Physiologic effects of oral supplemental feeding in malnourished patients with chronic obstructive pulmonary disease. A randomized control study. Nutritional supplementation in ambulatory patients with chronic obstructive pulmonary disease. Nutritional enhancement of exercise performance in chronic obstructive pulmonary disease: a randomised controlled trial. Effects of nutritional supplementation combined with low-intensity exercise in malnourished patients with COPD. Dietary supplementation and respiratory muscle performance in patients with COPD. Megestrol acetate stimulates weight gain and ventilation in underweight COPD patients. [High-caloric nutrition in chronic obstructive lung disease]. Nutritional repletion in malnourished patients with emphysema. The effect of supplementary oral nutrition in poorly nourished patients with chronic obstructive pulmonary disease.
The association between severe nutritional depletion and chronic obstructive pulmonary disease (COPD) has long been recognized. A potential therapeutic benefit to nutritional support was previously suggested by us in a pilot investigation. Subsequent studies have reported conflicting results regarding the role of nutritional therapy in this clinical population. We report a randomized controlled study of nutritional therapy in underweight patients with COPD that combines an initial inpatient investigation (controlled nutritional support) with a prolonged outpatient follow-up interval. Provision of adequate calorie and protein support, adjusted to metabolic requirements, resulted in weight gain (intervention = +2.4 kg versus control -0.5 kg), improved handgrip strength (intervention = +5.5 kg-force versus control -6.0 kg-force), expiratory muscle strength (intervention = +14.9 cm H2O versus control -9.2 cm H2O), and walking distance (intervention = +429 feet versus control -1.0 foot). Inspiratory muscle strength was also improved (intervention = +11.4 cm H2O versus control +4.8 cm H2O) although this did not quite reach statistical significance. We conclude that provision of adequate nutrient supply under controlled conditions results in significant clinical improvements in the COPD patient population. However, the intervention is costly, time-intensive, and of limited therapeutic magnitude. More detailed work of alternative outpatient strategies combined with additional rehabilitative measures is indicated to delineate the full therapeutic potential of nutritional support for this clinical population. We examined the effect of nutritional supplementation for 8 wk on respiratory muscle function (RMF) in 21 malnourished patients with COPD. Patients were randomized to a fed group or to a control group. Patients in the fed group were provided with an enteral formula in addition to their usual diet. Daily calorie and protein intake and weekly anthropometric measures were made. Pulmonary function tests were measured on Weeks 1, 4, and 8. Respiratory muscle strength was measured by means of maximal inspiratory and expiratory pressures (MIP), (MEP), and respiratory muscle endurance was measured by the maximal sustained ventilatory capacity (MSVC). The mean weight of the fed group increased from 52.2 +/- 6.4 to 53.3 +/- 6.9 kg (NS). The mean daily caloric intake of the fed group was significantly increased during the study (p less than 0.02). The mean calorie intake during the study of the fed group was 174 +/- 17% of the estimated basal energy expenditure. During the study period, no change was observed in anthropometric measures, pulmonary function studies, or RMF. Because patients tend to decrease their own food intake while receiving enteral formulas, it is difficult to provide sufficient calories and protein needed to effect changes in nutritional status and RMF in an outpatient COPD population. In addition, we compared RMF in 12 poorly nourished male patients (87.6 +/- 6.1% of ideal body weight) and 13 well-nourished male patients with severe COPD. Both groups had comparable degrees of air-flow limitation and hyperinflation. No difference was noted between the groups in either MIP, MEP, or MSVC.(ABSTRACT TRUNCATED AT 250 WORDS) Pulmonary rehabilitation is effective in improving exercise performance and health status in chronic obstructive pulmonary disease (COPD). However, the role of nutritional support in the enhancement of the benefits of exercise training has not been explored. A double blind, randomised, controlled trial of carbohydrate supplementation was undertaken in patients attending outpatient pulmonary rehabilitation.
                85 patients with COPD were randomised to receive a 570 kcal carbohydrate rich supplement or a non-nutritive placebo daily for the duration of a 7 week outpatient pulmonary rehabilitation programme. Primary outcome measures were peak and submaximal exercise performance using the shuttle walk tests. Changes in health status, body composition, muscle strength, and dietary macronutrient intake were also measured.
                Patients in both the supplement and placebo groups increased shuttle walking performance and health status significantly. There was no statistically significant difference between treatment groups in these outcomes. Patients receiving placebo lost weight whereas supplemented patients gained weight. In well nourished patients (BMI >19 kg/m(2)) improvement in incremental shuttle performance was significantly greater in the supplemented group (mean difference between groups: 27 (95% CI 1 to 53) m, p<0.05). Increases in incremental shuttle performance correlated with increases in total carbohydrate intake.
                When universally prescribed, carbohydrate supplementation does not enhance the rehabilitation of patients with COPD. This study suggests that exercise training results in negative energy balance that can be overcome by supplementation and that, in selected patients, this may improve the outcome of training. The finding of benefit in well nourished patients may suggest a role for nutritional supplementation beyond the treatment of weight loss in COPD. The first aim of this study was to investigate the effects of nutritional supplementation combined with low-intensity exercise on body components, exercise tolerance, and health-related quality of life (HRQOL) in malnourished patients with COPD. The second aim of this study was to examine the degree of systemic inflammation and the actual changes in levels of systemic CRP, TNFα, IL-6 and IL-8 actual changes after a combination of nutritional supplementation and low-intensity exercise in these patients.
                A prospective randomized trial.
                Thirty-two moderate to severe, clinically stable malnourished COPD patients.
                Patients were randomly divided into a nutritional supplementation with low-intensity exercise group and a control group. Lung function, maximum inspiratory and expiratory muscle force, the Chronic Respiratory Disease Questionnaire (CRQ), the 6-min walking distance (6MWD), and the Borg scale were measured at baseline and were re-assessed at 3 months after intervention. The degree of systemic inflammation and the changes in levels of systemic CRP, TNFα, IL-6 and IL-8 were assessed before and after a combination nutritional supplementation with low-intensity exercise.
                Body weight and FFM increased significantly after 12 weeks of nutritional supplementation therapy in patients with COPD. The dietary intake energy increased and the REE:REEpred ratio decreased significantly in the nutrition with low-intensity exercise group. PI(max), Quadriceps muscle force and the 6-min walking distance (6MWD) increased significantly from baseline through week 12. Health status, as assessed by CRQ, improved in the domains of dyspnea and total sores significantly in the nutrition with low-intensity exercise group after intervention. In this group, hsCRP, IL-6, IL-8, and TNFα, decreased significantly after intervention compared with the control group.
                The combination of nutritional supplementation with low-intensity exercise training was successful in increasing weight and energy intake as well as exercise capacity and health-related QOL in our patients. Moreover, REE and major inflammatory cytokines decreased significantly after nutritional supplementation with low-intensity exercise training. The present study results suggest a potential role for the combination of nutritional supplementation and low-intensity exercise in the management of malnourished patients with COPD.
                Copyright © 2010 Elsevier Ltd. All rights reserved. We studied the effects of oral nutritional supplementation on respiratory muscle (RM) performance in 25 ambulatory patients with severe chronic obstructive pulmonary disease (COPD). There was a relationship between body weight and anthropometric parameters of nutritional status (triceps skinfold thickness [r = 0.67; p less than 0.005], midarm muscle circumference (r = 0.53; p less than 0.005), but body weight did not correlate with daily caloric intake, serum albumin, transferrin, or blood lymphocyte count. None of these measurements of nutritional status correlated with any measure of RM strength or endurance. In a randomized observer-blinded crossover trial, patients were allocated to one of two groups. In the first eight weeks of the study, group A received nutritional supplementation, and patients in group B were control subjects. In the second eight weeks, patients in group A were control subjects, and group B received supplement. Mean daily caloric intake and body weight increased in both groups while receiving supplement (both p less than 0.05). Calories provided by the supplement were frequently substituted for normal dietary calories. Any increases in RM performance in the group receiving supplement were matched by increases (due to learning) in controls. We conclude that oral dietary supplements have no important effects on RM performance in ambulatory patients with COPD. To assess the effect of megestrol acetate (MA), a progestational appetite stimulant commonly used in patients with AIDS and cancer, on body weight and composition, respiratory muscle strength, arterial blood gas levels, and subjective perceptions in COPD patients.
                Prospective, double-blind, randomized, placebo-controlled trial conducted on an outpatient basis at 18 sites.
                Underweight (< 95% ideal body weight) COPD patients > or = 40 years old.
                Either MA, 800 mg/d oral suspension, or placebo at a 1:1 ratio for 8 weeks.
                Of 145 randomized patients (63% men), 128 patients completed the trial. Body weight increased by 3.2 kg in the MA group and 0.7 kg in the placebo group (p < 0.001). Anthropometric and dual-energy radiograph absorptiometry assessments confirmed that weight gain was mainly fat. Spirometry and maximal voluntary ventilation showed no significant changes from baseline in either group, and the difference in the change in maximum inspiratory pressure between groups was not significant. The 6-min walk distances did not differ statistically between groups at week 2 and week 4, but were greater in the placebo group at week 8 (p = 0.012). Consistent with the known ability of MA to stimulate ventilation, PaCO(2) decreased (4.6 mm Hg, p < 0.001) and PaO(2) increased (2.8 mm Hg, p < 0.04) in the MA group. Questionnaires revealed that body image and appetite improved in the MA group but not the placebo group. Adverse event frequency and type were similar in both groups, but cortisol and testosterone (in men) levels decreased substantially in the MA group.
                We conclude that MA safely increased appetite and body weight, stimulated ventilation, and improved body image in underweight COPD patients, but did not improve respiratory muscle function or exercise tolerance. A body weight lower than 90% of the optional value has an unfavorable influence on the prognosis of chronic obstructive pulmonary disease (COPD). Short term studies of up to three months duration have shown improved function of respiratory muscle exercise tolerance and immunologic parameters by an increased caloric intake of 45 kcal/kg body weight. In a randomized trial of twelve months 14 of 30 patients with an average FEV1 of 0.8 l were instructed to take a high calorie diet. For simplicity a part of the calories were administered as Fresubin, a fluid nutrient formula. Although a weight gain of 7 kg (p = 0.003) was obtained the difference to the control group was statistically not significant (p = 0.08). The same was true for skin fold thickness (12.4 vs 5.7 mm), change of ventilatory parameters and the 6 minute walking distance (-33 vs -86 m). Subjective improvement was, however, impressive in all patients with dietary intervention, explainable probably by increased attention. Dietary counselling for increased intake of calories, vitamins and also calcium is thus very important in the treatment of patients with COPD. We examined the effect of nutritional supplementation for 13 wk on anthropometric, pulmonary function, and immunological status in malnourished ambulant patients with pulmonary emphysema (EP). The study was placebo controlled, randomized and double blind. Twenty-eight patients were included. Thirteen patients in the fed group were provided with a nutritional formula providing 20% protein, 30% fat, and 50% carbohydrate, 1 Kcal/ml, 400 ml/day. The control group was provided with a reference product of the same consistency and taste containing 0.1 Kcal/ml, 400 ml/day for 13 wk. The fed group had a mean weight gain of 1.5 kg during the study period, the control group increased concomitantly 0.16 kg, the difference being significant (p less than 0.01). Sum of four skinfolds increased 2.7 mm in the fed group, and decreased 0.9 mm in the control group the difference being significant (p less than 0.01). No difference were observed regarding pulmonary function or immunological status. We also found a high habitual energy intake in our study group (204% Basal Energy Expenditure). We conclude that nutritional supplementation produce weight gain in malnourished patients with EP, but it does not change other indices of well-being. We carried out a prospective, randomized, controlled trial to investigate the effect of a 3-month period of supplementary oral nutrition in 14 poorly nourished outpatients with COPD. Seven patients were randomized into Group 1 who received their normal diet during Months 1 to 3, a supplemented diet during Months 4 to 6, and their original normal diet during Months 7 to 9. The other 7 patients received their normal diet for the entire 9-month study period (Group 2). Seven well-nourished patients (Group 3) matched for age and severity of air-flow obstruction served as control subjects; they received their normal diet for the 9-month study period. Measurements of nutritional status, respiratory muscle and handgrip strength, sternomastoid muscle function (including frequency/force curves, maximal relaxation rate, and a fatigability test), lung function, arterial blood gas tensions, general well-being and breathlessness scores, and 6-min walking distances were carried out monthly in all patients. At the start of the study, the poorly nourished patients had lower mean daily calorie and protein intakes than did the well-nourished patients. The poorly nourished patients had lower respiratory muscle and handgrip strength, and abnormal contractility and increased fatigability of the sternomastoid muscle compared with those in the well-nourished patients. After 3 months of supplementary oral nutrition, there was a significant improvement in the nutritional status of Group 1 patients, as evidenced by an increase in body weight, triceps skinfold thickness, and midarm muscle circumference. Respiratory muscle and handgrip strength increased in parallel with nutritional status, although there were no significant changes in lung function or arterial blood gas tensions.(ABSTRACT TRUNCATED AT 250 WORDS)
We found moderate-quality evidence that nutritional supplementation promotes significant weight gain among patients with COPD, especially if malnourished. Nourished patients may not respond to the same degree to supplemental feeding. We also found a significant change from baseline in fat-free mass index/fat-free mass, fat mass/fat mass index, MAMC (as a measure of lean body mass), six-minute walk test and a significant improvement in skinfold thickness (as measure of fat mass, end score) for all patients. In addition, there were significant improvements in respiratory muscle strength (MIP and MEP) and overall HRQoL as measured by SGRQ in malnourished patients with COPD.
These results differ from previous reviews and should be considered in the management of malnourished patients with COPD.