COPD: Medical Nutrition Therapy 2019
Click here to see the explanation of recommendation ratings (Strong, Fair, Weak, Consensus, Insufficient Evidence) and labels (Imperative or Conditional). To see more detail on the evidence from which the following recommendations were drawn, use the hyperlinks in the Supporting Evidence Section below.
COPD: Medical Nutrition Therapy (MNT)
The registered dietitian nutritionist (RDN) should provide MNT to adults with COPD to improve patient outcomes. Evidence indicates that MNT intervention provided by an RDN (or international equivalent) as part of a multidisciplinary program was effective in improving body weight status, quality of life, exercise capacity and body composition outcomes in adults with COPD.
Risks/Harms of Implementing This Recommendation
There are no potential risks or harms associated with the application of this recommendation.
Conditions of Application
There are no conditions that may limit the application of the recommendation.
Potential Costs Associated with Application
- Costs may include expenses related to medical nutrition therapy (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).
A total of six papers reporting the results of five different studies were included in the evidence analysis supporting the recommendation:
- One positive quality randomized controlled trial (RCT) (van Wetering et al, 2010)
- Two positive quality papers from one before-after clinical trial [McDonald et al, 2016; McLoughlin et al, 2017 (which was a secondary analysis)]
- One positive quality non-controlled trial (Farooqi et al, 2011)
- One neutral quality non-randomized trial (Norrhall et al, 2009)
- One neutral quality prospective cohort (Gale et al, 2011).
Studies evaluated COPD subjects receiving MNT intervention by an RDN (or international equivalent), compared to COPD control groups receiving standard or usual care. The studies evaluated multidisciplinary interventions such as pulmonary rehab, which included MNT. All studies included individualized MNT in a one-to-one session (e.g., home visits, nutrition assessment and counseling) and as part of group education.
MNT and Weight Status, Quality of Life, Exercise Capacity Outcomes
Post-intervention results from six papers (five studies) (Farooqi et al, 2011; Gale et al, 2011; McDonald et al, 2016; McLoughlin et al, 2017; Norrhall et al, 2009; van Wetering et al, 2010 were as follows:
- Weight status (six papers; five studies): Two papers reported improvements in body weight (Farooqi et al, 2011; McDonald et al, 2016) and percentage ideal body weight (Farooqi et al, 2011). Three papers reported body mass index (BMI) maintenance or improvements in BMI (McDonald et al, 2016; Norhall et al, 2009; van Wetering et al, 2010), while one paper did not report improvements in BMI (Gale et al, 2011). One paper did not find differences in percentage weight change (McLoughlin et al, 2017).
- Quality of life (QOL) (five papers; four studies): Four papers reported improvements in St. George's Respiratory Questionnaire scores (Gale et al, 2011; McDonald et al, 2016; van Wetering et al, 2010) and Three Factor Eating Questionnaire scores (McLoughlin et al, 2017), while one paper did not find significant improvements in Chronic Respiratory Disease Questionnaire scores (Norrhall et al, 2009).
- Exercise capacity (five papers; four studies): All papers reported improvements in quadriceps average power (van Wetering et al, 2010), Short Physical Performance Battery tests (McDonald et al, 2016), total physical activity (McLoughlin et al, 2017), and walking distance, as measured by 6-minute walking distance (6MWD) (McDonald et al, 2016; van Wetering et al, 2010), 12MWD (Farooqi et al, 2011) and incremental shuttle walk test (Gale et al, 2011). One paper reported improvements in hand-grip strength (Farooqi et al, 2011).
MNT and Body Composition and Lung Function Outcomes
Post-intervention results of four papers (three studies) (McDonald et al, 2016; McLoughlin et al, 2017; Norrhall et al, 2009; van Wetering et al, 2010) were as follows:
- Body composition (three papers; two studies): All reported improvements in body fat mass (McDonald et al, 2016), fat-free mass (van Wetering et al, 2010), percentage body fat (McDonald et al, 2016), waist circumference (McLoughlin et al, 2017) and waist to hip ratio (McDonald et al, 2016). One study did not find differences in skeletal muscle mass or appendicular skeletal muscle mass index (McDonald et al, 2016).
- Lung function or respiratory impairment (three studies): One study reported improvements in maximum inspiratory mouth pressure (PImax) (van Wetering et al, 2010), one study reported improvements in forced vital capacity (FVC) (McDonald et al, 2016), while one study did not find improvements in FVC (Norhall et al, 2009). Studies did not show improvements in forced expiratory volume in 1 minute (FEV1) (McDonald et al, 2016; Norrhall et al, 2009) and FEV1/FVC, functional residual capacity, residual volume, expiratory reserve volume, or total lung capacity (McDonald et al, 2016). No negative outcomes in lung function parameters were found.
Recommendation Strength Rationale
- Conclusion statements supporting the recommendation are Grade I, Good/Strong (body weight status, QOL, exercise capacity outcomes) and Grade II, Fair (lung function, body composition outcomes).
- All studies were conducted outside the U.S.
- Risks/Harms of Implementing This Recommendation
The recommendations were created from the evidence analysis on the following questions. To see detail of the evidence analysis, click the blue hyperlinks below (recommendations rated consensus will not have supporting evidence linked).
What is the effectiveness of medical nutrition therapy as part of a multidisciplinary program on body weight, quality of life and exercise capacity outcomes in adults with COPD?
What is the effectiveness of medical nutrition therapy as part of a multidisciplinary program on body composition and lung function outcomes in adults with COPD?
Farooqi N, Nordström L, Lundgren R, Sandström T, Håglin L. Changes in body weight and physical performance after receiving dietary advice in patients with chronic obstructive pulmonary disease (COPD): 1-year follow-up. Archives of Gerontology and Geriatrics 2011; 53:70-5
Gale N, Duckers J, Enright S, Cockcroft J, Shale D, Bolton C. Does pulmonary rehabilitation address cardiovascular risk factors in patients with COPD?. BMC Pulmonary Medicine 2011; 11:20
McDonald V,Gibson P,Scott H,Baines P,Hensley M,Pretto J,Wood L. Should we treat obesity in COPD? The effects of diet and resistance exercise training. Respirology (Carlton, Vic.) 2016; 21:875-82
McLoughlin RE, McDonald VM, Gibson PG, Scott HA, Hensley MJ, MacDonald-Wicks L, and Wood LG. The Impact of a Weight Loss Intervention on Diet Quality and Eating Behaviours in People with Obesity and COPD. Nutrients 2017; 9:1147
Norrhall M, Nilsfelt A, Varas E, Larsson R, Curiac D, Axelsson G, Månsson J, Brisman J, Söderström A, Björkelund C, Thorn J. A feasible lifestyle program for early intervention in patients with chronic obstructive pulmonary disease (COPD): a pilot study in primary care. Primary Care Respiratory Journal 2009; 18:306-12
van Wetering C, Hoogendoorn M, Broekhuizen R, Geraerts-Keeris G, De Munck D, Rutten-van Mölken M, Schols A. Efficacy and costs of nutritional rehabilitation in muscle-wasted patients with chronic obstructive pulmonary disease in a community-based setting: a prespecified subgroup analysis of the INTERCOM trial. Journal of the American Medical Directors Association 2010; 11:179-87
References not graded in Academy of Nutrition and Dietetics Evidence Analysis Process
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.