Nutritional modulation as part of the integrated management of chronic obstructive pulmonary disease

Weight loss is a frequent complication in patients with chronic obstructive pulmonary disease (COPD) and is a determining factor for functional capacity, health status and mortality. Weight loss in COPD is a consequence of an inbalance between increased energy requirements and dietary intake. Both metabolic and mechanical inefficiency may contribute to elevated energy expenditure during physical activity, while systemic inflammation has been associated with hypermetabolism at rest. Disease-specific symptoms and systemic inflammation may impair appetite and dietary intake. Altered intermediary metabolism may cause disproportionate wasting of fat-free mass in some patients. A combination of nutritional support and exercise as an anabolic stimulus appears to be the best approach to obtaining marked functional improvement. Patients responding to this treatment even demonstrated a decreased mortality. The effectiveness of anti-catabolic modulation requires further investigation.     

Nutritional management of the patient with chronic obstructive pulmonary disease.

The prevalence and prognostic importance of malnutrition in chronic obstructive pulmonary disease (COPD), the factors that contribute to development of nutritional depletion, and the available evidence regarding effects of nutrition support in these patients are the subjects of this review. Nutritional depletion, as indicated by weight loss and loss of lean body mass, is a common complication of advanced COPD (particularly, but not limited to, the emphysematous type). Low body weight or recent weight loss and in particular depleted lean body mass in patients with COPD have been shown to be independent predictors of mortality, outcomes after acute exacerbations, hospital admission rates, and need for mechanical ventilation. The factors thought to contribute to nutritional depletion in these patients include elevated resting and activity-related energy expenditure, reduced dietary intake relative to resting energy expenditure, accelerated negative nitrogen balance, particularly during acute exacerbations of COPD, medication effects, and perhaps most importantly an elevated systemic inflammatory response. Studies to date suggest that, although it can help limit weight loss and negative energy balance in these patients, the effect of nutritional supplementation alone on clinically significant outcomes such as pulmonary function and exercise capacity is minimal. However, nutritional supplementation may have a role in the management of COPD when provided as part of an integrated rehabilitation program incorporating a structured exercise component as an anabolic stimulus.     

Prise en charge nutritionnelle et effets respiratoires des apports nutritionnels chez l''insuffisant respiratoire chronique

Pulmonary cachexia is a frequently occurring complication in patients with chronic respiratory disorders and is a determining factor of health-related quality of life and mortality. Nutritional support is indicated for depleted patients with COPD, since it provides not only supportive care, but direct intervention through improvement in respiratory and peripheral skeletal muscle function and in exercise performance. Patients responding to energy supplementation by showing weight gain and improvement in functional performance even demonstrated a decreased mortality. Nutritional therapy has to consider acute and chronic effects on functional performance and ventilatory capacity. A combination of oral nutritional supplements and exercise or anabolic agents as anabolic stimulus appears to be the best treatment approach in order to obtain significant functional improvement. Only limited acute adverse effects on symptoms and exercise capacity have been demonstrated after nutritional support, being related to the immediate post-prandial caloric load, but not to the macro-nutrient composition of the supplements. More studies are needed to evaluate the effects of long-term nutritional therapy in clinically stable patients as well as the effectiveness of nutritional support during acute disease exacerbation.     

The pulmonary cachexia syndrome: aspects of energy balance.

The present paper reviews current knowledge of the pulmonary cachexia syndrome with reference to chronic obstructive pulmonary disease (COPD). Aspects of incidence, aetiology and management are discussed. Malnutrition occurs in approximately one-quarter to one-third of patients with moderate to severe COPD. Both fat mass and fat-free mass become depleted. Loss of fat-free mass is the more important and appears to be due to a depression of protein synthesis. Weight loss is an independent prognostic indicator of mortality, and is associated with increased morbidity and decreased health-related quality of life. The aetiology of malnutrition in COPD is not well understood. Reduced food intake does not seem to be the primary cause. Resting energy expenditure (REE) is elevated in a proportion of patients and probably contributes to negative energy balance. Measurement of actual REE is helpful when considering the adequacy of nutritional supplementation. The underlying reason for a hypermetabolic state is not known. Although weight-losing COPD patients are not catabolic, nutritional supplementation alone does not appear to reverse the loss of fat-free mass. Strategies involving nutritional supplementation in combination with a second intervention are being explored, and there are some encouraging results using anabolic hormones.     

Investigation into the nutritional status, dietary intake and smoking habits of patients with chronic obstructive pulmonary disease

Background and aims Weight loss and reduced fat‐free mass are prevalent amongst patients with chronic obstructive pulmonary disease (COPD). However, the causes of this weight loss are not clear. The aims of this study are to investigate the factors affecting body weight and dietary intake in a group of outpatients with COPD, and to investigate any differences between adequately nourished and malnourished patients. Methods In 103 stable outpatients, nutritional status was assessed using Body Mass Index (BMI) and upper arm anthropometry. Lung function, smoking status, exercise tolerance, dietary intake, dietary problems and health‐related quality of life were assessed. Patients were classed as either adequately nourished or malnourished. Results Twenty‐three per cent of subjects were classed as malnourished. The malnourished subjects had lower lung function measurements, suffered more dietary problems and had lower nutritional intake compared with the adequately nourished subjects. They also had poorer fatigue scores. In linear regression analysis, the factors that had the most effect on BMI were a low transfer factor, presence of early satiety, and being a current smoker. Conclusion Important differences were found between adequately nourished and malnourished subjects. These differences move us closer to understanding how best to screen and treat this group of patients.     

Protein Requirements and Recommendations for Older People: A Review

Declines in skeletal muscle mass and strength are major contributors to increased mortality, morbidity and reduced quality of life in older people. Recommended Dietary Allowances/Intakes have failed to adequately consider the protein requirements of the elderly with respect to function. The aim of this paper was to review definitions of optimal protein status and the evidence base for optimal dietary protein. Current recommended protein intakes for older people do not account for the compensatory loss of muscle mass that occurs on lower protein intakes. Older people have lower rates of protein synthesis and whole-body proteolysis in response to an anabolic stimulus (food or resistance exercise). Recommendations for the level of adequate dietary intake of protein for older people should be informed by evidence derived from functional outcomes. Randomized controlled trials report a clear benefit of increased dietary protein on lean mass gain and leg strength, particularly when combined with resistance exercise. There is good consistent evidence (level III-2 to IV) that consumption of 1.0 to 1.3 g/kg/day dietary protein combined with twice-weekly progressive resistance exercise reduces age-related muscle mass loss. Older people appear to require 1.0 to 1.3 g/kg/day dietary protein to optimize physical function, particularly whilst undertaking resistance exercise recommendations.     

Prise en charge nutritionnelle d’un patient atteint d’une insuffisance cardiaque

Weight loss in chronic heart failure (CHF) occurs frequently, progressively and its reversal is rare. Weight loss of more than 6% is used to define the presence of cachexia. Patients with CHF develop skeletal muscle and cardiac muscle atrophy. Anorexia plays a significant role in only 10–20% of all cases of cardiac cachexia. Higher resting metabolic rate in patients with heart failure at least partially accounts for unexplained weight loss. Fat malabsorption and protein loss are thought to be influenced mainly by bowel perfusion and bowel edema and may contribute to the development of cardiac cachexia. A severe catabolic/anabolic imbalance in favor of catabolic metabolism is observed in cachectic CHF patients. Food intake should be assessed in order to identify and stop dietary restrictions recommended for cardiovascular risk factors and no more indicated in patients with cachexia. Many enriched small meals are necessary to cover energy and protein requirements. If this first attempt fails, nasogastric tube feeding is indicated. Parenteral nutrition should be reserved for those patients in whom enteral nutrition has failed.     

Total daily energy expenditure in wasted chronic obstructive pulmonary disease patients

OBJECTIVES: To investigate total daily energy expenditure in chronic obstructive pulmonary disease (COPD) patients during a rehabilitation programme. DESIGN: Observational study involving a case and a control group. SUBJECTS: Ten COPD patients (six with body mass index (BMI) <18.5 kg/m(2) and four with BMI >18.5 kg/m(2)) were evaluated for their energy expenditure profile. Four additional healthy age-matched volunteers were also included for methodology evaluation. INTERVENTIONS: Measurements of total daily energy expenditure (TEE), resting energy expenditure (REE) and diet-induced thermogenesis (DIT) and energy intake were undertaken by indirect calorimetry and bicarbonate-urea methods and dietary records. RESULTS: REE in COPD patients was not significantly different from that predicted by the Harris-Benedict equation. Before the exercise day the mean TEE was 1508 kcal/day and physical activity level (PAL as calculated by TEE/REE) was 1.52. On the exercise day the TEE increased to 1568 kcal/day and PAL was 1.60, but neither of these changes were significant. The energy cost of increased physical activity during rehabilitation exercise was estimated to be 191 kcal/day. No significant change was found in DIT between the two patient groups. However, overall energy balances were found to be negative (-363 kcal/day). CONCLUSION: The rehabilitation programme did not cause a significant energy demand in COPD patients. TEE in COPD patients was not greater than in free-living healthy subjects. Patients, who were underweight, did not have a higher TEE than patients with normal weight. This suggested that malnutrition in COPD patients was not due to an increased energy expenditure. On the other hand, a significant negative energy balance due to insufficient energy intake was found in seven out of 10 patients.     

Lean mass loss is associated with low protein intake during dietary-induced weight loss in postmenopausal women

The health and quality-of-life implications of overweight and obesity span all ages in the United States. We investigated the association between dietary protein intake and loss of lean mass during weight loss in postmenopausal women through a retrospective analysis of a 20-week randomized, controlled diet and exercise intervention in women aged 50 to 70 years. Weight loss was achieved by differing levels of caloric restriction and exercise. The diet-only group reduced caloric intake by 2,800 kcal/week, and the exercise groups reduced caloric intake by 2,400 kcal/week and expended approximately 400 kcal/week through aerobic exercise. Total and appendicular lean mass was measured using dual energy x-ray absorptiometry. Linear regression analysis was used to examine the association between changes in lean mass and appendicular lean mass and dietary protein intake. Average weight loss was 10.8+/-4.0 kg, with an average of 32% of total weight lost as lean mass. Protein intake averaged 0.62 g/kg body weight/day (range=0.47 to 0.8 g/kg body weight/day). Participants who consumed higher amounts of dietary protein lost less lean mass and appendicular lean mass (r=0.3, P=0.01 and r=0.41, P<0.001, respectively). These associations remained significant after adjusting for intervention group and body size. Therefore, inadequate protein intake during caloric restriction may be associated with adverse body-composition changes in postmenopausal women.     

ESPEN Guidelines on Enteral Nutrition: Cardiology and pulmonology

These guidelines are intended to give evidence-based recommendations for the use of enteral nutrition (EN) in patients with chronic heart failure (CHF) and chronic obstructive pulmonary disease (COPD). They were developed by an interdisciplinary expert group in accordance with officially accepted standards and are based on all relevant publications since 1985. They have been discussed and accepted in a consensus conference. EN by means of oral nutritional supplements (ONS) or tube feeding (TF) enables nutritional intake to be maintained or increased when normal oral intake is inadequate. No data are yet available concerning the effects of EN on cachexia in CHF patients. However, EN is recommended to stop or reverse weight loss on the basis of physiological plausibility. In COPD patients, EN in combination with exercise and anabolic pharmacotherapy has the potential to improve nutritional status and function. Frequent small amounts of ONS are preferred in order to avoid postprandial dyspnoea and satiety as well as to improve compliance.     

Nutritional support in patients with chronic obstructive pulmonary disease during hospitalization for an acute exacerbation; a randomized controlled feasibility trial

BACKGROUND & AIMS: Previous studies reported a severely impaired energy balance in COPD patients during the first days of an acute exacerbation, mainly due to a decreased energy and protein intake. The aim of the study was to investigate the feasibility and effectiveness of energy- and protein-rich nutritional supplements during hospitalization for an acute exacerbation in nutritionally depleted COPD patients. METHODS: In a randomized double-blind, placebo-controlled two-center trial, 56 COPD patients were randomized and 47 patients completed the study. Nutritional intervention consisted of 3 x 125 ml (2.38 MJ/day) and the placebo group received similar amounts of a non-caloric fluid. Medical therapy and dietetic consultation were standardized and dietary intake was measured daily. Body composition, respiratory and skeletal muscle strength, lung function and symptoms were measured on admission and on days 4 and 8 of hospitalization. RESULTS: Forty-seven percent of the patients had experienced recent involuntary weight loss prior to admission. The degree of weight loss was inversely related to resting arterial oxygen tension (r = 0.31; P < 0.05). Nutritional intervention resulted in a significant increase in energy (16% vs. placebo) and protein intake (38% vs. placebo). Mean duration of hospitalization was 9 +/- 2 days. Relative to usual care, no additional improvements in lung function or muscle strength were seen after nutritional intervention. CONCLUSIONS: Oral nutritional supplementation during hospitalization for an acute exacerbation is feasible in nutritionally depleted COPD patients and does not interfere with normal dietary intake.     

The impact of a long-term reduction in dietary energy density on body weight within a randomized diet trial

We examined the effect of dietary energy density change on body weight in participants of a randomized trial. Intervention participants markedly increased fruit and vegetable intake while reducing energy intake from fat. Participants were 2,718 breast cancer survivors, aged 26-74 yr, with baseline mean body mass index of 27.3 kg/m(2) (SD = 6.3). We assessed dietary intake by sets of four 24-h dietary recalls and validated with plasma carotenoid concentrations. Weight and height were measured at baseline, 1 yr, and 4 yr. Dietary energy density was calculated using food but excluding beverages. Intervention participants significantly reduced dietary energy density compared to controls and maintained it over 4 yr -- both in cross-sectional (P < 0.0001) and longitudinal (Group x Time interaction, P < 0.0001) analyses. Total energy intake or physical activity did not vary between groups. The intervention group had a small but significant weight loss at 1 yr (Group x Time interaction, P < 0.0001), but no between-group weight difference was observed at 4 yr. Our study showed that reducing dietary energy density did not result in a reduction in total energy intake and suggests that this strategy alone is not sufficient to promote long-term weight loss in a free-living population.     

COPD合并肌少症病人营养与运动干预的护理研究进展

肌少症是机体在增龄过程中出现的进行性、广泛性骨骼肌肌量、肌力及功能下降进而引起残疾、生活质量下降或死亡等不良结局的综合征。骨骼肌是人体最重要的运动器官和能量代谢组织,COPD病人由于疾病的消耗、营养与运动不足,以及高龄等原因,肌少症患病风险较高。本文就COPD合并肌少症的发病机制、营养与运动的护理干预等方面进行综述,期望为COPD合并肌少症的病人提供合理有效的营养与运动干预方案,促进病人机体康复、减少COPD急性发作次数,提高病人生活质量提供参考。     

Improvement of metabolism among obese breast cancer survivors in differing weight loss regimens

OBJECTIVE: To compare the efficacy of different weight loss regimens on body weight loss and metabolic improvement in breast cancer survivors. RESEARCH METHODS AND PROCEDURES: Forty-eight obese breast cancer survivors were randomly divided into four groups and were followed for 1 year: 1) the Control group (subjects did not receive specific nutrition counseling); 2) the Weight Watchers group (subjects were given free coupons to attend weekly Weight Watchers meetings); 3) the Individualized group (a registered dietitian provided one-on-one nutritional counseling); and 4) the Comprehensive group (subjects received individualized dietary counseling and free coupons for the weekly Weight Watchers meetings). At baseline and 3-, 6-, and 12-month data collection visits, a fasting blood sample was obtained for assays. A three-day dietary record was kept during the week before these visits and dietary intake was analyzed. RESULTS: Subjects in the three intervention groups lost weight (Control: 1.1 +/- 1.7 kg; Weight Watchers: -2.7 +/- 2.1 kg; Individualized: -8.0 +/- 1.9 kg; Comprehensive: -9.5 +/- 2.7 kg) and percentage body fat, but only the Individualized and Comprehensive groups had significant losses. Subjects in the Comprehensive group showed the most improvement in cholesterol levels and had reductions in blood leptin levels. DISCUSSION: Because insulin resistance and high blood leptin levels are associated with breast cancer, losing weight to improve these parameters may reduce the risk of recurrence. Only subjects in the Comprehensive group showed significant reductions in body weight and fat, energy intake, and leptin levels. For breast cancer survivors, different weight loss strategies should be considered to assist them in losing weight.     

Dietary counselling effectively improves lipid levels in patients with endogenous hypertriglyceridemia: emphasis on weight reduction and alcohol limitation.

OBJECTIVE: To evaluate the short-term effect of dietary counselling in patients with endogenous hypertriglyceridemia and evaluate the effects of advised nutrient changes. DESIGN: A prospective dietary intervention study in patients with endogenous hypertriglyceridemia from January I st 1988 to December 31 st 1996 according to the Dutch guidelines for a healthy diet. Before and after the dietary intervention period of 12 weeks, 24h food recalls were used to assess dietary intake and macronutrient composition. Effectiveness was evaluated by assessment of body weight, serum lipids, lipoproteins and insulin resistance parameters. SETTING: Leiden outpatient Lipid Clinic. SUBJECTS: Forty-five newly diagnosed, untreated patients with endogenous hypertriglyceridemia. RESULTS: A significant reduction in energy intake and body weight as well as changes in macronutrient composition were observed. Total serum triacylglycerol and cholesterol levels decreased by 31% and 15%, respectively. No effects were observed on serum glucose and insulin levels. Weight reduction was significantly correlated with reduction of total plasma triacylglycerol levels and inversely correlated with changes in HDL cholesterol levels. Of all nutrients assessed, only reduction of alcohol intake correlated with improvement of total serum triacylglycerol. CONCLUSIONS: Short-term dietary counselling in patients with endogenous hypertriglyceridemia can effectively improve serum lipid and lipoprotein levels. With regard to the advised nutrient changes, weight loss and limitation of alcohol intake prove to be the best predictors of triacylglycerol reduction.     

Sarcopenia: a major modifiable cause of frailty in the elderly

Sarcopenia is the loss of muscle mass and strength that occurs with aging. It is a consequence of normal aging, and does not require a disease to occur, although muscle loss can be accelerated by chronic illness. Sarcopenia is a major cause of disability and frailty in the elderly. There are many candidate mechanisms leading to sarcopenia, including age-related declines in alpha-motor neurons, growth hormone production, sex steroid levels, and physical activity. In addition, fat gain, increased production of catabolic cytokines, and inadequate intake of dietary energy and protein are also potentially important causes of sarcopenia. The relative contribution of each of these factors is not yet clear. Sarcopenia can be reversed with high-intensity progressive resistance exercise, which can probably also slow its development. A major challenge in preventing an epidemic of sarcopenia-induced frailty in the future is developing public health interventions that deliver an anabolic stimulus to the muscle of elderly adults on a mass scale.     

The Impact of a Long-Term Reduction in Dietary Energy Density on Body Weight Within a Randomized Diet Trial

We examined the effect of dietary energy density change on body weight in participants of a randomized trial. Intervention participants markedly increased fruit and vegetable intake while reducing energy intake from fat. Participants were 2,718 breast cancer survivors, aged 26–74 yr, with baseline mean body mass index of 27.3 kg/m^{m 2} (SD = 6.3). We assessed dietary intake by sets of four 24-h dietary recalls and validated with plasma carotenoid concentrations. Weight and height were measured at baseline, 1 yr, and 4 yr. Dietary energy density was calculated using food but excluding beverages. Intervention participants significantly reduced dietary energy density compared to controls and maintained it over 4 yr—both in cross-sectional ( P m < 0.0001) and longitudinal (Group m × Time interaction, P m < 0.0001) analyses. Total energy intake or physical activity did not vary between groups. The intervention group had a small but significant weight loss at 1 yr (Group m × Time interaction, P m < 0.0001), but no between-group weight difference was observed at 4 yr. Our study showed that reducing dietary energy density did not result in a reduction in total energy intake and suggests that this strategy alone is not sufficient to promote long-term weight loss in a free-living population.     

The influence of calcium consumption on weight and fat following 9 months of exercise in men and women

BACKGROUND: There is some evidence that calcium consumption improves weight loss during energy restriction but the effects of calcium consumption in conjunction with chronic exercise are unknown. OBJECTIVE: The purpose of the study was to determine the degree to which calcium consumption influences weight and fat weight change as a result of 9 months of verified supervised exercise in the absence of energy restriction. METHODS: Participants were 50 previously sedentary, overweight and moderately obese men (n=20) and women (n=30). Exercise of moderate intensity was performed for 45 min/d, 5 d/wk, under supervision. Diet intake was ad libitum and was measured for energy, macronutrient and micronutrient composition at baseline, 4 and 9 months by use of observer recorded weighed plate waste and multiple-pass 24-h dietary recall procedures. RESULTS: Average calcium consumption was 987 +/- 389 mg/day for men and 786 +/- 276 mg/day for women. Weight change over the 9 months was -4.6 +/- 4.6 kg for men and 0.2 +/- 3.3 kg for women. Calcium consumption was associated with weight change (r =-0.47, p<0.05) in men. The calcium to protein ratio was associated with weight change (r=0.56) and fat weight change (r=-0.53) in men. There was no observed association between calcium and weight or fat weight change in women. CONCLUSION: Weight and fat weight loss as a result of nine months of moderate intensity exercise may be improved by increased calcium consumption in men but was not observed in women.     

Dietary problems in patients with severe chronic obstructive pulmonary disease

Background and aims Low body weight and low fat-free mass-index (FFMI) are common in patients with severe chronic obstructive pulmonary disease (COPD). Several factors seem to contribute. The aims of the present observational study were to investigate dietary problems in patients with severe COPD and to compare dietary problems to nutritional status, energy intake and smoking habits. Methods Nutritional status was assessed in 73 stable outpatients using body mass index and FFMI by single-frequency bioelectrical impedance. Lung function, smoking habits, energy intake and dietary problems were also assessed. Results The most frequently reported dietary problems were ‘anorexia’, ‘dyspeptic symptoms other than diarrhoea’, ‘slimming’, ‘fear of gaining weight’, ‘dyspnoea’, ‘diarrhoea’, ’depression, anxiety, solitude’. Smoking habits and gender had impact on the kind of dietary problems reported. Reporting two dietary problems correlated to low FFMI, whereas reporting one or more dietary problems correlated to decreased energy intake. Conclusion Dietary problems are common in the group studied and related to smoking habits and gender. Dietary problems affect energy intake and FFMI negatively. It is important to recognize dietary problems and to offer intervention of the dietary problems as a part of the dietary intervention.