The Meets and Eats of Pulmonary Rehabilitation November 3, 2015 Webinar Ellen Aberegg, MA, LD, RD Consultant
The Meets and Eats of Pulmonary Rehabilitation I HAVE NOTHING TO DISCLOSE AND NO CONFLICTS OF INTEREST. Ellen Aberegg, MA, LD, RDN Consultant
Risk Factors for COPD § Smoking primarily – Accounts for 55 -75% § What about the other 25 -45% – Environment – Diet – Interactions of all?
What do we know from population and observational studies examining nutrients and pulmonary function?
Foods and Food Patterns Intake of – Fruit – Vegetables – Fish – Whole grains COPD assocd. Development – Lower COPD mortality – Higher FEV 1 Varraso 2007 Am J Clin Nutr
Foods and Food Patterns 100 g Fruit assocd. of COPD mortality 24% risk Varrasco 2007 Am. J Clin Nutr
Foods and Food Patterns § Fruits and Vegetables for a lifetime – + effect lung function – Even as early as 8 -11 y. o. – Throughout adulthood – Into elderly years – Hanson 2013 Trans Res
Foods and Food Patterns § Asthma and Mediterranean diet α wheezing, rhinitis – margarine α wheezing, rhinitis – F/V, nuts – Chatzi 2007 Thorax
Nutrients-Diet Intake. Longitudinal Data § 9 year follow-up – Vit C α FEV 1 § 25 year follow-up – Specific nutrients no α with lung fxn – Solid fruit, all fruit lung disease » Mc. Keever 2008 Respir Res
Nutrients-Diet Intake Vit C Vit E Carotenes assocd. Individually with FEV 1 Together 24. 6 in FEV 1 HANES Hu 2000 Am J Epidemi
Clinical Change and Nutrients § Vit C FEV 1 (25 -79 ml) § β Carotene FEV 1 (79 ml) § Vit E ~ Couldn’t isolate benefit of Vit E without Vit C § Vit D intake lung function – Grievik 1998 Thorax – Britton 1995 Am J Res Crit Care Med
Nutrients-Diet Intake Vit D intake assocd . lung function – at risk Vit D because median intake at 50% rec’s – pulmonary patients live indoors § Shaheen 2011 Thorax
Nutrients-Diet Intake Fiber (25 mg) Assocd. FEV 1 (>60 ml) FVC FEV 1/FVC odds ratio (OR) COPD Can’t differentiate between soluble and insoluble ARCS Fonesca Wald 2014 Respiro.
Nutrients-Diet Intake § n-3 most consistently demonstrated to benefit to lung fxn § n-6 no consistent results – Fonesca Wald 2014 Respiro.
Nutrients-Serum values Vit A, Vit C, Vit E, Ca+, Cl, Fe 2++ Serum Vit D levels assocd. not assocd. FEV 1
Nutrients-Serum values TAC (Total antioxidant capacity) FEV 1, FVC (not ratio) Okubo 2013 Eur R J
Nutrients-Serum. Influence of Smoking § Smokers have serum carotinoids – Dose dependent § Rationale: – Smokers eat less F/V – Smoke is highly oxidative and destroys carotinoids in plasma – Strine 2005 J Prev Med – Hanson 2010 Trans Res
Nutrition Issues Seen in Pulmonary Rehab Now we are looking at the patient’s clinical state and what nutrients are associated with improvement in clinical status
Nutrition Issues Seen in Pulmonary Rehab § Cachexia/Malnutrition/Nutr § § Depletion Obesity/CVD risk/Met. S Inflammation Corticosteroid tx Co-morbidities
Cachexia/Malnutrition/Nutr Depletion § Incidence: 20 -35% of outpatient 70% of acute resp failure/lung trxplt Hallen 2007 Respir Med
Cachexia/Malnutrition/Nutr Depletion § Higher mortality – 1. 73 > Odds Ratio § Hospital Re-admission – 1. 29 > Odds Ratio – Zapatero 2013 J Hum Nutr Diet
Cachexia/Malnutrition/Nutr Depletion § Energy Imbalance – REE 15 -20% higher in COPD • Mechanical disadvantage • Metabolic insufficiency • Systemic inflammation – non REE • Mechanical inefficiency • catecholamines • Itoh 2013 Nutrients
Cachexia/Malnutrition/Nutr Depletion § Insulin resistance-Impaired glucose regulation w/o diabetes – Inability to utilize CHO calories § Dyslipidemia 2° Met. S – lipolysis – PSMOP – use of LBM for energy – Van den Borst 2013 Am J Crit Care
Cachexia/Malnutrition/Nutr Depletion § Muscle atrophy – Disuse/inactivity – protein breakdown pathways (catabolism) § Hypogonadism – anabolic hormones § ROS Airway Resistance § Acidosis § Inflammation – Toraldo 2013 J Aller Ther
Cachexia/Malnutrition/Nutr Depletion § If normal BMI § If BMI 15% lower FFM 12% lower FFM – Vermeeren 2006 Resp. Med
Cachexia/Malnutrition/Nutr Depletion § Energy Deficit consequences – # Alveoli – Lung and chest wall mechanical changes – Inspiratory muscle weakness • 2° FFM and contractile protein – Ottenheljm 2005 2007 Am J Res Crit Care Med
Recommendations and Priorities Cachexia/Mal Nutr § Perform Body Composition if possible – f BMI and FFM • calories • protein – If normal or BMI and FFM • Adequate calories • protein quantity/quality/frequency
How much calorie increase? § 1. 3 x REE is preferable mild to moderate COPD § 1. 7 x REE severe COPD
How to Calories § GRADUALLY encourage small changes – Eventually 500 -1000 calories
How to Calories § frequency feedings – less distention – achievable – between meals • liquid feedings • nuts and nut butters
How to Calories § healthy fat – olive, canola, nuts, liquid spread, mayo made with olive oil § favorite foods – take the time to find out
How Much Protein? § 20% total calories § RDA: 0. 8 gm/kg BW § 1. 2 – 1. 6 gm/ kg BW § ALWAYS WITH increased or adequate CALORIES
How to Protein § GRADUALLY – encourage small changes § Lean meat, chicken – Prepared with moisture, OK to fry with canola oil § Fish, esp. omega 3 § Egg or egg substitutes: Bfast for dinner
How to Protein § Nut spreads § Smoothies with – greek yogurt – NFDM – CIB (Carnation Instant Breakfast) – Protein supplements
How to Protein § Protein Supplements – Primarily whey but also soy and casein – Whey protein isolate is easily disguised – COLD: use blender with • ice, fruit, kale • Add flavorings – Add to milk and • use to make pudding, • add to coffee….
What Works? § PR 7 out 8 improved after nutrition guidance • Aniwidyaningshih 2009 Curr Opin Clin Nutr § Sometimes doesn’t improve wt gain – But may improve Pulm function
What Doesn’t Work? § “buy a can of _____” § health education class alone
Does Exercise Have a Role? § Stimulates anabolic process § Unlikely to burn enough calories to cause calorie deficit § Supplement peri-exercise session
Obesity/CVD risk/Met. S § Severe COPD – Obesity is protective • mortality risk (0. 52) • hospital re-admittance Lambdo 1999 Am J Res Crit Care
Obesity/CVD risk/Met. S § Mild to moderate COPD – Obesity risk • Ischemic HD #1 cause of death – Obesity 1° contributor • Insulin resistance Mc. Garvey 2007 Thorax – PSMOP (not just in cachexia) – visceral obesity – inflammation Van den Borst 2013 Am J Res Crit Care
Inflammation and METs Figure 3. Conceptual representation of the drivers of cardiovascular and metabolic risk in chronic obstructive pulmonary disease (COPD). : Bram van den Borst; Harry R. Gosker; Annemie M. W. J. Schols; Am J Respir Crit Care Med 2013, 187, 8 -13.
Obesity/CVD risk/Met. S § Obesity – Impairs pulmonary function – Impairs exercise performance – Kessler 2001 Chest
Recommendations and Priorities-Obesity § ? The big question § HOW? § Who should lose weight?
Recommendations and Priorities-Obesity (> 30 BMI) § Visceral Fat – 2 -5% BW/6 months § Overall- visceral and sub q fat – 5% BW/6 months – Benton 2010 JCPR and Prev
Recommendations and Priorities-Obesity § Tackle big things first – Food Records-Awareness – Excess portions, eating out, excess sugar fluids • Replace with less calorie dense foods – Knowledge deficit or emotional relationship with food?
Recommendations and Priorities-Obesity Key Issues – Avoid restriction – Teach management – Teach “Can-haves” – Provide structure only if demand • Better to teach how to create own structure
Inflammation § Progressive airflow limitation § Chronic inflammation of lung § Systemic inflammation
Inflammation and COPD Toraldo DM, J Aller Ther 2013
Inflammation and Diet-Vitamin C § Co-factor for enzymes § Neutralizes free radicals § Suppresses macrophage secretion § High redox potential § Cellular aqueous phase antioxidant capacity § Recycles antioxidant capacity of Vit D – Hanson 2010 Trans Res
Inflammation and Diet-Vitamin C § Smokers need Vit C – metabolic turnover of Vit C – localized protection of oxidative damage – metabolic stress 2° smoke
Inflammation and Diet-Vitamin E § Lipid phase antioxidant § Chain breaking antioxidant in cellular membrane § Prevents lipid peroxidation – Hanson 2010 Trans Res
Inflammation and Diet. Vitamin A/Carotenes § Lipid phase antioxidant – Differentiation of epithelial cells – Prevents lipid peroxidation § Best biologic marker for F/V intake
Inflammation and Vitamin D § Augments anti-inflammatory defenses § Deficiency impaired lung fxn – Indoors vs outdoors – Diet often poor in Vit D
Inflammation and micro nutrients § Flavonoids § Polyphenols – Revesterol • Caloric restriction mimetic • Known beneficial in CVD, DM • Esp. overwt/obese men – Rimmers 2011 Cell Metab • Increase c. AMP levels – oxidative metabolism – Park 2012 Cell
Inflammation and Fiber § gut immunity § systemic inflammation § Soluble – Fonesca 2014 Respiro – + short chain FA receptors in lumen – pre-inflammatory nuclear factor β
Inflammation and n-3 n-6 FA § Omega 3 fatty acids – DHA, EPA
Inflammation and n-3 n-6 – Figure 2 in Toraldo 2013 J Aller Ther
Recommendations and Priorities-Inflammation § Fruits and Vegetables, Grains § Nuts § n-3 sources § low-fat dairy
Recommendations and Priorities-Inflammation § Revesterol: Wine, red grapes, peanuts § Polyphenols: herbs, coffee, tea, dark berries – Flavonoids
Recommendations: Nutrients- Diet Intake Supplementation Individual Nutrients § BIG QUESTION – Benefit? – Harm?
Recommendations: Nutrients- Diet Intake Supplementation Individual Nutrients § Benefit? – Mixed results Mixed methodologies – If deficient is helpful § Harm? Higher than rec’d doses – 20 mg/day βcarotene, 5 -8 years • higher risk of lung CANEJM 1994 – Supplements false sense of adequacy
Corticosteroids § Weight gain – Abdominal fat hampers breathing § Lipid aberration – TG, HDL § Serum glucose § Osteoporosis
Recommendations and Priorities. Corticosteroids § Decrease any excess calories from unecessary or unhealthy foods – Increase low energy dense foods • Veggies • Sugar free gum • Rice cakes • Popcorn
Recommendations and Priorities. Corticosteroids § Calcium • Low fat dairy – Yogurt – Low fat cheese – Milk –include fortified almond and soy • Fortified juices § Stress management for stress related eating
Summary of Recommendations and Priorities Any and All PR Patients How do we intervene to improve prognosis?
Recommendations and Priorities Any and All PR patients § Increase Fruit and Vegetables – Brightly colored – Vitamin C sources § Increase fiber – Fruit – Whole Grains – Vegetables
Recommendations and Priorities Any and All PR patients § Smaller more frequent feedings
Recommendations and Priorities Any and All PR patients § Emphasize n-3 sources – Nuts: walnuts, almonds, flaxseed… – Salmon, tuna, scallops… – Canola, flaxseed oils and olive… – Legumes and tofu… – Veg: cauliflower, brussel sprouts, winter squash, spinach…
Recommendations and Priorities Any and All PR patients § Food Plan – Mediterranean – Dash – My Plate
Recommendations and Priorities Any and All PR patients § Avoids – Saturated fats – Cured meats – Processed meat, refined flours, high sugar
Nutrition Education In PR § Group classes: Any and all PR – 2 minutes teaching “why” – 28 minutes teaching “how” Activities, models, toys……. . – Increase Fruits and Vegetables • Sampling and recipe sharing • “What prevents you from adding F/V? ” • Sneaky
Nutrition Education In PR – Increase fiber • Whole grain breads • Oatmeal • Fiber bars • Some supplements – n-3 sources • Improve ratio n-6: n-3 • Ensure they know canola and olive oil
Nutrition Education In PR § Group classes: – Mediterranean/Dash/My. Plate – Avoid generalized classes • Ineffective to have obese and cachexic pts. hearing same advice on weight management
When to refer to dietitian? § Guidelines – Cachexic/Malnourished, rapid weight loss – Obese > 30 BMI – >10# Weight gain with corticosteroid use – Newly diagnosed diabetic – Evaluation tool: way out of whack
Evaluation Tools § Criteria – Measure what you care about changing – Raises flags about nutrients mentioned – Ask a dietitian
Evaluation Tools § Fr. V, FFr. V screeners – Block, etc. § Online options § DASH, My. Plate (USDA) – Diet Records as a screener
Questions Thank YOU!!!!
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