Nutritional Assessment & Support for COPD Why do we need nutritional support?

While weight loss has been known to occur in COPD patients for a very long time, it was generally assumed that this was inevitable due to the progressive and terminal nature of the disease. Hence nutritional management & support were not considered seriously for many years. However newer research has challenged this assumption and suggested that weight loss & muscle wasting may be associated with a poor prognosis and conversely helping weight gain in cases of advanced COPD may actually reduce mortality. Also, the new paradigm of COPD management suggests that it is important to not only target the primary problem of lung disease in these patients, but manage the complications like weight loss & muscle wasting too so that the best possible long term results can be achieved in these patients. Several research articles have suggested that recent weight loss (10 % in 6 months or 5 % in 1 month) or low FFM (fat free mass) a measure of body muscle mass, is associated with poor functional outcomes in COPD patients. COPD patients with low FFM have lower peak oxygen consumption, lower work rate, and earlier onset of lactic acidosis, while significant weight loss can be associated with increased risk of hospital readmission, and increased mortality risk. Overall, a BMI (body mass index) of < 25 kg/m2 was associated with a definitely increased risk of dying, while similar results were suggested for FFM < 15 (females) & < 16 (males). How can we assess the nutritional status? We can assess the weight & height of the patient and classify them as Normal weight BMI 20-25, Underweight < 20, and overweight > 25. However, while weight is important, it is as important to assess the FFM in these individuals to have an accurate assessment of their actual nutritional status. Bioelectrical Impedance analysis & DEXA (Dual energy X ray absorptiometry) can be used to noninvasively measure the FFM. Patients of COPD can be classified as having three types of wasting conditions Condition Cachexia Semistarvation Sarcopenia Body weight Low Low Normal FFM Low Normal Low

What are the causes of weight loss & muscle wasting? Weight & fat loss is generally related to the difference between dietary intake & energy expenditure. On the other hand, loss of muscle mass (atrophy) can be complicated and related to changes in protein metabolism & rates of muscle cell turnover. COPD patients have been shown to have higher REE (Resting Energy Expenditure) as compared to normal people. There are many possible reasons for this including increased work of breathing, inflammation due to the disease, abnormal hormone levels and even due to medicines. Use of bronchodilator medications like salbutamol nebulisation has been shown to increase REE by up to 20 %.

Elevated CRP (C reactive Protein) and TNF alpha (Tumor necrosis factor) levels have been noticed in COPD patients experiencing weight loss. Mechanical efficiency may be reduced in COPD patients during leg exercises, due to hyperinflation and increased oxygen consumption, and this may contribute to a higher total daily expenditure. The muscle fibres of COPD patients have been shown to shift from Type 1 (oxidative) to Type 2 (glycolytic), thus favoring anaerobic metabolism, which is less energy efficient as compared to aerobic metabolism seen in normal individuals. Peroxisome proliferator-activated receptors (PPARs) are reduced in COPD and these play a critical role in the oxidative capacity of skeletal muscles. Dietary intake Many COPD patients have an increased metabolism (hypermetabolism), however studies suggest that patients with lower weight actually eat less than normal weight COPD patients. This is very unusual because the usual body response to weight loss is to eat more. There are many suspected reasons for this including the fact that chewing and swallowing food may reduce oxygen saturation causing distress, and hyperinflation may reduce stomach capacity. Lower Leptin levels, a hormone that is related to appetite have been noted in patients with COPD and these may be also related to poor dietary intake in this situation. What interventions are likely to improve the nutrition? Many short term studies in hospital settings have shown that nutritional intervention have lead to increased weight gain and respiratory muscle function. However, since COPD is a chronic lifelong condition, there is need for appropriate & sustained nutritional interventions that can be applied in the community settings. A study focusing solely on gastrostomy tube based enteral nutrition given at night did not lead to a significant weight gain. This was because there was decreased daytime feeding in COPD patients. Other studies have looked at the impact of modifying the lifestyle with both diet (including supplements) & exercise based interventions to improve appetite and nutrition. This combined treatment showed far more encouraging results with a weight gain of 0.4 kg/ week and a significant increase in respiratory muscle strength & a decreased mortality rate. Preventing muscle atrophy Exercise training in addition to use of anabolic medications like steroids, testosterone and even Growth hormone has been associated with gain in muscle mass in COPD patients. High intensity exercise is theorized to work due to increasing the IGF 1 (Insulin like growth factor) levels in muscles. Supplementation with specific branched chain amino acids, specifically Leucine may help in upregulating protein synthesis too. To reduce the anti-inflammatory response in COPD, TNF blocker drug infliximab was tried, but the results were disappointing. Pulmonary rehabilitation regimens have been shown in studies to increase oxidative enzyme activity and exercise capacity, potentially reversing the reduced muscle oxidative capacity in COPD patients. Using

PUFA (Polyunsaturated Fatty acids) in diet enhanced exercise capacity as a result of increased PPARs and possibly reduced inflammation. Practical approach to nutrition The following steps (flowchart in original article) can be used to manage nutrition in COPD patients. 1. 2. 3. 4. 5. Screen patients by regular body weight measurements & BMI Supplement nutrition if BMI < 21 or significant weight loss in BMI < 25 Try to measure FFM to identify patients with sarcopenia and manage them accordingly Treat according to cause of weight loss (decreased intake or increase dietary requirements) Treatment modalities would include modification of dietary behavior, food pattern changes, and addition of energy dense nutritional supplements. Addition of exercise program can help. 6. Follow up after 4 8 weeks. Check for compliance if weight gain inadequate. 7. Multi-disciplinary approach involving a chest physician, dietitian, respiratory nurse and a physiotherapist can lead to optimum results. Further research will likely involve use of specific medications & nutritional supplementation that may alter weight loss & improve nutritional status of COPD patients.