Post on 28-Mar-2015
Dr. Elizabeth WeekesDepartment of Nutrition & DieteticsGuy’s & St. Thomas’ NHS Foundation TrustLondon
Dietetic intervention in the Dietetic intervention in the management of COPD –management of COPD –effects on patient-centred effects on patient-centred outcomesoutcomes
Outcome measures in nutrition researchOutcome measures in nutrition research
Dietary intake (energy & protein)
Weight change
Body composition (especially fat free mass)
Muscle function (handgrip strength)
Biochemical parameters
Patient-centred outcomesPatient-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
Subjective measures ofFunctional status
• Validity and reliability
• Statistical versus clinical significance
• Interpretation of score change(minimum clinically importantdifference)
• Location
• Timing
What is the evidence?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)
Consequences of malnutrition in COPDConsequences of malnutrition in COPD
Weight loss and low body weight are associatedwith 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)
Nutrition intervention in COPDNutrition 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)
Research questionsResearch 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?
Study designStudy design
Baseline Month 6 Month 12
Intervention
Follow-up
M1 M3 M7 M9W2
Dietary counselling and food fortificationDietary 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
Outcome measuresOutcome 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)
RecruitmentRecruitment
59 completed baseline assessmentIntervention n = 31
Control n = 28
50 completed 1 month assessment
37 (63 %) completed 12 month assessmentIntervention n=20
Control n = 17
40 completed 6 month assessment
Patient characteristics (n = 59)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)
-4
-3
-2
-1
0
1
2
3
4
5
Time (months)
Wei
ght c
hang
e (k
g)
InterventionControl
3 6 9 12
Weight change (kg)Weight change (kg)
-1.2
-1
-0.8
-0.6
-0.4
-0.2
0
0.2
0.4
0.6
0.8
Intervention
Control
Time (months)3 6 9 12
MA
MC
ch
ang
e (c
m)
Change in mid arm muscle circumference (cm)Change in mid arm muscle circumference (cm)
-6
-4
-2
0
2
4
6
8
10
12
S4SF
change (
mm
)
Intervention
Control
Time (months)
3 6 9 12
Change in sum of four skinfolds (mm)Change in sum of four skinfolds (mm)
-15
-10
-5
0
5
10
Ch
ang
e in
SG
RQ
Act
ivit
y sc
ore
Intervention
Control
6 months(n = 37)
12 months(n = 35)
Change in SGRQ Activity scoreChange in SGRQ Activity score
-20
-15
-10
-5
0
5
10
15
Ch
ang
e in
SG
RQ
Imp
acts
sco
re
Intervention
Control
6 months(n = 37)
12 months(n = 34)
Change in SGRQ Impacts scoreChange in SGRQ Impacts score
-15
-10
-5
0
5
10
Ch
ang
e in
SG
RQ
Tot
al s
core
Intervention
Control
6 months(n = 37)
12 months(n = 34)
Change in SGRQ Total scoreChange in SGRQ Total score
Short Form-36 scoreShort 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
Non-elective hospital admissionsNon-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 %)
6 (30 %)
1 (5 %)
4 (24 %)
9 (53 %)
5 (29 %)
7 (41 %)
-
0.16
0.63
0.01
Antibiotic therapyAntibiotic 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
Subjective functional measuresSubjective 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
Objective measures of muscle functionObjective measures of muscle function
• No differences between the groups in:-
- Handgrip strength (skeletal muscle)
- Maximal mouth pressures (respiratory muscles)
- Sniff pressures (diaphragm)
ConclusionsConclusions
• 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
Future researchFuture 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?