Body Composition Abnormalities and Nutrional Support in ChronicPulmonary Disseases

1. Body Composition Abnormalities and Nutrional Support in ChronicPulmonary Disseases Doç.Dr. Pınar Ergün Atatürk Chest Diseases and Chest Surgery Center/ Pulmonary Rehabilitation- Home Care Unit

2. RATIONALE Am J R Crit Care Med 1999;160: 1854-61

3. Weight is a reversible factor in the prognosis of COPD

4. Tissue wasting pattern: body composition • Cachexia • Semistarvation • Sarcopenia • Obesity • Sarcopenic obesity

5. Body composition models Anatomical

6. Body composition models Fat Lipids Lipids Extracellular water İntracellular water Waters Fat free mass Body weight Body cell mass Proteins Proteins Minerals Minerals

7. Measurement of body composition • Regional • MRI Scan } muscle, fat distribution • Dexa Scan } lean, FM, bone mass • (trunc, extremities) • Whole body • Dexa scan } lean, FM, bone mass • Skinfold thickness } FM • Bioelectrical impedance } TBW > FFM

8. Body composition and COPD subtypes

9. Body composition and COPD subtypes and healty volunteers Conclusion; skeletal muscle weakness i associated with wasting of extremity FFM in COPD patients, independent of air-flow obstruction and COPD subtype Am J Clic Nutr 2000; 71:733-8

10. Wasting pattterns and survival • Cachexia= Low BMI + Low FFMI • Sarcopeni=Low FFMI • Semistarvation= Low BMI Semistarvation Sarcopeni cachexia Schols AJCN 2005

11. Body composition, disease severity and mortality • Loss of FFM despite a normal BMI in(Gold stage 2+3) • Highest prevelance of cachexiain Gold stage 4 • Differances between emphysema and chronic bronchitis = Fat mass • FFM is a better predictor of survival than BMI Am J Clin Nutr 2005; 82:53-9

12. In patients with COPD weight loss and muscle atrophy • Respiratory and peripheral muscle functions, • Exercise capacity • Health Related Quality of Life • Mortality rates effected negatively 1-Eur Respir J 1994;7:1793-97 2-Eur Respir J 1997;10:2807-13 3-Eur Respir J 1997;10:1575-80 4-Am J Clin Nutr 2005;82:53-9

13. FFMI and Bone mineral density in COPD Osteoporosis Osteopenia No bone loss AJRCCM 2004

14. Weight and fat loss Dietary intake Energy metabolism

15. Muscle wasting Protein syntesis Protein sentezi Protein breakdown

16. Weight loss Energy expenditure Lungs Resting energy expenditure Systemic inflamation Energy requirement in physical activity Muscles

17. Rehabilitation Body composition

18. High intensity training in COPD patients is feasible and effective despite ventilatory limitation Endurance + Strength • Endurance training: ↑ muscle oxidative capacity ↑ exercise performance • Strength training: ↑ muscle mass ↑ Quadriceps strength ■ ↑Exercise performance ■ ↑ Muscle strength ■ ↑ Muscle mass, ↓Fat mass

19. Suboptimal training intensity in advance COPD • Patients are unable to participate in training program due to; • Severe dyspnea or gase exchange disturbances, • Too disabled, • Fear, anxiety • Weigth loss and muscle catabolism associated with exacerbation or episodes of respiratory failure lead to major functional decline exercise is difficult or imposible

20. Despite high exercise intensity: • No effect of exercise traning per se on body weight and muscle mass in COPD patients with cachexia Schols AJRCCM 1995

21. Additional Strategies Body composition

22. Home based neuromuscular electrical stimulation as a new rehabilitative strategy for severely disabled patients with chronic obstructive pulmonary disease (COPD) Thorax 2002; 57: 333-337

23. Additional Strategies Body composition

24. Classifying muscle disease in COPD

25. Pulmonary Cachexia Syndrome; Pharmacologic Interventions • What is the target of therapy? • Undernutrition ? • Inflamation ? Help!

26. Pharmacological interventions in weight loss and muscle atrophy • Restore energy balance Megesterol acetateFat mass Ghrelin • Stimulate muscle metabolismKas anabolizmasının stimülasyonu Anabolic steroids Testesteron Fat free mass Ghrelin ? • Decrease muscle catabolism Infliximab (Remicade) ? • Chest 2002; 121: 1070-78 • Chest 2005;Ghrelin……Nagaya … • J Clin Endocrinol Metab 2005;90:268 • İnflixi için…….

27. Additional Strategies Body composition

28. Nutritional supplementation Restore energy balance and stimulate anabolism • Balance (elevated) energy requirements • Stimulate protein synthesis Enhance efficacy of other interventions; Exercise, anabolic steroids

29. Nutrional Support for induviduals with stabil COPD Failure of interventions Failure of interventions Ferreira Im, et al. Cochrane Library 2006

30. Nutrional support is feasible and effective during rehabilitation to improve weight and body composition • Schols (AJRCCM 1995) • Positive effects on weight, FM and FFM relative to rehabilitation alone • Creutzberg (Nutrition 2000) • Gains in weight, fat, FFM, muscle functions, exercise capacity • Patients using systemic steroids less responsive • Steiner (Thorax 2004) • Positive effects on weight, FM and exercise capacity relative to rehabilitation alone, particularly in normal weight subjects • Broekhuizen (Thorax 2005) • Gains in weight, FM, FFM, muscle functions, exercise capacity

31. Is Pulmonary rehabilitation alone sufficient to improve body weight and composition in depleted COPD patients ?Creutzberg et al. Nutrition 2003 • No effect of exercise traning per se on body weight and muscle mass in COPD patients with cachexia Plasebo 8 Nutritional support 6 4 NS NS 2 P 0 Body weight P -2 FFM

32. Respons for Nutritional support isn’t same in all COPD patients Respiratory functions and BMI similar • Age • Oral intake/resting energy expenditure • sTNF-receptor 55 • Extracellular/intracellular water Uneffective AJRCCM 2000;161:745-52

33. Caloric contant and amount of oral nutritional support Macronutrient (CH, Fat) Anti-inflamatory modulation For maximum efficacy in nutritional treatment;

34. Content, amount and macronutrients in oral nutritional supports VAS Skoru (mm) Postprandial süre • Metabolic and ventilatory response to low caloric nutrients are much more better, • High CH content provide improvements in respiratory functions, and reduced dyspnea Am J Clin Nutr 2001;73:295-301

35. Maximal efficiencyNutrional support; amount • Grup A;(3X125ml) • Predicted=3.4 kg • Measured =3.3± 2.3 kg • Grup B;(3X200ml) • Predicted:4.8 kg • Measured= 1.9± 1.9 kg Broekhuizen, EJCN 2005

36. Anti-inflamatory contentBrockheuzen Thorax 2005 Anti-inflamatory content: Polyunsaturated fatty acids (n3/n6) • No effect on body weight and skeletal muscle strength on top of exercise and nutritional support • No effect on systemic inflamation • Effect on pulmonary inflamation ? (n3 PUFAs can downregulate the activity of NFkB ) • ↑ Exercise capacity

37. Amino acids, Creatine, Antioxidants, PUFA Micronutrients Exercise Muscle mass Muscle metabolism Strength Endurance

38. Creatin supplementation and pulmonary rehabilitation in COPD Thorax 2005;60:531-37

39. Effects; • Stimulates appetite in depleted COPD patients with improvements in body composition • ↑ FM, no effect on FFM • Reductions in exercise capacity • Reductions in plasma cortisol ve testesterone Results; not very encouraging Chest 2002;121:1070-78

40. Whole body protein breakdown has increased in cachectic COPD patients Conclusion; losses in myofibriller proteins must be the target in nutritional and pharmacological interventions Rutten, AM J Clin Nutr

41. Anabolic nutritional modulation; Amino acids • Branched-chain amino acids; Leucine,isoleucine, valine • Precursor • Upregulates protein syntesis in skeletal muscles

42. Anabolic nutritional modulation; • GLUTAMAT; - An important precursor for antioxidant glutathione and glutamine in muscles • Decreased Glutamat and glutathione levels were found in skeletal muscles of patients with emphysema • İntermediates to preserve high-energy phosphates at rest .Lactic asidosis may occur in the absence Am J Respir Crit Care Med 2001; 163:859-64

43. ●Placebo +no training ○Testesteron +no training ▲Placebo + Resistance Δ Testesteron + Resistance Am J Respir Crit Care Med ‘004

44. Under weight; <21 kg/m² Normal; 21-25 kg/m² Over weight; 25-30 kg/m² Obese; >30 kg/m² Unvoluntory weight loss weight stable ↓ BMI Normal BMI Yeterli Nutritional support Maintance theraphy 3 moths FOLLOW-UP 6 months Unsufficient Compliance? Anabolic stimulation Anti-catabolic intervention

45. Conclusions; • Weight loss and reductions in FFM are important predictors of disease progression, resulted in reductions in exercise capacity, increases in mortality and morbidities in COPD patients . • Nutritional support reverses the effects of hypermetabolism and negative energy balance that resulted weight loss. • With the addition of high caloric main menu,enteral nutrients must be used small sized porsions but frequantly in stable COPD patients. ESPEN Guidelines .Clinical Nutrition 2006;25:311-318

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