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Recommendations Summary

COPD: Assessment of Energy Intake 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.


  • Recommendation(s)

    COPD: Assessment of Energy Intake

    The registered dietitian nutritionist (RDN) should assess the energy intake of adults with COPD. Evidence suggests there was improvement in dyspnea scores with higher energy intakes. In addition, less robust evidence supported a beneficial relationship with functional status, healthcare utilization or duration of illness. 

    Rating: Fair
    Imperative

    • Risks/Harms of Implementing This Recommendation

      There are no potential risks or harms associated with the application of the recommendation.

    • Conditions of Application

      There are no conditions which 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.

    • Recommendation Narrative

      A total of nine studies were included in the evidence analysis supporting the recommendation:

      • Four randomized controlled trials: One positive-quality (Sugawara et al, 2012),  three neutral-quality (Førli and Boe, 2005; Planas et al, 2005; Weekes et al, 2009)
      • Five cross-sectional studies: Three neutral-quality (Lee et al, 2013; Renvall et al, 2009; Yazdanpanah et al, 2010) and two negative-quality (Benton et al 2010; Selvi et al, 2014). 

      There was improvement in dyspnea scores with higher energy intakes, with less robust evidence supporting a beneficial relationship with functional status, healthcare utilization or duration of illness.

      • Respiratory symptoms (three studies): All three studies found significant associations with dyspnea scores (Lee et al, 2013; Sugawara et al, 2012; Weekes et al, 2009)
      • Functional status (one study): The study found a significant association with activities of daily living scores (Weekes et al, 2009)
      • Healthcare utilization (one study): The study found a significant association with number of infections requiring antibiotics (Forli and Boe, 2009)
      • Duration of illness (one study): The study found a significant association with duration of disease in years (Selvi et al, 2014).

      The findings for the impact of energy intake on exacerbations, quality of life (QoL), weight status and body composition were mixed, with the majority supportive of an association.

      • Exacerbations (two studies): One study found a significant association with number of emergency room (ER) visits due to acute exacerbations (AEs) (Lee et al, 2013). One study did not find a association with number of ER visits due to AEs with energy intakes of either 1.7 x or 1.3 x Harris-Benedict Equation (HBE) (Planas et al, 2005).
      • QoL (three studies): All three studies found significant associations of Chronic Respiratory Disease Questionnaire (CRQ) scores with energy intakes of 1.3 x HBE (Planas et al, 2005), CRQ scores (Sugawara et al, 2012) and St. George Respiratory Quotient (SGRQ) scores (Weekes et al, 2009). One study did not find significant associations for CRQ scores with energy intakes of 1.7 x HBE (Planas et al, 2005)
      • Weight status (seven studies)
        • Six studies found significant associations
          • Weight gain with energy intakes of 1.7 x HBE (Planas et al, 2005)
          • Percentage IBW (Sugawara et al, 2012)
          • Weight gain (Forli and Boe, 2005; Sugawara et al, 2012; Weekes et al, 2009)
          • Body mass index (BMI) (Lee et al, 2013; Renvall et al, 2009).
        • Two studies did not find associations
          • BMI (Benton et al, 2010)
          • BW with energy intakes of 1.3 x HBE (Planas et al, 2005).
      • Body composition (three studies): All three studies found significant associations with fat mass (FM), triceps skinfold (TSF) and fat-free mass index (FFMI) with energy intakes of 1.7 x HBE (Planas et al, 2005), FM, fat mass index (Sugawara et al, 2012) and mid-arm circumference and sum of four skinfold thickness measurements (Weekes et al, 2009). All three studies also did not find associations with mid-arm muscle circumference (Weekes et al, 2009), FFMI and arm circumference (Sugawara et al, 2012) or FM, TSF and FFMI with energy intakes of 1.3 x HBE (Planas et al, 2005).

      The evidence for a relationship between energy intake and lung function, systemic inflammation or exercise capacity was inconsistent.

      • Lung function (five studies): Two studies found significant associations in forced vital capacity (FVC) and sniff pressure (Weekes et al, 2009) and Pmax inspiratory (PImax) (Sugawara et al, 2012). Three studies did not find associations in FEV in one second (FEV1) (Lee et al, 2013; Yazdanpanah et al, 2010), FEV1 with energy intakes of either 1.7 x or 1.3 x HBE (Planas et al, 2005), FVC,  FEV1/FVC, and vital capacity (Yazdanpanah et al, 2010), PImax and Pmax expiratory (PEmax) (Weekes et al, 2009) or PEmax (Sugawara et al, 2012). 
      • Systemic inflammation (one study): The study found a significant association with IL-6, but not CRP (Sugawara et al, 2012)
      • Exercise capacity (five studies): Three studies found significant associations with upper and lower body strength (Benton et al, 2010) and six-minute walking distance (Benton et al, 2010; Lee et al, 2013; Sugawara et al, 2012). Two studies did not find associations: Handgrip strength (HGS) with energy intakes of either 1.7 x or 1.3 x HBE (Planas et al, 2005) and HGS (Weekes et al, 2009).

      * For Sugawara et al, 2012, the workgroup considered the between-group analysis only in the conclusion statement. 

    • Recommendation Strength Rationale

      The conclusion statement supporting the recommendation was Grade II, Fair.

    • Minority Opinions

      None.