Nutrition and COPD What we will cover: • Malnutrition and COPD • Oral nutrition supplements • Recommended dietary patterns for people with COPD • Bone Health • Obesity • Micronutrient supplements Katherine Stern Dietitian 10/10/2014 Malnutrition  Malnutrition is more prevalent in people with COPD  25-40% of patients with COPD are malnourished  Observational studies suggest being underweight (<BMI <18.5-20) is associated with increase disease severity and poorer prognosis. ESPEN Guidelines 2006 Impact of Malnutrition  Reduced ability to fight infections  Impaired wound healing, longer hospital stays and recovery time  Muscle wasting- reduced ability to do usual activities and lower exercise capacity  Impaired temperature regulation ‘feeling the cold’  Micronutrient deficiencies BAPEN 2012 Identifying Malnutrition  Malnutrition can be described as:  5% unintentional weight loss in 3 months  10% unintentional weight loss in 6months  Underweight <BMI 18.5-20  Muscle and fat wasting PEN (Practice-based Evidence in Nutrition )2010 Increased energy requirements  Varied total energy requirements due to differences in resting energy expenditure and physical activity.  Estimated 5-10% increase in resting energy expenditure in acute COPD exacerbations. PEN (Practice-based Evidence in Nutrition )2010 Chewing and swallowing problems Reduced intake due to chewing/swallowing problems secondary to breathing problems  Small frequent meals  Soft, easily chewable foods  Convenience foods/ foods that require little preparation  Meals on Wheels, other provides e.g. Eat Oral Nutrition Supplements The most recent systematic reviews and meta-analysis’s have shown a benefit of nutritional supplements for people with COPD.  Systematic Review in The American journal of clinical nutrition 2012  Cochrane Systematic Review 2012 “ Moderate quality evidence that nutritional supplements promote weight gain among patients with COPD, especially if undernourished” High fat, low carbohydrate Supplements?  Pulmocare supplement- available on special authority for people with COPD and hypercapnia CO2 >55mgHg  Theory: fat produces less CO2 per O2 molecule consumed than carbohydrate decrease respiratory quotient (RQ)  Conflicting evidence of a benefit on improved lung function in individuals with COPD ESPEN 2006/ PEN 2010 Recommended dietary patterns for people with COPD 1-2 servings (palm size) of meat or meat alternatives A serving (about fist size) of carbohydrates at each meal (preferably wholegrain) 2-3 servings of milk and milk alternatives 2 or more servings of fruit and 3 or more servings of vegetables Bone Health Osteoporosis and bone fracture risk higher in people with COPD. Especially important if on steroids, low BMI, low fat free mass, older adult >65+  Adequate calcium sources- 3 or more serving  Adequate Vitamin D- consider supplements PEN (Practice-based Evidence in Nutrition )2010 Obesity and COPD  People with stable COPD and obesity may benefit from weight reduction.  Extra weight may worsen exercise tolerance and increase dyspnea.  Weight reduction may be more beneficial for those with OSA and Asthma.  Encourage increased exercise alongside dietary changes to prevent losses of muscle mass PEN (Practice-based Evidence in Nutrition )2010 Micronutrient Supplements  Studies have not shown a benefit or lack of studies to support supplementation for Vitamin C, E, beta-carotene, selenium, magnesium, omega 3 and omega 6.  Vitamin D- consider supplementation for bone health  Comprehensive Multivitamins e.g. Centrum if poor intake PEN (Practice-based Evidence in Nutrition )2010 Summary  Achieving adequate nutrition can be a challenge for some people with COPD and malnutrition in common in this patient group  Recent meta-analyses have shown a benefit of nutritional supplements  Ensure adequate intake of calcium sources and consider vitamin D supplementation  Consider weight reduction for those with obesity and stable COPD. References  Ferreira IM, Brooks D, White J, Goldstein R. Nutritional supplementation for stable chronic obstructive pulmonary disease (Review). The Cochrane Library 2012 Issue 12.  Collins PF, Strutton RJ, Elia M. Nutritional support in chronic obstructive pulmonary disease: a systematic review and meta-analysis. Am J Clin Nutr 2012; 95:1385-95.  Anker SD, John M, Pedersen PU et al. ESPEN (European Society for Parenteral and Enteral Nutrition). ESPEN Guidelines on Enteral Nutrition: Cardiology and Pulmonology. Clin Nutr. 2006 April ;25(2):311-8.  BAPEN (British association for parenteral and enteral nutrition) http://www.bapan.org.nz  PEN (Practise evidence based Nutrition) Nutrition and COPD pathway updated 2010.