Nutritional Intervention in COPD: A Systematic Overview

doi:10.1378/chest.119.2.353

Chest

Volume 119, Issue 2, February 2001, Pages 353-363

https://doi.org/10.1378/chest.119.2.353 Get rights and content

Objective

We conducted a systematic overview ofrandomized controlled trials (RCTs) to clarify the contribution ofnutritional supplementation for patients with stable COPD.

Methods

RCTs were identified from several sources, including the Cochrane Airways Group register of RCTs, a hand search ofabstracts presented at international meetings, and consultation withexperts. Two reviewers independently selected trials for inclusion, assessed quality, and extracted the data.

Results

Twenty-one reports were classified according to the type, duration ofsupplementation, and the presence of anabolic substances. Highcarbohydrate meals were associated with an increase in carbon dioxideproduction and a decrease in exercise capacity. Short-term crossoverstudies in which diets of various compositions were administeredsupported the notion that high carbohydrate loads increase the stresson the ventilatory system. The influence of longer-term supplementation(> 2 weeks) on weight, anthropometry, and exercise capacity varied, without there being a consistent effect. Lean body weight was onlyoccasionally reported and health-related quality of life too rarely tobe included as an outcome. The influence of recombinant human growthhormone was disappointing. Anabolic steroids increased body weight andlean body mass, but had little influence on exercise capacity.

Conclusion

This systematic overview in patients with COPDsupports the notion that those with marginal ventilatory reserve mightbenefit from a dietary regimen in which a high percentage of caloriesare supplied by fat. Although there are reports of the benefits ofnutritional repletion, trials of > 2 weeks failed to show consistentbenefit on body weight. Evaluating nutritional repletion is hampered bythe absence of information regarding body composition, exercise, andhealth-related quality of life. Growth hormone has not been shown to beuseful. Further studies are needed to refine the beneficial effects ofanabolic steroids as adjunctive agents together with nutritionalsupport and exercise.

Section snippets

Search Strategy

The following strategies were used to uncover relevantpublications from the English-language medical literature. RCTs wereidentified with assistance from the Cochrane Airways Group registry of, RCTs in COPD. We also searched MEDLINE (National Library of Medicinefrom 1966 to 1999), EMBASE, and CINAHL (Cumulated Index to Nursing and, Allied Health from 1982 to 1999) for original articles published in alllanguages. The following terms were used to uncover trials related tonutritional support in

Results

A total of 272 abstracts were identified. After the two primaryreviewers assessed the abstracts, the number was reduced to 55 reports(κ, 0.89; 95% confidence interval, 0.82 to 0.96) on nutrition and, COPD. When reviewed in detail, 21 reports were included. Both reviewersagreed on all except four reports (κ, 0.94; 95% confidence interval, 0.85 to 1.0), which were therefore sent to a third reviewer (Y.L.) forarbitration. Reasons for excluding studies included the following: uncontrolled study,⁸¹⁵

Discussion

How nutrients influence ventilation and metabolism at rest andduring low levels of activity among patients with COPD could assist inour understanding of how to minimize dyspnea on exertion and maximizeenergy reserves. Underweight patients with COPD are more dyspneic thannormal-weight patients, and although the origins of dyspnea in COPD aremultifactorial, changes in diffusing capacity as well as in respiratorymuscle strength may contribute to its intensity.⁶⁹Patients with COPD clearly have a

Conclusion

Nutritional depletion in COPD is common and has a negative impacton respiratory as well as skeletal muscle function, contributing to themorbidity and mortality of this condition.¹²³⁴⁵⁶⁷⁸⁹ It istherefore valuable to include management strategies that increaseenergy balance in order to increase weight and FFM. Although mostpatients tolerate CHO loads, diet content and volume per meal may haveto be modified for patients with severe dyspnea or hypercapnia. Although short-term studies of nutritional

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Lung diseases exert a negative impact on nutritional status, especially among older patients where aging per se is already associated with relevant changes in nutrient intake, metabolism, and body composition. Both respiratory (increased respiratory work, hypoxia, and local oxidative stress and inflammation) and nonrespiratory (sarcopenia, reduced mitochondrial biogenesis and anabolic hormones, balance of orexigenic/anorexigenic neuropeptides, and systemic inflammation and oxidative stress) contribute to the association between lung diseases and malnutrition. For these reasons, nutritional assessments are of paramount importance in older patients with lung diseases. Current evidence suggests that the Mini Nutritional Assessment is the most reliable instrument for nutritional screening in clinical practice. As regards body composition, bioimpedance analysis (BIA) is easy to apply and less expensive than dual energy X-ray absorptiometry (DEXA). Moreover, BIA may provide clinical benefit in the assessment of COPD patients. Nutritional interventions include correction of hypoxia, and supplementation of polyunsaturated fatty acids, branched-chain amino acids, vitamin D, iron, and antioxidants.
Effect of hospital use of oral nutritional supplementation on length of stay, hospital cost, and 30-day readmissions among medicare patients with COPD
2015, Chest
Citation Excerpt :
Nevertheless, existing evidence for the benefits of ONS in COPD is mixed. Until recently, meta-analyses and systematic reviews of the literature on nutritional supplementation found little evidence of benefit to patients with COPD.50,51 A systematic review of randomized control trials of nutrition supplementation in COPD by Ferreira et al,28 however, suggests increasing evidence that ONS use is associated with improved outcomes in patients with COPD, although their findings are mixed.
COPD is a leading cause of death and disability in the United States. Patients with COPD are at a high risk of nutritional deficiency, which is associated with declines in respiratory function, lean body mass and strength, and immune function. Although oral nutritional supplementation (ONS) has been associated with improvements in some of these domains, the impact of hospital ONS on readmission risk, length of stay (LOS), and cost among hospitalized patients is unknown.
Using the Premier Research Database, we first identified Medicare patients aged ≥ 65 years hospitalized with a primary diagnosis of COPD. We then identified hospitalizations in which ONS was provided, and used propensity-score matching to compare LOS, hospitalization cost, and 30-day readmission rates in a one-to-one matched sample of ONS and non-ONS hospitalizations. To further address selection bias among patients prescribed ONS, we also used instrumental variables analysis to study the association of ONS with study outcomes. Model covariates included patient and provider characteristics and a time trend.
Out of 10,322 ONS hospitalizations and 368,097 non-ONS hospitalizations, a one-to-one matched sample was created (N = 14,326). In unadjusted comparisons in the matched sample, ONS use was associated with longer LOS (8.7 days vs 6.9 days, P < .0001), higher hospitalization cost ($14,223 vs $9,340, P < .0001), and lower readmission rates (24.8% vs 26.6%, P = .0116). However, in instrumental variables analysis, ONS use was associated with a 1.9-day (21.5%) decrease in LOS, from 8.8 to 6.9 days (P < .01); a hospitalization cost reduction of $1,570 (12.5%), from $12,523 to $10,953 (P < .01); and a 13.1% decrease in probability of 30-day readmission, from 0.34 to 0.29 (P < .01).
ONS may be associated with reduced LOS, hospitalization cost, and readmission risk in hospitalized Medicare patients with COPD.
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To whom and how to prescribe oral nutritional supplements in hospital and in community?
2013, Nutrition Clinique et Metabolisme
Les compléments nutritionnels oraux (CNO) constituent un moyen simple pour augmenter les apports nutritionnels des patients dénutris ou à risque de dénutrition. L’observance au long cours de ces produits diététiques, en majorité prêts à l’emploi, peut être difficile mais peut aussi être améliorée si les objectifs nutritionnels sont raisonnables et bien explicités au patient et si des conditions de prescription et d’administration rigoureuses sont respectées. Les CNO ont ainsi montré leur efficacité clinique sur la réduction de la morbi-mortalité des personnes âgées polypathologiques hospitalisées ou non, des patients de chirurgie orthopédique ou présentant une fracture du col fémoral, lors de la préparation à la chirurgie digestive ou encore chez les patients hémodialysés. Leur efficacité est moins évidente chez les patients souffrant de bronchite chronique ou de cancer. Dans l’escarre, les CNO ont montré leur efficacité dans la prévention, notamment chez les patients à haut risque mais en revanche, les études sur la cicatrisation restent insuffisantes et de qualité médiocre. Enfin, les CNO n’ont démontré aucun effet positif sur les fonctions cognitives des patients souffrant de maladie d’Alzheimer ou sur la morbi-mortalité des patients non dénutris au décours d’un accident vasculaire cérébral.
Oral nutritional supplements (ONS) are a simple mean to increase the nutritional intake of undernourished people. Although generally well tolerated, the compliance to these dietetic products can be poor and then contribute to reduce their clinical efficacy. It may be improved by determining reasonable nutritional goals, which must be explained to the patient, and by observing rigorous conditions of prescription and administration of ONS. ONS have shown positive results in reducing both morbidity and mortality in poly-pathological elderly people, either in hospital or in community. Such positive clinical data were also reported in orthopedic surgery, in hip fractures, in preparative period of gastrointestinal surgery or in patients treated with hemodialysis. Their efficacy was less obvious in patients with chronic respiratory failure or cancer. ONS are able to prevent pressure sores in high risk patients. However, studies evaluating ONS efficacy on pressure sores healing are lacking and of poor quality. Finally, ONS have demonstrated no beneficial clinical effect on cognitive function in patients with Alzheimer's disease or on functional recovery of well-nourished people with stroke.
Dietary habits of firstly admitted Spanish COPD patients
2009, Respiratory Medicine
Citation Excerpt :
Since stratification according to severity stages did not reveal any difference in dietary habits, it is conceivable that the degree of non-response bias, if present, was very low such that the study provided a valid description of COPD patients' dietary habits. In conclusion, this is the first comprehensive study so far describing in detail dietary habits in Spanish COPD patients and reports mostly adequate dietary habits and adequate daily intake of the main food groups and macro- and micro-nutrients according to local recommendations, with the key exception of vitamin D. Its relevance relies mainly on the unknown but potentially relevant role of specific nutrients (i.e., antioxidants and omega-3 fatty acid) in the prognosis of COPD,4–7 and the accepted strong and independent association between nutritional status and COPD progression.12 Research in other geographic areas, with longitudinal follow up to assess changes in dietary intakes and disease progression, could be useful to provide a more global scenario of dietary habits of COPD patients, and provide insights relevant for the design of specific interventions in these patients.
We described dietary habits in a Spanish sample of COPD patients and assessed its adequacy according to dietary recommendations, which so far have never been published.
275 patients hospitalized for the first time for a COPD exacerbation in Spain answered a 122-item food frequency questionnaire on their last 2 years dietary habits. A Spanish food composition table was used to estimate nutrient intake. Adequacy of dietary intakes was assessed using the Spanish Nutrition Society guidelines for the elderly.
Mean(SD) age was 68(8)years, 93% males, 32% current smokers, and post-bronchodilator FEV₁ 53(16)% predicted. Mean(SD) body mass index was 28(5) kg/m², with only 2% of subjects under 20 kg/m². Mean intake of meat, poultry and eggs was slightly higher (mean 108 g/d) than recommended. Fish and shellfish (86 g/d) as well as fruit and vegetables (567 g/d) were adequate. Mean energy intake was 2033 kcal/d. The proportion of energy from carbohydrates was lower (39%) whereas that from proteins and lipids were higher than recommended (20% and 35%, respectively). Alcohol intake was <30 g in 80% of patients. Fatty acids, vitamin and mineral intakes were adequate, except for a deficiency in vitamin D (4.5 μg/d). Stratification by socio-demographic and clinical characteristics showed very similar results.
Moderate-to-severe Spanish COPD patients report an adequate intake of the main food groups and macro- and micro-nutrients according to local recommendations, excepting vitamin D.

View all citing articles on Scopus

: This study was made possible due funding from FAPESP–Fundacao de, Amparo a pesquisa do Estado de Sao Paulo, Brazil (IMF), Canadian Lung Association/MRC/Glaxo Welcome Postdoctoral fellowship (DB), and West Park Hospital Foundation.

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Chest

Clinical InvestigationsCOPD/AsthmaNutritional Intervention in COPD: A Systematic Overview

Objective

Methods

Results

Conclusion

Section snippets

Search Strategy

Results

Discussion

Conclusion

Clin Chest Med

Am J Med

Chest

Chest

Control Clin Trials

Chest

Nutr Res

Am J Clin Nutr

Chest

Am J Clin Nutr

Am J Clin Nutr

Chest

Clin Nutr

Chest

Nutrition

Chest

Nutrition

Chest

Chest

Phys Med Rehab Clin North Am

Chest

Prevalence and characteristics of nutritional depletion in patients with stable COPD eligible for pulmonary rehabilitation

Am Rev Respir Dis

Nutrition and chronic obstructive disease: a clinical overview

Tissue depletion in relation to physical function and quality of life in patients with severe COPD [abstract]

Am J Respir Crit Care Med

Nutritional support in advanced lung disease: the pulmonary cachexia syndrome

Clin Chest Med

Body weight in chronic obstructive pulmonary disease: the National Institutes of Health Intermittent Positive Pressure Breathing trial

Am Rev Respir Dis

Respiratory muscle strength and maximal voluntary ventilation in undernourished patients

Am Rev Respir Dis

New weight standards for men and women

Stat Bull Metrop Life Found

Anthropometric parameters in the assessment of nutritional status

Nutritional status and mortality in chronic obstructive pulmonary disease

Am J Respir Crit Care Med

The effect of an aggressive nutritional support regimen on body composition in patients with severe COPD and weight loss [abstract]

Am J Respir Crit Care Med

An outpatient nutritional supplementation programme in COPD patients

Eur Respir J

Nutritional intervention in malnourished patients with emphysema

Am Rev Respir Dis

Fat-rich diets in patients with mild chronic obstructive lung disease

Nutr Hosp

Clinical observation on short term nutritional support in the treatment of advanced chronic obstructive pulmonary disease

Chung Hua Nei Ko Tsa Chih

Is loss of body weight in chronic obstructive pulmonary disease patients with emphysema secondary to low tissue oxygenation?

Respiration

Energy expenditure in patients with chronic obstructive pulmonary disease

Chest

Role of the thermic effect of food in malnutrition of patients with COPD

Am J Respir Crit Care Med

Comparisons between basal metabolic rate and diet induced thermogenesis in different types of chronic obstructive pulmonary disease

Clin Sci

Clinical Investigations
COPD/Asthma
Nutritional Intervention in COPD: A Systematic Overview