COPD: Benefits and Risks/Harms of Implementation (2019)

Benefits and Risks/Harms of Implementing the Recommendations

Factors to consider when exploring treatment options include:

Patient’s socioeconomic status, cultural issues, psychosocial and mental health status, and other health history, and individual and health conditions
Referral to a behavioral specialist, if psychosocial issues are a concern
Referral to social services to assist individuals with financial arrangements, if economic issues are a concern
Use clinical judgement when evaluating patients with co-morbid conditions, such as hypertension, diabetes, obesity, osteoporosis and dialysis.
Costs may include expenses related to MNT visits from an RDN.
For group counseling, such as pulmonary rehabilitation, adequate staffing with expertise in the major component areas of COPD management and adequate space for counseling are required.
Cognitive ability and healthy literacy may impact the learning process (Blackstock et al, 2018). Therefore, an understanding of patient needs should be incorporated into the intervention format (Blackstock et al, 2018). Training and educational materials should be appropriate, and culturally relevant for each participant.
Absenteeism and attrition may impact the success of counseling. Participation may be limited by the location of counseling (distance from home or workplace), the duration length and frequency of sessions.
To optimize outcomes, identification of factors that may hinder learning (e.g., conditions such as anxiety or depression) should be identified and addressed (Blackstock et al, 2018).
Costs may be incurred due to lab testing to evaluate serum 25(OH)D levels.
Achievement of normal serum 25(OH)D levels may not be possible in all instances. Therefore, optimizing serum 25(OH)D levels is the goal (Rusinska et al, 2018).
Frequency of monitoring serum 25(OH)D levels post supplementation should be at 3-month intervals (Rusinska et al, 2018).
Coordination with the prescribing provider may be required for vitamin D supplement orders or changes in orders.
Costs may be incurred related to the purchase of over-the-counter vitamin D supplements or co-pays.
Lifestyle, financial barriers, personal preferences should be considered when individualizing the macronutrient distribution.
If necessary data are not available, the RDN should use professional judgment to request or obtain additional data.
An optimal body weight goal should be individualized for each patient.
The Westerterp equation requires body composition measurements (fat-free mass and body fat) for calculation of RMR. Thus, its utility in clinical care may be limited.
Clinical judgement should be used in applying predictive equations for total energy expenditure (TEE) to individuals ≥30kg/m².
The RDN should use clinical judgement in determining the body weight value used in calculations. Use of adjustments to body weight for obesity or volume status were not mentioned anywhere in the available studies.

For more information on benefits, risks/harms, conditions and costs of applying the recommendations, see full recommendations in the Recommendations and Supporting Evidence tab.

References:

Blackstock FC, Lareau SC, Nici L, ZuWallack R, Bourbeau J, Buckley M, Durning SJ, Effing TW, Egbert E, Goldstein RS, Kelly W, Lee A, Meek PM, and Singh S; on behalf of the American Thoracic Society, Thoracic Society of Australia and New Zealand, Canadian Thoracic Society, and British Thoracic Society. Chronic Obstructive Pulmonary Disease Education in Pulmonary Rehabilitation. An Official American Thoracic Society/Thoracic Society of Australia and New Zealand/Canadian Thoracic Society/British Thoracic Society Workshop Report. 2018. Ann Am Thorac Soc Vol 15, No 7, 769–784, Jul 2018.

Rusinska A, Pludowski P, Walczak M, Borszewska-Kornacka MK, Bossowski A, Chlebna-Sokól D, Czech-Kowalska J, Dobrzanska A, Franek E, Helwich E, Jackowska T, Kalina MA, Konstantynowicz J, Ksiazyk J, Lewinski A, Lukaszkiewicz J, Marcinowska-Suchowierska E, Mazur A, Michalus I, Peregud-Pogorzelski J, Romanowska H, Ruchala M, Socha P, Szalecki M, Wielgos M, Zwolinska D, Zygmunt A. Vitamin D Supplementation Guidelines for General Population and Groups at Risk of Vitamin D Deficiency in Poland-Recommendations of the Polish Society of Pediatric Endocrinology and Diabetes and the Expert Panel With Participation of National Specialist Consultants and Representatives of Scientific Societies-2018 Update. Front Endocrinol (Lausanne). 2018 May 31;9:246. doi: 10.3389/fendo.2018.00246. eCollection 2018. Review. PMID: 2990437.

Potential Benefits

When implementing these recommendations, consider the following general benefits:

Improve the patient's ability to achieve optimal nutrition through healthful food choices and physically active lifestyle.
Achieve and maintain body weight goals
Achieve better QOL through decreased exacerbations and dyspnea.

Risk/Harm Considerations

Potential risks/harms to consider, when exploring treatment options include:

Predictive equations may under- or over-estimate energy needs in adults with COPD. Therefore, if adverse changes in body weight or composition are occurring, equal attention should be paid to the possibility that the patient is not consuming up to the target intake, or that the target intake is not correct.

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