort associated with breathing. As their disease progresses, people with COPD may experience infective exacerbations with consequential reduction in their body mass index (BMI) and skeletal mass and strength, in the form of sarcopenia or cachexia.5,6
For people with COPD who are malnourished and underweight, the consequences are significant and can further impair nutritional intake7 and lead to reduced muscle strength and respiratory muscle function, more hospital admissions, longer hospital stays, and higher mortality rates.1 The annual health and social care costs of managing patients with malnutrition are more than three times greater than those of managing non-malnourished patients.1 Therefore, it is essential for both the patient and the healthcare system that malnutrition is proactively and effectively managed in people with COPD.
Managing malnutrition in COPD1 is a best-practice guide launched in 2016. Developed by a multi-professional expert panel, it collates clinical evidence, clinical experience, and best practice to support primary care professionals incorporate malnutrition screening and management in COPD care pathways. The guide is endorsed by 10 professional and patient associations and includes an endorsement statement from NICE. In January 2020, a second edition of the guide was published to incorporate:
- recent NICE guidance (NICE Guideline [NG] 115, Chronic obstructive pulmonary disease in over 16s: diagnosis and management)8
- the Global Initiative for Chronic Obstructive Lung Disease (GOLD) strategy9
- updates on energy and protein requirements for people with COPD10–12
- revised advice on nutritional intervention alongside pulmonary rehabilitation programmes that have been found to improve patient outcomes.8,13–16
The Managing malnutrition in COPD guide includes information on screening for malnutrition as well as on management and is supported by three patient information leaflets that are free to download:
- Eating well for your lungs for those at low risk of malnutrition (www.malnutritionpathway.co.uk/library/green.pdf)
- Improving your nutrition in COPD for those at medium risk of malnutrition (www.malnutritionpathway.co.uk/library/yellow.pdf)
- Nutrition support in COPD for those at high risk of malnutrition (www.malnutritionpathway.co.uk/library/red.pdf)
This article highlights the key learning points for primary care from the Managing malnutrition in COPD guide.
1. Screen for malnutrition routinely
NICE Guideline 115 recommends routine nutritional risk screening for all individuals with COPD across all settings using a validated screening tool. It also recommends that BMI is calculated in all patients with particular attention to unintentional weight loss in older people.8
The Malnutrition Universal Screening Tool (MUST)17 is a validated, simple, and widely used five-step screening tool that combines assessment of BMI, recent unplanned weight loss, and presence of acute illness to generate a malnutrition risk score (see Figure 1). It can be embedded in existing COPD care pathways with regular recording of weight. The MUST is integrated in Managing malnutrition in COPD,1 which outlines the appropriate management options for people who are at low, medium, and high risk of malnutrition and includes information on monitoring intervals.
2. Manage malnutrition according to risk
People with COPD who are at low risk of malnutrition should follow general healthy eating advice. The patient information leaflet Eating well for your lungs (www.malnutritionpathway.co.uk/library/green.pdf) provides information on healthy eating along with tips on coping with common symptoms like dry mouth and taste changes. These patients should be rescreened annually or if there is clinical concern.
Obesity, malnutrition, and COPD can coexist. Therefore, when offering dietary advice to overweight or obese patients with COPD, consider the preservation of muscle mass with enough protein.1 Further definitive randomised controlled trials are needed to formulate guidance for the management of obesity in COPD.
People at medium risk of malnutrition should be given dietary advice including information on food fortification. The leaflet Improving your nutrition in COPD (www.malnutritionpathway.co.uk/library/yellow.pdf) contains information and advice. Progress should be reviewed every 1–3 months.
Based on the evidence available, people at high risk of malnutrition should be given dietary advice as above, and prescribed two oral nutritional supplements (ONS) per day for up to 12 weeks or according to clinical need.1 In addition, NICE recommends that patients with COPD and a BMI less than 20 kg/m2 should be prescribed ONS.8
Figure 2 outlines the pathway for using ONS in the management of COPD, including goal setting, reviewing timeframes, what to do if a patient has not met their nutritional goals, and when to stop an ONS prescription. Compliance with ONS should be monitored after 4 weeks and progress and goals reviewed every 4 weeks thereafter or more often if there is clinical concern. The leaflet Nutrition support in COPD (www.malnutritionpathway.co.uk/library/red.pdf) provides tips on how people can best incorporate ONS in their diet.
3. Ensure nutritional support is acceptable and effective
NICE Guideline 115 recommends that nutritional interventions should be incorporated as part of exercise programmes as this has been found to improve outcomes.8 Regular monitoring is key to effective management of malnutrition in COPD. At each appointment, the acceptability and practicality of nutritional support should be reviewed to ensure the patient is adhering to both dietary advice and ONS, if prescribed. Barriers such as lifelong perceptions about healthy eating, breathlessness, gas trapping, early satiety, reduced mobility, and access to food may cause difficulty in applying dietary advice. The importance of good nutrition to help maintain lung health, overcome infection, and/or improve physical ability to carry out activities of daily living should be discussed with the patient or their carer to support behaviour change.
Clinical evidence illustrates that ONS are a clinically and cost-effective method of nutritional support for patients with COPD at high risk of malnutrition and are associated with clinical benefits including significant improvements in functional outcomes, respiratory muscle strength, exercise performance, and quality of life.1 Muscle protein is directly affected by protein intake in the diet and muscle oxidative metabolism may be stimulated nutritionally;1,18 therefore, high-protein (greater than or equal to 20% of energy from protein) and high-energy (greater than or equal to 2 kcal/ml) ONS may be particularly beneficial to patients with COPD due to their increased nutritional requirements, particularly during pulmonary rehabilitation or acute exacerbations.1 Low ONS volumes (125 ml) are associated with better compliance19 than standard volumes (200–237 ml) and may be more suitable for patients with COPD. Other factors should also be considered when assessing the most clinically appropriate ONS, including the patient’s physical ability to prepare a powdered ONS and any other patient preferences.
4. Refer for dietetic input
Dietetic referrals should be incorporated in local pathways of care. Access to dietitians will vary but referral should be considered in people with COPD at high risk of malnutrition who:
- struggle to adopt dietary advice
- have multiple morbidities for which dietary advice is conflicting e.g. diabetes and COPD
- have poor compliance to an ONS prescription
- have continued deterioration in nutritional status or
- fail to respond to the nutritional intervention within 1–3 months.
If there is limited access or long waiting times for dietetic expertise in your area, consider discussing your patient case remotely with a dietitian. It would also be useful to involve your local dietetic department in planning and undertaking potential audits assessing the impact of a nutritional intervention on outcomes in patients with COPD.20,21
Malnutrition is an important consideration in people with COPD and best practice community guidance is available to support the nutritional care of patients at risk of or experiencing disease-related malnutrition in primary care. Optimising nutritional interventions has been demonstrated to lead to improved clinical and cost-effective outcomes.
Dr Anita Nathan
Member of the expert panel for Managing malnutrition in COPD
Member of the GPs Interested in Nutrition Group (an RCGP specialist group)
- Malnutrition is common in patients with COPD and is an important determinant of clinical outcome and survival
- Individuals with COPD have increased energy and protein requirements due to the increased effort associated with breathing and systemic inflammation
- Encourage patient and carer discussions about the role of good nutrition in overall health and to support behaviour change
- Nutritional intervention alongside pulmonary rehabilitation is associated with improved outcomes and is recommended by NICE
- Include screening with a validated tool such as MUST at annual disease reviews or if there is clinical concern
- Patients at medium risk of malnutrition should receive dietary advice including food fortification
- Do not delay the treatment for malnutrition while investigations are underway for an underlying cause of weight loss e.g. malignancy
- When used appropriately, ONS are clinically and cost effective
- Monitor patients regularly to ensure nutritional care plans are effective
- The Managing malnutrition in COPD guide provides information for community healthcare professionals on malnutrition screening, appropriate management including goal setting, dietary advice, ONS prescribing, and monitoring. It is supported by patient information materials that are free to download.
COPD=chronic obstructive pulmonary disease; MUST=Malnutrition Universal Screening Tool; ONS=oral nutritional supplements
- All people with COPD are at increased risk from COVID-19 infection and patients with the greatest risk should receive information from the NHS regarding shielding. NICE has produced guidance on the treatment and care planning for this group during the COVID-19 pandemic (www.nice.org.uk/ng168/)22
- Malnutrition impairs the immune system4 making people more vulnerable to infections such as COVID-19
- Patients are unlikely to be able to be given more than 1 month’s supply of medication during the pandemic and they should register with their GP practice for online services including prescriptions23
- COPD patient reviews can be carried out remotely to reduce viral exposure unless a face-to-face is more clinically appropriate. BMA/RCGP workload prioritisation guidance is available for more information (www.rcgp.org.uk/-/media/Files/Policy/A-Z-policy/2020/covid19/RCGP-guidance/202003233RCGPGuidanceprioritisationroutineworkduringCovidFINAL.ashx)24
- Patients should be advised to follow their COPD self-management plan if available to them. The British Lung Foundation has produced a range of information for this group of patients (www.blf.org.uk/support-for-you/coronavirus/what-should-people-with-a-lung-condition-do-now/copd)23
- The Malnutrition Pathway has produced resources specifically for individuals during and after COVID-19 illness, information in these leaflets has been largely derived from the Managing malnutrition in COPD and Managing malnutrition in the community resources and what is known about the nutritional needs of patients with COVID-19 to date. It includes advice on factors that can be common in both COPD and COVID-19 illness, including eating when short of breath, dealing with dry mouth, and taste changes (www.malnutritionpathway.co.uk/covid19).25
Implementation actions for STPs and ICSs
written by Dr David Jenner, GP, Cullompton, Devon
The following implementation actions are designed to support STPs and ICSs with the challenges involved with implementing new guidance at a system level. Our aim is to help you consider how to deliver improvements to healthcare within the available resources.
- Offer educational support to primary care clinicians through PCNs or online forums to help inform them about nutrition in patients with COPD
- Consider building a nutritional assessment into auto-consultation templates for GP reviews of patients with COPD
- Instigate web resources for both patients and clinicians in order to faciliate patient self-help and management
- Ensure adequate community dietetic services are commissioned to respond to any identified need (could be by video or phone consultation)
- Publish criteria for the prescription for nutritional supplements in local formularies, as these products are expensive and not always necessary.
STP=sustainability and transformation partnership; ICS=integrated care system; PCNs=primary care networks; COPD=chronic obstructive pulmonary disease
Implementation actions for clinical pharmacists in general practice
written by Gupinder Syan, Training and Clinical Outcomes Manager, Soar Beyond Ltd
The following recommendation actions are designed to support clinical pharmacists and other primary care healthcare professionals (HCPs) in general practice with implementing the guidance at a practice level.
- Agree patient scope: identify patients with COPD in the practice and undertake a notes review to see if patients should be screened for malnutrition using MUST, or if they are on ONS and need to be reviewed. Further stratify your search by identifying those at risk of malnutrition (look at recent weight/BMI)
- Establish who will manage nutrition in these patients and set accountabilities. e.g. GP pharmacist or nurse to undertake COPD medication review including malnutrition management, HCP to undertake MUST screen
- Prepare before seeing patients to ensure personal competence:
- familiarise yourself with the relevant guidelines for COPD and malnutrition
- understand your role in managing malnutrition: all HCPs should screen patients with COPD for malnutrition, prescribers can initiate ONS and non-prescribers can recommend it to prescribers
- collate all the useful leaflets from the malnutrition pathway to provide to patients so that they leave with an achievable action plan and goal to meet individualised targets
- know red flags and when to refer patients to dietitians and other services, such as exercise plans, local social prescribing initiatives, etc.
- Deliver clinics: ensure that an agreed management plan is put in place with a date for reviewing suitability of continuing ONS or other dietary measures if appropriate. Refer more complex patients to relevant services as appropriate. Code all interventions
- Evaluate your outcomes: examples include:
- number of patients seen for a COPD review, number of MUST scores recorded, and occasions ONS initiated
- number of patients in whom ONS has been initiated, reduced, or stopped, or changed to an alternative more appropriate ONS.
For more online training, please visit the i2i website join up as a free member to access a 3-part series on managing malnutrition in primary care www.i2ipharmacists.co.uk/members/therapy-areas/?therapy=frailty-in-older-people&insight
COPD=chronic obstructive pulmonary disease; MUST= Malnutrition Universal Screening Tool; ONS=oral nutritional supplements; BMI=body mass index; HCP=healthcare practitioner
After reading this article, ‘Test and reflect’ on your updated knowledge with our multiple-choice questions. We estimate that this activity will take you 30 minutes—worth 0.5 CPD credits.
- Malnutrition Pathway. Holdoway A, Anderson L, Banner J et al. Managing malnutrition in COPD. 2nd ed. 2020. Available at: www.malnutritionpathway.co.uk/copd This consensus statement was funded by an unrestricted educational grant from a nutrition company.
- Steer J, Norman E, Gibson G, Bourke S. P117 Comparison of indices of nutritional status in prediction of in-hospital mortality and early readmission of patients with acute exacerbations of COPD. Thorax 2010; 65 (4): A127.
- Collins P, Stratton R, Kurukulaaratchy R et al. Prevalence of malnutrition in outpatients with chronic obstructive pulmonary disease. Proc Nutr Soc 2010; 69 (OCE2): E147.
- Stratton R, Green R, Elia M, editors. Disease-related malnutrition: an evidence-based approach to treatment. Wallingford: CABI Publishing, 2003.
- Jones S, Maddocks M, Kon S et al. Sarcopenia in COPD: prevalence, clinical correlates and response to pulmonary rehabilitation. Thorax 2015; 70 (3): 213–218.
- Wagner P. Possible mechanisms underlying the development of cachexia in COPD. Eur Respir J 2008; 31 (3): 492–501.
- Cochrane W, Afolabi O. Investigation into the nutritional status, dietary intake and smoking habits of patients with chronic obstructive pulmonary disease. J Hum Nutr Diet 2004; 17 (1): 3–11.
- NICE. Chronic obstructive pulmonary disease in over 16s: diagnosis and management. NICE Guideline 115. NICE, 2018 (updated 2019). Available at: www.nice.org.uk/ng115
- Global Initiative for Chronic Obstructive Lung Disease (GOLD). Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease 2019 report. GOLD, 2019. Available at: goldcopd.org/wp-content/uploads/2018/11/GOLD-2019-v1.7-FINAL-14Nov2018-WMS.pdf
- Gandy J, editor. Manual of dietetic practice. 6th ed. Chichester: Wiley-Blackwell, 2019.
- Parenteral and Enteral Nutrition Group. A pocket guide to clinical nutrition. 5th ed. British Dietetic Association, 2018. Available at: www.peng.org.uk/publications-resources/pocket-guide.php
- Bauer J, Biolo G, Cederholm T et al. Evidence-based recommendations for optimal dietary protein intake in older people: a position paper from the PROT-AGE study group. J Am Med Dir Assoc 2013; 14 (8): 542–559.
- Collins P, Elia M, Stratton R. Nutritional support and functional capacity in chronic obstructive pulmonary disease: a systematic review and meta-analysis. Respirology 2013; 18 (4): 616–629.
- Sugawara K, Takahashi H, Kasai C et al. Effects of nutritional supplementation combined with low-intensity exercise in malnourished patients with COPD. Resp Med 2010; 104 (12): 1883–1889.
- van Wetering C, Hoogendoorn M, Broekhuizen R et al. Efficacy and costs of nutritional rehabilitation in muscle-wasted patients with chronic obstructive pulmonary disease in a community-based setting: a prespecified subgroup analysis of the INTERCOM trial. J Am Med Dir Assoc 2010; 11 (3): 179–187.
- Schols A, Ferreira I, Franssen F et al. Nutritional assessment and therapy in COPD: a European Respiratory Society statement. Eur Respir J 2014; 44 (6): 1504–1520.
- Elia M, editor. The ‘MUST’ report. Nutritional screening for adults: a multidisciplinary responsibility. Redditch: British Association for Parenteral and Enteral Nutrition, 2003. Available at: www.bapen.org.uk/pdfs/must/must-report.pdf
- van de Bool C, Rutten E, van Helvoort A et al. A randomized clinical trial investigating the efficacy of targeted nutrition as adjunct to exercise training in COPD. J Cachexia Sarcopenia Muscle 2017; 8 (5): 748–758.
- Hubbard G, Elia M, Holdoway A, Stratton R. A systematic review of compliance to oral nutritional supplements. Clin Nutr 2012; 31 (3): 293–312.
- Fry G, Brown F, Cawood A et al. Appropriate management of disease related malnutrition in GP practices improves nutritional status & reduces healthcare use, with potential cost savings. Clin Nutr ESPEN, 2018; 28: 271.
- Cawood A, Kominek N, Janik L et al. Local implementation of a pathway to manage malnourished COPD patients in the community. Eur Resp J 2017; 50: PA1609
- NICE. COVID-19 rapid guideline: community-based care of patients with chronic obstructive pulmonary disease (COPD). NICE Guideline 168. NICE, 2020. Available at: www.nice.org.uk/ng168
- British Lung Foundation. Coronavirus and COVID-19. What should I do if I have COPD?www.blf.org.uk/support-for-you/coronavirus/what-should-people-with-a-lung-condition-do-now/copd (accessed 11 May 2020).
- British Medical Assocation, Royal College of General Practitioners. RCGP guidance on workload prioritisation during COVID-19. Version 8. RCGP, 10 April 2020. www.rcgp.org.uk/-/media/Files/Policy/A-Z-policy/2020/covid19/RCGP-guidance/202003233RCGPGuidanceprioritisationroutineworkduringCovidFINAL.ashx
- Malnutrition Pathway. Managing adult malnutrition. COVID-19 & good nutrition. www.malnutritionpathway.co.uk/covid19 (accessed 11 May 2020).