1. Dietetic intervention in the management of COPD –
effects on patient-centred
outcomes
Dr. Elizabeth Weekes
Department of Nutrition & Dietetics
Guy’s & St. Thomas’ NHS Foundation Trust
London

2. Outcome measures in nutrition research
Dietary intake (energy & protein)
Weight change
Body composition (especially fat free mass)
Muscle function (handgrip strength)
Biochemical parameters

4. Patient-centred outcomes
Quality of Life
Generic e.g. Short Form-36 (SF-36)
Disease-specific e.g. St. George’s Respiratory Questionnaire
Utilisation of healthcare resources
Hospital admissions, post-operative complications,
GP visits, drug therapy
Functional measures
Objective e.g. maximal sniff pressures
Subjective e.g. MRC dyspnoea scale, Activities of Daily Living score
Appropriate to clinical condition

5. Subjective measures of Functional status
Validity and reliability
Statistical versus clinical
significance
Interpretation of score change
(minimum clinically important
difference)
Location
Timing

6. What is the evidence? Crohn’s disease (Imes at al., 1987, 1988)
- ↑ incidence of remission
- ↓ length of stay and time lost from work
COPD (Rogers et al., 1992)
- ↑ respiratory muscle and handgrip strength
- ↑ walking distances
Liver disease (Hirsch et al., 1993)
- ↓ incidence of severe infections and hospitalisation
Elderly
- ↓ number of falls (Gray-Donald et al., 1995)
- ↑ activities of daily living (Woo et al., 1994)

7. Consequences of malnutrition in COPD
Weight loss and low body weight are associated
with poor prognosis and increased mortality
Increased risk of :
Acute exacerbations (Connors et al., 1996)
Hospital readmission (Pouw et al., 2000)
Mechanical ventilation (Vitacca et al., 1996)
Decreased exercise tolerance (Schols et al., 1991)
Poor quality of life (Shoup et al., 1997)

8. Nutrition intervention in COPD
16 randomised controlled trials (RCTs)
All used proprietary nutritional supplements
(5 included dietary advice/encouragement)
Minimal effects on weight gain and respiratory muscle function (Ferreira et al., 2004)
Research is required in dietary counselling and food manipulation (Schols & Brug , 2003)

9. Research questions
Can six months intervention with dietary counselling and food fortification result in weight gain in outpatients with COPD?
Is weight gain associated with measurable clinical benefit for the patient?

10. Study design Month 12 Baseline Month 6 M7 M9 M1 M3 W2 Intervention
Follow-up

11. Dietary counselling and food fortification
Intervention
- Experienced dietitian
- Advice tailored to clinical condition,
lifestyle and preferences etc.
- Six months free supply of milk
powder for food fortification
(Pluspints, Kerry Foods, Eire)
NAGE leaflet, written advice
and practical demonstrations
Control
- NAGE leaflet

12. Outcome measures Weight change Body composition Dietary intake
Health-related quality of life (QoL)
Non-elective hospital admissions
Antibiotic therapy
Perceived dyspnoea
Activities of Daily Living (ADL)
Depression score
Muscle function (skeletal and lung)

13. Recruitment 59 completed baseline assessment
Intervention n = 31
Control n = 28
50 completed 1 month assessment
40 completed 6 month assessment
37 (63 %) completed 12 month assessment
Intervention n=20
Control n = 17

14. Patient characteristics (n = 59)
Intervention
N = 31
Control
N = 28
Females:Males
Age (years)
Weight (kg)
Body mass index (kg/m2)
FEV1 (% predicted)
SGRQ Total score
SF-36 General Health score
Dyspnoea score
ADL score
15:16
68.9 (47 – 89)
54.5 (7.3)
19.9 (1.4)
30.9 (12.8)
55.3 (19.9)
34.7 (23.0)
3 (1 – 5)
15 (7 – 18)
14:14
69.2 (46 – 85)
53.5 (8.5)
19.5 (1.9)
32.7 (14.6)
62.0 (16.7)
29.5 (21.6)
4 (1 – 5)
11 (8 – 18)

15. Weight change (kg)

16. Change in mid arm muscle circumference (cm)

17. Change in sum of four skinfolds (mm)

18. Change in SGRQ Activity score

19. Change in SGRQ Impacts score

20. Change in SGRQ Total score

21. Short Form-36 score
Significant correlation between weight change and health change score
Patients who reported improved health gained 3.8 (+ 6.7) kg body weight over 12 months
Patients who reported no change or a deterioration in health lost 1.6 (+ 2.8) kg body weight over 12 months
p = 0.005

22. Non-elective hospital admissions
Intervention
n = 20
Control
n = 17 p
Year prior to study
Year of the study
Months 1 to 6
Months 7 to 12
8 (40 %)
6 (30 %)
1 (5 %)
4 (24 %)
9 (53 %)
5 (29 %)
7 (41 %) -
0.16
0.63
0.01

23. Antibiotic therapy Patients prescribed antibiotics (ABX)
Intervention n = 13 (65 %)
Control n = 15 (88 %)
p = 0.10
Prescribed ABX (+ 4.5) kg
Not prescribed ABX (+ 7.8) kg
P = 0.03

24. Subjective functional measures
Dyspnoea score - Significant difference between the groups at 6 (but not 12) months
Activities of daily living score – Significant difference between the groups at 6 and 12 months
Depression score – Significant difference between the groups at 12 months

25. Objective measures of muscle function
No differences between the groups in:-
- Handgrip strength (skeletal muscle)
Maximal mouth pressures (respiratory muscles)
Sniff pressures (diaphragm)

26. Conclusions Clinical benefits for the intervention group:-
- non-elective hospital admissions
- antibiotic therapy (ABX)
- quality of life (QoL)
- activities of daily living (ADL)
- perceived dyspnoea
Benefits in QoL, ADL, non-elective hospital admissions and ABX persisted for at least six months after the intervention ceased
No differences in disease severity, skeletal or lung muscle function

27. Future research
More research is needed on the effects of nutrition intervention on patient-centred outcomes (dietary counselling, food fortification, oral nutritional supplements, tube feeding or parenteral nutrition)
Nutritional intervention may be more effective in sedentary patients in combination with other therapies e.g. pulmonary rehabilitation programmes
In the absence of improvements in muscle function, what are the mechanisms of action on QoL and ADL?