RT to RD: NUTRITION NOTES FOR CF & COPD

1. RT to RD: NUTRITION NOTES FOR CF & COPD Vanessa Clark RD, LD Medical University of South Carolina

2. 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

3. 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)

4. 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

5. 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

6. 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)

7. 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

8. 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

9. 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

10. 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

11. * Cystic Fibrosis Foundation

12. * Cystic Fibrosis Foundation

13. 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 meals • Increased post-prandial dyspnea • Mucus accumulation • GI distress and coughing induced emesis • Hormonal irregularities: leptin • Anorexia of chronic disease • Anxiety, depression, psychosocial factors

14. Calories and Protein • Increased energy expenditure caused by: • 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 WOB • COPD: • ~95-150% of predicted caloric needs • ~150-200% increase in protein needs • REE elevation due to: medications, inflammation, activity, inefficient ventilation

15. Balanced nutrient and meal profiles: Carbohydrates 40-55% of calories Fat 30-45% of calories Protein 15-20% of calories MIXING MACRONUTRIENTS

16. Macronutrients: Carbohydrates • RQ of 1 • Excessive CO2 production seen with carbohydrate administration has been isolated to cases of energy excess

17. Macronutrients: Fats • Higher caloric load: 9kcal/g • Increased gastric emptying time • Malabsorption in CF

18. 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

19. 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

20. 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

21. 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

22. 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

23. 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

24. 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

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

26. 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

27. 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

28. 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

29. 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

30. 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

31. 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

32. 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

33. 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

34. 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

35. 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

36. 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

37. 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

38. FOOD FOR THOUGHT

39. References • Collins PF, Stratton RJ, Elia M. Nutritional support in chronic obstructive pulmonary disease: a systematic review and meta-analysis. Am J ClinNutr. 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.

40. QUESTIONS?