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Nutrition Management in

Chronic Obstructive
Pulmonary Disease
Dr.Etisa Adi Murbawani, M.Si
Definition of COPD

Chronic Obstructive Pulmonary

Disease (COPD) is a preventable and
treatable disease state characterised
by airflow limitation, decreasing flow in
airways (bronchial obstruction) that is not
fully reversible.
Bronchial obstruction is in the progress and

is connected with abnormal inflammatory

response of lungs caused by toxic pollutants.

Why COPD is Important ?

COPD is the only chronic disease that is

showing progressive upward trend in both
mortality and morbidity
It is expected to be the third leading cause of
death by 2020

*The Indian J Chest Dis & Allied Sciences 2001; 43:139-47

Malnutrition in COPD : occurs in 25
% 40% with moderate to severe
Average weight loss : 5% - 10% of
initial body weight
The incidence of malnutrition
depends on the severity of the

: clinically relevant weight loss ( 5%

of actual weight within three months

or 10% within 6 months ) is found in
25-40% of all cases when lung
function is severely impaired
Weight loss occurs frequently

Underweight and low fat free

mass are independently
associated with a poor
prognosis in patients with
chronic respiratory insufficiency,
especially in COPD
Reasons for nutritional intake
include the following :
Difficulty swallowing /chewing due to
Chronic mouth breathing, which can
alter the taste of food
Chronic mucous production
Low dietary intake & weight loss
occurs because of symptoms with
dyspneu, fatigue, and early satiety
Taste perception may be altered
with chronic mouth breathing
Individual with adequate dietary
intake may lose weight as elevation
Food & nutrition
Maintaining optimal energy balance
is essential in order to preserve body
weight, lean body mass and general
well being
Indirect calorimetry is the best
method to asses kcal needs without
overfeeding or underfeeding
Not available : 25 30 Kkal/kgBW
In the person with stable COPD,
requirement for water, protein, fat and
CHO are determined by the underlying
lung disease, oxygen therapy,
medications, weight status, and any fluid

Often other concurrent disease processes

exist : CVD, renal disease, DM, cancer
affect the total amounts, ratio,kinds of
protein, fat, and CHO prescribed
Sufficient protein : 1,2 1,7 g/kgBW
Necessary to maintain or restore
lung & muscle strength as well as to
promote immune function
Protein : 15% -20% of total calories
Fat : 30%-45% of calories
CHO : 40% - 55% calories
A balanced ratio of P : Fat : CHO is
important to preserve a satisfactory
respiration quotient ( RQ ) from
substrate utilization

Standard formulae, which are usually

rich in CHO (50-60% energy ) would
induce greater ventilatory demand
due to a higher respiratory quotient.
Using mechanical
In patient with COPD , using
mechanical ventilator, overfeeding is
a primary concern
It is associated with increased CO2
production further complicate
Glucose and protein have been
shown to stimulate ventilatory drive
Excess glucose administration
( > 5mg/kg/minute) increase CO2
Makes it difficult to wean or remove
patients from mechanical ventilation
Intervention : objectives

Screen early & correct any

malnutrition prognosis
Promote a nutrient-dense diet
Overcome anorexia resulting from
slowed peristalsis & digestion
Alleviate difficulty in chewing or
swelling related to SOB
Prevent or correct dehydration
Avoid constipation & straining at stool
Food & nutrition
Proper nutrition can help reduce CO2
& improve breathing
A high - calorie diet is necessary to
correct malnutrition
ADA : a high fat, low-carbohydrate
It is best to meet energy needs, but
avoid overfeeding as excess calories
are more significant in production of
CO2 than the CH to fat ratio
The production of excess CO2 occurs
when patients are overfed ( > 1,5 x
Commercial enteral formulas that
have been specifically designed for
individuals with respiratory disease
contain a lower CHO content ( 30%)
and higher lipid content (50%)

Side effect of higher fat meals or

supplement : delayed gastric
emptying, which may result in
abdominal discomfort, bloating or
early satiety
Protein needs should be assessed on
an individual basis.
Vitamins & minerals

Antioxidant influence respiratory

Studies : smokers have lower intakes
of antioxidants vitamin
vitamins C, A, E and beta carotene
For people continuing to smoke
tobacco, additional vitamin C may
be necessary

people who smoke 1 pack of

cigarettes/day appear require about 16
mg more ascorbate / day
Those who smoke 2 packs need about
32 mg
more ascorbate / day
Individual with COPD undergo
oxidative damage during both
exacerbation of the disease and
stable periods.

Tug ,et al : during periods of

exacerbation, serum concentration of
vitamin A & E have been shown to
Magnesium & calcium

These minerals are very important in

muscle contraction & relaxation
particularly in people with COPD
Intake at least equivalent to the RDA
should be provided
RDA Mg : 400 450 mg
RDA calcium : 800 1000 mg
Ratio Ca : Mg = 2 : 1

Phosphate is essential for the

synthesis of ATP and 2,3
diphosphoglycerate (DPG )
essential for pulmonary function
Studies : respiratory & peripheral
muscle stores of phosphate have
been shown to be depleted in patient
with COPD
Medical treatment with drugs
commonly used for COPD, such as
corticosteroids, bronchodilators,
diuretics, is associated with
hypophosphatemia and likely
contributes to the depleted phosphate

Serum phosphate level needs to be


The epidemiological evidence indicated

that increased folate intake could lead to
reductions in the prevalence of COPD &
breathlessness with significant dose-
response relationships
Folate intake from diet has been similarly
shown to be beneficial against lung cancer
The underlying mechanism is still
RDA : 400 mcg
Vitamin D bone density

Studies :
Low serum 25 hydroxyvitamin D
levels have been documented in
individual with COPD
Suggesting that vitamin D deficiency
due to poor intake and decreased
sun exposure may play a role in bone
The use of glucocorticosteroid has
been shown to increase the
incidence of osteoporosis
Bone mineral density should be
measured in individual who have
COPD, particularly in those receiving
long-term glucocorticoid treatment
( > 7,5 mg prednisone/day )
Intake calcium & vitamin D should be
RDA : Ca = 800 1200 mg/day
vitamin D = at least 400 IU
A diet without tough or stringy
Gas forming vegetables may cause
Enrich diet with antioxidants
General rule
Small frequent feeding
Fiber should be increased gradually
Limit liquids with meals drink
fluids an hour after meal
Eat more slowly