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 consumption
Reduction in peak work rate
Reduction 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
QOL
weight = decreased lifespan and
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 exercise
testing 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 after
walking 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
due to:








in appetite and intake is common
Changes in breathing induced by eating (chewing
and swallowing)
Decreased oxygen saturation during meals
Increased post-prandial dyspnea
Mucus accumulation
GI distress and coughing induced emesis
Hormonal irregularities: leptin
Anorexia of chronic disease
Anxiety, depression, psychosocial factors
CALORIES AND PROTEIN
 Increased energy expenditure caused
 Increased WOB
 Chronic infections
 Medical treatments and therapies
 CF:
 ~120-200% increase in caloric needs
 ~150%-200% increase in protein needs
 Malabsorption, increased REE, increased
by:
WOB
 COPD:
 ~95-150% of predicted caloric needs
 ~150-200% increase in protein needs
 REE 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 1
 Excessive CO2
production seen
with carbohydrate
administration has
been isolated to
cases of energy
excess
MACRONUTRIENTS: FATS
 Higher
caloric load:
9kcal/g
 Increased gastric
emptying time
 Malabsorption in
CF
MACRONUTRIENTS: PROTEIN

No storage form of protein in the body
 Stable:
1.5g/kg body weight
 Acute: 1.5-2g/kg body weight
 Protein 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 outpatient
 Protein 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
 Bonus points
protein/carb combo
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 ~200400kcal/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 antioxidant 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

Increase in fruit and vegetable consumption
reduces risk for COPD


your fruits and vegetables!
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-inflammatory
 Replaces 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 omega6/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 toxicity

 Abundant
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


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:


Deficiency in 57-93% of inpatients and 60% of patients with
severe disease
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 fish
Studies 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.
QUESTIONS?