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Nutritional management in COPD and the role of targeted nutrition . COPD and Nutritional Status. Malnutrition in COPD can present in a number of ways Obesity Under nutrition / nutritional depletion Low weight categorised by low BMI (kg / m 2 ) Acute weight loss Muscle wasting

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Nutritional management in COPD and the role of targeted nutrition


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copd and nutritional status
COPD and Nutritional Status
  • Malnutrition in COPD can present in a number of ways
    • Obesity
    • Under nutrition / nutritional depletion
      • Low weight categorised by low BMI (kg / m2)
      • Acute weight loss
      • Muscle wasting

Categorised in ERS/ATS COPD Guidelines:

BMI < 21kg/m2 &/or

wt loss 5% in 3 mths,10% in 6 mths &/or

FFMI < 16 kg/m2 (males) < 15 kg/m2 (females)

incidence of malnutrition in copd
Incidence of malnutrition in COPD

How is it identified?

  • Weight
  • Body Mass Index
    • Weight kg/ height m2
  • Fat Free Mass Index [muscle mass]
    • FFM kg / m2
  • Nutritional Screening
    • E.g. “MUST”
incidence of malnutrition in copd4
Incidence of malnutrition in COPD
  • What happens in practice?
    • Weight Not always!
    • BMI Not always!
    • FFM
    • Screening Not always!
incidence of malnutrition in copd5
Incidence of malnutrition in COPD
  • Depends on severity of disease and how assessed
  • More common in severe COPD patients and patients with emphysema
  • Under recognised –
    • High / Normal BMI with muscle wasting or unintentional wt loss
    • Nutritional status of patient not reviewed

-- Around 21 % found to have nutritional depletion 1

-- Around 25 % patients will develop cachexia 2

-- Between 25-40% with advanced COPD are malnourished 3

References:

1Engelen et al. Eur Resp J 1994; 7:1793-1797 2Wagner PD Eur Resp J 2008; 31:492-591

3Anker et al. Clin Nutr 2006; 25: 311-318

the causes of malnutrition in copd
The causes of malnutrition in COPD
  • POOR NUTRITIONAL INTAKE
    • Loss of appetite [inflammatory processes in body]
    • Shortness of breath whilst eating
    • Post prandial dyspnoea
    • Fatigue
    • Immobility
    • Social isolation
    • Type of patient

REDUCED

INTAKE

the causes of malnutrition in copd7
The causes of malnutrition in COPD
  • INCREASED REQUIREMENTS
    • Increased Energy Expenditure
      • resting energy expenditure
      • total energy expenditure
    • Described as hyper catabolic (over burning calories)
      • Underlying energy turnover increased, systemic inflammation
      • Increased requirements energy used during breathing
      • Inefficient muscle use move from type I to type II
cachexia wasting
Cachexia / Wasting
  • Symptoms of severe wt loss, loss of muscle mass
  • Possible causes
    • Energy imbalance
    • Tissue hypoxia
    • Disuse atrophy
    • Systemic inflammation
    • Hormonal insufficiency
    • Genetic make up
consequences of under nutrition in copd
Consequences of under nutrition in COPD:
  • Mortality in COPD linked to weight, BMI and body composition1
  • Fat Free Mass better predictor of survival than body weight2
  • Declining lung function reduced respiratory muscle function
  • Declining muscle function reduced exercise capacity
  • Reduced quality of life
  • Linked to exacerbations [wt loss associated with admission, wt loss at admission associated with readmission]

References: 1Anker et al. Clin Nutr 2006; 25: 311-318 2Schols et al. AJCN 2005; 82:53-59

registering the significance of muscle mass
Registering the significance of muscle mass
  • Active tissue, more relevant than total weight
  • Academics, leading COPD experts recognise importance of muscle mass and role plays in spiral of decline. Now thinking about muscle mass earlier on in disease.
  • Muscle mass linked directly with physical activity and outcomes
  • Muscle wasting hard to monitor/ measure in clinical practice (not a consideration for most COPD clinicians & health professionals - BMI and Wt loss more clinically relevant for them)
summary current situation
Summary : Current situation
  • Poor nutritional status is clearly linked to poor outcomes
  • Need to bear in mind – unlike other diseases patients who are overweight have better prognosis (avoid aggressive treatment of obesity)
  • Intervention
    • Limited as poorly recognised
    • Few dedicated respiratory Dietitians
    • Only for severe / hospitalised patients
    • Mixed success
  • Evidence
    • Inconclusive to date
    • New interventions being considered
is this approach too little too late 1 2
Is this approach too little, too late?1,2

1GOLD guidelines updated Nov 2008

2ATS/ERS Standards for the diagnosis and management of patients with COPD. 2004

guidelines in copd
Guidelines in COPD
  • NICE1
    • BMI should be calculated in patients with COPD
    • If BMI is low (<20kg/m 2 ) or changing over time should be referred to Dietitian
    • If the BMI is low patients should also be given nutritional supplementation to increase their total calorific intake, and be encouraged to take exercise to augment the effects of nutritional supplements
  • ESPEN2
    • The evidence to support use of Enteral Nutrition in COPD is limited
    • EN in combination with exercise and anabolic pharmacotherapy has the potential to improve nutritional status and function

1NICE Guideline CG12 Chronic Obstructive Pulmonary Disease 2004, Unchanged Update 2010

2ANker et al. 2004 Clinical Nutrition 25:311-318

proven benefits of pulmonary rehabilitation physical capacity 1
Proven benefits of pulmonary rehabilitation (physical capacity)*1
  • Increased exercise capacity
  • Reduced dyspnoea
  • Improved health-related quality of life
  • Decreased healthcare utilization

*All based on consistent findings in randomized controlled trials in patients with chronic obstructive pulmonary disease (i.e., “Evidence A”) according to the GOLD 2008 Guidelines.

1 ZuWallack R and Hedges H. The American Journal of Medicine. 2008:121;S25–S32

thinking differently targeted nutritional intervention
Thinking differently:Targeted Nutritional Intervention

Take Respifor in combination with physical training to improve physical capacity

what is respifor
What is Respifor?

Respifor is a specialist high energy (1.5kcal/ml), high protein Oral Nutritional Supplement enriched with vitamins and minerals designed for patients with COPD

Pack: 125mls

Flavours: Strawberry, Vanilla and Chocolate

Recommended dose: 3 x 125ml per day in combination with

activity plan for 3 months

key features
Key features:
  • Low volume 125ml
  • Macronutrient ratio
    • CHO 60% En, Protein 20% En, Fat 20% En
  • High carbohydrate
  • High protein (whey/casein)
  • Low fat
  • Vitamins and minerals
  • Antioxidants
    • Vitamin C, Vitamin E, Selenium
evidence
Evidence
  • 3 studies that demonstrate positive effect of Respifor in combination with exercise / activity on physical capacity
  • Positive effects seen in undernourished severe and moderate patients also in patients BMI >19 kg/m2
  • Data to show improved and sustained outcomes
evidence study 1 pison et al 2009
Evidence: Study 1 – Pison et al. 2009
  • Aim:
    • Investigate effects of 3 mth home care programme compared with health education alone in severe COPD
  • Study participants:
    • 122 undernourished pts with chronic lung disorders (severe COPD) randomised to receive homecare package or education alone
  • Intervention:
    • 7 visits received education, exercise, androgenic steroids and Respifor 125ml tds v's 7 visits education
evidence study 1 pison et al 200921
Evidence: Study 1 – Pison et al. 2009
  • Results
    • Peak workload by 7.2W 20% (p < 0.001)
    • Quadriceps isometric force by 28.3 N (p <0.01)
    • Endurance time at 55% Pmax by 5.9 mins, 70% (p<0.001)
    • Survival 15 mths 3/52 cf 12/62 (p<0.05)
    • Increased BMI by 2.7% (p<0.05)
    • Increased FFM by 3.8% (p=0.01)
  • Status
    • 2 abstracts published, full paper due to be published later this year

Pison et al. www.ers.org 2009; Cano et al. Clinical Nutrition Suppls. 2008: 3(1);16

evidence study 2 van wetering et al 2010
Evidence: Study 2 – van Wetering et al. 2010
  • Aim:
    • To provide data on specific nutritional intervention in depleted patients with moderate COPD in a community based setting
  • Study participants:
    • 39 undernourished pts recruited within a larger study (n=199) with moderate COPD randomised to receive nutritional supplement with exercise compared to usual care (UC)
  • Intervention:
    • 4 months Respifor (125mls tds) plus exercise training v's usual care
    • 24 month follow up

Van Wetering et al. JAMDA 2010; 11(3):179-187

evidence study 2 van wetering et al 201023
Evidence: Study 2 – van Wetering et al. 2010
  • Results
    • Improvement after 4 months
      • 6MWD in UC decreased where as in intervention group remained the same (p=0.028)
      • CET increased by 40% from baseline (p<0.05) with intervention, declined in UC
      • Respiratory Strength significantly better (p=0.011) compared to UC
      • Quadriceps average power significantly higher (p=0.036)
      • BMI and FFM increased (p=0.009, p<0.001 respectively)
evidence study 2 van wetering et al 201024
Evidence: Study 2 – van Wetering et al. 2010
  • Sustained benefits after 24 mths
    • Difference in 6MWD & CET sustained for 24 months (p=0.006)
evidence study 2 van wetering et al 201025
Evidence: Study 2 – van Wetering et al. 2010
  • Sustained benefits after 24 mths
    • Quadriceps strength significantly improved at 24mths (p=0.005)
    • Respiratory Function was maintained over 24mths in intervention but declined in usual care (p=0.004)
    • Quality of Life declined in usual care (p=0.04)

First study showing a prolonged positive response to nutritional support as part of an integrated lifestyle programme

evidence study 3 steiner et al 2003
Evidence: Study 3 – Steiner et al. 2003
  • Aim:
    • To Investigate the effects of specific oral nutritional support on exercise performance in stable COPD patients in pulmonary rehabilitation
  • Study participants:
    • 60 pts with COPD
  • Intervention:
    • Randomised to receive 7 weeks Respifor (125mls tds) plus pulmonary rehabilitation v's non nutritive placebo plus pulmonary rehabilitation

Steiner et al. Thorax 2003:58;745-51

evidence study 3 steiner et al 200327
Evidence: Study 3 – Steiner et al. 2003
  • Results
    • Incremental Shuttle Walking Test and Endurance Shuttle Walking Test improved in supplement group (non significant)
    • Subgroup analysis (n=52 of 60 BMI>19 kg/m2)

Steiner et al

Thorax 2003:58;745-51

summary
Summary
  • Thinking differently about nutrition
    • Think about intervening earlier
    • Think about targeted nutritional intervention alongside activity or exercise
    • Think about different patient outcomes
respifor v s standard supplements
Respifor v’s standard supplements

Broekhuizen et al. 2005

n=19 (Respifor) n=19 (Standard supplements)