The nutritional guideline provides recommendations for the nutritional management of COPD patients. Its objectives are to raise awareness of nutrition among respiratory healthcare professionals, provide a simple tool for first-line nutritional management, and improve the nutritional status of COPD patients. It recommends screening patients for nutritional status using BMI and asking questions about appetite, weight changes, diet, and body shape. Based on the screening, healthcare professionals can identify a patient's position on the guideline and take appropriate action such as monitoring weight, discussing diet, or prescribing supplements.

1. Nutritional Guideline
for COPD Patients
Supporting Slide Deck

2. The objectives of the guideline:
 To raise the awareness of nutrition with
respiratory healthcare professionals and their
patients
 To provide a simple tool to aid first line
nutritional management of this group
 To improve the nutritional status of COPD
patients

3. Nutritional Screening
 NICE recommends that all patients, whether in the community or in
hospital, should be regularly screened using a tool like “MUST”. In
some centres a nutritional screening tool may be being regularly
used with your COPD patients. In other centres this is not the case
 The Nutritional Guideline for COPD is not designed to replace a
more formal screening tool but is designed to be something you
can use either along side the results from nutritional screening (see
the colour coding on the guideline), or as a first line approach to
tackling nutritional issues in this group
 If you have up to date screening information you can use this to
understand where your patient fits on the guideline. If your team
are not using a formal screening process you can make a simple
assessment using a Body Mass Index and by asking some key
questions that you can incorporate into your patient’s appointment

4. Simple Steps:
1. Obtain patient’s weight (if possible review weight
history)
2. Calculate Body Mass Index (BMI)
3. Understand current nutritional situation
4. Identify your patient’s position on the guideline
5. Take appropriate action
6. Review and monitor: build a quick check regarding
diet and nutrition into every appointment

5. Note your patients weight:
 Start to regularly keep a check on
your patients weight
 Weigh the patient if possible every
time they are in clinic
 Look at a weight history if available
◦ If their weight has been changing this
can indicate a cause for concern

6. Calculate BMI (Body Mass Index)
 Body Mass index or BMI is the patients weight in
kg divided by their height in meters squared:
Weight (kg)
Height2 (m2)
 Alternatively, use the BMI chart found on the
back of the guideline
 Once you have a BMI, categorise your patient as:
◦ Underweight <20
◦ Normal weight 20-25
◦ Overweight 25-30
◦ Obese >30

7. Understand your patients nutritional status
 Poor nutritional status in COPD is not always easy to identify
 There should be cause for concern if your patient has:
◦ A low Body Mass Index (<20 kg/m2)
◦ Unintentional weight loss (your patient is losing weight without deliberately
trying to) – they may have what appears on the surface to have perfectly
healthy BMI but if they are losing weight without trying, this needs to be
monitored
◦ Muscle wasting – this is often the hardest to spot, there are complicated
techniques to identify this, but your patient should be able to tell you that
they have noticed changes in their body shape, loss of muscle in arms and
legs and loss of muscle strength
 Although not always considered as a cause for concern, it is also
important to think about those patients who are:
◦ Very overweight, i.e. obese (>30 kg/m2), their weight can be affecting their
breathing and mobility
◦ Eating well and have a stable body weight but have very poor quality diet

8. The 5 Key Open Questions to Ask
1. How is your appetite?
2. Are you managing to eat as well as you usually
do?
3. Have you noticed any changes in your weight?
Useful prompts:
◦ Clothes and jewellery becoming looser
◦ Have friends/family made comments
4. Have you noticed any other changes to your
body shape? Useful prompts:
◦ Changes to arms and legs
◦ Muscle strength
5. Do you have any concerns about your food
intake and diet?

9. Use the Guideline
 Once you have a BMI
for your patient and
have had a short
discussion around
food, diet and weight,
you should be able to
use the colour coded
guideline to identify
the appropriate
course of action for
them

10. Resources
Guidance around prescription of Oral Nutritional Supplements in disease related
malnutrition & COPD:
NICE Clinical Guide CG 32 Nutrition Support in Adults
NICE Clinical Guideline CG 101 Chronic Obstructive Pulmonary Disease (update)
Evidence and support for the use of Oral Nutritional Supplements in COPD
patients:
Stratton RJ, Green CJ, Elia M. Evidence base for Oral Nutritional Support. In Disease
Related Malnutrition: An Evidence based Approach to Treatment Stratton RJ, Green
CJ, Elia M.(eds). CABI Publishing , Wallingford, Oxon pp168-236, 2003.
NICE Clinical Guideline CG 101 Chronic Obstructive Pulmonary Disease (update)
Collins PF, Stratton RJ and Elia M (2011) Nutritional support in chronic obstructive
pulmonary disease (COPD): a systematic review and meta-analysis. Clinical
Nutrition, 6 (Suppl. 1): 153.
Collins PF, Stratton RJ and Elia M (2011) Nutritional support and functional capacity in
chronic obstructive pulmonary disease (COPD): a systematic review and meta-
analysis. Clinical Nutrition, 6 (Suppl. 1): 153-154.
Evidence in support of COPD patient’s having an energy gap of around 600kcal:
Baarends EM et al. Total Free Living Energy Expenditure in Patients with Severe Chronic
Obstructive Pulmonary Disease. Am J RespirCrit Care Med 1997; 155: 549-544.
Schols AMWJ et al. Energy Balance in Chronic Obstructive Pulmonary Disease. Am
RevRespirDis 1991; 143: 1248-1252

11. Resources
Guidelines in support of combining nutritional intervention and exercise to
improve outcomes:
NICE Clinical Guideline CG 101 Chronic Obstructive Pulmonary Disease (update)
Anker SD et al. ESPEN Guidelines on EnteralNutrition:Cardiology and Pulmonology
Clinical Nutrition 2006; 25:311-31
Evidence in support of COPD patients having better outcomes if they are
overweight:
Landbo C, Prescott E, Lange P, Vestbo J, Almdal TP Prognostic value of nutritional status
in chronic obstructive pulmonary disease. Am J RespirCrit Care Med. 1999;
Dec;160(6):1856-61.
Schols AM, Broekhuizen R, Weling-Scheepers CA, Wouters EF Body composition and
mortality in chronic obstructive pulmonary disease. Am J ClinNutr. 2005; Jul;82(1):53-
9.
Guideline that suggests nutritional issues should be addressed as part of a PR
programme:
Nici et al.ATS/ERS Statement on Pulmonary Rehabilitation. Am J RespirCrit Care Med
2006;173:1390-1413 (Pulmonary Rehabilitation programs should address body
composition abnormalities, which are frequently present and under recognised in
chronic lung disease)