NS480 Unit 10 COPD Malnutrition Case Report Example

Breathless at the Table: A Unit 10 Comprehensive Case Report of Malnutrition in Severe COPD, From Weigh-In to Four-Week Evaluation

[Student Name]

Purdue University Global

NS480: Medical Nutrition Therapy I

Unit 10 Comprehensive Case Report

[Instructor Name]

[Date]

The patient and all values are composite; the malnutrition criteria, the respiratory society statement and the nutritional support meta-analysis cited are real.

Introduction

Chronic obstructive pulmonary disease often brings weight loss and muscle wasting, which in turn weaken breathing muscles and worsen outcomes. A European Respiratory Society statement recommends nutritional assessment as part of routine COPD care and describes weight loss and low muscle mass as treatable features of the disease (Schols et al., 2014). This report follows one patient, step by step through the care process, after a referral referred from a pulmonary clinic.

Step 1: Assessment

Client history. Walter, 67, a retired machinist, has severe COPD and uses home oxygen at 2 liters during exertion. He lives with his wife, who cooks. He quit smoking five years ago. He was referred because of weight loss noticed at his last clinic visit.

Anthropometrics. Height 172 cm. Weight 55 kg, down from 63 kg six months ago, a loss of 8 kg, or 12.7 percent. BMI 18.6.

Food and nutrition history. Walter eats two meals a day, breakfast at 9 and dinner at 6. He describes getting breathless while chewing and swallowing, feeling full quickly, and stopping meals early. His wife estimates he eats half of a normal plate. A 24-hour recall suggests about 1,250 kcal and 45 g of protein.

Nutrition-focused physical findings. Visible loss of muscle at the temples, collarbones and thighs. Grip strength low for his age and sex.

Biochemical data. No recent nutrition-specific labs; kidney function normal.

Step 2: Diagnosis

The Global Leadership Initiative on Malnutrition criteria require at least one phenotypic criterion and one etiologic criterion (Cederholm et al., 2019). Walter meets two phenotypic criteria, losing over a tenth of his weight within half a year, and reduced muscle mass on physical examination, and two etiologic criteria, reduced food intake and a chronic inflammatory disease. Weight loss above 10 percent within six months meets the threshold for severe malnutrition under those criteria.

Because his weight loss comes from intake limited by breathlessness, the nutrition diagnosis names breathing during meals as the cause, which points the intervention at how he eats as well as what he eats.

Nutrition diagnosis: inadequate oral intake related to breathlessness and early fullness during meals, as evidenced by a recall showing roughly 1,250 kcal against a target near 1,900 and a 12.7 percent weight loss in six months.

Step 3: Intervention

Estimated needs. Energy is estimated at about 30 to 35 kcal per kilogram of current weight, 1,650 to 1,925 kcal, rounded to a target of about 1,900 kcal to allow for weight regain. Protein is set between 66 and 83 g a day, which works out to 1.2 to 1.5 grams for each of his 55 kilograms, to support muscle.

Changes to meal pattern. Based on the diagnosis, the plan changes how he eats.

1. Six small meals and snacks instead of two larger meals, so each eating occasion requires less breathing effort.

2. Main meal at midday, when Walter reports he has the most energy.

3. Rest for 20 minutes before meals and use his oxygen while eating if his physician agrees.

4. Soft, moist foods that need less chewing, such as eggs, fish, stews and yogurt.

5. Drinks between meals rather than with them, to avoid early fullness.

Energy and protein density. His wife adds butter, olive oil, cheese and milk powder to foods he already eats, increasing energy without increasing volume.

Oral nutrition supplement. One energy- and protein-dense supplement drink daily between meals. A meta-analysis of nutritional support in COPD found that supplements increased energy and protein intake and improved body weight and grip strength compared with control (Collins et al., 2012).

Coordination. Referral to pulmonary rehabilitation, since the respiratory society statement recommends combining nutritional support with exercise training to rebuild muscle rather than adding only fat (Schols et al., 2014).

Step 4: Monitoring and Evaluation

Indicators set at the start, taken from the assessment and the diagnosis:

1. Weight, weekly, on the clinic scale.

2. Energy and protein intake, by three-day food record at two and four weeks.

3. Grip strength, at baseline and four weeks.

4. Breathlessness at meals, by his own rating from 0 to 10.

Four-Week Evaluation

At four weeks, Walter weighed 56.3 kg, a gain of 1.3 kg. His food record showed about 1,750 kcal and 68 g of protein, up from 1,250 kcal and 45 g. He was drinking the supplement on most days. His grip strength was unchanged. He rated breathlessness at meals at 4 out of 10, down from 7, and said eating six small meals felt easier. He had attended his first two pulmonary rehabilitation sessions.

Evaluation against the diagnosis: intake has risen to about 92 percent of the energy target and within the protein range, and weight has begun to rise. The etiology, breathlessness at meals, has improved. Grip strength is not expected to change in four weeks and will be rechecked at twelve weeks, when rehabilitation has had time to work.

Walter's and His Wife's Part

Much of the plan depends on Walter's wife, who shops and cooks. She was included in the second session, and her questions shaped the changes: she worried that adding butter and cheese would harm his heart, and she needed to hear that for a man losing weight this fast, regaining it took priority, with his physician's agreement. She also suggested the midday main meal, having noticed he was most alert then. Plans for older adults with chronic lung disease often fail when the person cooking is left out, and her involvement is a large part of why intake rose.

Plan Going Forward

Continue the meal pattern and supplement. Recheck weight every two weeks and grip strength at twelve weeks. If weight gain stalls, consider a second daily supplement. Share results with his pulmonary team.

Discussion

The case shows why each step must build on the one before. The assessment found that breathlessness, not appetite or food access, limited his intake. The diagnosis named that cause. The intervention therefore changed meal timing, texture and size as well as adding energy, and the monitoring tracked breathlessness alongside weight. If the plan had simply prescribed more calories, Walter might not have been able to eat them.

Limitations

Intake estimates rely on food records kept by his wife. Grip strength was measured once at baseline. Four weeks is too short to judge changes in muscle. The case is composite and illustrates the process rather than reporting a real outcome.

References

Cederholm, T., Jensen, G. L., Correia, M. I. T. D., Gonzalez, M. C., Fukushima, R., Higashiguchi, T., Baptista, G., Barazzoni, R., Blaauw, R., Coats, A. J. S., Crivelli, A. N., Evans, D. C., Gramlich, L., Fuchs-Tarlovsky, V., Keller, H., Llido, L., Malone, A., Mogensen, K. M., Morley, J. E., . . . Yu, J. (2019). GLIM criteria for the diagnosis of malnutrition: A consensus report from the global clinical nutrition community. Clinical Nutrition, 38(1), 1-9. https://doi.org/10.1016/j.clnu.2018.08.002

Collins, P. F., Stratton, R. J., & Elia, M. (2012). Nutritional support in chronic obstructive pulmonary disease: A systematic review and meta-analysis. The American Journal of Clinical Nutrition, 95(6), 1385-1395. https://doi.org/10.3945/ajcn.111.023499

Schols, A. M., Ferreira, I. M., Franssen, F. M., Gosker, H. R., Janssens, W., Muscaritoli, M., Pison, C., Rutten-van Mölken, M., Slinde, F., Steiner, M. C., Tkacova, R., & Singh, S. J. (2014). Nutritional assessment and therapy in COPD: A European Respiratory Society statement. European Respiratory Journal, 44(6), 1504-1520. https://doi.org/10.1183/09031936.00070914