A talk on Nutrition and COPD

1. NUTRITIONAL
ASPECTS OF COPD
Dr.P.S.Shajahan
Associate Professor of Pulmonary Medicine
Government TD Medical College Alappuzha

2. Disclosures
NIL
NAPCON 2014

3. Nutritional problems in COPD
Does it really matter?
 20-30% of COPD patients are underweight.
 Among inpatients 30% -60% and outpatients 10% - 45%
 Depletion of fat free mass(FFM) ie loss of muscle
mass may be present despite normal body weight.
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Stratton RJ, Green CJ, Elia M. Disease-related malnutrition: an evidence
based approach to treatment. Oxford, United Kingdom: CABI Publishing
(CABI International), 2003.

4. Nutritional problems in COPD
Does it really matter?
Consequences of malnutrition in COPD
Malnutrition in patients with COPD is associated
with
 impaired pulmonary status,
 reduced diaphragmatic mass,
 lower exercise capacity.
Nutritional problems in COPD
Does it really matter?
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5. Nutritional problems in COPD
Does it really matter?
 Increased risk of :
Acute exacerbations (Connors et al., 1996)
Hospital admissions (Pouw et al., 2000)
Mechanical ventilation (Vitacca et al., 1996)
 Decreased exercise tolerance (Schols et al., 1991)
 Poor quality of life (Shoup et al., 1997)
Weight loss and low body weight are associated
with poor prognosis and increased mortality rate when
compared to adequately nourished individuals with
COPD
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6. Nutrition and COPD-
How they are related ?
 Nutrition affects COPD
 COPD affects Nutrition
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7. Nutrition affects COPD
 Anorexic and bulimic individuals may develop
emphysema without smoking and without
inhalation injury.
 Postmortem studies of patients who died in the
Warsaw Ghetto during World War II suggested
that death from starvation was associated with
pulmonary emphysema
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Harvey O. Coxson et al American Journal of Respiratory and Critical
Care Medicine Vol170. pp. 748-752, (2004)

8. Nutrition affects COPD
Under-Nutrition
 Less muscle mass
 Decreased exercise
tolerance
 Increased fatigue
 Compromised immunity
Over-Nutrition
 Weight gain from
decreased activity and:
 Obesity takes up
breathing space !
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9. COPD affects Nutrition
 Breathlessness interferes with eating.
 Hyper inflation, gas or bloating takes up
space in the chest.
 Medications have some nutritional effects -
eg prednisone.
 Breathing takes energy – need calories
 Too tired to plan menus, shop, cook or eat!
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10. It is not simple malnutrition alone…
 Weight loss and low body weight in COPD patients
cannot solely be explained by malnutrition resulting
from poor appetite, reduced food intake.
COPD is a systemic disease and
many factors come in to play.
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11. COPD and Muscle Dysfunction
 Peripheral muscle dysfunction is common and adversely
affects clinical outcomes in COPD.
 Inflammatory mediators elevated in some COPD
patients, responsible for weight loss & muscle wasting.
 Decreased levels of circulating anabolic hormones.
 Corticosteroids are known to cause muscle weakness.
 Chronic hypoxemia or hypercapnia or the effects of
cigarette smoking may damage the muscles.
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12. COPD and Hypermetabolism
 Hypermetabolism at rest in COPD is present in 25%.
 Elevated resting metabolic rate and increased total
energy expenditure.
Creutzberg Eur J Clin Nutr 1998, Nguyen Clin Nutr 1999
Schols, Thorax, 1996, Takabatake,
AM J Respir Crit Care Med, 1999 Dentener, Thorax, 2001
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13. COPD is catabolic
Inadequate food intake, but calorie requirement for
respiration is high!
When calorie intake is decreased the body begins to
break down muscle stores including respiratory
muscles affecting its function
(Excerpt from Nutrition & Diet Therapy; P 476-477; 3rd Edition; Carooll
Lutz 7 Karen Praytulski; 2001)
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14. General Dietary Advice
 Enjoy variety of foods
 Limit salt intake
 Drink plenty of fluids 6-8 glasses/day
 Include high fibre foods e.g. Vegetables, fruits,
wholegrain foods, cereal, pasta, rice
 Eat several small meals per day
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15. Carbohydrates,protein, fats …..
 A low carbohydrate( 40%), high protein(30%), high fat diet(30%)
is recommended.
 Carbohydrates are associated with an increased minute
ventilation (VE) secondary to increased CO2 production. (VCO2)
 High carbohydrate in COPD precipitates respiratory failure and
impaired ability to wean patients from mechanical ventilation.
 Low carbohydrate, high fat diet resulted in a lower CO2
production (VCO2) and respiratory quotient (RQ=VCO2/VO2)
Robert E. and Hobbs; J of Pediatric Gastroenterology
and Nutrition 12:217-223,199
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16. Sodium
 Limit salt intake
 Too much sodium may cause fluid retention
 Recommendations may be to limit to 2,000 mg or
2,500 mg sodium per day
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17. Fluids
 Drink plenty of fluids
 Helps keep mucous thin and easier to cough up
from the lungs
 Presence of cardiac/ renal co morbidities may need to
limit fluids
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18. Dietary Advice for Underweight
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19. Underweight
Weight loss
Loss of respiratory
muscle strength
More energy required
to breathe
Increased breathing
difficulty
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20. Poor appetite
 Have regular meals and snacks
 Eat anything fancied
 Eat from a smaller plate
 Avoid filling up with vegetables, salads, carbonated
drinks
 A short walk before meals may increase appetite
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21. Short of Breath While Eating/ After Meals
 Eat more slowly
 Choose foods that are easy to chew - softer foods
 Try eating 5-6 small meals/day
 Try drinking liquids at the end of the meals.
 Eat while sitting up to ease pressure on the lungs
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22. Feeling of fullness quickly
 Eat smaller meals more frequently, rather than
one or two big meals
 Try not to fill up on fluid whilst eating.
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23. Dietary Advice for Overweight
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24. Overweight
 Consequence of :
 high energy intake from food
 reduced exercise
 steroid use
 Extra weight increases workload of heart and lungs
to supply oxygen around body
 Excess fat in abdominal area makes it difficult for
the lungs to expand fully
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25. Starchy Foods
 Include at each meal
 Should be the main source of energy
 Starchy foods are filling
 Choose whole meal
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26. Fruit and Vegetables
 Low in calorie, rich in vitamins and minerals
 Help protect against infection
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27. Meat and Fish
 Avoid roasting or frying in large amounts of
oil/fat
 Choose lean meat
 Remove visible fat & skins from meat and
poultry.
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28. Milk and Dairy Products
 Provides protein and calcium
 Use semi-skimmed milk instead of full cream milk
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29. Nutritional screening in COPD
BMI (kg/m2) Classification Clinical Action
< 20 underweight Refer to a dietician for nutritional support advice;
prescribe oral nutritional supplements
20-24.9 Normal weight Maintain weight; encourage healthy eating
25-29.9 Over weight Maintain weight; encourage healthy eating
≥30 Obese Encourage weight loss through moderate calorie
restriction and increased physical activity
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30. When to refer to a Dietician
 A patient who has had significant weight loss such as a weight
loss of 5% of their body weight in the previous month or 10%
of their body weight in the previous 6 months.
 An overweight/obese patient who requires nutritional
education to achieve weight loss
 A patient with coexisting health problems in addition to
COPD, such as renal failure, heart disease, diabetes, etc.
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Clinical Subcommittee of the Chronic Disease Network and Access Program of
the Prince Albert Grand Council and its partners and funded by the Aboriginal
Health Transition Fund.

31. What Studies tell - adding confusion
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32. Am J Clin Nutr. 2012 Jun;95(6):1385-95. doi: 10.3945/ajcn.111.023499. Epub 2012 Apr 18.
Nutritional support in chronic obstructive pulmonary disease: a systematic
review and meta-analysis.
Collins PF, Stratton RJ, Elia M.
The objective was to conduct a meta-analysis of
randomized controlled trials (RCTs) to clarify the efficacy of
nutritional support in improving intake, anthropometric
measures, and grip strength in stable COPD.
This systematic review and meta-analysis
showed that nutritional support, mainly in
the form of oral nutritional support,
improves total intake, anthropometric
measures, and grip strength in COPD
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33. Respirology 2012 Nov 20. doi: 10.1111/resp.12019. [Epub ahead of print
The Effects of Nutritional Supplementation Combined with
Conventional Pulmonary Rehabilitation in Muscle Wasted Chronic
Obstructive Pulmonary Disease: A Prospective, Randomised and
Controlled Study.
They evaluated the effects of nutritional supplementation (NS)
with pulmonary rehabilitation (PR) on body composition, mid-
thigh cross-sectional area (CSA), dyspnea, exercise capacity,
HRQoL, anxiety and depression in advanced COPD patients.
The combination of nutritional support with
pulmonary rehabilitation resulted in
improvements particularly in lean body mass
and mid-thigh cross sectional area. This study
suggests combining NS with PR in reversing
weight loss and muscle wasting in COPD.
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34. 1)Nutritional status is an important determinant of outcome of COPD.
2) Nutritional risk can be assessed by longitudinal measurement of body weight
and body composition.
3) The prevalence of vitamin D nutrient deficiency is high in COPD and could be
incorporated into nutritional risk screening.
4) Nutritional intervention is likely to be effective in undernourished patients and
is probably most effective if combined with an exercise programme.
5) A well-balanced diet with sufficient intake of fresh fruits and vegetables is
beneficial to COPD patients, not only for its potential benefits on the lung
but also for its proven benefits on metabolic and cardiovascular risk.
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35. What guidelines tell us?
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36. Looking at the guidelines
With regard to nutritional interventions
 GOLD recommends identification and correction of
the potential reasons for reduced calorie intake,
including breathlessness while eating, poor dentition,
and co morbidities.
 Present evidence suggests that nutritional
supplementation alone may not be a sufficient
strategy, and that increased calorie intake is best
accompanied by exercise regimes that have a
nonspecific anabolic action.
Global Initiative for Chronic Obstructive Lung Disease (GOLD)
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37. Looking at the guidelines
With regard to nutritional interventions
 ACCP/AACVPR states that there is insufficient
evidence to support its routine nutritional
supplementation.
 GOLD and ACCP/AACVPR agree that current
scientific evidence does not support the routine use
of anabolic agents in pulmonary rehabilitation for
patients with COPD.
American College of Chest Physicians/American Association of
Cardiovascular and Pulmonary Rehabilitation (ACCP/AACVPR).
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38. to conclude
 Malnutrition is common in COPD- 30% in stable cases
and up to 50% in severe stages.
 Screening and assessment for nutritional depletion is
required for early intervention.
 Reduced body weight is an independent predictor of
mortality in COPD.
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39. to conclude
 Nutritional review and support is vital in association
with pulmonary rehabilitation to ensure increased
energy demands are met.
 Nutrition is an important component of Pulmonary
rehabilitation in COPD
 The long term effects of weight maintenance and
weight gain on morbidity and mortality need further
study.
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40. thank you
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