Title: Estimating nutritional requirements what is the evidence
1Dietetic intervention in the management of COPD
effects on patient-centred outcomes
Dr. Elizabeth Weekes Department of Nutrition
Dietetics Guys St. Thomas NHS Foundation
Trust London
2Outcome measures in nutrition research
- Dietary intake (energy protein)
- Weight change
- Body composition (especially fat free mass)
- Muscle function (handgrip strength)
- Biochemical parameters
3(No Transcript)
4Patient-centred outcomes
- Quality of Life
- Generic e.g. Short Form-36 (SF-36)
- Disease-specific e.g. St. Georges 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
6What is the evidence?
- Crohns 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)
7Consequences 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)
8Nutrition 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)
9Research 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?
10Study design
Month 12
Baseline
Month 6
M7
M9
M1
M3
W2
Intervention
Follow-up
11Dietary 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
12Outcome 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)
13Recruitment
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 Interventi
on n20 Control n 17
14Patient characteristics (n 59)
15Weight change (kg)
16Change in mid arm muscle circumference (cm)
17Change in sum of four skinfolds (mm)
18Change in SGRQ Activity score
19Change in SGRQ Impacts score
20Change in SGRQ Total score
21Short 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
22Non-elective hospital admissions
23Antibiotic therapy
- Patients prescribed antibiotics (ABX)
- Intervention n 13 (65 )
- Control n 15 (88 )
- p 0.10
- Prescribed ABX - 1.2 ( 4.5) kg
- Not prescribed ABX 4.0 ( 7.8) kg
- P 0.03
24Subjective 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
25Objective measures of muscle function
- No differences between the groups in-
- - Handgrip strength (skeletal muscle)
- Maximal mouth pressures (respiratory muscles)
- Sniff pressures (diaphragm)
26Conclusions
- 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
27Future 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?