RT to RD: NUTRITION NOTES FOR CF

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RT to RD NUTRITION NOTES FOR CF COPD

• Vanessa Clark RD, LD
• Medical University of South Carolina

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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

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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)

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Methods of Measurement

• Weight those numbers you see on a scale
• BMI weight / height
• lt18.5 underweight
• 18.5-25 normal
• gt25 overweight
• gt30 obese
• FFM Fat Free Mass
• Water (73)
• Protein
• Minerals
• Muscle

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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

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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 lt20 or lt90 IBW)

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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
  lt50
• BMI lt20 is associated with higher exacerbation
  risk
• Skeletal muscle weakness is related to
• Worsened health status
• Increased healthcare costs
• Increased mortality risk

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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,
101105
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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
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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 gt80 in normal weight patients
• Patients with FFM depletion have reduction in
  FEV1 and bone density even if BMI value is
  maintained
• Goals
• gt50th ile weight/length for children 0-2y
• gt50thile BMI for children 2-20y
• BMI gt23 for male adults
• BMI gt22 for female adults

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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

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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

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MIXING MACRONUTRIENTS

• Balanced nutrient and meal profiles
• Carbohydrates 40-55 of calories
• Fat 30-45 of calories
• Protein 15-20 of calories

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Macronutrients Carbohydrates

• RQ of 1
• Excessive CO2 production seen with carbohydrate
  administration has been isolated to cases of
  energy excess

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Macronutrients Fats

• Higher caloric load 9kcal/g
• Increased gastric emptying time
• Malabsorption in CF

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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

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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

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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

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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

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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

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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

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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

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Edible Antioxidants

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

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Preventing Catabolism Inhibiting Inflammation

• 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)

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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

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Preventing Catabolism Inhibiting Inflammation

• Omega-6s
• Linoleic Acid --gt 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 21 to 31
• Current intake is 4 times this
• Food Sources polyunsaturated oils (soybean,
  corn, safflower, sunflower), poultry, eggs,
  coconut, margarine

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AMAZING ANTIOXIDANTS VITAMIN A

• Lipid soluble
• Stored in bodys 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

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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

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AMAZING ANTIOXIDANTS VITAMIN C

• Water Soluble
• Excreted when consumed in amounts that exceed the
  bodys 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

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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

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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

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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

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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

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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

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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

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FOOD FOR THOUGHT
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References

• Collins PF, Stratton RJ, Elia M. Nutritional
  support in chronic obstructive pulmonary disease
  a systematic review and meta-analysis. Am J Clin
  Nutr. 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. Krauses 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.

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QUESTIONS?