Nutritional Rehabilitation in Stable COPD

The study on 'Nutritional Rehabilitation in stable COPD' is an ongoing collaborative work of Doncaster and Bassetlaw NHS Foundation Trust and CLAHRC SY. The overarching aim of the study is to find out whether nutritional support and pulmonary rehabilitation exercise programme (PR) will improve nutritional status and health outcomes in COPD.

It is known that undernourished COPD patients carry a poor prognosis. We have followed the Medical Research Council's Framework for Complex Interventions and staged our approach across three processes within two years: a systematic literature review, a feasibility study to test the nutritional component, and a pilot randomised controlled trial (RCT) to test the acceptability and feasibility of the whole intervention with a view to plan a future full-scale RCT.

The feasibility study aimed at designing and evaluating the nutritional component of the intervention. A mixed quantitative and qualitative methodology was used. We sought input from eight focus groups formed by 15 underweight COPD patients, ten carers and 16 healthcare professionals. We concluded that the nutritional intervention should be an individualised dietetic consultation with 'food first' approach, incorporating food fortification, snacks and/or sip-feeds. The intervention was then tested for three weeks and the acceptability and adherence were assessed.

With the three week intervention, a trend towards an increase in daily calorie intake with a mean difference of 773 calories per day was observed. Focus group feedback confirmed that the programme was acceptable.
The pilot RCT is ongoing. The trial intends to test the important components of the definitive trial such as retention rate and acceptability. We have recruited 40 participants, with the intervention group receiving the evaluated nutritional intervention and pulmonary rehabilitation exercise programme, and the control group receiving the exercise programme only. The design of the pilot study has also been informed by the literature review. As previous studies on nutritional supplementation in COPD have included a wider range of participants over a shorter period, in our pilot study we have recruited only underweight participants aiming for a substantial additional calorie increase (600 calories) and the interventional duration is set at three months with three months of follow up. As recent studies have also highlighted the improved outcomes achieved by coupling nutrition with exercise, we incorporated PR to the pilot study.

As the project is still ongoing, the final results of the study are yet to be published to inform and develop COPD care further. However, by hosting the study, Doncaster is already witnessing subtle changes in service provision and development around COPD care.

  • There has been a significant increase in referral of COPD patients to PR Department and of undernourished COPD patients to dietetic outpatient clinics since the start of the study.
  • The retention rate of the patients to the PR programme is significantly higher than before.
  • The inpatient COPD dietetic referral threshold has been lowered to accommodate those with low MUST (Malnutrition Universal Screening Tool) scores.
  • Dietetic referral forms have been updated and piloted to provide more clinical information such as the presence of COPD to improve the quality of referrals and subsequent review rates.
  • More outpatient dietetic follow-
ups are given than before to ensure sustainability of their changed lifestyle.

By hosting and sponsoring this project, the Trust has gained opportunities to further fine tune its infrastructure to create a research friendly environment, such as recognition and incorporation of various clinical support units to research and research governance in clinical setting.

For more information please contact Dr Moe Kyi