FN 418/618: Medical Nutrition Therapy II Spring 2017

Chronic Obstructive Pulmonary Disease

Dakota Cossairt

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A Stella Bernhardt is a 62 yo female who is diagnosed with COPD. She

states that her appetite is poor and she feels full quickly after just a few
bites. She explains that she is too tired to eat after preparing a meal. Her
increased coughing makes it difficult to eat. Says food doesnt taste good
anymore; it tastes bitter. She lost 20# in the last year; she is 20% below her
UBW.
24-hr recall showed low caloric intake, consuming less than 50% of
estimated energy needs. Also, low in protein, only getting 9g/day.
Physical finding include decreased breath sounds, wheezing, rhonchi, and
use of accessory muscles at rest.
Medical history includes bronchitis and upper respiratory infections.
Family medical history includes mother and 2 aunts passing away from lung
cancer.
Lab values indicate increased levels of CO2, WBC, segs and decreased levels
of protein, albumin, SO2, RBC, Hgb, Hct, and lymphocytes.
Highest adult wt. = 145#-150#
Nutritional intake from 24-hr recall = 720 kcals

Ht. = 63 Wt. = 119# UBW= 145-150# BMI = 21.1 BP = 130/88

mmHg

Recommended kcals = 1,650-1,900 kcal/day

Recommended protein = 65-90 grams/day

D Inadequate oral intake R/T decreased caloric intake, loss of appetite, and
self-feeding difficulty AEB diet history and low levels of protein and albumin

I increase caloric intake to 1,650-1,900 kcal/day. Increase protein intake to

65-90g/day. Educate patient on nutrient dense diet rich in antioxidant foods.
Educate on smaller more frequent meals, which are easy to prepare.
ME schedule f/u in one month. Will have patient use food diary to keep
track of intake. Will assess pertinent lab values.

1-Day Meal Plan

Breakfast
1 cup decaffeinated coffee or tea
1 cup hot or cold cereal
cup low-fat or skim milk
cup orange juice
Snack
Fruit smoothie
Nuts
Lunch
cup fruit juice
1 tuna salad sandwich
3 oz. salad with vinaigrette or low fat dressing
1 cup decaf beverage
Snack
Peanut butter & celery
Dinner
4 oz. chicken breast (grilled or baked)
Tomatoes with onion, green peppers, and vinegar
3 oz. fresh fruit

Questions
1. Mrs. Bernhardt was diagnosed with stage 1 emphysema/COPD
five years ago. What criteria are used to classify this staging?
a. FEV1/FVC ratio of <70%
b. FEV1 value of >80% predicted
c. Presence or absence of chronic symptoms

2. COPD includes two distinct diagnoses. Outline the similarities

and differences between emphysema and chronic bronchitis.
a. Emphysema and chronic bronchitis are both diseases
characterized by slow, progressive obstruction of the airways.
 b. Emphysema is characterized by abnormal, permanent
enlargement and destruction of the alveoli.
c. Chronic bronchitis (type II) is characterized by a productive
cough with inflammation of the bronchi and other lung changes.
d. Both are a result of exposure to pollutants, such as cigarette
smoke
e. Emphysema patients are thin, where as chronic bronchitis
patients are of normal weight, and can often be overweight.
f. Chronic bronchitis patients have hypoxia and high hematocrits,
where as emphysema patients have mild hypoxia and normal
hematocrits.

3. What risk factors does Mrs. Bernhardt have for this disease?
a. Cigarette smoking (1 pack/day) for last 46 years
b. History of bronchitis and upper respiratory infections during
winter months
c. Family history of lung cancer

4. .
a. Identify symptoms described in the MDs history and
physical that are consistent with Mrs. Bernhardts
diagnosis. Then describe the pathophysiology that may
be responsible for each symptom.
i. Decreased breath sounds (SOB) & gasping
1. Loss of surface area in lungs
2. Loss of elasticity in bronchioles
3. Inflammation of bronchiole tubes
4. Damage to the alveoli sac
ii. Build up of mucus (green)
1. Damage to cilia, which prevents it from clearing
away mucus properly
2. Green because build up can cause infection
iii. Persistent coughing
1. Body is trying to get rid of mucus build up

b. Now identify at least four features of the physicians

physical examination consistent with her admitting
diagnosis. Describe the pathophysiology that might be
responsible for each physical finding.
i. Decreased breath sounds
1. Inflammation of bronchiole tubes
2. Damage to the alveoli sac
ii. Prolonged expiration with wheezing
1. Air is unable to pass through the lungs causing
wheezing
iii. Rhonchi
 1. Due to inflammation that make the airways narrow,
which produces a ratting sound (rhonchi)
iv. Use of accessory muscles at rest
1. Occurs when the lungs have a hard time passing air
through. Accessory muscles start to work harder to
pass air through when the lungs cant.

7. Mrs. Bernhardt has quit smoking. Shouldnt her condition now

improve? Explain.
a. Mrs. Bernhardts condition will not improve, because there has
already been significant destruction to her alveoli, which is
irreversible. The positive thing about her quitting smoking
though, is that her condition may not progress as quickly.

8. What is a respiratory quotient? How is this figure related to

nutritional intake and respiratory history?
a. A respiratory quotient is the ration of CO2 expired to the volume
of oxygen inspired
b. Excessive amounts of carbohydrate increases the RQ and the
output of CO2
c. Excessive amounts of lipids decreases the RQ and the output of
CO2
d. The RQ can be used to help correct malnutrition, and help
determine how well a persons calories are being used as energy

9. What are the most common nutritional concerns for someone

with COPD? Why is the patient diagnosed with COPD at higher
risk for malnutrition?
a. Reduced and/or inadequate oral intake
b. Decreased vitamin and mineral levels
c. Patients diagnosed with COPD are at higher risk for malnutrition,
because their energy expenditure is generally elevated due to
airflow obstruction. This increases their energy needs. Many
patients with COPD often experience symptoms, such as fatigue,
difficulty swallowing, abdominal discomfort, etc., that makes it
difficult for them to eat, thus causing them to eat less and get
inadequate energy intake.

10. Is there specific nutrition therapy prescribed for these

patients?
a. Consume adequate oral intake (for those underweight)
b. Decrease caloric intake to lose some weight (for those
overweight)
c. Cutting back on smoking/quitting completely
d. Prevent or correct dehydration, which thickens mucus
e. Promote intake of nutrient dense diet rich in antioxidant foods
 11. Calculate Mrs. Bernhardts %UBW and BMI. Does either of
these values indicate she is at nutritional risk? How would her
1+ bilateral pitting edema affect elevation of her weight?
UBW = 145-150# Current wt. = 119# = 54.1kg Ht. = 63 =
160cm = 1.6m

%UBW
(119/145) x 100 = 82% UBW
(119/150) x 100 = 79& UBW

BMI
54.1/(1.6x1.6) = 21.1 kg/m2

o Her %UBW is of concern if this weight loss was recent and due to
her diagnosis. If it was more recent since her diagnosis, I would
be concerned that the weight loss was due to her being
malnourished.
o Her BMI is in the normal healthy range, but that does not mean
that there is no need for nutritional concern.

13. Calculate Mrs. Bernhardts energy and protein

requirements. What activity and stress factors would you use?
What is your rationale?

Energy Requirements 1,620-1,900 kcal

30-35 kcal/kg bw

54.1 kg x (30kcal/kg) = 1623 kcal

54.1 kg x (35kcal/kg) = 1894 kcal

Protein Requirements 65-92 grams

1.2-1.7 g/kg bw

54.1 kg x (1.2g/kg) = 64.92 g

54.1 kg x (1.7g/kg) = 91.97 g

14. Using Mrs. Bernhardts nutritional history and 24-hour

recall as a reference, does she have an adequate oral intake?
Explain
a. According to her nutritional history and 24-hour recall, Mrs.
Bernhardt does not have an adequate oral intake.

15. Evaluate Mrs. Bernhardts laboratory values. Identify

those that are abnormal. Which of these may be used to assess
her nutritional status?
 a. Increased levels of CO2, WBC, and segs
b. Decreased levels of protein, albumin, SO2, RBC, Hgb, Hct, and
lymphocytes
c. Low protein and albumin could be due to malnutrition
d. Low Hgb and Hct can be indicators for anemia
e. Her other values indicate that she is not getting enough oxygen
and/or that oxygen therapy isnt working properly

16. Why may Mrs. Bernhardt be at risk for anemia? Does her
laboratory values indicate that she is anemic?
a. She may be at risk, as her RBC, hemoglobin and hematocrit
levels are low.

17. What factors can you identify from her nutrition interview
that probably contributes to her difficulty in eating?
a. Poor appetite
b. Fills up quickly, after just a few bites (early satiety)
c. Increased coughing
d. Finds food to be unappetizing lately
e. Exhaustion due to increased efforts to breath
f. Improperly fitted dentures

18. Select two high-priority nutrition problems and complete

the PES statement for each.
a. Inadequate oral intake R/T decreased caloric intake, symptoms of
COPD, and self-feeding difficulty AEB diet history and low levels
of protein and albumin
b. Self-feeding difficulty R/T fatigue, SOB, loss of appetite, and lack
of energy AEB unintentional weight loss and diet history

19. What is the current recommendation on the appropriate

mix of calories from carbohydrates, protein, and lipids for this
patient?
a. Protein: 1.2-1.7 grams/kg (15-20%)
b. Lipids: 30-45%
c. Carbohydrates: 40-55%

20. For each of the PES statements that you have written,
establish an ideal goal (based on the signs and symptoms) and
an appropriate intervention (based on etiology).
a. Inadequate oral intake
i. Goal
1. Increase kcal intake to 1,650-1,900 kcal/day
2. Consume smaller more frequent meals
3. Choose nutrient dense foods
ii. Intervention
 1. Educate on appropriate COPD diet
2. Educate on smaller more frequent meals which are
easy to prepare
b. Self-feeding difficulty
i. Goal
1. Incorporate more flavorful foods by using spices and
other flavorings
2. Consume smaller more frequent meals
3. Rest before meal times
4. Choose nutrient dense foods
ii. Intervention
1. Provide recipes and lists of calorie dense foods which
are easy to prepare
2. Provide recipes and lists of high calorie & high
protein snacks that are also easy to prepare

21. What goals might you set for Mrs. Bernhardt as she is
discharged and beginning pulmonary rehabilitation?
a. Increase total kcal intake
b. Decrease portion sizes, while increasing meal frequency
c. Incorporate more nutrient-dense foods

22. You are now seeing Mrs. Bernhardt at her second visit to
pulmonary rehabilitation. She provides you with the following
information from her food record. Her weight is now 116 lbs.
She explains adjustment to her medications and oxygen at
home has been difficult, so she hasnt felt like eating very
much. When you talk with her, you find she is hungriest in the
morning, and often by evening she is too tired to eat. She is
having no specific intolerances, but she does tell you she
hasnt consumed any milk products because she thought they
would cause more sputum to be produced.

a. Is she meeting her calorie and protein goals?

i. According to the food record Mrs. Bernhardt provided, she

is still not meeting her calorie and protein goals. On
Monday she only got about 1,000 kcals and 28g of protein.
On Tuesday she got about 1,350 kcals and 40g of protein.

b. What would you tell her regarding the use of

supplements and/or milk and sputum production?
 i. Milk doesnt make the body produce more mucus, but it
does thicken phlegm. With having damage to her cilia, it
makes it harder to remove the thick phlegm, causing it to
build up, therefore causing her to cough excessively.

ii. Mrs. Bernhardt should consider drinking skim or low fat

milk in moderation. If she does not want to drink milk at all,
I would recommend she take a multivitamin, calcium
and/or vitamin D supplement to reduce the risks of
deficiency or possibly even osteoporosis.

c. Using information from her food diary as a teaching tool,

identify three interventions you would propose for Mrs.
Bernhardt to increase her calorie and protein intakes.

i. Avoid/limit empty calorie intake. She can substitute Pepsi

for club soda and/or water.

ii. Incorporate small, frequent meals that are easily prepared

and high in calories and protein

iii. Allow the biggest meal of the day to be at breakfast time,

since that is when she is the hungriest.