Patients with chronic obstructive pulmonary disease are at increased risk of malnutrition. Nurses should ensure they screen patients and offer advice or referral
Nutrition and weight management are increasingly recognised as important factors in managing patients with chronic obstructive pulmonary disease (COPD). This article discusses the impact of COPD symptoms on nutrition, and gives advice on the importance of regular nutritional screening using a validated tool.
Citation: Evans A (2012) Nutrition screening in patients with COPD. Nursing Times [online]; 108: 11, 12-14.
Author: Alison Evans is respiratory specialist dietitian, BreathingSpace, The Rotherham Foundation Trust, Rotherham.
- This article has been double-blind peer reviewed
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Nutrition is a significant issue in managing patients with chronic obstructive pulmonary disease (COPD), because they are at increased risk of malnutrition as the disease progresses. Nurses caring for this group should carry out regular nutrition screening so that changes in weight can be identified as soon as possible and dietary treatment started.
COPD is characterised by airflow obstruction, which is usually progressive, not fully reversible and does not change markedly over several months (National Institute for Health and Clinical Excellence, 2010). In the very early stages, patients may not have significant symptoms but, as the disease progresses, symptoms increase and include breathlessness, chronic cough, regular sputum production and wheeze (NICE, 2010).
The Respiratory Dietitians’ Network and Association of Respiratory Nurse Specialists have been involved in the development of the Nutritional Guideline for COPD Patients. This Department of Health-endorsed guideline and accompanying information can be downloaded from the COPD Education website at (www.copdeducation.org.uk).
The guideline includes recommendations for the management of nutritional problems in patients with COPD and there are dietary advice sheets that can be downloaded and given to patients.
Nutrition and COPD
For patients who are relatively “well”, nutrition advice can focus on the importance of eating a healthy, balanced
diet, based on the “eatwell plate” model (DH, 2011).
In addition, research has found some dietary factors are particularly beneficial for those with COPD. There is evidence that vitamins A, C and possibly E and colouring pigments in fruit and vegetables help to prevent the development of lung disease (Watson et al, 2002; Tabak et al, 2001). For those who already have COPD, lung function appears to be better in those who eat more fruit and vegetables (Keranis et al, 2010).
Oily fish such as salmon, mackerel, sardines, herrings and fresh tuna are rich in omega-3 oils, which are well known to be beneficial for heart health. Research shows that one of the omega-3 oils may also have a positive effect on the inflammatory response in COPD (Shahar et al, 1999).
Patients with COPD appear to be at increased risk of osteoporosis, thought to be due to a combination of factors including smoking, low vitamin D levels, low body mass index (BMI), low skeletal muscle mass and use of corticosteroids (Ionescu and Schoon, 2003). Added to this is the widespread myth that those with COPD should not eat dairy products, which puts them at even higher risk of osteoporosis. Nurses should stress the importance of including dairy products such as milk, cheese and yoghurts in the diet to ensure adequate calcium.
In terms of sputum consistency, it is important to ensure patients are hydrated by drinking enough fluids, so that the sputum has a high enough water content to make it easier to expectorate. Generally, everyone is advised to drink 6-8 mugs or glasses of fluid per day to keep hydrated, and to increase this in hot weather or if they have a raised temperature. This is based on advice from the Parenteral and Enteral Nutrition Group (2011), which specifically recommended a daily intake of:
- 35ml of fluid per kg body weight for adults aged 18-60 years;
- 30ml per kg body weight for adults over 60 years (PEN Group, 2011).
Using these figures allows more individualised requirements to be calculated for patients.
Fluids include water, squash and fizzy drinks, coffee and tea, fruit juices and milk. There has been some controversy about whether caffeine-containing drinks can count, but generally habitual drinking seems to make people adjust to the diuretic effect of the caffeine. Alcoholic drinks, however, cannot be counted towards fluid intake due to their dehydrating effect.
Effect of symptoms on nutrition
As the disease progresses and symptoms increase, they start to affect nutritional intake. It is common for patients to report difficulties with eating due to:
- Difficulties in shopping and preparing meals;
- Decreased appetite;
- Increased breathlessness on eating;
- Dry mouth (due to side-effects of medication);
- COPD-related swallowing difficulties - fatigue on chewing, reluctance to eat due to fear of choking and an unco-ordinated swallow;
- Early satiety and feeling bloated;
- Anxiety and depression.
Added to this are increased nutritional requirements due to inefficient and overworking of respiratory muscles and cachexia in the later stages of the disease. Most of these factors contribute to reduced nutritional intake, weight loss and low BMI.
However, an increasing number of patients with COPD are overweight or obese, which is more difficult to explain.
Possible reasons for this could be that they still manage to eat without problems, but that fatigue and breathlessness on exertion leads them to be less active, and therefore gain weight. Or it could be due to the numbers of overweight people in the general population increasing and so proportionately more patients with COPD are overweight or obese.
In Rotherham, audits done at BreathingSpace (the local specialist service for people with COPD) in 2008 identified more patients with “abnormal” BMIs (under 20kg/m2 or over 24.9kg/m2) than in the local general population. NICE (2010) defined the normal range for BMI in COPD as 20kg/m2 to less than 25kg/m2; although the healthy range for BMI is usually 18.5-24.9kg/m2, the guidance pointed out that this may not be appropriate for people with COPD.
Patients with COPD are therefore at high risk of malnutrition, according to the following definition: “Malnutrition is a state of nutrition in which a deficiency or 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” (British Association for Parenteral and Enteral Nutrition, 2011).
Importance of screening
Nutritional screening of patients with COPD should be carried out regularly,
even in those who seem to be generally well; they may begin to experience exacerbations more frequently and this can have a negative effect on nutrition. NICE (2010) recommended that BMI should be calculated; those with abnormal (high or low) BMI, or one that changes over time, should be referred for dietetic advice.
Early nutritional intervention is important as it is easier to maintain weight than regain lost weight. It is also important to use a validated screening tool; probably the most widely used is the Malnutrition Universal Screening Tool (MUST) (BAPEN, 2003; updated). Velasco et al (2011) compared MUST with other European tools and showed it to be reliable. MUST includes recommendations for action depending on the “score” achieved, which is extremely valuable. Whichever screening tool is used, it is vital that prompt action is taken to correct any nutritional problems.
Being underweight, especially when this is linked to having less muscle, is independently associated with a poor prognosis in COPD (Anker et al, 2006). It is also associated with impaired pulmonary status, reduced diaphragmatic mass, lower exercise capacity and a higher mortality rate in people with COPD (Ferreira et al, 2000).
Once patients have been screened and identified as being at nutritional risk, it is important that they are supported to make dietary changes to improve their nutritional status as soon as possible. In this group, it is common to see gradual weight reduction over the years, and this often seems to follow a pattern of weight loss during exacerbations followed by an inability to regain lost weight on recovery.
Encouraging underweight patients to make dietary changes to reduce the weight lost during an exacerbation and changes to encourage weight gain after recovery can help to prevent this downward spiral. Research supports this, as Prescott et al (2002) found the best survival in underweight patients was in those who gained weight, while Weekes et al (2009) found significant improvement can be made by dietary counselling and food fortification. Box 1 contains dietary advice for patients during exacerbations and after recovery.
It is vital to monitor patients’ progress with the dietary changes recommended. If a patient is still losing weight despite these changes, consider making a referral to a registered dietitian. The dietitian will be able to assess nutritional requirements and compare these with intake, and may be able to suggest further changes or nutritional supplements, including advice for prescribers on the most appropriate number and type of supplement.
BOX 1. DIETARY ADVICE DURING AND AFTER COPD EXACERBATIONS
During exacerbations, advise patients to:
- Eat small amounts, frequently throughout the day
- Choose soft, easy-to-eat foods that do not need much chewing, such as soup, omelette, fish pie, shepherd’s pie, pasta with sauce, milk pudding, sponge and custard, yoghurt, trifle and mousses
- Have nutritious drinks regularly through the day such as malted milk drinks, drinking chocolate, milky
- coffee and milkshakes, all made using fortified milk made from milk with 2-4 tablespoons milk powder added per pint
- Use nutritional supplements such as Build Up and Complan to boost intake during exacerbations. Ideally, make these up with full-fat milk. Keep these in the store cupboard
After recovery, advise them to:
- Eat smaller meals more often and, if they become full or breathless, delay desserts for 30-60 minutes after the main course
- Supplement with snacks and milky drinks between meals
- Continue to increase protein, by fortifying milk with milk powder, and using this on cereals, in cooking and in drinks
- Increase protein by adding cheese to soups and mashed potatoes, and evaporated milk to cereals and desserts
- Increase energy intake by adding double cream, butter, margarine, sugar, jams, honey and syrup to foods as appropriate
- Continue to exercise as nutritional support is more effective if accompanied by exercise (Anker et al, 2006)
COPD-related swallowing difficulties
COPD-related swallowing issues are a developing area of research. This issue should be considered, especially in patients who experience recurrent back-to-back chest infections, which may be caused by silent aspiration (Ilsley, 2011).
Swallowing difficulties can make eating and drinking difficult and often result in patients losing weight if no support is given. They often need to have softer foods but manage normal fluids. Altering the texture of foods to make them softer can result in diluted nutrients so it is often necessary to fortify foods.
Managing obesity and overnutrition
Despite many patients with COPD having undernutrition and a low BMI, increasing numbers are presenting with a high BMI. Research supports the fact that obesity carries not only risk factors for heart disease but also leads to pulmonary problems (Rabec et al, 2011). It causes difficulties in thoracic cage expansion and diaphragm movement. Ventilatory work is increased, arterial hypoxaemia is frequently altered and obstructive sleep apnoea is more common in obese people.
However, the decision over whether to treat obesity in patients with COPD poses a dilemma. Prescott et al (2002) identified the best outcomes for overweight and obese patients was when they maintained their weight, while Landbo et al (1999) found mortality decreased with increasing BMI in severe COPD. At BreathingSpace we decided to advise only obese patients to lose weight (those with a BMI of 30kg/m2 or higher) and to aim to do so slowly and steadily, with a conservative 5-10% weight loss target.
Dietary advice for obese patients with COPD is as follows:
- Eat three regular meals and reduce snacking;
- Fill up on vegetables at meals and, if very hungry between, snack on fruit;
- Eat a balanced diet according to the “eatwell plate” model (DH, 2011);
- Reduce intake of fatty and sugary foods;
- Increase physical activity;
- Make changes gradually, one step at a time;
- Avoid strict or crash diets;
- Aim to prevent further weight gain or lose 0.5kg (1lb) per week;
- Make dietary changes permanent.
Comorbidities affecting nutrition
COPD rarely exists in patients as the only condition. They may also have ischaemic heart disease, heart failure, osteoporosis, anaemia, lung cancer, depression, diabetes or cataracts (Barnes and Celli, 2009; Soriano et al, 2005).
Some of their comorbidities may be related to COPD while others may exist independently. This may mean that dietary management of nutritional problems is more difficult as it is necessary to take into account dietary advice for other conditions as well, which can sometimes conflict.
If nutritional screening identifies problems in patients with multiple comorbidities, consider asking advice from or referring them to a registered dietitian, who will be able to balance the dietary prescriptions required for the different diseases and come to an appropriate compromise.
COPD is a chronic progressive condition. Although nutrition is a significant factor at all stages of the disease, the risk of patient malnutrition increases as the disease progresses.
It is important to identify nutritional issues early by regular screening, allowing prompt and appropriate actions to be taken to improve nutritional status, thus improving quality of life and prognosis for people with COPD.
- Patients with COPD should be encouraged to eat a variety of fruit and vegetables every day and a portion of oily fish every week
- They should also be encouraged to eat 2-3 portions of dairy products every day
- COPD patients should have regular nutritional screening to ensure early identification of problems and prompt treatment
- Referral to a speech and language therapist should be considered if swallowing difficulties are suspected
- If screening reveals problems in patients with comorbidities, advice from a dietitian should be considered
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