RT to RD: NUTRITION NOTES FOR CF & COPD

Vanessa Clark RD, LD

Medical University of South Carolina

DISCLOSURES

I work primarily with cystic fibrosis patients

Food and nutrient-specific research is difficult and multi-layered Cross-sectional analysis vs RCT Foods vs nutrients Diet recalls vs Food frequency vs Serum levels

Reporting accuracy Sometimes I eat cake

A NUMBERS GAME Chronic Obstructive Pulmonary Disease:

WHO predicts that by 2020 COPD will be the 3rd leading cause of death worldwide and will rank 5th for disease burden and chronic disability worldwide

Is among the 3rd leading cause of death in the US

Cystic Fibrosis: Affects 70,000 people worldwide Median survival is in the late 30s (CF Foundation)

Methods of Measurement

Weight = those numbers you see on a scale

BMI = weight / height <18.5 = underweight 18.5-25 = normal >25 = overweight >30 = obese

FFM = Fat Free Mass Water (~73%) Protein Minerals Muscle

COPD: HOW NECESSARY IS NUTRITION?

Body weight and FFM affect exercise tolerance and response, gas trapping, and diffusing capacity

Reduction in FFM is related to…Reduction in peak O2 consumptionReduction in peak work rateReduction in respiratory muscle mass & strength

Earlier lactic acid production Muscle fiber atrophy, particularly type II

COPD: HOW NECESSARY IS NUTRITION?

25-40% of COPD patients experience weight loss

25% of patients with moderate-severe disease have reduced FFM

35% of patients with very severe disease have reduced FFM

45% of COPD pts eligible for pulm rehab are underweight or have depletion of FFM

Malnutrition in 30-60% of inpatients and 10 to 45% of outpatients (BMI <20 or <90% IBW)

COPD: HOW NECESSARY IS NUTRITION?

Decreased weight = decreased lifespan and QOL 2-4 year estimated survival time in patients with severe disease who are lean and have an FEV1% of <50%

BMI <20 is associated with higher exacerbation risk

Skeletal muscle weakness is related to… Worsened health status Increased healthcare costs Increased mortality risk

EXERCISE CAPACITY IN COPD PATIENTS POST-LUNG TRANSPLANT

Williams, T. J., Patterson, G. A., McClean, P. A.,Zamel, N. and Maurer, J. R. (1992) Maximal exercisetesting in single and double lung transplant recipients.Am. Rev. Respir.Dis. 145, 101–105

LIMITATIONS TO BIKING EXERCISE AMONG COPD PATIENTS

Man, W. D., Soliman, M. G., Gearing, J., Radford, S. G.,Rafferty, G. F., Gray, B. J., Polkey, M. I. and Moxham, J.(2003) Symptoms and quadriceps fatigability afterwalking and cycling in chronic obstructive pulmonary

CF: HOW NECESSARY IS NUTRITION? BMI is strongly associated with lung function: Malnourished patients have lower average vital capacity, arterial oxygen partial pressure, and FEV1

Malnutrition among adolescents 12-18 years was associated with an FEV1 drop of ~20%; FEV1 was maintained at >80% in normal weight patients

Patients with FFM depletion have reduction in FEV1 and bone density even if BMI value is maintained

Goals: >50th %ile weight/length for children 0-2y >50th%ile BMI for children 2-20y BMI >23 for male adults BMI >22 for female adults

* Cystic Fibrosis Foundation

* Cystic Fibrosis Foundation

APPETITE AND INTAKE

Reduction in appetite and intake is common due to:Changes in breathing induced by eating (chewing and swallowing)

Decreased oxygen saturation during mealsIncreased post-prandial dyspnea Mucus accumulation GI distress and coughing induced emesisHormonal irregularities: leptin Anorexia of chronic diseaseAnxiety, depression, psychosocial factors

CALORIES AND PROTEIN Increased energy expenditure caused by:Increased WOBChronic infectionsMedical treatments and therapies

CF: ~120-200% increase in caloric needs~150%-200% increase in protein needs Malabsorption, increased REE, increased WOB

COPD:~95-150% of predicted caloric needs ~150-200% increase in protein needsREE elevation due to: medications, inflammation, activity, inefficient ventilation

MIXING MACRONUTRIENTS

Balanced nutrient and meal profiles:Carbohydrates 40-55% of calories

Fat 30-45% of calories

Protein 15-20% of calories

MACRONUTRIENTS: CARBOHYDRATES

RQ of 1Excessive CO2 production seen with carbohydrate administration has been isolated to cases of energy excess

MACRONUTRIENTS: FATS

Higher caloric load: 9kcal/gIncreased gastric emptying time Malabsorption in CF

MACRONUTRIENTS: PROTEIN

No storage form of protein in the bodyStable: 1.5g/kg body weightAcute: 1.5-2g/kg body weightProtein repletion and muscle preservation is difficult during acute exacerbations

Body prioritizes making other proteins Prealbumin and albumin are poor indicators of nutritional status in an acute setting

Optimize protein status as outpatientProtein Sources: milk, yogurt, meat, fish, shellfish, tofu, poultry, beans, nuts

SNEAK A SNACK: POST-WORKOUT NUTRITION

Both weight and FFM improve with daily nutritional snack provision as a part of a pulmonary rehab program

Better weight gain than with nutrition intervention alone

Improvement in respiratory muscle strength, exercise capacity, health status, and survival rates Strength training in conjunction with nutrition support was an important component of this data

Recommend a protein/carb combo Bonus points for fruit or veg

HIGH CALORIE FOOD ADDITIVES

Mayonnaise Whole milk Whole yogurt Nuts & Nut butters

Full fat dressing Ground nuts Avocado Sour cream Whole milk powder

Oils Coconut, palm for CF

Peanut, olive, safflower, sunflower, canola, etc for COPD

Butter Cheese Heavy cream Chocolate Whipped Cream

ORAL SUPPLEMENTS

“In addition” vs “instead of”Supplements and COPD:

Increases daily caloric intake by ~200-400kcal/day

Produced a weight gain of ~1.8kg (3% body wt)

Increased grip strength by ~5%Supplements and CF:

Limited efficacy Better results with enteral nutrition

ORAL SUPPLEMENTS

High calorie supplement examples Boost Plus Ensure Plus Scandishake Opt2Thrive NutraBalance Homemade Shakes

Peanut Butter & Banana Peanut Butter & Chocolate Frozen Berries with Yogurt & Milk Nutella Greek yogurt, regular yogurt, kefir, ice cream, milk

Protein powder

INFLAMMATION Pulmonary dysfunction as an imbalance between oxidation production and anti-oxidant function Alveolar wall destruction Loss of elastic recoil

Pro-inflammatory cytokines are associated with muscle wasting

Free radicals cause cellular damage through oxidation Increases inflammation

Antioxidants: eliminate oxidants or prevent creation of more toxic compounds Reduces inflammation

YOUR MOM WAS RIGHT

Eat your fruits and vegetables!Increase in fruit and vegetable consumption reduces risk for COPD Possible risk reduction of 24%

Cross-sectional study following patients for 5-7 years found an association between increased fruit and vegetable intake and a higher FEV1 Decrease in consumption was associated with a decrease in FEV1

EDIBLE ANTIOXIDANTS

Omega-3 Fatty Acids (EPA & DHA) Vitamin A (beta-carotene) Vitamin C (ascorbic acid) Vitamin E (alpha-tocopherol) Selenium Flavonoids Ubiquinone (CoQ10)

PREVENTING CATABOLISM: INHIBITING INFLAMMATION

Omega-3 polyunsaturated fats (PUFA) Eicosapentaenoic acid (EPA)

Docosahexaenoic acid (DHA)

Food Sources: Oily fish (salmon, mackerel, tuna, sardines, herring, bluefish, trout, catfish), shrimp, monounsaturated oils (canola, flaxseed, olive oil)

PREVENTING CATABOLISM: INHIBITING INFLAMMATION

Omega-3s: Anti-inflammatoryReplaces pro-inflammatory fatty acids in actively inflammatory cells

May decrease production of pro-inflammatory mediator cells and TNF- and interleukin-1

Increased peak exercise capacity & submaximal endurance time seen with adequate intake Caution with supplementation

PREVENTING CATABOLISM: INHIBITING INFLAMMATION Omega-6s:

Linoleic Acid --> Arachidonic acid Present in higher quantities in inflammatory cells

Pro-inflammatory compound Western diets have seen an increase in the omega-6/omega-3 ratio Optimal ratio = 2:1 to 3:1 Current intake is ~4 times this

Food Sources: polyunsaturated oils (soybean, corn, safflower, sunflower), poultry, eggs, coconut, margarine

AMAZING ANTIOXIDANTS: VITAMIN A Lipid soluble

Stored in body’s fat cells

Best absorbed with a source of fat

Inactivates free radicals and superoxide anions

Food Sources: liver, fortified milk, egg, carrots, spinach, kale, cantaloupe, apricots, papaya, mango, oatmeal, peas, peaches, red pepper, sweet potato, pumpkin

AMAZING ANTIOXIDANTS: VITAMIN E Lipid soluble

Stored in fat, absorbed with fat

Works by stopping reactions that cause lipid peroxidation

FEV1 better maintained in subjects with higher vitamin E intake

Food Sources: fortified cereal, sunflower seeds, almonds, sunflower oil, hazelnuts, pine nuts, peanuts, peanut butter, peanut oil, safflower oil, olive oil, corn oil, canola oil, turnip greens, spinach, avocado

AMAZING ANTIOXIDANTS : VITAMIN C

Water Soluble Excreted when consumed in amounts that exceed the body’s requirement

Little risk for toxicityAbundant in the extracellular fluid surrounding the lungs Beta-carotene scavenges free radicals and inhibits inflammatory metabolites

Functions in the immune system Found in neutrophils and lymphocytes

AMAZING ANTIOXIDANTS: VITAMIN C

FEV1 better maintained in subjects with higher vitamin C intake

Food Sources: red pepper, kiwi, orange, grapefruit, strawberries, brussels sprouts, cantaloupe, papaya, broccoli, sweet potato, pineapple, kale, mango, tomato juice

BONUS BENEFITS

Flavonoids: fruits & vegetables Ubiquinone (CoQ10): meat, fish, poultry, nuts, oils

Selenium: tuna, beef, cod, turkey, chicken, enriched noodles, egg, bread, oatmeal, rice, cottage cheese, walnuts

Magnesium: cereals, nuts, green vegetables, dairy products

VITAMIN D: BETTER THAN BONES Increased risk for vitamin D deficiency among patients with chronic obstructive lung disease Deficiency in 57-93% of inpatients and 60% of patients with severe disease

More than just a bone builder: Anti-inflammatory properties Immune function Ameliorate symptoms of depression VDR in kidneys, intestines, bones, pancreas, gonads, liver, heart, brain, breast, hematopoietic, and immune systems

COPD: Large, cross-sectional NHANES study showed an FEV1 improvement of 126mL with highest level of vitamin D intake

CF: Decrease in serum vitamin D level correlated significantly with decrease in lung function

VITAMIN D

Lipid soluble Best absorbed with a source of fat

Food sources: herring, salmon, halibut, catfish, mackerel, oysters, shitake mushrooms, sardines, tuna, shrimp, egg, fortified foods (juices, milks, pudding, cereal, etc.)

Sunlight!Supplements!

D3

ANABOLIC AGENTS: GLUTAMINE, CARNITINE, CREATINE

Glutamine: Branched-chain amino acid

Possible increse in whole body protein synthesis, increase in body weight and FFM, decrease in blood lactic acid, increase in arterial blood oxygen partial pressure

Creatine: Abundant in meat and fishStudies have been unable to show an improvement in muscle strength, exercise tolerance, or HRQoL with creatine supplementation

ANABOLIC AGENTS: GLUTAMINE, CARNITINE, CREATINE

L-Carnitine: Amino acid derivative Increases energy production by promoting lipid breakdown

RCT demonstrated an increase in inspiratory muscle strength and walk test tolerance; decrease in blood lactate levels

Needs more testing

FOOD FOR THOUGHT

REFERENCES 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: 1385-1395.

Cystic Fibrosis Foundation. cff.org. September 2013. Gilbert CR, Arum SM, Smith CM. Vitamin D deficiency and chronic lung

disease. Can Respir J. 2009; 16(3): 75-80. Engelen MPKJ, Schroder R, van der Hoorn K, Deutz NEP, Com G. Use of

body mass index percentiles to identify fat-free mass depletion in children with cystic fibrosis. Clinical Nutrition. 2012; 10.

Itoh M, Tsuji T, Nemoto K, Nakamura H, Aoshiba K. Undernutrition in patients with COPD and its treatment. Nutrients. 2013; 5: 1316-1335.

Mahan LK, Escott-Stump S. Krause’s food and nutrition therapy. Saunders Elsevier. 2008: St. Louis, MO.

Man WDC, Kemp P, Moxham J, Polkey MI. Skeletal muscle dysfunction in COPD: clinical and laboratory observations. Clin Sci. 2009; 117: 251-264.

Schols, A. Nutritional modulation as part of the integrated management of chronic obstructive pulmonary disease. Proceedings Nutr Society. 2003; 62: 783-791.

Steinkamp G, Wiedemann B. Relationship between nutritional status and lung function in cystic fibrosis: cross sectional and longitudinal analyses from the German CF quality assurance (CFQA) project. Thorax. 2002; 57: 596-601.

Romieu I, Trenga C. Diet and obstructive lung disease. Epidemiol Rev. 2001; 23: 268-287.

Woestenenk JW, Castelijns SJAM, van der Ent CK, Houwen RHJ. Nutritional intervention in patients with Cystic Fibrosis: A systematic review. J Cyst Fibros. 2013; 12: 102-115.

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