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Estimating nutritional requirements what is the evidence

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Dr. Elizabeth Weekes. Department of Nutrition & Dietetics ... Hospital admissions, post-operative complications, GP visits, drug therapy. Functional measures ... – PowerPoint PPT presentation

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Title: Estimating nutritional requirements what is the evidence


1
Dietetic 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
2
Outcome 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)
4
Patient-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

6
What 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)

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 Interventi
on n20 Control n 17
14
Patient characteristics (n 59)
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
23
Antibiotic 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

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?
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