Nutritional Support in pulmonary Disease Topic 38

Transcription

1 Nutritional Support in pulmonary Disease Topic 38 Module Diet and COPD Frode Slinde, RD, PhD Dept. of Internal Medicine and Clinical Nutrition, Sahlgrenska Academy at University of Gothenburg, P.O. Box 459, SE Göteborg, Sweden Learning Objectives: To understand the role of dietary habits in the aetiology of COPD To be able to explain the dietary recommendations for patients with COPD To develop an overview of hinders and problems limiting the energy intake of a COPD patient Contents: 1. The role of the diet in the aetiology of COPD 2. Dietary recommendations in COPD 2.1 Stable COPD 2.2 Patients experiencing involuntary weight loss 3. Eating problems in COPD 4. Summary 5. References Key Messages: A high intake of fruit and vegetables might contribute to the prevention of COPD There is no special diet for stable COPD In patients experiencing involuntary weight loss, the nutritional intervention should be based on an energy- and protein enriched diet, possibly with addition of nutritional supplements Different kind of eating problems is common and should be considered in the care of COPD patients.

2 1. The role of the diet in the aetiology of COPD The most important risk factor in Europe to develop COPD is tobacco smoking. To stop smoking is therefore the most important preventive measure to prevent COPD and further progress of the disease. In a recently published systematical review article (1), the authors concluded that current data indicates that there is possible evidence that an increase in vegetable and fruit consumption may contribute to the prevention of COPD. You should note that this is not the strongest evidence, rather it is the weakest evidence grade (in the article evidence was graded as convincing, probable, possible and insufficient). Results from 22 studies lay the foundation of this conclusion; 4 prospective cohort studies, 2 case-control studies and 16 cross-sectional studies. The results from these studies showed quite varied results. One prospective studied showed that an increase in fruit consumption by 100 g/day was associated with a reduction in the COPD risk by 24% to while a case-control study in smokers showed that high consumption of vegetables (93 g/day) and fruit (121 g/day) was associated with a COPD risk reduction by 54% each. It seems overall that the preventive effect of fruit is higher compared to the preventive effect of vegetables. The mechanisms behind this possible preventive effect could be that vegetables and fruits (and the phytochemicals therein) has been shown to influence not only inflammatory processes, but also cellular redox processes as well as endothelial and metabolic processes. The American Thoracic Society has similar conclusions regarding fruit and vegetable intake in their policy statement (2). In this article it is also stated that omega-3 polyunsaturated fatty acids and fish intake has been shown protective in some epidemiological studies while other studies have found no effect. The only data on vitamin D so far comes from the NHANES III study showing that the greatest quintile of serum vitamin D levels was associated with higher mean FEV 1 and FVC compared with the lowest quintile (2). Data from the NHANES III study also suggests that higher intake of cured meat (bacon, hot dogs and processed meat such as sausage, salami and cured ham) is associated with a lower FEV 1 and a greater risk of self-reported diagnosis of COPD. Cured meat contains preservatives such as nitrites that can generate reactive nitrogen species and amplify pulmonary inflammation. Studies on diet and pulmonary function are subjects to limitations. Dietary surveys usually reflect recent intakes and very seldom cumulative intake or past intake. A decline in pulmonary function develops during a long period of time and could therefore not directly be linked to the measured short-time dietary intake. A healthier diet may also be associated with other aspects of a healthy lifestyle that may confound the relation between COPD risk and dietary intake. Due to the lack of evidence, the American Thoracic Society states that it is premature to recommend specific dietary interventions for COPD prevention until further data are available. However, a diet high in fruit, vegetables and fish and limited in cured meat has been shown to prevent several other widespread diseases and are common dietary public health messages around Europe. 2. Dietary recommendations in COPD 2.1. Stable COPD How to best manage COPD is presented by the Global Initiative for Chronic Obstructive Lung Disease (GOLD) (3). For stable COPD these guidelines states that patients should receive general advice on healthy living, including diet and the fact that physical exercise is safe and encouraged for people with COPD. GOLD also recommends rehabilitation programmes for COPD patients stating that a comprehensive program includes exercise training, smoking cessation, nutrition counselling, and education. It is however not stated what focus the nutrition counselling should have except that the goal should be prevention of weight loss commonly found in COPD. Given this, the focus of nutrition counselling in stable COPD should therefore be focused on energy intake (fat, protein,

3 carbohydrates and alcohol) and energy expenditure (basal metabolic rate and physical activity). In a study of 87 patients included in a multi-disciplinary rehabilitation program individual dietary intervention showed slight, but uniform, indications of positive effects in energy, protein and carbohydrate intake as well as body weight and distance walked during six minutes (4). The aim of the dietary intervention was to provide the patient with an adequate amount of energy and the counselling was personalised and based on each individuals own dietary intake and living conditions. Another study investigating the effects of dietary counselling was a randomized trial in 59 patients (5). They found that the intervention group consumed more energy and protein compared to controls. The intervention group also gained weight and improved quality of life. Both the control group and the intervention group in this study received a leaflet providing advice on nourishing snacks and drinks and also encouraging food fortification. The leaflet contained information regarding ideas for between meal drinks, how to make meals easier, ideas for quick and nourishing snack ideas, the usual dietary advice (fruit/vegetables, wholemeal etc), how to enrich foods and also ideas about which food to have home. In addition to this leaflet the intervention group were offered a package of treatment by the dietitian. This package contained dietary counselling for the patient, nutrition-related advice for the carer(s) and a free 6-month supply of milk powder for food fortification use. The goal of the intervention was to increase energy intake by up to 600 kcal/d and to ensure an adequate balance of macro- and micronutrients in according with national recommendations. The dietary counselling was based on different kind of behaviour modification techniques and given by a dietitian with 15 y of clinical experience, using a variety of clinical skills. The first counselling session lasted for minutes and follow-up visits lasted for minutes. Counselling included both food choice and portion size modification and the advice was tailored to take account to each subjects eating habits, lifestyle, symptoms, likes and dislikes. This study clearly shows that an individual dietary counselling has several significant positive effects, compared to a leaflet. Three controlled trials have been performed studying the effect of an increased intake of fruit and vegetables in patients with COPD. In a 3-year randomised prospective study (6) an increase in FEV 1 was shown, while in the other two (one lasted for 5 weeks (7) and one for 12 weeks (8)) no effects were seen in pulmonary function, clinical symptoms or oxidative stress. A recent study of 274 COPD patients showed that a, retrospectively reported the last 2 years, high intake of cured meat (> 22.7 g/d) increased the risk of readmissions (9). This finding needs to be confirmed in prospective studies and other cohorts. Patients with stable COPD and stable body weight do not need any special diet. A diet following national recommendations seems to be the best starting point. However, regular monitoring of body weight should be a standard routine, since a large proportion of COPD patients experience weight loss and this worsens the prognosis (10) Patients experiencing involuntary weight loss Studies have shown that weight loss is common in COPD and is a negative prognostic factor (10). Body weight anamnesis should always be included at the first visit and both body weight and height should regularly be monitored. Severe weight loss can be defined as a weight loss of > 5% during 1 month, > 7% during 3 months or > 10% during 6 months. On-going, progressive and involuntary weight loss should always be assessed more severe compared to weight loss followed by recovery. A sudden drop in body height could be a marker of development of osteoporosis. The following criteria from WHO regarding body mass index (BMI) is commonly used in the health care; underweight (BMI < 18.5 kg/m 2 ), normal weight (BMI kg/m 2 ), overweight (BMI kg/m 2 ), and obesity (BMI > 30 kg/m 2 ). Though, in COPD, strong motives exist to evaluate a BMI < 22 kg/m 2 as a risk factor for early death (11).

4 Patients losing weight is in the state of negative energy balance and needs to increase intake of energy so their energy requirement is covered. An energy- and protein enriched diet (in Sweden called the E-diet) is based on several small portions spread throughout the whole day (12). The E-diet has ha higher fat content (45 % of total energy) compared to recommendations for healthy individuals. Due to the high proportion of fat, considerations needs to be taken to the quality of fat, especially in choice of fat used for cooking, to minimize a high proportion of saturated fat. Protein should provide 20 % of the total energy intake. Fortification products can be used to increase energy- and protein content in different meals. A general starting point in the E-diet is to choose foods rich in protein and fat. The dietitian tailors the E-diet to take account to each subjects eating habits, lifestyle, symptoms, likes and dislikes. At low energy intakes, it can be hard to fulfil the needs of vitamins, minerals and trace elements. A daily supplement of these could therefore be needed. Due to the high prevalence of osteoporosis in COPD, the patients requirements and intake of vitamin D is especially important to evaluate. An oral nutritional supplement (ONS) is what it sounds like; a supplement to the usual diet when the requirement of energy and nutrients not could be satisfied through food and drink. ONS occurs as powders, puddings and as liquids. Two recently published meta-analyses on COPD patients concludes that nutritional support, mainly in form of ONS, increases energy, improves anthropometry (i.e. body weight and upper arm circumference), hand grip strength and both inspiratory and expiratory muscle strength (13, 14). 3. Eating problems Which factors determine a person s dietary/energy intake depends of several background factors. In patients with COPD it has been shown that different kinds of eating problems, both of physical and psychological nature, is common (15). In that study it came evident that malnourished patients had a higher prevalence of eating problems such as anorexia, early satiety, dyspnoea and dryness of the mouth. In a Swedish study it was shown that the most common eating problems in COPD was anorexia, different kind of gastrointestinal symptoms, slimming while underweight, fear of gaining weight, dyspnoea and depression/anxiety/solitude (16). The eating problems differed between smokers/former smokers (fig. 1) and between men/women (fig. 2). The patients having the most number of eating problems also had a poor nutritional status (low fat free mass index) and energy intake. It has been shown that the number of eating problems is possible to reduce and that patients succeeding in reducing their eating problems improve their physical function (17).

5 Fig.1 Prevalence of different eating problems in men and women (n=73) (adapted from (16)).

6 Fig.2 Prevalence of different eating problems in current and former smokers (n=73) (adapted from (16)). 4. Summary Patients with stable COPD and stable body weight do not need any special diet. However, patients losing weight should be provided individually target nutritional treatment focusing on energy balance. 5. References 1. Boeing H, Bechthold A, Bub A, Ellinger S, Haller D, Kroke A, et al. Critical review: vegetables and fruit in the prevention of chronic diseases. Eur J Nutr. 2012;51: Eisner MD, Anthonisen N, Coultas D, Kuenzli N, Perez-Padilla R, Postma D, Romieu I, Silverman EK, Balmes JR. Committee on Nonsmoking COPD, Environmental, and Occupational Health Assembly. An official American Thoracic Society public policy statement: novel risk factors and the global burden of chronic obstructive pulmonary disease. Am J Respir Crit Care Med 2010;182: Global Strategy for the Diagnosis, Management and Prevention of COPD, Global Initiative for Chronic Obstructive Lung Disease (GOLD) Available from: 4. Slinde F, Grönberg AM, Engström CP, Rossander-Hulthén L, Larsson S. Individual dietary intervention in patients with COPD during multidisciplinary rehabilitation. Resp Med 2002;96: Weekes CE, Emery PW, Elia M. Dietary counselling and food fortification in stable COPD: a ranodmised trial. Thorax 2009;64: Keranis E, Makris D, Rodopoulou P, Martinou H, Papamakarios G, Daniil Z, et al. Impact of dietary shift to higher-antioxidant foods in COPD: a randomised trial. Eur Respir J. 2010;36: ,

7 7. Cerda B, Soto C, Albaladejo MD, Martinez P, Sanchez-Gascon F, Tomas-Barberan F, et al. Pomegranate juice supplementation in chronic obstructive pulmonary disease: a 5- week randomized, double-blind, placebo-controlled trial. Eur J Clin Nutr. 2006;60: Baldrick FR, Elborn JS, Woodside JV, Treacy K, Bradley JM, Patterson CC, et al. Effect of fruit and vegetable intake on oxidative stress and inflammation in COPD: a randomised controlled trial. Eur Respir J. 2012;39: de Batlle J, Mendez M, Romieu I, Balcells E, Benet M, Donaire-Gonzalez D, Ferrer JJ, Orozco-Levi M, Anto JM, Garcia-Aymerich J and the PAC-COPD Study Group. Cured meat consumption increases risk of readmission in COPD patients. Eur Respir J 2012; 40: Vestbo J, Prescott E, Almdal T, Dahl M, Nordestgaard B G, Andersen T, Sörensen T I A, Lange P. Body mass, fat-free body mass, and prognosis in patients with chronic obstructive pulmonary disease from a random population sample. Am J Respir Crit Care Med 2006;173: Berrington de Gonzales A et al. Body-mass index and mortality among 1.46 million white adults. N Engl J Med 2010;363: The National Board of Health and Welfare (Socialstyrelsen). Näring för god vård och omsorg en vägledning för att förebygga och behandla undernäring. (Nutrition for good health and welfare a guide to prevent and treat malnutrition) Collins PF, Stratton RJ, Elia M. Nutritional support in chronic obstructive pulmonary disease: a systematic review and meta-analysis. Am J Clin Nutr 2012;95: Collins PF, Stratton RJ, Elia M. Nutritional support and functional capacity in chronic obstructive pulmonary disease: a systematic review and meta-analysis. Respirology 2013 Feb 22. Doi: /resp [Epub ahead of print]. 15. Cochrane WJ, Afolabi OA. Investigation into the nutritional status, dietary intake and smoking habits of patients with chronic obstructive pulmonary disease. J Hum Nutr Diet ;17: Grönberg AM, Slinde F, Engström CP, Hulthen L, Larsson S. Dietary problems in patients with severe chronic obstructive pulmonary disease. J Hum Nutr Diet. 2005;18: Grönberg AM, Slinde F, Hulthén L, Larsson S. Individually adapted nutritional intervention reduces dietary problems and improves physical function in chronic obstructive pulmonary disease patients. J Ageing Res & Clin Pract. 2012;1:98-100