COPD and the role of nutrition and PR

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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 / 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

How is it identified?

  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 COPD

 What happens in practice?

  – Weight                   Not always!

  – BMI                      Not always!

  – FFM

  – Screening                Not always!
   Incidence of malnutrition in COPD

      Depends on severity of disease and how assessed
      More common in severe COPD patients and patients with
      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

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

  – Loss of appetite [inflammatory processes in body]
  – Shortness of breath whilst eating
  – Post prandial dyspnoea
  – Fatigue
  – Immobility
  – Social isolation
  – Type of patient
The causes of malnutrition in COPD

   – Increased Energy Expenditure
      • resting energy expenditure
      • total energy expenditure
  – Described as hyper catabolic (over burning calories)
      • Underlying energy turnover increased, systemic
      • Increased requirements energy used during
      • Inefficient muscle use move from type I to type II
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

  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
Spiral of decline
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
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)
   – Limited as poorly recognised
   – Few dedicated respiratory Dietitians
   – Only for severe / hospitalised patients
   – Mixed success
   – Inconclusive to date
   – New interventions being considered
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

  – 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
  – The evidence to support use of Enteral Nutrition in COPD is
  – 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

 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

              Take Respifor in combination with
              physical training to improve
              physical capacity
 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:

 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
  – Vitamin C, Vitamin E, Selenium

 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

 Data to show improved and sustained outcomes
Evidence: Study 1 – Pison et al. 2009

  – 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

   – 7 visits received education, exercise, androgenic steroids and
     Respifor 125ml tds v's 7 visits education
Evidence: Study 1 – Pison et al. 2009

  – 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)

  – 2 abstracts published, full paper due to be published later this

       Pison et al. 2009; Cano et al. Clinical Nutrition Suppls. 2008: 3(1);16
Evidence: Study 2 – van Wetering et al. 2010

  – 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)

   – 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. 2010

  – 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
     • BMI and FFM increased (p=0.009, p<0.001
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.

   – 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

  – To Investigate the effects of specific oral nutritional support on
    exercise performance in stable COPD patients in pulmonary

 Study participants:
  – 60 pts with COPD

   – Randomised to receive 7 weeks Respifor (125mls tds) plus
     pulmonary rehabilitation v's non nutritive placebo plus pulmonary

        Steiner et al. Thorax 2003:58;745-51
Evidence: Study 3 – Steiner et al. 2003

  – 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

 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

 Broekhuizen et al. 2005
 n=19 (Respifor) n=19 (Standard supplements)

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