Introduction

Chronic Obstructive Pulmonary Disease (COPD) is a progressive chronic inflammatory lung disease characterised by persistent respiratory symptoms due to airflow limitation.1 COPD is a growing global health problem, with a prevalence of more than 200 million cases in 2019, and it is the third leading cause of death worldwide.2,3 The majority of people diagnosed with COPD are older and frail, living with frequent exacerbations of their COPD and multi-comorbidities that affect the patients both physically and psychosocially.4,5 COPD is associated with the development of malnutrition, with prevalence rates ranging from 13% to 45%.6,7 Disease-related malnutrition negatively affects the immune response and physical capacity, as a low intake of macro- and micronutrients is a key factor in muscle wasting.8 A reduction in muscle mass leads to physical inactivity, need for support, hospitalisation, low quality of life and increased mortality.9,10 In addition to medications, supplemental oxygen, and non-invasive ventilation, regular physical activity combined with nutritional support are crucial for the long-term prevention of malnutrition and muscle wasting.1 Despite a clear rationale for nutritional support, the definition and content of nutritional support is less clear in the literature. Within nutritional research, concepts like nutritional therapy, nutritional support or care, may refer to both parenteral and enteral nutritional treatment, dietary advice and organisation of the nutritional process, as well as the role of each member of the multidisciplinary team.11,12

Oral nutritional supplementation has, within enteral nutrition, shown a positive impact on physical function, body composition and patient survival in underweight patients with stable COPD.13 Despite a positive effect of oral nutritional supplementation, the patients’ ability to uphold their nutritional needs faces several barriers that are more related to their needs, eg, transporting groceries, fatigue, dyspnoea, lack of energy to prepare and eat the meals, loss of appetite, and loneliness.14 So far, the nutritional intervention for patients with COPD, mainly focusing on enteral nutrition, has shown an inconclusive effect due to research heterogeneity and short timespan.15

Pulmonary rehabilitation aims to reduce symptoms and improve physical function and health-related quality of life.16,17 Although pulmonary rehabilitation is internationally recognised and implemented, barriers still exist. For patients, these barriers include a lack of knowledge and belief in its benefits, frequent interruptions due to COPD exacerbation and hospitalisation, and personal issues such as poor scheduling, disruption of daily routines, and transportation problems, all of which lead to low participation and completion rates.18

Recently, the American Thoracic Society conducted workshops on modernising pulmonary rehabilitation, highlighting the need to personalise programs by incorporating patients’ preferences and needs.19 A review by Leplege (2007) explored person-centredness in rehabilitation and found it to be used as a multi-dimensional concept with a range of interpretations; thus, consensus on its meaning and implications remains elusive.20 The concept of person-centredness in rehabilitation is still a challenge, due to a lack of consensus about its definition, and the absence of knowledge of how to operationalise the concept into a clinical rehabilitation setting.21 To date, fifteen domains of supportive needs have been identified to promote and enhance interventions with a person-centred approach to patients with COPD.22 Reviews have independently investigated nutritional support and physical activity for patients with COPD, but few studies have utilised these components within a person-centred approach.15,23 Therefore, the aim of this study is to map the existing evidence, summarise components of nutritional support and/or physical activity interventions with a person-centred approach for people with COPD to make recommendations for future intervention research.

Material and Methods Protocol Registration

The protocol is registered December 19th, 2022, in Open Science Framework https://doi.org/10.17605/OSF.IO/AZMFS. The registration was performed retrospectively following a pilot literature search for advancing the original search to encompass studies with a key relevance to this study.

Study Design

This review uses the methodological framework developed by Arksey & O’Malley with the following five stages: Identification of research questions, identification of relevant studies, selection of studies, charting of data, and summary and reporting of findings.24 The latter is described according to the PAGER framework for improving the quality of reporting.25 The Reporting Items for Systematic Reviews and Meta-analysis extension for Scoping Reviews (PRISMA-ScR) guide was used to qualify the review.26 The Template for Intervention Description and Replication (TIDieR) checklist was used to structure the data charting.27

Identification of Research Questions

The primary research inquiry was identified through the application of the PICo framework, comprising the population, the interventions, and the contextual elements.

The primary research question is:

What is the available evidence for nutritional support and/or physical activity interventions with a person-centred approach targeting people with COPD?

The research question is further addressed by the following sub-questions:

1. What characterises the interventions? (What? How much? Who delivered?)

2. Which outcomes are used to measure the interventions?

3. What is the effect of the interventions?

Identifying Relevant Studies

The literature search was conducted in June 2022 and updated in June 2023. We included two research databases, PubMed, and CINAHL, combined with a search for grey literature in four online databases (Google Scholar, Open Grey, National Grey Literature Collection, and NY Academy of Medicine Grey Literature Report) and five websites (European Respiratory Society, The Danish Lung associations, Danish Health Authority, The Danish pulmonary society, and Centre for clinical guidelines). The search strategy was planned in collaboration with a librarian from the University of Aarhus, Denmark. A full search string is attached in Appendix 1. We did a preliminary iterative search in PubMed and CINAHL to identify Medical Subject Headings, Mesh Terms, CINAHL headings, and Free text keywords with reference to “nutritional support“, “physical activity”, “COPD”, and “Person-centred approach”. Boolean terms “OR”/”AND” and truncation “*” were used in the final search. The following terms were used and combined with keywords and searched for as Free text in Title/Abstract:

- (Chronic obstructive pulmonary disease, COPD)

AND

- (Nutrition, Nutritional support, Nutrition assessment, Nutrition therapy, Nutritional care, Food, Mealtime, Malnutrition, Mobility limitation, Physical activity, Mobility, Exercise test, Exercise physical fitness)

AND

- (Person-centred care, Patient care management, Patient preference, Patient participation, Patient care planning).

The identified papers were imported into the Covidence Systematic Review software program, where duplicates were eliminated.28 Additionally, the first author and a researcher separately searched for grey literature using a structured search strategy with the keywords: (COPD OR Chronic obstructive pulmonary disease) AND (Physical activity OR Movements OR Physical function OR Nutrition OR Nutritional care OR Clinical nutrition) AND (Person-centred OR Patient-centered). Finally, references listed in the included papers were screened to identify further relevant studies.

Study Selection

Studies were selected based on the following inclusion criteria and definitions presented as population, intervention, and context.

Population:

- People diagnosed with COPD at all stages and in all conditions.1

Interventions:

- A person-centred approach was used when patients expressed needs, wants, and/or preferences were a key part of the intervention.

AND

- A Nutritional support included any form of nutrition, nutrient delivery, educational and dietary advice, meal and eating support, and medical nutritional therapy.8

OR

- A physical activity was defined as any body movement produced by a skeletal muscle that requires energy expenditure.29

Context:

- All designs, measurements, analyses, and outcomes were eligible for inclusion: qualitative, before-after, quantitative and mixed methods intervention studies. We included all countries, hospitals, and primary care settings as we aimed for a wide range of contexts.

Studies with a mixed population or reviews were excluded as only primary intervention studies for people with COPD were of interest. The studies were limited to publications between January 2012 and June 2022 written in either English, Danish, Norwegian, or Swedish.

During the initial screening, the titles and abstracts were independently evaluated by three reviewers. The first 50 abstracts were screened as a pilot assessment to identify and clarify any discrepancies in meeting the inclusion and exclusion criteria. Subsequently, a full-text screening of the included literature was conducted by the main reviewer, who thus assessed all selected studies. This was done in collaboration with three reviewers, who each assessed one-third of the included literature. Disagreements in the results from the full-text screenings were resolved through discussion between all reviewers until consensus was reached. Finally, a total of fifteen papers were included in the scoping review. The screening is shown in the PRISMA flow diagram (Figure 1).

Figure 1 PRISMA flow diagram providing an overview of the review process.

Charting the Data

A data charting form was developed in line with the research question and the TIDieR checklist (see Appendix 2). A pilot test and adaptation of the charting table was conducted prior to charting the data. The reviewers performed the data extraction independently. The main reviewer extracted all data, while the other reviewers extracted one-third each. The data extractions were compared, and consensus was reached. Data extraction was iterative, and the data charting form was adapted during the process.

Summarise and Report the Results

The results are summarised and reported in Tables 1–4 supplemented by a narrative description. In the tables, the studies are presented in order by the year of publication. Studies using similar intervention are presented in groups with a headline. The study characteristics are presented in Table 1. Patterns from the intervention within physical activity, nutritional support, and person-centred approach are categorised according to TIDieR checklist and presented in Table 2 and Table 3. 27 The used outcome-measurements and the primary and secondary outcomes between the intervention and control groups are presented in Table 4.

Table 1 Summary of study characteristics

Table 2 Patterns for the Intervention

Table 3 Patterns of Elements of the Intervention

Table 4 Endpoints, Outcome Measurements, and Outcomes

Results

In total, 2181 studies were identified. After screening titles and abstracts, 1899 studies were excluded according to the inclusion and exclusion criteria, leaving 85 studies to be assessed for eligibility for full-text review. In total, 15 studies were included in the review (Figure 1).

Characteristics of Study Objectives, Design, Participants, and Key Findings

The reviewed studies cover a wide geographic range, spanning eight countries across four continents, with most studies conducted in Europe. The studies were published between 2013 and 2022. The results of the study characteristics are summarised in Table 1.

The overall patterns within the study objectives were to evaluate the effectiveness of the interventions on outcomes like health-related quality of life and hospitalisation. One intervention, known as the self-management program of activity, coping, and education (SPACE), was evaluated in various settings.41–43 Prior to the evaluation, the SPACE intervention was developed, by involving patients and healthcare professionals, and pilot tested for effectiveness.44 One study, developed and tested a home pulmonary rehabilitation programme that adapted health coaching,39 which previously had shown to reduce the short-term readmission for patients hospitalised for an acute exacerbation.40 Three of the included studies explored the acceptability or/and feasibility of their intervention,35,36,39 while two studies tested the process of the delivery and acceptability alongside the randomised control trial (RCT) study.30,41 Most of the studies used the RCT design to test the effectiveness of the intervention (n = 10). The patients’ age ranged from 59 to 83 years with a primary pulmonary status from moderate-to-severe grade of COPD as per the GOLD standard. Five studies included patients with an acute COPD exacerbation.32–34,40,42 One study included outpatients with home oxygen therapy.37 Four studies described the patients as stable,30,31,36,43 while the remaining studies did not include the COPD status as a criteria for participation. The key findings indicate notable improvements in the patient’s functional capacity, health status, health-related quality of life, and disease knowledge. Additionally, the interventions demonstrated high feasibility and well-acceptance by the patients.

Patterns of the Intervention

A detailed description of the content of the interventions is presented in Table 2. The overall programme consisted of behaviour of change interventions (n = 7) or/and self-management (n = 10) where PR was included alongside or in combination but only explicitly described in three studies. Interventions involving partnership establishment37,38 and shared decision-making components32 were integrated into the self-management program. The intervention period lasted from four weeks to six months with six weeks being the most common duration. Seven studies had a follow-up period between three months to one year.

The interventions were mainly delivered by physiotherapists (n = 4), nurses (n = 4) or multidisciplinary teams (n = 3). A focus group interview by Apps et al (2013) noted that those delivering the intervention should have knowledge of COPD and physical activity while being familiar with the patient and their abilities.44

The interventions were primarily delivered as home-based (n = 12), followed by hospital-initiated interventions for patients with an acute COPD exacerbation (n = 4). The interventions located in the community focused on enhancing patients’ activity and participants’ retention.35,41 A focus group interview pointed to that the main factor for participation in a group-based intervention, was that the venue was placed in the local community nearby the patient’s home.41

Patterns of Intervention Elements

Table 3 illustrates the patterns of person-centred approach, physical activity and/or nutritional support in the interventions. The overall structure of the person-centred approach is to assess and prepare the patients for change using motivational interview, personal assessment of needs or shared decision-making, followed by goal setting, a personal action plan and different supportive activities to ensure participation. The approach included family involvement with joint goal-setting,30 elaboration of support from family members,34,37 and a partnership-based educational programme.38 The personalised supportive activities were primarily provided through a combination of face-to-face conversations in the beginning of the intervention, combined with telephone follow-up (n = 8), eg, a telephone follow-up with health coaching sessions.40

Physical activity was the primary intervention and applied in all studies. Half of the studies included more than one type of physical activity. Healthy lifestyle promotion and neuromuscular stimulation therapy of quadriceps accompanied by lower limb exercises were delivered during hospitalisation.32,33 A home-based exercise program delivered after discharge consisted of, eg, upper extremity exercises combined with a step trainer,40 or a daily walking-program combined with resistance training of the upper and lower limbs.42 One intervention provided a personal assessment and a tailored educational programme delivered during and after hospitalisation.34

Another main element is the diverse and comprehensive educational programmes (n = 11) consisting of multiple components for COPD management, encompassing knowledge about physical activity (n = 11) and nutrition (n = 8). Overall, the educational programmes emphasise promotion and motivation for adopting a healthy diet and lifestyle while also providing advice on nutrition and improving physical activity. The educational programme for the SPACE intervention consists of an educational information manual (176 pp), providing an exercise program and addressing multiple topics with interactive tasks including healthy eating, how to stay fit, and the right food when you feel unwell.44 In another intervention, focusing on reducing sedentary behaviour, the patients underwent education on the negative health consequences of sedentary behaviour.30

Self-monitoring of activity levels, goal attainment, nutritional status, or clinical scores is used to provide feedback or to adjust physical activity, provide encouragement, and motivate and/or setting new goals.30,31,35,37,39,40

Endpoints, Outcome Measurements and Outcomes

Table 4 presents the primary and secondary endpoints, outcome measurements, and the outcome differences between the intervention and the control group within the included RCT studies (n = 10) and a nonrandomised control trial (n = 1). Improvement in health-related quality of life is the most prevalent primary endpoint (n = 5), but no clinically significant differences were found between the intervention and control groups. One study showed a clinically significant difference using the clinical visit-PRO active survey45 by aiming to improve the patients’ experience of performing physical activity using a behaviour of change intervention.31 Two studies found a positive effect on the overall health state,32 using the European quality of life-5 dimensions scale46 and a reduction in COPD-related emergency visits and length of stays at hospital.34 All studies include physical activity/function as a secondary endpoint, but health status, physical parameters, and nutritional assessment were only present in one study. An overview of the included outcome measurements is listed with references in Appendix 3. Eight studies show an improvement within multiple secondary outcome measures, including physical activity30,41 using the physical activity measurement (PAM),47 step counts steps/day,30–32 muscle capacity,31 functional independence32,33 by using functional independence measurements,48 6 minutes walking distance (6MWD),34 activity of daily living,37 and incremental/endurance shuttle walking test.43 In the study by Granados-Santiago et al (2020), nutritional assessment is quantified using the Minimal Nutritional Assessment Survey,49 revealing a statistically significant advantage for the intervention group compared to the control group.

Discussion

This scoping review aims to map the evidence related to interventions with a person-centred approach, focusing on nutritional support and/or physical activity in people with COPD. The overall pattern that emerges highlights self-management programmes that use the rationale of supporting people with COPD to change behaviour, become more physically active, and manage their COPD to increase their health-related quality of life. The pattern underscores current research on COPD self-management interventions, which are defined as “structured but personalised and often multi-component, with goals of motivating, engaging and supporting the patients to positively adapt their health behaviour(s) and develop skills to manage their disease better”. 50 Behaviour change techniques focus primarily on improving the motivational factor at the individual level. Motivational interviews are used in various settings as a technique to prepare and support the person to make individual changes of behaviour.51 However, patients with COPD experience several barriers in their everyday life and in their communication with the health professionals that hinder their ability to respond positively to the recommendation of being physical active.52 A notable deficiency within the included studies was the limited attention to patients’ individual opportunities and capability to change their behaviour, particularly in relation to their physical and social environment. Changing one or several components related to motivation, capability, and/or opportunity plays a crucial role in shaping individuals’ behaviour, and all the components should be considered when designing future behaviour of change interventions.53 Additionally, the omission of incorporating the patients’ relatives as a main and general component in the included studies is notable, in as much as people with severe COPD often depend on relatives who act as informal caregivers in patients’ everyday life.54 Involving relatives to the patient may enhance the ability of both patients and relatives to cope with and adjust to managing a complex disease such as COPD.55 This indicates a need to include the informal caregivers and the patient’s ability and resources to comply with health recommendations in interventions with a person-centred approach. This review explicitly identifies a knowledge gap regarding both person-centred nutritional support and physical activity that involves the patient’s social environment, as well as how interventions should be designed to incorporate these aspects in future studies.

This review describes a gap in the literature that relates to person-centred nutrition support as a primary intervention component for people with COPD. Nutritional support is primarily described as a subordinate part of educational programs and is also referred to among other topics as nutrition or dietary advice or counselling. This finding is consistent with the pulmonary rehabilitation guideline, in which physical activity is the primary intervention.16 To date, dietary counselling for older adults with disease-related malnutrition has demonstrated some efficacy in promoting weight gain, yet its comparative advantage over oral nutritional supplementation remains uncertain.56 A recent review concluded, based on two older studies, that clinical guideline recommendations for nutritional support were of moderate quality.57 In addition, the review found that international clinical guidelines gave limited consideration to nutritional support and family involvement. This is notable as the prevalence of malnutrition among patients with COPD is reported at 30%, while the risk of malnutrition is up to 50%.58 Unintentional weight loss is a key component of malnutrition and an independent risk factor for poor outcomes and mortality.59 Disease-related malnutrition leads to increased protein catabolism and, for patients with COPD, increases the risk of developing cachexia.60 Poor nutritional status contributes to the development of muscle weakness and exercise intolerance, leading to dyspnoea,60 which enhances unintentional weight loss, leading to extended hospitalisations and a low quality of life.9

Another review investigated nutrition’s role in managing COPD, demonstrating a persistently significant impact on the patient’s symptoms and future health risks.61,62 The main conclusion was the identification of a therapeutic window for personalised nutritional interventions during and after an acute exacerbation of COPD, necessitating interventions to formulate strategies for personalised nutrition.58,61 For patients with COPD, taking part in a meal can be complex and challenging and requires emotional and physical support in addition to nutritional counselling or oral nutritional supplementation.59,63 Person-centred nutritional support interventions must be expanded in a broader context of nutritional care.

Strength and Limitations

This review offers a comprehensive analysis of studies with a person-centred approach, using a well-described method to extract and synthesise knowledge related to physical activities and nutritional support. This can in turn serve as a foundation for the development of person-centred interventions that encompass the patient’s environmental context and available social resources, with a focus on nutritional support and physical activity. Heterogeneity is to be expected when complex interventions, such as person-centred nutritional support and/or physical activity, are being tested with reference to vulnerable patients. The lack of transparency in the description of the interventions makes the development of evidence-based care strategies difficult as the level of replication will be low. In this study, we used the templates of TIDieR as a guide to structure and qualify the extracting data of the intervention content. The TIDieR templates have been developed to increase the ability to replicate interventions, by offering structured descriptions of the components in the intervention.27 The search strategy applied here was comprehensive and included several keywords, not all were inherently linked to nutritional support, physical activity, and a person-centred approach, resulting in a large number of excluded studies. In addition, the inclusion criteria for a person-centred approach: “When patients expressed needs, wants, and/or preferences were a key part of the intervention”, proved to be ambiguous. This made interpretation difficult due to the lack of explicit descriptions of the intervention components.

Finally, several of the studies in this review include additional components (eg, education and disease adherence, smoking cessation, and action plan for exacerbation) to complement the nutritional support and physical activity intervention. This presented a challenge for the evaluation of effectiveness, as this review did not include the effect of the other component, although all primary endpoints of the intervention studies were included in the analysis.

Conclusion

Nutritional support and physical activity interventions incorporating a person-centred approach are primarily characterised as behaviour of change and/or self-management interventions. Physical activity is the main element of the interventions, while the focus on nutritional support is limited. Despite the person-centred approach, there is minimal involvement of the patient’s physical and social environment. Motivational techniques to enhance physical activities appear to have limited clinical effect on health-related quality of life, and moderate effect on physical capacity. Future person-centred interventions should include patients’ opportunities to engage in physical activity and improve or maintain nutritional status.

Acknowledgments

We thank the Aarhus University Health Science librarians for contributing to the search strategy. We thank the Danish Lung Foundation, Lån & Spar Foundation, Novo Nordisk Foundation, and Aarhus University grants for contributing with funding to perform the study and this article.

Disclosure

The authors report no conflicts of interest in this work.

References

1. Global Initiative for Chronic Obstructive Lung Disease. Global Initiative for Chronic Obstructive Lung Disease. Global strategy for the diagnosis, management, and prevention of COPD Global Initiative for Chronic Obstructive Lung Disease. Global Initiative for Chronic Obstructive Lung Disease - GOLD. Published 2022. Available from: https://goldcopd.org/2022-gold-reports-2/. Accessed May23, 2022.

2. Safiri S, Carson-Chahhoud K, Noori M, et al. Burden of chronic obstructive pulmonary disease and its attributable risk factors in 204 countries and territories, 1990-2019: results from the Global Burden of Disease Study 2019. BMJ. 2022;378:e069679. doi:10.1136/bmj-2021-069679

3. World Health Organisation. The top 10 causes of death. Available from: https://www.who.int/news-room/fact-sheets/detail/the-top-10-causes-of-death. Accessed January2, 2024.

4. Brown JP, Martinez CH. Chronic obstructive pulmonary disease comorbidities. Curr Opin Pulm Med. 2016;22(2):113–118. doi:10.1097/MCP.0000000000000241

5. Yohannes AM, Alexopoulos GS. Depression and anxiety in patients with COPD. Eur Respir Rev. 2014;23(133):345–349. doi:10.1183/09059180.00007813

6. Christensen T, Mikkelsen S, Geisler L, Holst M. Chronic obstructive pulmonary disease outpatients bear risks of both unplanned weight loss and obesity. Clin Nutr ESPEN. 2022;49:246–251. doi:10.1016/j.clnesp.2022.04.010

7. Hogan D, Lan LTT, Diep DTN, Gallegos D, Collins PF. Nutritional status of Vietnamese outpatients with chronic obstructive pulmonary disease. J Hum Nutr Diet. 2017;30(1):83–89. doi:10.1111/jhn.12402

8. Cederholm T, Barazzoni R, Austin P, et al. ESPEN guidelines on definitions and terminology of clinical nutrition. Clin Nutr. 2017;36(1):49–64. doi:10.1016/j.clnu.2016.09.004

9. Tramontano A, Palange P. Nutritional state and COPD: effects on dyspnoea and exercise tolerance. Nutrients. 2023;15(7):1786. doi:10.3390/nu15071786

10. Waschki B, Kirsten A, Holz O, et al. Physical activity is the strongest predictor of all-cause mortality in patients with COPD: a prospective cohort study. Chest. 2011;140(2):331–342. doi:10.1378/chest.10-2521

11. Jefferies D, Johnson M, Ravens J. Nurturing and nourishing: the nurses’ role in nutritional care. J Clin Nurs. 2011;20(3–4):317–330. doi:10.1111/j.1365-2702.2010.03502.x

12. Volkert D, Beck AM, Cederholm T, et al. ESPEN practical guideline: clinical nutrition and hydration in geriatrics. Clin Nutr. 2022;41(4):958–989. doi:10.1016/j.clnu.2022.01.024

13. Ferreira IM, Brooks D, White J, Goldstein R. Nutritional supplementation for stable chronic obstructive pulmonary disease. Cochrane Database Syst Rev. 2012. doi:10.1002/14651858.CD000998.pub3

14. Odencrants S, Theander K. Assessment of nutritional status and meal-related situations among patients with chronic obstructive pulmonary disease in Primary health care – obese patients; a challenge for the future. J Clin Nurs. 2013;22(7–8):977–985. doi:10.1111/j.1365-2702.2012.04184.x

15. Furulund E, Bemanian M, Berggren N, et al. Effects of nutritional interventions in individuals with chronic obstructive lung disease: a systematic review of randomized controlled trials. COPD. 2021;Volume 16:3145–3156. doi:10.2147/COPD.S323736

16. Spruit MA, Singh SJ, Garvey C, et al. An official American thoracic society/European respiratory society statement: key concepts and advances in pulmonary rehabilitation. Am J Respir Crit Care Med. 2013;188(8):e13–e64. doi:10.1164/rccm.201309-1634ST

17. Mccarthy B, Casey D, Devane D, Murphy K, Murphy E, Lacasse Y. Pulmonary rehabilitation for chronic obstructive pulmonary disease. Cochrane Database Syst Rev. 2015;2015(2):CD003793. doi:10.1002/14651858.CD003793.pub3

18. Cox NS, Oliveira CC, Lahham A, Holland AE. Pulmonary rehabilitation referral and participation are commonly influenced by environment, knowledge, and beliefs about consequences: a systematic review using the theoretical domains framework. J Physiotherapy. 2017;63(2):84–93. doi:10.1016/j.jphys.2017.02.002

19. Holland AE, Cox NS, Houchen-Wolloff L, et al. Defining modern pulmonary rehabilitation. an official American thoracic society workshop report. Ann Am Thorac Soc. 2021;18(5):e12–e29. doi:10.1513/AnnalsATS.202102-146ST

20. Leplege A, Gzil F, Cammelli M, Lefeve C, Pachoud B, Ville I. Person-centredness: conceptual and historical perspectives. Disability Rehabil. 2007;29(20–21):1555–1565. doi:10.1080/09638280701618661

21. Yun D, Choi J. Person-centered rehabilitation care and outcomes: a systematic literature review. Int J Nurs Stud. 2019;93:74–83. doi:10.1016/j.ijnurstu.2019.02.012

22. Gardener AC, Ewing G, Farquhar M. Enabling patients with advanced chronic obstructive pulmonary disease to identify and express their support needs to health care professionals: a qualitative study to develop a tool. Palliative Med. 2019;33(6):663–675. doi:10.1177/0269216319833559

23. Xiang X, Huang L, Fang Y, Cai S, Zhang M. Physical activity and chronic obstructive pulmonary disease: a scoping review. BMC Pulm Med. 2022;22:22. doi:10.1186/s12890-022-02099-4

24. Arksey H, O’Malley L. Scoping studies: towards a methodological framework. Int J Soc Res Methodol. 2005;8(1):19–32. doi:10.1080/1364557032000119616

25. Bradbury-Jones C, Aveyard H, Herber OR, Isham L, Taylor J, O’Malley L. Scoping reviews: the PAGER framework for improving the quality of reporting. Int J Soc Res Methodol. 2022;25(4):457–470. doi:10.1080/13645579.2021.1899596

26. Tricco AC, Lillie E, Zarin W, et al. PRISMA extension for scoping reviews (PRISMA-ScR): checklist and explanation. Ann Intern Med. 2018;169(7):467–473. doi:10.7326/M18-0850

27. Hoffmann TC, Glasziou PP, Boutron I, et al. Better reporting of interventions: template for intervention description and replication (TIDieR) checklist and guide. BMJ. 2014;348(mar07 3):g1687. doi:10.1136/bmj.g1687

28. Covidence. Covidence - Better systematic review management; 2014. Available from: https://www.covidence.org/home. Accessed September27, 2019

29. Caspersen CJ, Powell KE, Christenson GM. Physical activity, exercise, and physical fitness: definitions and distinctions for health-related research. Public Health Rep. 1985;100(2):126–131.

30. Cheng SWM, Alison J, Stamatakis E, et al. Six-week behaviour change intervention to reduce sedentary behaviour in people with chronic obstructive pulmonary disease: a randomised controlled trial. Thorax. 2022;77(3):231–238. doi:10.1136/thoraxjnl-2020-214885

31. Armstrong M, Hume E, McNeillie L, et al. Behavioural modification interventions alongside pulmonary rehabilitation improve COPD patients’ experiences of physical activity. Respir Med. 2021;180:106353. doi:10.1016/j.rmed.2021.106353

32. Granados-Santiago M, Valenza MC, López-López L, Prados-Román E, Rodríguez-Torres J, Cabrera-Martos I. Shared decision-making and patient engagement program during acute exacerbation of COPD hospitalisation: a randomised control trial. Patient Educ Couns. 2020;103(4):702–708. doi:10.1016/j.pec.2019.12.004

33. Lopez-Lopez L, Valenza MC, Rodriguez-Torres J, Torres-Sanchez I, Granados-Santiago M, Valenza-Demet G. Results on health-related quality of life and functionality of a patient-centered self-management program in hospitalised COPD: a randomised control trial. Disability Rehabil. 2020;42(25):3687–3695. doi:10.1080/09638288.2019.1609099

34. Wang LH, Zhao Y, Chen LY, Zhang L, Zhang YM. The effect of a nurse‐led self‐management program on outcomes of patients with chronic obstructive pulmonary disease. Clin Respir J. 2020;14(2):148–157. doi:10.1111/crj.13112

35. Bartlett YK, Webb TL, Hawley MS. Using persuasive technology to increase physical activity in people with chronic obstructive pulmonary disease by encouraging regular walking: a mixed-methods study exploring opinions and preferences. J Med Internet Res. 2017;19(4):e124. doi:10.2196/jmir.6616

36. Damps-Konstańska I, Werachowska L, Krakowiak P, et al. Acceptance of home support and integrated care among advanced COPD patients who live outside large medical centers. Appl Nurs Res. 2016;31:60–64. doi:10.1016/j.apnr.2015.12.003

37. Moriyama M, Takeshita Y, Haruta Y, Hattori N, Ezenwaka CE. Effects of a 6-month nurse-led self-management program on comprehensive pulmonary rehabilitation for patients with COPD receiving home oxygen therapy. Rehabil Nurs. 2015;40(1):40–51. doi:10.1002/rnj.119

38. Jonsdottir H, Amundadottir OR, Gudmundsson G, et al. Effectiveness of a partnership-based self-management programme for patients with mild and moderate chronic obstructive pulmonary disease: a pragmatic randomised controlled trial. J Adv Nurs. 2015;71(11):2634–2649. doi:10.1111/jan.12728

39. Benzo RP, Kramer KM, Hoult JP, Anderson PM, Begue IM, Seifert SJ. Development and feasibility of a home pulmonary rehabilitation program with health coaching. Respir Care. 2018;63(2):131–140. doi:10.4187/respcare.05690

40. Benzo R, Vickers K, Novotny PJ, et al. Health coaching and chronic obstructive pulmonary disease rehospitalization. A randomised study. Am J Respir Crit Care Med. 2016;194(6):672–680. doi:10.1164/rccm.201512-2503OC

41. Bourne C, Houchen-Wolloff L, Patel P, Bankart J, Singh S. Self-management programme of activity coping and education—SPACE for COPD(C)—in primary care: a pragmatic randomised trial. BMJ Open Respir Res. 2022;9(1):e001443. doi:10.1136/bmjresp-2022-001443

42. Johnson-Warrington V, Rees K, Gelder C, Morgan M, Singh S. Can a supported self-management program for COPD upon hospital discharge reduce readmissions? A randomised controlled trial. COPD. 2016;1161. doi:10.2147/COPD.S91253

43. Mitchell KE, Johnson-Warrington V, Apps LD, et al. A self-management programme for COPD: a randomised controlled trial. Eur Respir J. 2014;44(6):1538–1547. doi:10.1183/09031936.00047814

44. Apps LD, Mitchell KE, Harrison SL, et al. The development and pilot testing of the self-management programme of activity, coping and education for chronic obstructive pulmonary disease (SPACE for COPD). COPD. 2013;317. doi:10.2147/COPD.S40414.

45. Dobbels F, de Jong C, Drost E, et al. The PROactive innovative conceptual framework on physical activity. Eur Respir J. 2014;44(5):1223–1233. doi:10.1183/09031936.00004814

46. EuroQol Group. EuroQol - a new facility for the measurement of health-related quality of life. Health Policy. 1990;16(3):199–208. doi:10.1016/0168-8510(90)90421-9.

47. Hibbard JH, Stockard J, Mahoney ER, Tusler M. Development of the patient activation measure (PAM): conceptualising and measuring activation in patients and consumers. Health Ser Res. 2004;39(4p1):1005–1026. doi:10.1111/j.1475-6773.2004.00269.x

48. Keith RA, Granger CV, Hamilton BB, Sherwin FS. The functional Independence measure: a new tool for rehabilitation. Adv Clin Rehabil. 1987;1:6–18.

49. Guigoz Y, Vellas B, Garry PJ. Assessing the nutritional status of the elderly: the mini nutritional assessment as part of the geriatric evaluation. Nutr Rev. 1996;54(1 Pt 2):S59–65. doi:10.1111/j.1753-4887.1996.tb03793.x

50. Effing TW, Vercoulen JH, Bourbeau J, et al. Definition of a COPD self-management intervention: international Expert Group consensus. Eur Respir J. 2016;48(1):46–54. doi:10.1183/13993003.00025-2016

51. Miller WRS. Motivational Interviewing: Preparing People for Change. Vol 2nd ed ed. New York, NY: Guilford Press; 2002.

52. Zhang X, Buttery SC, Sterniczuk K, Brownrigg A, Kennington E, Quint JK. Patient experiences of communication with healthcare professionals on their healthcare management around chronic respiratory diseases. Healthcare. 2023;11(15):2171. doi:10.3390/healthcare11152171

53. Michie S, van Stralen MM, West R. The behaviour change wheel: a new method for characterising and designing behaviour change interventions. Implement Sci. 2011;6(1):42. doi:10.1186/1748-5908-6-42

54. Nakken N, Janssen DJ, van den Bogaart EH, et al. Informal caregivers of patients with COPD: home sweet home? Eur Respir Rev. 2015;24(137):498–504. doi:10.1183/16000617.00010114

55. Marques A, Jácome C, Cruz J, Gabriel R, Brooks D, Figueiredo D. Family-based psychosocial support and education as part of pulmonary rehabilitation in COPD: a randomised controlled trial. CHEST. 2015;147(3):662–672. doi:10.1378/chest.14-1488

56. Baldwin C, van der Schueren MA, Kruizenga HM, Weekes CE. Dietary advice with or without oral nutritional supplements for disease‐related malnutrition in adults. Cochrane Database Syst Rev. 2021;2021(12):CD002008. doi:10.1002/14651858.CD002008.pub5

57. Fu Y, Chapman EJ, Boland AC, Bennett MI. Evidence-based management approaches for patients with severe chronic obstructive pulmonary disease (COPD): a practice review. Palliative Med. 2022;36(5):770–782. doi:10.1177/02692163221079697

58. Deng M, Lu Y, Zhang Q, Bian Y, Zhou X, Hou G. Global prevalence of malnutrition in patients with chronic obstructive pulmonary disease: systemic review and meta-analysis. Clin Nutr. 2023;42(6):848–858. doi:10.1016/j.clnu.2023.04.005

59. Kwan HY, Maddocks M, Nolan CM, et al. The prognostic significance of weight loss in chronic obstructive pulmonary disease‐related cachexia: a prospective cohort study. J Cachexia, Sarcopenia Muscle. 2019;10(6):1330–1338. doi:10.1002/jcsm.12463

60. De Brandt J, Beijers RJHCG, Chiles J, et al. Update on the etiology, assessment, and management of COPD cachexia: considerations for the clinician. Int J Chron Obstruct Pulmon Dis. 2022;17:2957–2976. doi:10.2147/COPD.S334228

61. Yde SK, Mikkelsen S, Brath MSG, Holst M. Unintentional weight loss is reflected in worse one-year clinical outcomes among COPD outpatients. Clin Nutr. 2023;42(11):2173–2180. doi:10.1016/j.clnu.2023.09.012

62. Sørensen D, Wieghorst AR, Elbek JA, Mousing CA. Mealtime challenges in patients with chronic obstructive pulmonary disease: who is responsible? J Clin Nurs. 2020;29(23–24):4583–4593. doi:10.1111/jocn.15491

63. Beijers RJHCG, Steiner MC, Schols AMWJ. The role of diet and nutrition in the management of COPD. Eur Respir Rev. 2023;32(168):230003. doi:10.1183/16000617.0003-2023