Nutrition in COPD

DR. ANIMESH ARYA

 Chronic Obstructive Pulmonary Disease
COPD is a common, preventable and treatable disease that is
characterized by persistent respiratory symptoms and airflow
limitation that is due to airway and/or alveolar abnormalities
usually caused by significant exposure to noxious particles or
gases.
Types of COPD
 Emphysema— destruction of the air sacs
 Chronic bronchitis—inflammation of the bronchial tubes

POCKET GUIDE TO COPD DIAGNOSIS, MANAGEMENT, AND PREVENTION A Guide for Health Care Professionals 2017 EDITION
Image used for Academic purpose only. Abbott is not responsible for copyright
 COPD Epidemiology

Current decade saw significant increase in cases of COPD in India

COPD in India: Iceberg or volcano?
Arvind B. Bhome
 Characterization of COPD

Thomas L. Petty 42nd Annual Aspen Lung Conference: Mechanisms of COPD

 Pulmonary Cachexia

Pulmonary Cachexia syndrome in COPD patients is characterized

by a weight loss of 5% to 10% of initial body weight, weight less
than 90% of ideal body weight (IBW), or weight loss exceeding
5% in the past 3 to 12 months.
Unplanned weight loss occurs in COPD patients due to higher
REE (approx. 15 to 26%)
The greater energy expenditure of individuals with COPD is
probably due to increased respiratory muscle effort and
inflammatory mediators, in addition to the effects of medication

Ramires BR, de Oliveira EP, Pimentel GD, et al. Nutrition Journal. 2012;11:37. doi:10.1186/1475-2891-11-37 .
Rawal G et al. J Transl Int Med. 2015 Oct-Dec; 3(4): 151–154
 Vicious cycle of COPD

COPD

Weight loss Dyspnea

& loss of Cycle of &
respiratory weight decrease
muscle loss d
strength appetite

Impaired
nutrition
status
Source: COPD Foundation
 Energy dysbalance &Inflammation

Inflammation influences energy expenditure by an increase of REE. Inflammation

negatively influences energy uptake by increasing levels of leptin, a fat-derived
hormone. Leptin represents the afferent hormonal signal to the brain regulating
food intake by the hypothalamic transmitter neuropeptide Y.
Nutrition and Metabolism in COPD Emiel F.M. Wouters, MD,
PhD, FCCP (CHEST 2000; 117:274S–280S)
Gea et al."Muscle dysfunction in chronic obstructive pulmonary disease: update on
causes and biological findings." Journal of Thoracic Disease[Online], 7.10 (2015)
 COPD and Malnutrition
Malnutrition is either too much, not enough, or
an imbalance of nutrients
• 20%-70% of COPD patients are malnourished
• Malnutrition in emphysema usually is because of
not getting enough nutrients
• Many factors cause malnutrition in emphysema
patients
 Causes & consequences of Malnutrition in
COPD

NICE Endorsement Statement - Managing Malnutrition in COPD, National

Institute for Health and Care Excellence. August 2016
(www.malnutritionpathway.co.uk/copd/ accessed on: 27th Sept 2017)
 Observations in COPD patients
• A study evaluating the body composition in relation to
respiratory and peripheral skeletal muscle function in
72 COPD patients who came for routine lung function
measurements

• Patients were characterized by degree of weight loss

and fat free mass depletion

Tissue depletion was concomitant with lower

values for respiratory and peripheral skeletal
muscle strength (assessed by HGS)

Eur Respir J, 1994, 7, 1793–1797

 If Individual is Underweight:

• May be more likely to get an infection

• May become weak and tired more often

• May weaken the muscles that control

breathing
 If Individual is Overweight:
• Heart and lungs must work harder
• Increased weight increases oxygen needs
• Breathing may become more difficult, especially if
weight is around middle
• Weight may decrease ability to expand chest well for
breathing
• Increased risk of developing other health problems
Case 1: Stable COPD Grade B patient, BMI 20, no wt loss,
coming for rehab. program, what will be his nutritional
program?

• Case 2: COPD patient with acute infective

exacerbation, BMI 17,
increased purulence and amount of sputum and needs
admission in hospital, what will change in his
nutritional support program?

• Case 3: COPD patient with RF II and mechanically

ventilated in
ICU and hypotensive, how will u manage his nutrition?
 Impact of Nutritional Support on Functional
Status During an Acute Exacerbation of Chronic
Obstructive Pulmonary Disease
HELGA SAUDNY-UNTERBERGER, JAMES G. MARTIN, and KATHERINE GRAY-DONALD

Objective: To assess the impact of oral nutritional supplementation during

an acute exacerbation of COPD on functional status was through measuring
change in lung function, strength testing, and general wellbeing.

Method: Subjects hospitalized for an acute exacerbation of COPD (n=33)

were randomized to extra nutritional support or the regular hospital care.
They consumed an additional 10 kcal/kg/d. Outcome measures were
measured at 2 week as change scores.

Results: Forced vital capacity (% predicted) improved in the treatment group

as compared with the control group (18.7% versus 23.5%, p=0.015)

Conclusion: An important increase in oral intake in patients hospitalized with

an acute exacerbation is possible using ONS.
Am J Respir Crit Care Med Vol. 156. pp. 794–799, 1997
Identifying Malnutrition According to Risk
Category Using ‘MUST’ - First Line
Management Pathway
NICE Endorsement Statement - Managing Malnutrition in COPD, National
Institute for Health and Care Excellence. August 2016
(www.malnutritionpathway.co.uk/copd/ accessed on: 27th Sept 2017)
 ESPEN Recommendation of ONS in COPD

Subject Recommendations

Indication EN in combination with exercise and anabolic pharmacotherapy

has the potential to improve nutritional status and function
Application Frequent small amounts of oral nutritional supplements (ONS) are
preferred to avoid postprandial dyspnoea and satiety and to
improve compliance.
Type of Formula In stable COPD there is no additional advantage of disease
specific low carbohydrate, high fat ONS compared to standard
high protein or high energy ONS.

Based on the available evidence it is concluded that in clinically stable COPD

patients, optimal efficacy of ONS is best achieved not by manipulating macronutrient
composition but by giving EN in small frequent doses thereby avoiding complications
and improving compliance composition.

S.D. Anker et al. ESPEN Guidelines on Enteral Nutrition: Cardiology and Pulmonology Clinical Nutrition (2006) 25, 311–318 .
 Pathway for Using ONS in Management of
Malnutrition in COPD

NICE Endorsement Statement - Managing Malnutrition in COPD, National

Institute for Health and Care Excellence. August 2016
(www.malnutritionpathway.co.uk/copd/ accessed on: 27th Sept 2017)
 Pathway (contd.)

NICE Endorsement Statement - Managing Malnutrition in COPD, National

Institute for Health and Care Excellence. August 2016
(www.malnutritionpathway.co.uk/copd/ accessed on: 27th Sept 2017)
 Increased protein intake
• Protein needs are increased up to
1.2-1.7 grams (g)/day
• To calculate how much protein is needed:
̶ Take the weight of the patient and divide by 2.2
̶ Take that number and multiply it by 1.2 and 1.7
̶ This will give you the range of protein needed
̶ Example: 150 pounds divided by 2.2=68
68 x 1.2=82
68x 1.7=116
Protein needs are 81-116 g/day
 To Conclude
 Monitor the patient for the COPD status

 Monitor the Medicines

 Assess the nutritional status with HGS

for peripheral muscle weakness

 Support the patient nutritionally with an

ONS
 Benefits of ONS

• Improve hand grip strength

• Improve respiratory muscle strength
• Improve exercise performance
• Improve patients’ nutritional intake
• Improve weight
• Improve quality of life
• Increase energy and protein without
affecting dietary intake

NICE Endorsement Statement - Managing Malnutrition in COPD, National

Institute for Health and Care Excellence. August 2016
(www.malnutritionpathway.co.uk/copd/ accessed on: 27th Sept 2017)
Fill Your Plate With Color!
THANK YOU
 Weight Gain or Maintenance
• Small meals and snacks throughout day
• Nutrient-dense, High calorie, High protein
• Role of fat
• Overall nutritional quality of foods
• May use commercial nutrition supplements
(Not a meal replacement)