Estimating nutritional requirements what is the evidence

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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
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Outcome measures in nutrition research

• Dietary intake (energy protein)
• Weight change
• Body composition (especially fat free mass)
• Muscle function (handgrip strength)
• Biochemical parameters

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(No Transcript)
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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

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

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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)

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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)

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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)

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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?

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

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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)

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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
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Patient characteristics (n 59)
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Weight change (kg)
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Change in mid arm muscle circumference (cm)
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Change in sum of four skinfolds (mm)
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Change in SGRQ Activity score
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Change in SGRQ Impacts score
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Change in SGRQ Total score
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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

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Non-elective hospital admissions
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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

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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

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Objective measures of muscle function

• No differences between the groups in-
• - Handgrip strength (skeletal muscle)
• Maximal mouth pressures (respiratory muscles)
• Sniff pressures (diaphragm)

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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

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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?