REVIEW

Nutritional support and functional capacity in chronic obstructive

pulmonary disease: A systematic review and meta-analysis
PETER F. COLLINS,
1,2
MARINOS ELIA
1
AND REBECCA J. STRATTON
1
1
Faculty of Medicine, Institute of Human Nutrition, Southampton General Hospital, University of Southampton,
Southampton, UK, and
2
Faculty of Health, School of Exercise and Nutrition Sciences, Queensland University of Technology,
Brisbane, Australia
ABSTRACT
Currently, there is confusion about the value of using
nutritional support to treat malnutrition and improve
functional outcomes inchronic obstructive pulmonary
disease (COPD). This systematic review and meta-
analysis of randomized, controlled trials (RCT) aimed
to clarify the effectiveness of nutritional support in
improving functional outcomes in COPD. A systematic
review identied 12 RCT (n = 448) in stable COPD
patients investigating the effects of nutritional support
(dietary advice (1 RCT), oral nutritional supplements
(10 RCT), enteral tube feeding (1 RCT)) versus control
on functional outcomes. Meta-analysis of the changes
induced by intervention found that while respiratory
function (forced expiratory volume in 1 s, lung capac-
ity, blood gases) was unresponsive to nutritional
support, both inspiratory and expiratory muscle
strength (maximal inspiratory mouth pressure +3.86
standard error (SE) 1.89 cm H
2
O, P = 0.041; maximal
expiratory mouth pressure +11.85 SE 5.54 cm H
2
O,
P = 0.032) and handgrip strength (+1.35 SE 0.69 kg,
P = 0.05) were signicantly improved and associated
with weight gains of 2 kg. Nutritional support pro-
duced signicant improvements in quality of life in
some trials, althoughmeta-analysis was not possible. It
also led to improved exercise performance and
enhancement of exercise rehabilitation programmes.
This systematic review and meta-analysis demon-
strates that nutritional support in COPD results in sig-
nicant improvements in a number of clinically
relevant functional outcomes, complementing a previ-
ous review showing improvements in nutritional
intake and weight.
Key words: chronic obstructive pulmonary disease, functional
capacity, meta-analysis, nutritional support.
Abbreviations: BMI, body mass index; COPD, chronic
obstructive pulmonary disease; ETF, enteral tube feeding; FEV1,
forced expiratory volume in 1 s; HGS, handgrip strength; IBW,
ideal body weight; ONS, oral nutritional supplements; PE max,
maximal expiratory mouth pressure; PI max, maximal inspiratory
mouth pressure; QoL, quality of life; RCT, randomized, controlled
trial; SD, standard deviation; SE, standard error.
INTRODUCTION
Chronic obstructive pulmonary disease (COPD) is a
progressive multi-organ systemic disease and a major
cause of morbidity and disability in aging. While
COPD has its primary effects in the lungs, adverse
structural and functional changes also occur in the
tissues of the heart and skeletal muscle, leading to
individuals with COPD experiencing a range of dis-
abilities that impact on their well-being and ability to
perform daily activities. Reduced respiratory function
and a decline in fat-free mass result in reduced exer-
cise tolerance
1
and peripheral muscle weakness,
2,3
both disabling features of COPD, which are associated
with a poorer quality of life (QoL). Fat-free mass
depletion (even if body mass index (BMI) is within the
ideal range)
4,5
has recently been found to be a signi-
cant independent predictor of disability even after
adjustment for disease severity.
6
Disease-related malnutrition is a common problem
in individuals with COPD, with between 30%and 60%
of inpatients and 10% and 45% of outpatients said to
be at risk.
7
Malnourished COPDpatients demonstrate
greater gas trapping, lower diffusing capacity and a
reduced exercise performance when compared with
heavier non-malnourished patients with a similar
severity of disease.
8
However, the exact causal links
between malnutrition and COPD are difcult to
establish. Malnutrition may be the consequence of
greater disease severity. Alternatively, malnutrition
may be responsible for the wasting of the muscles
involved in breathing, exacerbating the progressive
nature of COPD. Similarly, in chronic anorexia
nervosa, the loss of body weight includes substantial
loss of lung tissue, which develops emphysematous-
like changes.
9
In addition to the uncertainty about the
causal links between malnutrition and COPD, there
Correspondence: Marinos Elia, Institute of Human Nutrition,
Faculty of Medicine, University of Southampton, MP 113, South-
ampton General Hospital, Southampton SO16 6YD, UK. Email:
m.elia@soton.ac.uk
Conict of Interest Statement: Rebecca Stratton, PhD, RD,
RNutr, is also an employee of Nutricia Ltd.
Received 15 November 2012; invited to revise 9 January 2013;
revised 4 February 2013; accepted 7 February 2013 (Associate
Editor: Paul Thomas).
bs_bs_banner
2013 The Authors
Respirology 2013 Asian Pacic Society of Respirology
Respirology (2013) 18, 616629
doi: 10.1111/resp.12070
are controversies about how effective nutritional
support is in this patient group. Previous reviews and
meta-analyses
1012
suggested that malnutrition fails to
respond to nutritional treatment in COPD nding no
signicant improvements in anthropometric or func-
tional measures. These conclusions have been
challenged by several randomized, controlled trials
(RCT),
1316
and a recently published meta-analysis
concluded that nutritional support was able to signi-
cantly increase nutritional intake (energy and
protein), which was associated with a signicant
improvement in a variety of anthropometric meas-
ures.
17
The contrast in conclusions between the
reviews has been largely attributed to methodological
differences in data analysis discussed at length in the
paper.
17
In essence, the previous Cochrane Collabora-
tion review
12
carried out cross-sectional analysis
between intervention and control groups but failed to
account for baseline variability. The other review
accounted for pre- and post-intervention variability
nding a number of signicant within-group im-
provements to be masked by cross-sectional analy-
sis.
17
Nevertheless, confusion remains over whether
the recent positive ndings translate beyond nutri-
tional intake and body weight, and into functional
improvements. The aim of this current systematic
review is to establish whether nutritional support
results in signicant improvements in functional
capacity and QoL in patients with COPD.
METHODS
Search strategy and identication of trials
The review was planned, conducted and reported
according to published guidelines.
1820
The same
methodological approach to that of the previous
review
17
was used; however, an updated systematic
search of the literature was carried out in July 2012
(databases accessed up to 4 July 2012) in order to
identify any additional RCT investigating nutritional
support in COPD reporting functional outcomes
(Fig. 1). Potentially relevant studies were identied
by searching electronic databases. The databases
searched included PubMed (accessed 4 July 2012),
Web of Science (accessed 4 July 2012) and OVID
(accessed 4 July 2012). In order to identify the largest
number of trials, a broad search strategy was imple-
mented, although trials were restricted to English lan-
guage citations only. The search terms and mesh
headings used included: chronic obstructive pulmo-
nary disease, COPD, emphysema, weight, depletion,
diet*, nutrition*, supplement*, protein, carbohydrate,
calori*, feed*, malnutrit*, nourish*, sip, nutrition
intervention, nutrition support. These search terms
were also systematically combined in order to identify
trials. In addition to electronic database searching,
manual searching of previous reviews on nutritional
support in COPD as well as references of identied
trials was undertaken.
Studies were initially screened by reading the
abstract, and where a study could not be excluded,
the full article was reviewed. The assessment of trial
eligibility was done by two independent assessors
(P.F.C. and M.E.), with any disagreement discussed
prior to inclusion.
Inclusion and exclusion criteria
Studies were deemed eligible for inclusion in the
review if they conformed to the pre-determined
inclusion criteria. To investigate the overall efcacy of
nutritional support (food strategies (food fortica-
tion, food snacks, dietary advice), oral nutritional
supplements (ONS) and enteral tube feeding (ETF),
the following inclusion criteria for trials were devised:
(i) randomized trials; (ii) intervention with food strat-
egies, ONS or ETF; (iii) duration of intervention >2
weeks; (iv) control group receiving placebo or no
dietary intervention (e.g. usual care, which could
include advice and encouragement to eat), but other-
wise the same treatment as the interventiongroup; (v)
stable patients with a diagnosis of COPD (not exacer-
bating); (vi) human studies only; and (vii) English lan-
guage only.
The intervention could provide either a proportion
or all of the daily nutritional requirements for energy,
protein and micronutrients, and where feeds were
used (e.g. ONS), these could be nutritionally complete
or incomplete. Studies using parenteral nutrition and
single nutrient interventions were excluded.
Figure 1 Study selection process.
Nutrition support in COPD 617
2013 The Authors
Respirology 2013 Asian Pacic Society of Respirology
Respirology (2013) 18, 616629
Data extraction
Functional outcome data sought included respiratory
function (forced expiratory volume in 1 s (FEV
1
)), res-
piratory muscle strength (maximal inspiratory mouth
pressure (PI max) and maximal expiratory mouth
pressure (PE max)), peripheral muscle strength
(maximum voluntary handgrip strength (HGS)), exer-
cise performance (walking distance), QoL and addi-
tional outcomes including immunological measures.
In trials where mean values were reported without
standard deviations (SD) or standard errors (SE), they
were calculated from reported P-values. In one trial
that assessed HGS,
15
data reported in kilograms were
considered to be unrealistic and therefore assumed to
be in pounds. Whenever possible, data from indi-
vidual subjects were used to calculate the summary
values from specic studies.
15,21
Graphical data were
also used to establish summary values either when
there were no other data reported or when reported
results were imprecise due to rounding.
22
Quality assessment
The quality of included studies was assessed by one
researcher (P.F.C.) and independently veried by
another assessor (R.J.S.) using the most commonly
used scoring system (Jadad scoring system).
23
The
Jadad scoring system comprises of three components
addressing whether a study is described as rand-
omized, whether it is double-blind and whether drop-
outs were accounted for. It then scores on the
appropriateness of the randomization and blinding.
The Jadad scoring system does not assess the sample
size of trials.
Synthesis of data and statistical analysis
Following the extraction of data from included trials,
where appropriate and feasible, the results of compa-
rable outcome measures were combined in order to
carry out random effects meta-analyses using Com-
prehensive Meta-analysis (Biostat, Inc., Englewood,
NJ, USA, version 2) (Table 1). The overall treatment
difference was considered statistically signicant if
the P-value was <0.05. Analysis explored differences
between groups as well as within group changes.
The effect size was reported as the difference in
mean SE. Four studies reported values adjusted for
baseline data.
16,22,24,25
Meta-analysis was subjected to
sensitivity analysis whenever imputation of missing
data was carried out (this involved imputation of SD
for the change for the control arm of one study).
13
Meta-regression was undertaken to examine whether
the differences in functional outcomes between the
two arms of the studies were related to each of the
following moderators: duration of intervention, %
ideal body weight (IBW) and age.
RESULTS
A total of 49 studies were identied as potentially eli-
gible from the literature search;
1316,21,22,2466
of these,
37 failed to achieve the inclusion criteria (Fig. 1).
Reasons for exclusion included an unsuitable study
design or review in 10 studies,
28,37,38,40,46,56,58,6163
limited
or no nutrition provided in 9 studies,
32,36,39,41,43,49,51,64,65
5
non-randomized trials,
27,35,45,55,59
5 studies involving
an unsuitable population,
26,30,47,54,57
5 studies with no
control or placebo,
31,33,35,53,60
and inadequate interven-
tion duration in 2 studies.
29,42
Goris et al.,
44
which
was included in the previous review, could not be
included as it reported no functional outcomes. The
reviewincluded 12 RCTinvolving 448 individuals with
COPD who were randomized into either a treatment
group (n = 232) or a control group (n = 216) (Table 2).
Seven studies were performed completely within the
outpatient setting,
13,24,25,48,50,52,66
three in the inpatient
setting
16,21,22
and two involving periods inbothof these
settings.
14,15
The study by Schols et al.
16,22
is referred to
as two separate trials in order to distinguish between
patients who were considered to be adequately
nourished
16
and undernourished
22
(Table 2). All the
patients recruited to the earlier trials had a diagnosis
Table 1 Functional outcome measures from randomized, controlled trials included in the systematic review and
meta-analyses
Outcome measure
Systematic review Meta-analysis
No. studies
No. participants
treatment/control No. studies
No. participants
treatment/control
FEV
1
10 102/105

2 43/40
PI max 8 153/124 5 91/86
PE max 6 81/59 4 58/48
HGS 5 87/90 4 77/79
Walk and shuttle tests 7 150/149 0
QoL and breathlessness 6 85/90 0
Immunological 3 24/20 0
ADL 1 23/18 0

Numbers refer to only eight studies. An additional two studies involving 217 patients reported changes in FEV1 without specifying
the number that completed the tests in each group.
16,22
Numbers reported are for those subjects that completed the intervention phase.
ADL, activities of daily living; FEV1, forced expiratory volume in 1 s; HGS, handgrip strength; PE max, maximum expiratory pressure;
PI max, maximum inspiratory pressure; QoL, quality of life.
PF Collins et al. 618
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Respirology 2013 Asian Pacic Society of Respirology
Respirology (2013) 18, 616629
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Nutrition support in COPD 619
2013 The Authors
Respirology 2013 Asian Pacic Society of Respirology
Respirology (2013) 18, 616629
T
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PF Collins et al. 620
2013 The Authors
Respirology 2013 Asian Pacic Society of Respirology
Respirology (2013) 18, 616629
of COPD(FEV
1
/forced vital capacity <0.70), which was
severe
67
(mean FEV
1
<50% predicted (stage III) in all
trials). The patients were in a stable condition free
from exacerbation. Studies involving patients with
acute exacerbations were excluded.
Out of the 12 trials included in the analyses, 10
(n = 379; intervention 195 vs control 184) provided
nutritional support by ONS,
1316,22,24,44,48,50,52,66
mostly
ready-made, liquid supplements, some of which were
specically formulated for use in patients with COPD.
One trial used nocturnal ETF (n 6 vs 4),
21
and another
used tailored dietary advice delivered by a dietitian
and the provision of whole milk powder (n 31 vs 28).
25
No trials were found involving interventions of food
snacks or food fortication alone. The intervention
period ranged from 16 days
21
to 6 months,
25
with the
amount of nutritional support prescribed ranging
from 355
66
to 1080 kcal/day.
13
Eight studies (n 8)
1315,21,25,50,52,66
principally in-
volved malnourished (depleted) individuals (BMI
<20 kg/m
2
or %IBW<90%). Three trials included both
adequately nourished and undernourished patients
who participated in a rehabilitation exercise pro-
gramme,
16,22,24
but subgroup analysis according to
nutritional status was undertaken to examine some of
the outcomes. The remaining study included both
undernourished and nourished subjects (Table 2) but
with a predominance of underweight individuals
(over half with <85% IBW
48
).
The most commonly reported outcome was
pulmonary function (FEV
1
) reported in 10 tri-
als,
13,14,16,21,22,25,48,50,52,66
followed by respiratory muscle
strength (PI max and PE max). Breathlessness was
reported in ve studies,
1315,25,52
three studies reported
QoL obtained using validated tools,
15,24,25
and two
trials reported subjective feelings of well-being,
13,52
which can also be regarded as measures of
QoL.
Quality of studies
The review identied three studies assessed to be of
high quality (4)
21,24,52
and nine of lesser quality (2)
using the Jadad scoring system
23
(Table 2).
Pulmonary function and respiratory
muscle strength
Respiratory function (FEV
1
) was assessed in 10 stud-
ies,
13,14,16,21,22,25,48,50,52,66
9 of which
13,14,16,21,22,25,48,50,52,66
provided separate information in intervention and
control groups. However, the results were presented
in different ways: two reported no signicant differ-
ences in the change in FEV
1
over time,
25,52
seven
reported no signicant change in either group over
time,
13,16,21,22,25,48,52
and two reported the mean values of
FEV
1
at the start and end of the study period, but
because they were virtually identical
50
or very close to
each other
66
within the control and the intervention
groups, it can be deduced that there were no signi-
cant changes over time in either group and no signi-
cant differences between groups. Indeed, there was
no evidence from any of the studies that the changes
in FEV
1
or changes in other measures of respiratory
function, such as forced vital capacity,
13,21,25,48,50,52
FEV
1
/forced vital capacity,
21,50
total lung capacity
13,21,48
and blood gases
48,50,52
differed between intervention
and control groups. Two studies reporting measured
FEV
1
25
and percentage predicted FEV
1
52
were meta-
analysed using standardized differences. Nutritional
support was not associated with any improvement in
FEV
1
(-0.213 SE 0.22 L, P = 0.335).
PI max was reported in eight studies
13,15,16,21,22,25,48,50
of ONS (n 6), ETF (n 1) and dietary advice (n 1). Five
of these studies
13,15,16,21,25
were amenable to meta-
analysis, four of which favoured nutritional support
(Fig. 2). The overall summary measure obtained using
random effects meta-analysis was signicant in
Figure 2 Random effects meta-analysis
of ve studies measuring changes in
maximal inspiratory mouth pressure (PI
max) (cm H2O) in nutritional intervention
(n = 91) and control groups (n = 86). The
forest plot shows the difference in the
mean changes between groups. CI, con-
dence interval.
Nutrition support in COPD 621
2013 The Authors
Respirology 2013 Asian Pacic Society of Respirology
Respirology (2013) 18, 616629
favour of nutritional support (+4.04 SE 1.86 cm H
2
O,
P = 0.030). The meta-analysis was undertaken assum-
ing that the SD of the change in the control group of
one of the studies
13
was the same as that of the ONS
group. The latter was established from the combina-
tion of the reported mean change in PI max and a
P-value of 0.05 (but because the reported P-value was
<0.05, the calculated value is larger than the true
value). When a sensitivity analysis was carried out
assuming the SD of the change ranged from 75% to
125% of that in the ONS group, there was little change
in the overall point estimate (+4.11 SE 1.83 cm H
2
O,
P = 0.024 and +3.98, SE 1.90 cm H
2
O, P = 0.049,
respectively). The associated weight change in the
same ve studies also favoured nutritional support
(+2.17 SE 0.44 kg; P < 0.001). Meta-regression found
no signicant relationship between PI max (cm H
2
0)
and each of the following variables: duration of inter-
vention (weeks) (slope = -0.294, SE 0.250, P = 0,239),
% IBW (slope = -0.124, SE 0.187, P = 0.058) and age
(years) (slope = -0.867, SE 0.779, P = 0.266); excluding
the study of Schols et al.,
16,22
which did not report the
mean age of the patients who had the PI max tests.
Of the three studies that could not be included in
the meta-analysis, one found a signicant increase
in PI max over time in the ONS group and not in
the control group,
48
one reported PI max to be
unchanged,
50
and the nal study did not report
the relevant data needed for inclusion in the
meta-analysis.
22
PE max was reported in six studies, four involving
ONS,
13,15,21,25,48,50
one ETF
21
and one using dietary
advice,
25
but meta-analysis was only possible in four
of them
13,15,21,25
(Fig. 3). This meta-analysis found that
nutritional support signicantly improved PE max in
favour of the intervention group (+13.06 SE 5.81 cm
H
2
O, P = 0.025), with all four studies favouring the
intervention group and two signicant in their own
right (one involving ETF
21
and the other involving
ONS
15
) (Fig. 3). The meta-analysis of PE max was
undertaken assuming that the SDof the change in the
control group of one of the studies
13
was the same as
that in the ONS group. When a sensitivity analysis was
carried out assuming that the SD of the change
ranged from 75% to 125% of that of the ONS group,
there was virtually no change in the point estimate
obtained by the random effects meta-analysis
(+13.02, SE 5.83 cm H
2
O, P = 0.026; and +13.12 SE
5.78 cm H
2
O, P = 0.024, respectively). The associated
weight change in the same four studies also signi-
cantly favoured the nutritional support group (+3.10
SE 0.67 kg; P < 0.001). Meta-regression found no sig-
nicant relationship between PE max (cm H
2
0) and
each of the following variables: duration of interven-
tion (weeks) (slope = -0.071, SE 0.430, P = 0.869), %
IBW (slope = -0.321, SE 0.809, P = 0.691) and age
(years) (slope = 1.494, SE 1.224, P = 0.266).
Of the two studies that could not be included in the
meta-analysis, one reported no signicant difference
in measurements between groups
48
and the other no
signicant change within groups.
50
To assess respiratory accessory muscle strength, a
further study measured sternomastoid strength and
fatigability, and found that ONS resulted in signi-
cantly increased strength (P < 0.05) and reduced fati-
gability after 3 months of supplementation, while
non-signicant changes in the opposite direction
occurred in the control group. The differences
between groups returned towards baseline after
cessation of treatment.
13
Other functional measures
Maximum voluntary peripheral
(non-respiratory) muscle strength
Five studies assessed peripheral muscle strength
using HGS,
13,15,24,25,50
with four of the ve providing
nutritional support using ONS. Four studies
13,15,24,25
were amenable to meta-analysis and all favoured
intervention, two signicant in their own right
13,15
(Fig. 4). The mean changes were +1.41 SE 0.66 kg,
P = 0.032 (range 0.35.2 kg (1.318.5%) above baseline
in favour of the intervention group). In undertaking
Figure 3 Random effects meta-analysis
of four studies measuring changes in
maximal expiratory mouth pressure (PE
max) (cm H2O) in nutritional intervention
(n = 58) and control groups (n = 48). The
forest plot shows the difference in the
mean changes between groups. CI, con-
dence interval.
PF Collins et al. 622
2013 The Authors
Respirology 2013 Asian Pacic Society of Respirology
Respirology (2013) 18, 616629
this meta-analysis, two assumptions were made: the
SD of the change for the control group in the study of
Efthimiou et al.,
13
was the same as that for the ONS
group, and the unrealistically high grip strength
values reported for both intervention and control
groups in the study of Rogers et al.
15
were in pounds
rather than in kilograms. To address the latter uncer-
tainty about the units of measurement, the meta-
analysis was repeated using standardized differences
(overall point estimate 0.56, SE 0.22; P = 0.009,
Figure 4). To address the former uncertainty, a sensi-
tivity analysis was undertaken by altering the SD of
the change by 25%(75125%), which produced little
change in the overall point estimate and the associ-
ated statistical signicance of the differences between
groups (using a value of 75% for the SD of the change,
the overall effect size in the meta-analysis was 0.59, SE
0.23 (P = 0.010); and with 125% for the SD of the
change, the effect size was 0.52, SE 0.20 (P = 0.008)).
Even when the sensitivity analysis involved an altera-
tion of the SD of the change by as much as 50%
(50150%), there was little overall impact on the effect
sizes and P-values (effects sizes ranging from 0.48 to
0.58 and P-values from 0.021 to 0.018, respectively).
The associated change in body weight in the same
four studies signicantly favoured the intervention
group (+2.06 SE 0.65 kg; P = 0.001). Meta-regression
found no signicant relationship between HGS (kg)
and each of the following variables: duration of inter-
vention (weeks) (slope = -0.033, SE 0.041, P = 0.428)
and % IBW (slope = -0.322, SE 0.035, P = 0.364).
Steiner et al.,
24
reported that quadriceps muscle
strength increased more in the supplemented than
control group (+17.4 kg or ~5% vs +3.6 kg or ~1%
increase, P = 0.068) after adjustment for baseline
values. When these results replaced those of HGS in
the random effects meta-analysis on muscle strength
and the amalgamated results analysed using stand-
ardized differences, the point estimate remained
signicant (effect size 0.56, SE 0.22, P = 0.010).
A small study of ETF reported no signicant differ-
ences in the changes between intervention and
control groups inelectrical stimulationtests involving
the adductor pollicis muscle.
21
Walking distance and endurance
during walking
Seven studies examined the inuence of nutritional
support on improving exercise tolerance.
13,15,16,22,24,52,66
Four studies favoured the intervention group,
13,15,24,66
one favoured the control group,
52
and the remaining
two studies
16,22
did not provide the necessary informa-
tion to assess which group was favoured. Meta-
analysis was not performed due to the use of different
methodologies, types of tests, and ways of reporting
results (e.g. some reporting median values
24
and
others mean values) and lack of measures of variation
and/or P-values for some of the within-group
changes.
13
Using the 6-min walk test, Efthimiou et al.
13
reported signicant improvements in the ONS group
(53 m (~+12.8%); P < 0.05) but not in the control
group (1 m (~+1.4%) non-signicant), and DeLetter
did the same
66
[+35.4 m (~+11.6%) vs -1.2 m
(~-0.4%)]. Using the 12-min walk test, Rogers et al.
15
found that the distance walked increased signicantly
more in the ONS group (34 m (~7%) at 4 weeks and
143 m(~28%) at 4 months) compared with the control
group (a deterioration of 42 m (-8%) at 4 weeks and
0.3 m (-0.1%) at 4 months) (P = 0.03 for the difference
in the mean change between the two groups). Otte
et al.
52
reported no signicant changes in the 12-min
walking distance in either the ONS or control groups
(-81 m (~-9.0%) vs +50 m (~6.3%), respectively).
Schols et al.
16,22
reported an improvement in the
12-min walking distance in subgroups of depleted
(173 m, 29%) and non-depleted (147 m, 24%) patients
undergoing pulmonary rehabilitation, with no signi-
cant differences between the intervention and control
groups. Using the shuttle walk tests in subjects under-
going pulmonary rehabilitation, Steiner et al.
24
found
that performance improved to a greater extent in the
intervention (ONS) than control group with respect to
Figure 4 Random effects meta-analysis
of four studies measuring changes in
peripheral muscle strength (standardized
differences) in nutritional intervention
(n = 77) and control groups (n = 79). The
forest plot shows the difference in the
standardized mean changes between
groups. CI, condence interval.
Nutrition support in COPD 623
2013 The Authors
Respirology 2013 Asian Pacic Society of Respirology
Respirology (2013) 18, 616629
endurance walk tests (mean increase in distance
walked, 60.0 mvs 42.6 m; ~29%vs 19%; P = 0.182) and
the incremental walk tests (median increase in dura-
tion, 328 s (~2 baseline value vs 191 s, ~0.9 base-
line value; P = 0.172), but the differences were not
signicant.
QoL and subjective measures of breathlessness
Five studies examined the effect of nutritional
support on QoL, but because the results were
obtained using different tools and reported in differ-
ent ways, they were not subjected to meta-
analysis.
13,15,24,25,52
One study reported a signicant
improvement in total score in favour of the interven-
tion group: the St Georges Respiratory questionnaire
(with the components also favouring the intervention
group: Activity (P = 0.06), Impacts (P = 0.004), symp-
toms (P = 0.73) using the intention-to-treat analysis),
as well as the short-form 36, which measured health
change. The overall scores represented an improve-
ment of 18% and 55% improvement, respectively,
according to the intention-to-treat analysis).
25
These
changes were mirrored by signicant differences in
breathlessness. Another study reported a signicant
improvement in general well-being of the nutrition
intervention (ONS) group (~27%) and not in the
control group (~6%),
13
which was paralleled by a sig-
nicant improvement in breathlessness in the inter-
vention and not in the control group. A third study of
ONS reported that a greater proportion of subjects felt
that their well-being had improved as a result of the
nutrition intervention compared with control (23%vs
13%) and a smaller proportion felt that it had deterio-
rated (15% vs 33%), but given the small sample size
(13 vs 15), the differences were not statistically signi-
cant.
52
This same study reported a tendency for
breathlessness to improve in favour of the interven-
tion group (P = 0.20). One of the two remaining
studies briey reported no signicant differences in
health-related QoL assessed at enrolment or at 4
months using the Sickness Impact Scores
15
and no
signicant differences in breathlessness scores, which
contributed to the overall QoL. The nal study involv-
ing subjects undergoing exercise rehabilitation found
signicant improvements in health-related QoL and
in breathlessness (both assessed using the self-
reported Chronic Respiratory Questionnaire) in both
the control and intervention groups,
24
with no signi-
cant differences between them.
Other outcomes
The only study that examined activities of daily living
in malnourished patients with COPD reported that
the nutrition intervention group found it signicantly
easier to perform everyday activities compared with
the control group (P = 0.009 inthe per-protocol analy-
sis and P = 0.06 in the intention-to-treat analysis, the
difference in the changes being about 18%and 11%of
the baseline values, respectively
25
).
Four studies reported changes in immunological
tests.
14,21,48,52
One of these
14
found signicant improve-
ments in delayed cutaneous hypersensitivity and
total circulating lymphocyte count, without associ-
ated changes in circulating immunoglobulin concen-
trations, during nutritional repletion of malnourished
patients with COPD. Two trials, one involving ETF
21
and one ONS
48
briey reported that lymphocyte
counts remained unchanged over the study period.
Finally, a study
52
involving ONS reported no signi-
cant changes in T-helper/T-suppressor ratio and
mitogen reaction of T lymphocytes to phytohemag-
glutinin. None of these three studies reported sepa-
rately the changes that occurred in each group.
Furthermore, none of these three studies or any of the
other studies included in this systematic review
measured cytokines or acute phase proteins.
DISCUSSION
This review found that nutritional support in COPD
produces signicant improvements in several func-
tional outcomes including respiratory and limb
muscle strength. These ndings demonstrate the
positive effects of nutritional support on respiratory
muscle tests and other functional outcomes, building
on the conclusions of a recent review that nutritional
support signicantly improves energy and protein
intakes with resulting increase in body weight.
17
This
earlier review did not consider functional outcomes
other than change in HGS, which was reported as a
percentage change rather than in kilogram as in this
review. However, it did consider methodologi-
cal issues, including those involved in an earlier
Cochrane review. The ndings of the present review
also strengthen the argument that a causal pathway
exists linking increased nutritional intake provided
primarily by standard ONS to increased body weight
and function. The current ndings are in contrast
with the previous Cochrane review including the
same trials that reported no effect of nutritional
support in COPD
12
probably because it considered
only cross-sectional differences between groups at
the end of the intervention period and not within-
group changes induced by the interventions (see
Collins et al.
17
for a discussion on methodological
issues). However, an updated Cochrane review, which
appeared very recently following submission of the
present review for peer review, changed its conclu-
sions. A comparison of this review with the updated
Cochrane reviewis provided after the mainndings of
the present review are discussed.
The current review with a series of meta-analyses
found that for each of the tests used to document
improved respiratory muscle function (PI max and PE
max) and non-respiratory (handgrip/quadriceps)
muscle strength, there was a highly signicant
increase in body weight of more than 2 kg (2.13.1 kg)
in favour of the nutrition intervention group. Schols
et al.
68
found that both an improved inspiratory
mouth pressure (PI max) and a weight gain of >2 kg
were associated with signicantly improved survival
in keeping with a previous review reporting that sig-
nicant functional improvements were seen in mal-
nourished patients receiving ONS when weight gain
was >2 kg.
7
It appears that this level of weight gain
should be a therapeutic target in malnourished COPD
PF Collins et al. 624
2013 The Authors
Respirology 2013 Asian Pacic Society of Respirology
Respirology (2013) 18, 616629
patients, especially as recently reviewed evidence
highlights that this level of weight gain is achievable
in malnourished COPD patients.
17
The current review
conrms that weight gain of this magnitude is associ-
ated with functional improvements in this patient
group.
In the clinical setting, increasing importance is
being placed on the assessment of functional out-
comes. HGS is not only a reliable marker of peripheral
muscle strength but it also predicts clinical out-
comes
69
such as mortality, morbidity, postoperative
complications and increased length of hospital stay.
Inthe elderly, a loss of grip strength oftenmeans a loss
of independence. Although muscle strength is closely
related to mid-arm muscle area,
70
whole body protein
content,
71
and even body weight and BMI,
72
a variety
of studies suggest that changes in muscle function
can occur independently of muscle mass.
7
It has
recently been suggested that muscle strength
responds faster to nutritional depletion and repletion
than anthropometric measures such as BMI and
fat-free mass
69
probably as a result of increased avail-
ability of energy, electrolytes and micronutrients in
muscle. Therefore, the improvement in muscle
strength induced by nutritional intervention in mal-
nourished COPD patients is likely to be due to a com-
bination of increased force generated by the available
muscle and increased muscle mass, which is consist-
ent with the increase in mid-arm muscle circumfer-
ence (or area) reported in RCT of COPD
17
and other
conditions.
73
Mid-arm muscle area has been found to
be a better predictor of mortality than BMI in patients
with COPD.
74
Therefore, nutritional support leading
to weight gain (>2 kg) and increased mid-arm muscle
circumference could confer survival benets as sug-
gested by previous studies.
68,75
Exercise tests in COPD have also been found to
predict outcomes,
76
such as mortality and postopera-
tive complications.
77,78
This review examined the
effect of nutritional support in COPD patients under-
taking different types of walking and shuttle tests per-
formed on a at surface, but the reviewed studies
were not amenable to meta-analysis. However, four of
the ve studies favoured the nutritional support
group, and the only studies reporting signicant
improvements in performance also favoured those
receiving nutritional support. While these tests have
limitations (e.g. some patients still have difculties
walking faster on at surfaces as their condition
improves, but they can walk up a steeper slope), they
at least assess important aspects of the patients
ability to function in ways that are relevant to every-
day life.
79
The evidence based on the effect of nutritional
support on immunological function is very limited
not least because none of the three studies
14,21,48
that
assessed restricted aspects of immune function
reported the results separately for the intervention
and control groups. In addition, the total absence
from these studies of cytokine measurements and
acute phase proteins as markers of the inammatory
response highlights the need to examine immune/
inammatory-nutrition interactions. This is because
the immune system not only helps prevent and aid
recovery from respiratory infections but also because
it is linked to the processes involved in nutritional
depletion and repletion of body tissues and their
responsiveness to nutritional support.
34
Whether
exercise has a pro- or anti-inammatory role in COPD
is unclear;
80,81
however, a recent trial
82
involving a
combination of low-intensity exercise education ses-
sions and an ONS with immunomodulatory proper-
ties (immunonutrition) in a cohort of malnourished
(meanBMI 18.0 kg/m
2
) patients with moderate COPD
produced some very promising results that included
improvements in weight, peripheral and respiratory
muscle strength, exercise capacity, QoL, and a reduc-
tion in inammation (measured by interleukin-6,
interleukin-8, tumour necrosis factor-a, high sensi-
tive C-reactive protein levels). Further work is
required to examine whether these improvements are
due to the exercise intervention, the immunonutri-
tion (or other components of the ONS) or a combina-
tion of these. Further work is also needed to examine
the extent to which the changes in outcome could be
reproduced by using a standard ONS.
An outcome that was found to be unresponsive to
nutritional support in the current review was lung
function (assessed by tests such as FEV
1
, forced vital
capacity and blood gases), but this is likely to reect
the irreversible nature of lung pathology in COPD. It
may seemsurprising that the lack of an effect of nutri-
tional support on objective tests of lung function were
sometimes associated with signicant improvements
in subjective measures of breathlessness. However,
because malnutrition has effects on the central
nervous system, including modulation of the sensitiv-
ity of the respiratory centre to hypoxic stimulation,
81
it is plausible that nutritional support inuences
the sensation of breathlessness through centrally
mediated mechanisms. Interestingly, cross-sectional
studies of men with COPD have reported that breath-
lessness is inversely related to BMI independently of
respiratory function tests (diffusing capacity to
carbon monoxide, partial arterial oxygen concentra-
tion, P0.1/PI max).
83
Breathlessness inuences QoL,
which probably explains the striking concordance
between them, both within and between groups of
the reviewed RCT.
The extent to which changes in functional outcome
measures reect clinically relevant improvements in
patient well-being can be difcult to establish. For
example, a small change in muscle strength (which
may be as little as a few percent, as in some of the
reviewed studies) may go totally unnoticed in strong
well-nourished subjects, but in malnourished
patients who are close to the threshold of disability,
84
they may be easily noticed and make the difference
between being able to get up and not get up from a
bed or a chair, and between being independent and
dependent on others. Nevertheless, attempts have
been made to establish the minimum clinically rel-
evant changes associated with some of these tests. For
example, it has been conservatively estimated that
the minimumclinically important difference in 6-min
walking distance is 5480 m
85
, which exceeds that
found in the only two nutrition intervention studies
that employed the 6-min walk test (an improvement
Nutrition support in COPD 625
2013 The Authors
Respirology 2013 Asian Pacic Society of Respirology
Respirology (2013) 18, 616629
in favour of ONS by a mean of 47
13
and 37 m
66
).
However, much larger changes have been found with
the 12-min walk test, for example, an improvement of
143 m has been attributed to ONS in the study of
Rogers et al..
15
The minimum clinically important
improvement in incremental shuttle walk test has
been estimated to be 47.5 m. The minimum benet
distinguishable by patients relates to 78.7 m.
86
Of the
studies considered in the present systematic review,
the only one that used the incremental shuttle walk
test to examine the effects of ONS during pulmonary
rehabilitation
24
found improvements in walking dis-
tance in favour of the nutrition intervention group
that were less than the suggested thresholds.
However, the patients were studied during pulmonary
rehabilitation and the effect of ONS in combination
with the other treatments showed a statistically sig-
nicant overall improvement of 60 m. Because both
non-malnourished (87%) and malnourished patients
(13%) received ONS if they were randomized to the
nutritional support armof the study, it is possible that
those with malnutrition responded differently from
those without malnutrition, but such information
was not reported. The benets of exercise rehabilita-
tion are well established;
87
however, as alluded to by
Steiner and colleagues,
24
it can produce a negative
energy balance that might require reversal by supple-
mentation before an improvement in training out-
comes can be demonstrated. A recent RCT of patients
with chronic respiratory failure, the majority of whom
had COPD, participating in an exercise rehabilitation
programme and classied as malnourished (BMI
21.5, SD 3.8 kg/m
2
and fat-free mass deplete) found
that nutritional support (ONS 3 per day), education
and oral testosterone undecanoate led to signicant
improvements in body weight, fat-free mass, strength
and function above control.
62
At present, it is unclear
whether all malnourished COPD patients undertak-
ing exercise training should receive additional nutri-
tional support or indeed whether training should
commence in those who are malnourished without
nutritional support.
61
It would appear pertinent to
recommend that all COPD patients at risk of malnu-
trition should receive some form of nutritional
support during rehabilitation and recommendations
are required.
The present analysis also examined the effect of
potential explanatory variables, such as duration of
intervention with nutritional support, % IBW and age
of the participants, on functional outcomes (PI max,
PE max and HGS), but generally, they were not found
to be signicantly related to the outcomes. This is not
too surprising given that the meta-regressions
involved a small numbers of studies that differed in
design and prescribed amounts of nutritional support
(see Table 2), and also involved examination of each
variable individually. In addition, there was only small
variation between the mean age of the populations
involved with different studies (6269 years) and in
some cases involved signicant effects on outcomes
followed short periods of supplementation (e.g. sig-
nicant improvement in PE max reported in one
study after 16 days of supplementation).
21
Further
insights might emerge if individual patient data
(instead of mean study data) were analysed together,
but unfortunately, such data are not available.
To understand the signicance, strengths and limi-
tations of this review and the way it differs from the
updated Cochrane review,
88
it is necessary to consider
certain methodological issues. Although the conclu-
sions of both reviews appear to be similar (and both at
variance with those of the earlier Cochrane review,
12
the two should not be confused because apart
from not addressing the same issues, they have used
different methodology to meta-analyse different
studies, which were selected according to different
criteria.
The present review excluded three studies,
61,63,82
which were also absent from the previous Cochrane
review. However, in the updated Cochrane review,
these three studies contributed to the assessment of
almost all of the functional outcomes, dominating
some of the analyses such as the overall health-
related QoL (accounting for three out of the four
studies) and their domains (two out of three studies in
each domain
61,82
) and the 6-min walk test (three out of
ve studies). The studies totally dominated the meta-
analyses of quadriceps strength (only two studies
61,63
),
yet in the present review, data on quadriceps strength
from another paper were able to be used.
24
Two of the
three papers were excluded from the present review
because they both incorporated an exercise pro-
gramme in the nutritional support arm of the study
and not in the control arm,
61,63
and one of them
63
also
included additional interventions in the nutritional
support arm and not the control arm. (The depleted
patients who received nutritional support in this
study accounted for minority of the population,
which was predominantly overweight with mild
COPD.) These study designs make it difcult to isolate
the effects of nutritional support. The multiple
reported functional outcomes in favour of nutritional
support arm may have been due to the non-
nutritional interventions or a combination of nutri-
tional and non-nutritional interventions. The third
study
82
was not included in the present review
because it became available after the literature search
was carried out. It involved a nutritional supplement
with immunomodulatory properties, which can be
attributed to an anti-inammatory whey peptide,
pharmacological doses of the anti-oxidant vitamins
C, E and A, and sh oils. Arguably, this study should be
treated separately from other studies, none of which
involved an immunonutrition feed.
In the present review, the meta-analyses examined
whether the changes induced by the interventions
differed between the two arms of studies, whereas in
both the previous and updated Cochrane reviews,
most of the meta-analyses, including those involving
PI max and PE max, involved only the values at the
end of the intervention period. It is considered pref-
erable to generally use the change method than the
end value method to assess the impact of interven-
tions, especially when there is a relatively large base-
line imbalance (which could fortuitously affect the
two arms of individual studies in opposite directions
(e.g. for variables such as PI max and PE max)).
Another difference between the two reviews concerns
PF Collins et al. 626
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Respirology 2013 Asian Pacic Society of Respirology
Respirology (2013) 18, 616629
the uncertainty associated with imputation of
missing data (missing SE or SD). Inthe present review,
imputation involved only 1 of the 12 studies,
13
affected only the control group (for PI max, PE max
and HGS), and was always accompanied by sensitivity
(uncertainty) analysis, which assessed the potential
errors associated with imputation. The uncertainty
associated with the some of the analyses in the
updated Cochrane review appears is less clear
because imputation involved 5 out of 14 studies (and
more than half of the studies in some meta-analyses,
such as those involving changes in anthropometry
including weight, and 6-min walk test), often both
arms of some studies or the difference between them
and in the absence of sensitivity analyses.
Although the type of functional outcomes exam-
ined by the two reviews was similar, the present
review systematically considered HGS and immuno-
logical function, which was not the case with either of
the Cochrane reviews.
12,88
In addition, the present
review provided new data using meta-regression
(involving duration of intervention, %IBW, age and as
moderators) and considered the minimally important
clinical differences and related the ndings associ-
ated with one type of outcome variable to that of
another another (e.g. the extent of weight gain asso-
ciated with improvements in functional outcomes).
In contrast, the Cochrane review, following the formal
format of Cochrane Collaboration to produce a docu-
ment of almost 100 pages long, included more
detailed information about individual studies, listed
the excluded studies and undertook some subgroup
meta-analyses, such as those involving the compo-
nents of QoL (made possible by inclusion of the three
new studies that did not feature in this review).
However, the present review included a semiquanti-
tative and narrative description of QoL data and well-
being
13,15,24,52
that were not synopsized by the
Cochrane review.
Because a cure is impossible for COPD patients, a
major goal in the management of the disease is the
improvement or maintenance of body function and
QoL. This systematic review describes the types and
magnitude of functional benets that are likely to
arise through nutritional support. It suggests that at
least some of the adverse functional consequences of
severe COPD are reversible by nutritional support.
The review also suggests that while several of the
studies were judged to be of high quality, many were
of lower quality, and therefore, the evidence base for
the role of nutritional support in COPD needs to be
strengthened with sufciently powered RCT.
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