Nutritional support in chronic obstructive pulmonary disease: a systematic review and meta-analysis

Effect of Macronutrients or Micronutrients Supplementation on Nutritional Status, Physical Functional Capacity and Quality of Life in Patients with COPD: A Systematic Review and Meta-Analysis

Given the importance that a correct and balanced nutrition has on patients with chronic obstructive pulmonary disease (COPD), supplementation of macro and micronutrients has been proposed, but the results of previous meta-analyses are contrasting. We performed an update of the latest evidence through a systematic review and meta-analysis of studies to assess the role of nutritional supplements in improving nutritional status, pulmonary function, physical performance, and quality of life of these patients.We included randomized controlled trials (RCTs) published between 01-01-2010 and 11-01-2023 evaluating the effectiveness of nutritional support in patients affected by stable COPD with an intervention of at least 2 weeks. Primary outcomes were changes in body mass index (BMI) and fat free mass index (FFMI). Secondary outcomes were exercise tolerance (6-min walking test, 6MWT), quality of life (St George's Respiratory Questionnaire, SGRQ) and respiratory function (FEV1). According with supplements type (macronutrients or micronutrients), we calculated the pooled adjusted mean difference (MD) and 95% confidence intervals (95%CIs) of the selected outcomes, using random-effects models in presence of high heterogeneity (I2>50%) or fixed-effects models otherwise. The risk of publication bias was evaluated with the trim and fill method.From 967 articles, 20 RCTs were included. Macronutrients supplementation improved BMI (MD 1.0 kg/m2, 95%CI 0.21-1.79), FFMI (MD 0.77 Kg/m2, 95%CI 0.48-1.06), 6MQT (MD 68.39 m, 95%CI 40.07-96.71), and SGRQ (MD -5.14, 95% CI -7.31-2.97), while it does not ameliorate respiratory function (MD 0.26% 95%CI -1.87-2.40). Micronutrients supplementation alone did not improve any of the considered outcomes.

An Ontology-Based Decision Support System for Tailored Clinical Nutrition Recommendations for Patients With Chronic Obstructive Pulmonary Disease: Development and Acceptability Study

BACKGROUND

Chronic obstructive pulmonary disease (COPD) is a chronic condition among the main causes of morbidity and mortality worldwide, representing a burden on health care systems. Scientific literature highlights that nutrition is pivotal in respiratory inflammatory processes connected to COPD, including exacerbations. Patients with COPD have an increased risk of developing nutrition-related comorbidities, such as diabetes, cardiovascular diseases, and malnutrition. Moreover, these patients often manifest sarcopenia and cachexia. Therefore, an adequate nutritional assessment and therapy are essential to help individuals with COPD in managing the progress of the disease. However, the role of nutrition in pulmonary rehabilitation (PR) programs is often underestimated due to a lack of resources and dedicated services, mostly because pneumologists may lack the specialized training for such a discipline.

OBJECTIVE

This work proposes a novel knowledge-based decision support system to support pneumologists in considering nutritional aspects in PR. The system provides clinicians with patient-tailored dietary recommendations leveraging expert knowledge.

METHODS

The expert knowledge-acquired from experts and clinical literature-was formalized in domain ontologies and rules, which were developed leveraging the support of Italian clinicians with expertise in the rehabilitation of patients with COPD. Thus, by following an agile ontology engineering methodology, the relevant formal ontologies were developed to act as a backbone for an application targeted at pneumologists. The recommendations provided by the decision support system were validated by a group of nutrition experts, whereas the acceptability of such an application in the context of PR was evaluated by pneumologists.

RESULTS

A total of 7 dieticians (mean age 46.60, SD 13.35 years) were interviewed to assess their level of agreement with the decision support system's recommendations by evaluating 5 patients' health conditions. The preliminary results indicate that the system performed more than adequately (with an overall average score of 4.23, SD 0.52 out of 5 points), providing meaningful and safe recommendations in compliance with clinical practice. With regard to the acceptability of the system by lung specialists (mean age 44.71, SD 11.94 years), the usefulness and relevance of the proposed solution were extremely positive-the scores on each of the perceived usefulness subscales of the technology acceptance model 3 were 4.86 (SD 0.38) out of 5 points, whereas the score on the intention to use subscale was 4.14 (SD 0.38) out of 5 points.

CONCLUSIONS

Although designed for the Italian clinical context, the proposed system can be adapted for any other national clinical context by modifying the domain ontologies, thus providing a multidisciplinary approach to the management of patients with COPD.

Nutritional Support in Malnourished Outpatients with Chronic Obstructive Pulmonary Disease (COPD): A Randomized Controlled Pilot Study

(1) Background: The evidence for nutritional support in COPD is almost entirely based on ready-to-drink oral nutritional supplements (ONSs). This study aimed to explore the effectiveness of powdered ONSs alongside individualized dietary counseling in the management of malnutrition. (2) Methods: Malnourished outpatients with COPD were randomized to receive either routine care (Group A: counseling + recommended to purchase powdered ONSs) or an enhanced intervention (Group B: counseling + provision of powdered ONSs at no cost to the patient) for 12 weeks. Outcomes of interest were nutritional intake, weight status, and quality of life. (3) Results: A total of 33 outpatients were included, categorized as follows: Group A (n = 21); Group B (n = 12); severely malnourished (n = 9), moderately malnourished (n = 24), mean BMI 18.0 SD 2.5 kg/m2. No differences were observed between groups at baseline or at week 12; however, analysis of the whole cohort (Group A + B) revealed nutrition intervention resulted in significant improvements in protein intake (+25.4 SD 53.4 g/d; p = 0.040), weight (+1.1 SD 2.6 kg; p = 0.032) and quality of life (-4.4 SD 10.0; p = 0.040). Only 41.2% of Group A and 58.3% of Group B reported consuming ONSs at week 12. Adherence to ONSs was associated with weight gain (+1.9 SD 2.5 kg vs. +0.4 SD 2.5 kg; p = 0.098). (4) Conclusions: Nutritional support results in significant improvements in nutrition status and quality of life in malnourished outpatients with COPD. However, improvements are associated with adherence to ONSs, suggesting the type of ONSs and how they are provided are important considerations in clinical practice and future studies.

Systematic review of tailored dietary advice and dietitian involvement in the treatment of chronic obstructive pulmonary disease (COPD)

BACKGROUND

Chronic obstructive pulmonary disease (COPD) is a leading public health concern globally. Interdisciplinary pulmonary rehabilitation programs exist and should ideally consider nutritional health impacts since the nutritional status of COPD patients is often compromised. However, little is known about the role of dietary counseling in COPD management.

RESEARCH QUESTION

Does providing tailored dietary advice to adult patients with COPD improve outcomes?

STUDY DESIGN AND METHODS

We conducted a systematic review. The following electronic databases and registrars were used: MEDLINE, EMBASE, Web of Science, CINAHL, Cochrane Library, and ClinicalTrials.gov. The original search was conducted in June 2021 with an updated search conducted on February 21, 2024. Validity and bias assessments were completed.

RESULTS

We selected 14 articles for inclusion. Multiple outcomes were considered including functional, body composition, nutritional intake, cost analyses, quality of life, and others. The most common measured outcomes were quality of life and the 6 min walk test. A number of interventions were used with most interventions being interdisciplinary pulmonary rehabilitation packages where nutrition counseling was one component. A number of interventions showed positive results but there tended to be inconsistency.

INTERPRETATION

Evidence shows that various interventions appear to improve outcomes, but it is difficult to determine if improvements are due to nutritional intervention specifically or a rehabilitation program as a whole. More specific randomized controlled trials should be completed regarding tailored nutritional counseling and therapy in adults with COPD to determine the benefits attributable to nutritional interventions.

Systematic review and meta-analysis of nutrient supplements for treating sarcopenia in people with chronic obstructive pulmonary disease

Individuals with chronic obstructive pulmonary disease (COPD) are prone to malnutrition and sarcopenia as a result of nutritional deficiencies and increased energy metabolism. However, the effects of nutrient supplements (NS) on treating sarcopenia in patients with COPD are not well established from systematic evidence. This meta-analysis examined the effect of NS on sarcopenia in patients with COPD. A systematic search of multiple databases was conducted, and 29 randomized controlled trials involving 1625 participants (age, mean [SD] = 67.9 [7.8] years) were analyzed. NS demonstrated significant improvements in body weight (MD,1.33 kg; 95% CI, 0.60, 2.05 kg; P = 0.0003; I2 = 87%), fat-free mass index (MD, 0.74 kg/m2; 95% CI, 0.21, 1.27 kg/m2; P = 0.007; I2 = 75%), and 6-min walk test (MD, 19.43 m; 95% CI, 4.91, 33.94 m; P = 0.009; I2 = 81%) compared with control. However, NS had nonsignificant effects on handgrip strength (SMD, 0.36; 95% CI, - 0.15, 0.88; P = 0.16; I2 = 87%) and quadriceps muscle strength (SMD, 0.11; 95% CI, -  0.06, 0.27; P = 0.20; I2 = 25%) compared with the control. In conclusion, NS may be an effective treatment for improving body composition and physical performance in COPD. Future studies should explore the effects of intervention durations, specific NS types, or combined training in patients with COPD and sarcopenia.

The genetic etiology of body fluids on chronic obstructive airways disease

BACKGROUND

Numerous studies have documented significant alterations in the bodily fluids of Chronic Obstructive Pulmonary Disease (COPD) patients. However, existing literature lacks causal inference due to residual confounding and reverse causality.

METHODS

Summary-level data for COPD were obtained from two national biobanks: the UK Biobank, comprising 1,605 cases and 461,328 controls, and FinnGen, with 6,915 cases and 186,723 controls. We also validated our findings using clinical data from 2,690 COPD patients and 3,357 healthy controls from the First Affiliated Hospital of Guangzhou Medical University. A total of 44 bodily fluid biomarkers were selected as candidate risk factors. Mendelian randomization (MR) and meta-analyses were used to evaluate the causal effects of these bodily fluids on COPD and lung function (FEV1/FVC).

RESULTS

Mendelian randomization (MR) and meta-analyses, by integrating data from the UK Biobank and FinnGen cohort, found that 3 bodily fluids indicators (HDLC, EOS, and TP) were causally associated with the risk of COPD, two (EOS and TP) of which is consistent with our observational findings. Moreover, we noticed EOS and TP were causally associated with the risk of lung function (FEV1/FVC).

CONCLUSIONS

The MR findings and clinical data highlight the independent and significant roles of EOS and TP in the development of COPD and lung function (FEV1/FVC), which might provide a deeper insight into COPD risk factors and supply potential preventative strategies.

Targeting malnutrition in patients with COPD in the community

The number of individuals living with chronic obstructive pulmonary disease (COPD) is increasing, but nutritional care can be inconsistent, especially in those with stable COPD. Historically, poor appetite and weight loss have been considered the norm during the progression of COPD into the later stage. However, it is imperative that nutritional assessment, support and management is undertaken from diagnosis, because malnutrition can lead to exacerbations of COPD and increased hospitalisation. Poor nutrition in individuals with COPD has been shown to predict an increase in mortality and with the care of patients taking place principally in the community, the nutritional aspects of care should be assessed, monitored and managed, in accordance with the latest guidance. The lack of a nutritional Quality Outcome Framework indicator for COPD can leave nutrition overlooked, but evidence shows that screening, assessment and planning can have an overall positive impact.

The Possible Role of Food and Diet in the Quality of Life in Patients with COPD-A State-of-the-Art Review

Diet has been described as a modifiable risk factor for the development and progression of chronic diseases, and emerging evidence increasingly points to its preventive and therapeutic role in chronic obstructive pulmonary disease (COPD). While the relationship between the underlying disease and diet is natural in conditions such as metabolic disorders, obesity, diabetes, etc., the direct effect is not so evident in chronic obstructive pulmonary disease. Poor diet quality and the development of nutrient deficiencies in respiratory diseases, including COPD, can be associated with disease-specific factors such as the exacerbation of respiratory symptoms. These symptoms can be improved by dietary interventions, leading to positive changes in the pathogenesis of the disease and the quality of life of patients. Therefore, our aim was to review the latest randomized controlled trials (RCTs) of dietary interventions in chronic respiratory patients and describe their effects on respiratory function, physical activity, systemic inflammatory parameters, and quality of life. We conducted a literature search on dietary interventions for COPD patients in the PubMed, ClinicalTrials.gov, and Cochrane Central Register of Controlled Trials (CENTRAL) databases, focusing on publications from 1 July 2018 to 1 July 2023. We used specific keywords and MESH terms, focusing on RCTs. A total of 26 articles and 1811 COPD patients were included in this review. On the basis of our findings, dietary interventions, in particular components of the Mediterranean diet such as protein, omega-3 polyunsaturated fatty acids, and vegetables, appear to have beneficial effects in patients with chronic respiratory diseases, and their application is beneficial. However, long-term follow-up studies are still needed to examine the effects of dietary interventions in this patient population.

Predictors of longitudinal changes in body weight, muscle and fat in patients with and ever-smokers at risk of COPD

BACKGROUND AND OBJECTIVE

Weight and muscle loss are predictors of poor outcomes in chronic obstructive pulmonary disease. However, to our knowledge, no study has investigated the predictors of longitudinal weight loss or its composition from functional and morphological perspectives.

METHODS

This longitudinal observational study with a median follow-up period of 5 years (range: 3.0-5.8 years) included patients with COPD and ever-smokers at risk of COPD. Using chest computed tomography (CT) images, airway and emphysematous lesions were assessed as the square root of the wall area of a hypothetical airway with an internal perimeter of 10 mm (√Aaw at Pi10) and the percentage of low attenuation volume (LAV%). Muscle mass was estimated using cross-sectional areas (CSAs) of the pectoralis and erector spinae muscles, and fat mass was estimated using the subcutaneous fat thickness at the level of the 8th rib measured using chest CT images. Statistical analyses were performed using the linear mixed-effects models.

RESULTS

In total, 114 patients were enrolled. Their body mass index remained stable during the study period while body weight and muscle CSA decreased over time and the subcutaneous fat thickness increased. Reduced forced expiratory volume in 1 s and peak expiratory flow (PEF) at baseline predicted the future decline in muscle CSA.

CONCLUSION

Severe airflow limitation predicted future muscle wasting in patients with COPD and ever-smokers at risk of COPD. Airflow limitation with a PEF slightly below 90% of the predicted value may require intervention to prevent future muscle loss.

Effectiveness of Pulmonary Rehabilitation for Chronic Obstructive Pulmonary Disease Therapy: Focusing on Traditional Medical Practices

Chronic obstructive pulmonary disease (COPD) is a complex and serious disease that is characterized by dyspnea, fatigue, decreased exercise tolerance, peripheral muscle dysfunction, and mood disorders. These manifestations are successfully treated with pulmonary rehabilitation, a comprehensive intervention and holistic approach designed to improve the physical and psychological condition of people with COPD. Exercise is a big component of pulmonary rehabilitation programs, but the efficacy of non-traditional forms of exercise as used in alternative medicine is poorly understood. Here, we aim to address this gap in knowledge and summarize the clinical evidence for the use of traditional exercise regimens in the pulmonary rehabilitation of COPD patients.

Efficacy of interventions to alter measures of fat-free mass in people with COPD: a systematic review and meta-analysis

Introduction

Low fat-free mass (FFM) is linked to poor health outcomes in COPD, including impaired exercise tolerance and premature death. The aim of this systematic review was to synthesise evidence on the effectiveness of interventions for increasing FFM in COPD.

Methods

Searches of electronic databases (MEDLINE, Cochrane Library, Embase, Web of Science, Scopus) and trial registers (ClinicalTrials.gov) were undertaken from inception to August 2022 for randomised studies of interventions assessing measures of FFM in COPD. The primary outcome was change in FFM (including derivatives). Secondary outcomes were adverse events, compliance and attrition.

Results

99 studies (n=5138 people with COPD) of 11 intervention components, used alone or in combination, were included. Exercise training increased mid-thigh cross-sectional area (k=3, standardised mean difference (SMD) 1.04, 95% CI 0.02-2.06; p=0.04), but not FFM (k=4, SMD 0.03, 95% CI -0.18-0.24; p=0.75). Nutritional supplementation significantly increased FFM index (k=11, SMD 0.31, 95% CI 0.13-0.50; p<0.001), but not FFM (k=19, SMD 0.16, 95% CI -0.06-0.39; p=0.16). Combined exercise training and nutritional supplementation increased measures related to FFM in 67% of studies. Anabolic steroids increased FFM (k=4, SMD 0.98, 95% CI 0.24-1.72; p=0.009). Neuromuscular electrical stimulation increased measures related to FFM in 50% of studies. No interventions were more at risk of serious adverse events, low compliance or attrition.

Discussion

Exercise training and nutritional supplementation were not effective in isolation to increase FFM, but were for localised muscle and index measures, respectively. Combined, exercise and nutritional supplementation shows promise as a strategy to increase FFM in COPD. Anabolic steroids are efficacious for increasing FFM in COPD.

Interrelationships between tuberculosis and chronic obstructive pulmonary disease

PURPOSE OF REVIEW

Our objective was to review the current literature regarding socioeconomic, environmental, clinical, and immunologic factors common to chronic obstructive pulmonary disease (COPD) and tuberculosis (TB).

RECENT FINDINGS

Recent studies suggest that TB patients might be at increased risk for developing COPD. Conversely, additional prospective cohort studies have determined that COPD patients are at increased risk for active TB: a risk that appears to be partially mediated through inhaled corticosteroid use. Tobacco smoking, poverty, air pollution, and malnutrition are associated with COPD and TB. Vitamin D has been shown to prevent COPD exacerbations, but its use for preventing TB infection remains unclear. Surfactant deficiency, elevated matrix metalloproteinases, and toll-like receptor 4 polymorphisms play key roles in the pathogenesis of both diseases.

SUMMARY

Recent studies have elucidated interrelationships between COPD and TB. Future research is needed to optimize clinical and public health approaches that could mitigate risk factors contributing to both diseases.

Mapping the global research landscape on nutritional support for patients with gastrointestinal malignancy: visualization analysis

BACKGROUND

Early nutritional treatment is crucial for the care of patients with operable and advanced gastrointestinal malignancies. Therefore, much research has focused on nutritional support for patients with gastrointestinal malignancies. Therefore, this study aimed to evaluate the global scientific output and activity with respect to nutritional support and gastrointestinal malignancy.

METHODS

We searched in Scopus for publications on gastrointestinal cancer and nutritional assistance published between January 2002 and December 2021. Then, using VOSviewer 1.6.18 and Microsoft Excel 2013, we conducted bibliometric analysis and visualization.

RESULTS

A total of 906 documents were published between 2002 and 2021, including 740 original articles (81.68%) and 107 reviews (11.81%). China ranked first (298 publications, 32.89%), Japan ranked second (86 publications, 9.49%) and the USA ranked third (84 publications, 9.27%). The organisation with the highest number of publications was the Chinese Academy of Medical Sciences & Peking Union Medical College from China, with 14 articles, followed by the Peking Union Medical College Hospital from China and the Hospital Universitari Vall d'Hebron from Spain (13 publications for each). Before 2016, most studies focused on 'nutrition support for patients undergoing gastrointestinal surgery'. However, the latest trends showed that 'nutrition support and clinical outcomes in gastrointestinal malignancies' and 'malnutrition in patients with gastrointestinal cancer' would be more widespread in the future.

CONCLUSIONS

This review is the first bibliometric study to provide a thorough and scientific analysis of gastrointestinal cancer and nutritional support trends worldwide over the last 20 years. This study can aid researchers in decision-making by helping them understand the frontiers and hotspots in nutrition support and gastrointestinal cancer research. Future institutional and international collaboration is expected to accelerate the advancement of gastrointestinal cancer and nutritional support research and investigate more efficient treatment methods.

Multidimensional individualized nutritional therapy for individuals with severe chronic obstructive pulmonary disease: study protocol for a registry-based randomized controlled trial

BACKGROUND

Individuals with severe chronic obstructive pulmonary disease (COPD) are often at risk of undernutrition with low health-related quality of life (HRQoL). Undernutrition can worsen COPD and other comorbidities, be an independent predictor of morbidity and functional decline resulting in increased healthcare consumption and increased risk of death. Especially exacerbations and acute infections result in unintentional weight loss. The aim is to investigate the effect of an individualized nutritional intervention among individuals with severe COPD.

METHODS

An open-label randomized controlled trial with two parallel groups. Participants are recruited from the pulmonary outpatient clinic at the Department of Pulmonary and Infectious Diseases, Copenhagen University Hospital, North Zealand, Denmark, and randomly allocated to either the intervention (intervention + standard of care) or control group (standard of care). The intervention has a duration of 3 months and combines individual nutritional care with adherence support and practical tools. It contains 4 elements including an individual nutritional plan, regular contacts, adherence support, and weight diary. The primary outcome is a difference in HRQoL (EQ-5D-5L) between the intervention and control group 3 months after baseline. Difference in functional capacity (grip strength, 30-s stand chair test, and physical activity), disease-specific quality of life (COPD Assessment Test), anxiety and depression (Hospital Anxiety and Depression Scale), nutritional parameters (energy and protein intake), anthropometry (weight, body mass index, waist, hip, and upper arm circumference), body composition (total fat-free and fat mass and indices), and prognosis (exacerbations, oxygen therapy, hospital contacts, and mortality) 3 months after baseline will be included as secondary outcomes. Data will be collected through home visits at baseline and 1 and 3 months after baseline.

DISCUSSION

Currently, nutritional care is a neglected area of outpatient care among individuals with severe COPD. If this patient-centered approach can demonstrate a positive impact on HRQoL, mortality, and hospital contacts, it should be recommended as part of end-of-life care for individuals with severe COPD.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04873856 . Registered on May 3, 2021.

Uncovering undernutrition in chronic obstructive pulmonary disease: Beyond body mass index

BACKGROUND

Undernutrition, a common but treatable complication of chronic obstructive pulmonary disease (COPD), contributes to poor outcomes but is under-detected. Improved detection could prompt dietary intervention which may improve outcomes. We investigated whether adding a measure of muscle mass (fat-free mass index, FFMI) or a malnutrition screening tool (Mini Nutritional Assessment, MNA®) to the commonly used measure of body mass index (BMI), helps detect undernutrition in COPD.

METHODS

We conducted a retrospective chart review of 86 outpatients with COPD. Demographic and disease severity data were collected, and nutritional status assessed using BMI, FFMI and MNA®.

RESULTS

Patients comprised 55% males with median age 71.5 years, severe COPD (median FEV₁ = 0.74 (30.5% predicted)) and high symptom impact (median COPD Assessment Test (CAT) = 23). Twenty-eight percent of patients had low BMI, 27% had low FFMI, 22% were MNA®-classified malnourished and 43% were MNA®-classified at risk of malnutrition. MNA® correlated moderately with BMI and classified 55% of patients with healthy/high BMI as either malnourished or at risk of malnutrition. FFMI and BMI correlated strongly, and low FFMI was present in 5% of patients with healthy/high BMI. The undernutrition measures also showed weak to moderate correlations with disease severity (spirometry data) and MNA® weakly correlated with symptom impact (CAT).

CONCLUSION

The MNA® identified more undernourished patients than FFMI or BMI. It also correlated with disease severity and broader symptom burden. The MNA® appears to be a simple tool for earlier detection of patients who may benefit from dietary intervention, potentially enhancing their quality of life.

Oral nutritional interventions in frail older people who are malnourished or at risk of malnutrition: a systematic review

BACKGROUND

Malnutrition worsens the health of frail older adults. Current treatments for malnutrition may include prescribed oral nutritional supplements, which are multinutrient products containing macronutrients and micronutrients.

OBJECTIVE

To assess the effectiveness and cost-effectiveness of oral nutritional supplements (with or without other dietary interventions) in frail older people who are malnourished or at risk of malnutrition.

DATA SOURCES

MEDLINE, EMBASE, Cochrane Library, Scopus, CINAHL (Cumulative Index to Nursing and Allied Health Literature) and grey literature were searched from inception to 13 September 2021.

REVIEW METHODS

A systematic review and meta-analysis was conducted to evaluate the effectiveness and cost-effectiveness of oral nutritional supplements in frail older people (aged ≥ 65 years) who are malnourished or at risk of malnutrition (defined as undernutrition as per National Institute for Health and Care Excellence guidelines). Meta-analysis and network meta-analysis were undertaken, where feasible, along with a narrative synthesis. A cost-effectiveness review was reported narratively. A de novo model was developed using effectiveness evidence identified in the systematic review to estimate the cost-effectiveness of oral nutritional supplements.

RESULTS

Eleven studies (n = 822 participants) were included in the effectiveness review, six of which were fully or partly funded by industry. Meta-analyses suggested positive effects of oral nutritional supplements compared with standard care for energy intake (kcal) (standardised mean difference 1.02, 95% confidence interval 0.15 to 1.88; very low quality evidence) and poor mobility (mean difference 0.03, p < 0.00001, 95% confidence interval 0.02 to 0.04; very low quality evidence) but no evidence of an effect for body weight (mean difference 1.31, 95% confidence interval -0.05 to 2.66; very low quality evidence) and body mass index (mean difference 0.54, 95% confidence interval -0.03 to 1.11; very low quality evidence). Pooled results for other outcomes were statistically non-significant. There was mixed narrative evidence regarding the effect of oral nutritional supplements on quality of life. Network meta-analysis could be conducted only for body weight and grip strength; there was evidence of an effect for oral nutritional supplements compared with standard care for body weight only. Study quality was mixed; the randomisation method was typically poorly reported. One economic evaluation, in a care home setting, was included. This was a well-conducted study showing that oral nutritional supplements could be cost-effective. Cost-effectiveness analysis suggested that oral nutritional supplements may only be cost-effective for people with lower body mass index (< 21 kg/m2) using cheaper oral nutritional supplements products that require minimal staff time to administer.

LIMITATIONS

The review scope was narrow in focus as few primary studies used frailty measures (or our proxy criteria). This resulted in only 11 included studies. The small evidence base and varied quality of evidence meant that it was not possible to determine accurate estimates of the effectiveness or cost-effectiveness of oral nutritional supplements. Furthermore, only English-language publications were considered.

CONCLUSIONS

Overall, the review found little evidence of oral nutritional supplements having significant effects on reducing malnutrition or its adverse outcomes in frail older adults.

FUTURE WORK

Future research should focus on independent, high-quality, adequately powered studies to investigate oral nutritional supplements alongside other nutritional interventions, with longer-term follow-up and detailed analysis of determinants, intervention components and cost-effectiveness.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42020170906.

FUNDING

This project was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 26, No. 51. See the NIHR Journals Library website for further project information.

Association of Red Cell Index and Adverse Hospitalization Outcomes in Chronic Obstructive Pulmonary Disease Patients with Acute Exacerbation: A Retrospective Cohort Study

Purpose

Previous studies have shown that the red cell index (RCI) can be considered as a simple and useful method to evaluate respiratory function. However, at present its association with adverse hospitalization outcomes in patients with acute exacerbation of chronic obstructive pulmonary disease (AECOPD) is not fully understood. Our study aimed to examine the relationship between adverse hospitalization outcomes and RCI among AECOPD patients.

Patients and Methods

We performed a retrospective analysis of consecutive patients from January 2015 to October 2021. In this study, RCI was the independent variable, measured at baseline, and adverse hospitalization outcome was the dependent variable. According to the RCI median (RCI=2.221), we divided 377 patients into two roughly equal groups (188 and 189, respectively). Next, the association between RCI and adverse hospitalization outcomes was explored using multivariable logistic regression models. To identify any non-linear relationship, a generalized additive model (GAM) was employed.

Results

With a total of 377 patients with AECOPD, we divided them into two roughly equal groups to compare the clinical factors and RCI levels. The patients in the higher RCI group showed poorer outcome incidence (18 [9.57%] vs 31 [16.40%]; p = 0.049). After accounting for potential confounders, the results showed that RCI was positively associated with adverse hospitalization outcomes (odds ratio [OR] = 1.15, 95% CI: 1.01-1.32). In addition, a non-linear relationship was detected between RCI and adverse hospitalization outcomes, which had an inflection point of 3.2. There were odds ratios and confidence intervals of 0.8 (0.7-1.0) and 1.3 (1.2-1.4) on the left and right sides of the inflection point, respectively.

Conclusion

The RCI and adverse hospitalization outcomes exhibited a non-linear relationship in the AECOPD patients. RCI is strongly positively correlated with adverse hospitalization outcomes when it was greater than 3.2.

Effects of Carbohydrate and Protein Administration by Food Items on Strength Response after Training in Stable COPD

Background: Chronic obstructive pulmonary disease (COPD) is one of the world’s most common diseases and reasons for death. Systemic consequences, especially reduced muscle strength, muscle mass and muscle function, are common and contribute to worsening prognosis and increasing morbidity and mortality. There is strong evidence that physical activity and strength training are effective in prolonging life and lead to better quality of life. Numerous studies have shown that ingestion of protein and carbohydrates after strength training can increase regeneration of strength in young athletes. Recently, we demonstrated that the same effect can be achieved with these macronutrients administered in a meal. Until now, it is not clear if patients with COPD, integrated in regular physical training, respond similarly. Methods: Prescribed strength training, consisting of two sets circular training with machines for big muscle groups was supplemented with a meal rich in protein and carbohydrates. Changes in maximum strength after 24 h were investigated to find out about the impact of this meal on physical capacity. A pilot study was conducted with pragmatic cross-over design. Results: With nutritive intervention, strength in both knee extensor and chest press were significantly higher than in control training. Conclusion: The study showed beneficial effects for the intake of protein and carbohydrates in changes in maximum strength. For now, the underlying mechanism remains unclear. Clinical relevance needs further research. The study design and study protocol can be used for further studies with only small adaptions.

The Role of Zinc in the Pathogenesis of Lung Disease

Lung diseases, such as asthma, chronic obstructive pulmonary diseases (COPD), and cystic fibrosis (CF), are among the leading causes of mortality and morbidity globally. They contribute to substantial economic burdens on society and individuals. Currently, only a few treatments are available to slow the development and progression of these diseases. Thus, there is an urgent unmet need to develop effective therapies to improve quality of life and limit healthcare costs. An increasing body of clinical and experimental evidence suggests that altered zinc and its regulatory protein levels in the systemic circulation and in the lungs are associated with these disease’s development and progression. Zinc plays a crucial role in human enzyme activity, making it an essential trace element. As a cofactor in metalloenzymes and metalloproteins, zinc involves a wide range of biological processes, such as gene transcription, translation, phagocytosis, and immunoglobulin and cytokine production in both health and disease. Zinc has gained considerable interest in these lung diseases because of its anti-inflammatory, antioxidant, immune, and metabolic modulatory properties. Here we highlight the role and mechanisms of zinc in the pathogenesis of asthma, COPD, CF, acute respiratory distress syndrome, idiopathic pulmonary fibrosis, and pulmonary hypertension.

Increased energy and/or protein intake improves anthropometry and muscle strength in chronic obstructive pulmonary disease patients: a systematic review with meta-analysis on randomised controlled clinical trials

Compromised nutritional status is associated with a poor prognosis in chronic obstructive pulmonary disease (COPD) patients. However, the impact of nutritional support in this group of patients is controversial. The present study systematically reviewed the effect of energy and or protein supplements or food fortification on anthropometry and muscle strength of COPD patients. We searched MEDLINE (PubMed), EMBASE, Cochrane Library and Scopus for all published randomised clinical trials without language restriction up to May 2021. Three reviewers performed study selection and data extraction independently. We judged the risk of bias by RoB 2 and the certainty of evidence by the GRADE approach. We included thirty-two randomised controlled trials and compiled thirty-one of them (1414 participants) in the random-effects model meta-analyses. Interventions were energy and/or protein oral nutritional supplements or food fortification added to the diet for at least one week. Pooled analysis revealed that nutritional interventions increased body weight (muscle circumference (MD) = 1·44 kg, 95 % CI 0·81, 2·08, I2 = 73 %), lean body mass (standardised mean difference (SMD) = 0·37; 95 % CI 0·15, 0·59, I2 = 46 %), midarm muscle circumference (MD = 0·29 mm2, 95 % CI 0·02, 0·57, I2 = 0 %), triceps skinfold (MD = 1·09 mm, 95 % CI 0·01, 2·16, I2 = 0 %) and handgrip strength (SMD = 0·39, 95 % CI 0·07, 0·71, I2 = 62 %) compared with control diets. Certainty of evidence ranged from very low to low, and most studies were judged with some concerns or at high risk of bias. This meta-analysis revealed, with limited evidence, that increased protein and/or energy intake positively impacts anthropometric measures and handgrip strength of COPD patients.

COPD profiles and treatable traits using minimal resources: identification, decision tree and stability over time

Background and objective

Profiles of people with chronic obstructive pulmonary disease (COPD) often do not describe treatable traits, lack validation and/or their stability over time is unknown. We aimed to identify COPD profiles and their treatable traits based on simple and meaningful measures; to develop and validate a decision tree and to explore profile stability over time.

Methods

An observational, prospective study was conducted. Clinical characteristics, lung function, symptoms, impact of the disease (COPD Assessment Test—CAT), health-related quality of life, physical activity, lower-limb muscle strength and functional status were collected cross-sectionally and a subsample was followed-up monthly over six months. A principal component analysis and a clustering procedure with k-medoids were applied to identify profiles. A decision tree was developed and validated cross-sectionally. Stability was explored over time with the ratio between the number of timepoints that a participant was classified in the same profile and the total number of timepoints (i.e., 6).

Results

352 people with COPD (67.4 ± 9.9 years; 78.1% male; FEV1 = 56.2 ± 20.6% predicted) participated and 90 (67.6 ± 8.9 years; 85.6% male; FEV1 = 52.1 ± 19.9% predicted) were followed-up. Four profiles were identified with distinct treatable traits. The decision tree included CAT (< 18 or ≥ 18 points); age (< 65 or ≥ 65 years) and FEV1 (< 48 or ≥ 48% predicted) and had an agreement of 71.7% (Cohen’s Kappa = 0.62, p < 0.001) with the actual profiles. 48.9% of participants remained in the same profile whilst 51.1% moved between two (47.8%) or three (3.3%) profiles over time. Overall stability was 86.8 ± 15%.

Conclusion

Four profiles and treatable traits were identified with simple and meaningful measures possibly available in low-resource settings. A decision tree with three commonly used variables in the routine assessment of people with COPD is now available for quick allocation to the identified profiles in clinical practice. Profiles and treatable traits may change over time in people with COPD hence, regular assessments to deliver goal-targeted personalised treatments are needed.

Nutritional Status and Body Composition in Patients Suffering From Chronic Respiratory Diseases and Its Correlation With Pulmonary Rehabilitation

As part of an individualized intervention to improve the physical, emotional, and social functioning of patients with chronic respiratory diseases in general and chronic obstructive pulmonary disease in particular, awareness of the presence and consequences of changes in body composition increased enormously during the last decades, and nutritional intervention is considered as an essential component in the comprehensive approach of these patients. This review describes the prevalence and the clinical impact of body composition changes and also provides an update of current intervention strategies. It is argued that body composition, preferentially a three-component evaluation of fat, lean, and bone mass, must become part of a thorough assessment of every patient, admitted for pulmonary rehabilitation.

Effects of Nutritional Interventions in Individuals with Chronic Obstructive Lung Disease: A Systematic Review of Randomized Controlled Trials

Background

The role of nutrition and dietary patterns has been widely investigated in cancer, cardiovascular disease, and diabetes, but there are limited data on nutritional impact on COPD. This systematic review (PROSPERO-reg. no: CRD42020172712) aimed to investigate the effect of nutritional interventions on pulmonary and physical function, inflammation, and health-related quality of life among individuals with COPD.

Methods

Systematic searches were conducted in Medline, Embase, and Cochrane, resulting in 3861 references. Studies focusing exclusively on inpatient-stays, underweight or obese patients were excluded. Double screening, extraction and bias assessment were conducted. Bias was assessed according to the Cochrane risk of bias tool for randomized controlled trials. Thirteen randomized controlled trials with 916 participants were included.

Results

These trials investigated effects of protein supplementation, beetroot juice, increased fruit and vegetable intake, black seed oil, Tualang honey, Chlorella vulgaris-extract, whey-peptide containing nutritional drink, and increased macronutrient intake. The durations of the interventions were from weeks to a few months, and only one with duration >1 year (investigating increased fruit/vegetable intake). The intervention increasing fruit/vegetables found improvement in pulmonary function tests. Some interventions observed effects on systemic inflammation, health-related quality of life and physical function, although with some mixed results. Five were classified as poor, five as fair, and three as good in terms of risk of bias and quality.

Conclusion

Increasing intake of fruits and vegetables over prolonged periods might have positive effects on lung function in individuals with COPD. Some nutritional interventions also observed effects on systemic inflammation, health-related quality of life, and physical function, although with some mixed results. Many of the trials were underpowered, had high dropout rates, or had a high risk of bias. Further research should investigate effect of prolonged dietary interventions.

Effect of low protein intake on acute exacerbations in mild to moderate chronic obstructive pulmonary disease: data from the 2007-2012 KNHANES

Background

Several researchers have reported that the amount of protein intake is associated with lung function and airflow obstruction. However, few studies have investigated the effect of low protein intake on acute exacerbations of chronic obstructive pulmonary disease. This study aimed to investigate the effect of low protein intake on exacerbations in mild to moderate chronic obstructive pulmonary disease.

Methods

We used data obtained from the Korean National Health and Nutrition Examination Survey (KNHANES) between 2007 and 2012, linked to the National Health Insurance claims data. The clinical outcomes and the rate of exacerbation were retrospectively compared between the low protein intake group and the non-low protein intake group which was stratified by quartile categories of protein intake in 2,069 patients with mild to moderate chronic obstructive pulmonary disease.

Results

The low protein intake group was significantly associated with older age, women, never smoker, low household income, and low education level, compared with the non-low protein intake group. The low protein intake group was significantly associated with increased hospitalization (18.0% vs. 10.5%, P<0.001) and emergency department utilization (1.6±1.0 vs. 1.1±0.4, P=0.033) compared with the non-low protein intake group. In multivariate analysis, the low protein intake group was associated with hospitalization (odds ratio 1.46; 95% CI, 1.09-1.96; P=0.012). The multiple linear regression analysis revealed that the amount of protein intake was associated with FVC % predicted (β=0.048, P<0.001) and FEV_1% predicted (β=0.022, P=0.015).

Conclusions

Low protein intake was associated with an increased risk of exacerbations in mild to moderate chronic obstructive pulmonary disease. The data are available at the KNHANES website (https://knhanes.cdc.go.kr).

Talking the same language on patient empowerment: Development and content validation of a taxonomy of self-management interventions for chronic conditions

CONTEXT

The literature on self-management interventions (SMIs) is growing exponentially, but it is characterized by heterogeneous reporting that limits comparability across studies and interventions. Building an SMI taxonomy is the first step towards creating a common language for stakeholders to drive research in this area and promote patient self-management and empowerment.

OBJECTIVE

To develop and validate the content of a comprehensive taxonomy of SMIs for long-term conditions that will help identify key characteristics and facilitate design, reporting and comparisons of SMIs.

METHODS

We employed a mixed-methods approach incorporating a literature review, an iterative consultation process and mapping of key domains, concepts and elements to develop an initial SMI taxonomy that was subsequently reviewed in a two-round online Delphi survey with a purposive sample of international experts.

RESULTS

The final SMI taxonomy has 132 components classified into four domains: intervention characteristics, expected patient/caregiver self-management behaviours, outcomes for measuring SMIs and target population characteristics. The two-round Delphi exercise involving 27 international experts demonstrated overall high agreement with the proposed items, with a mean score (on a scale of 1-9) per component of 8.0 (range 6.1-8.8) in round 1 and 8.1 (range 7.0-8.9) in round 2.

CONCLUSIONS

The SMI taxonomy contributes to building a common framework for the patient self-management field and can help implement and improve patient empowerment and facilitate comparative effectiveness research of SMIs. Patient or public contribution. Patients' representatives contributed as experts in the Delphi process and as partners of the consortium.

Nutritional management of diabetes mellitus during the pandemic of COVID-19: a comprehensive narrative review

Objectives

According to the recent epidemiological studies, patients with diabetes mellitus (DM) may be at higher risk of hospitalization due to COVID-19. Regarding the important role of nutrition on the immunity, the present review article aimed to outline nutritional support of DM during the outbreak of COVID-19 with a mechanistic insight.

Methods

Searches were performed in PubMed/MEDLINE, ScienceDirect, Scopus, and Google Scholar databases from 2000 until December 2020 using the following keywords. All relevant clinical and experimental studies published in English were included.

Results

Evidences revealed that hyperglycemia is a significant predictor of some viral infections including COVID-19 which can exacerbate the complications of DM. According to the literature review, adequate intake of dietary protein, fiber, essential fatty acids and some micronutrients especially vitamins D, C, B12, folate, zinc and selenium has beneficial effects on the prevention and treatment of COVID-19 in diabetic patients through modulation of innate and adaptive immune responses or direct effects on virus enzymes or the rate of cell entrance.

Conclusions

It is well understood that malnutrition may increase susceptibility to viral infections and disease progression. Therefore, considering nutritional status of diabetic patients and reasonable supplementation of the above mentioned nutrients can ameliorate the symptoms of COVID-19 in DM. However, further well-designed clinical trials are needed to determine their therapeutic dose.

Nutritional approach for increasing public health during pandemic of COVID-19: A comprehensive review of antiviral nutrients and nutraceuticals

Background: The novel coronavirus (COVID-19) is considered as the most life-threatening pandemic disease during the last decade. The individual nutritional status, though usually ignored in the management of COVID-19, plays a critical role in the immune function and pathogenesis of infection. Accordingly, the present review article aimed to report the effects of nutrients and nutraceuticals on respiratory viral infections including COVID-19, with a focus on their mechanisms of action. Methods: Studies were identified via systematic searches of the databases including PubMed/ MEDLINE, ScienceDirect, Scopus, and Google Scholar from 2000 until April 2020, using keywords. All relevant clinical and experimental studies published in English were included. Results: Protein-energy malnutrition (PEM) is common in severe respiratory infections and should be considered in the management of COVID-19 patients. On the other hand, obesity can be accompanied by decreasing the host immunity. Therefore, increasing physical activity at home and a slight caloric restriction with adequate intake of micronutrients and nutraceuticals are simple aids to boost host immunity and decrease the clinical manifestations of COVID-19. Conclusion: The most important nutrients which can be considered for COVID-19 management are vitamin D, vitamin C, vitamin A, folate, zinc, and probiotics. Their adequacy should be provided through dietary intake or appropriate supplementation. Moreover, adequate intake of some other dietary agents including vitamin E, magnesium, selenium, alpha linolenic acid and phytochemicals are required to maintain the host immunity.

Characteristics and treatable traits of patients with chronic obstructive pulmonary disease (COPD) with and without paid employment

Introduction

Patients with COPD are vulnerable to workforce detachment. Better knowledge of features associated with paid work loss might be of help to design and select appropriate interventions.

Method

This cross-sectional study aimed to explore the presence of treatable traits in COPD patients without paid work. Patients with COPD below 65 years at first referral to a hospital-based patient clinic were included. Using binary logistic regression analysis, the relationship between paid work and the following characteristics was explored: low daily physical activity, exercise, active smoking, Medical Research Council dyspnea scale (MRC), poor nutritional status, exacerbations, and fatigue (checklist individual strength (CIS)). Variables were adjusted for age, sex, forced expiratory volume in 1 s (FEV 1), and education level.

Results

In total, 191 patients (47.3%) were without paid work. The following treatable traits were related to not being in paid work: < 5000 steps/day (OR 2.36, 95% CI (1.52–3.68)), MRC ≥ 3 (OR 1.78, 95%CI (1.14–2.77)), CIS ≥ 36 points (OR 1.78, 95% CI (1.10–2.87)), six-minute walk distance (6MWD) < 70% of predicted (OR 2.62, 95% CI (1.69–4.06)), and ≥ 2 exacerbations per year (OR 1.80, 95% CI (1.12–2.92)). Significant differences were also seen in age (OR 1.06, 95% CI (1.02–1.10) per year), FEV 1% predicted (OR 0.98, 95% CI (0.97–1.00) per % predicted increase), and medium/high education level (OR 0.62, 95% CI (0.41–0.93)). When adjusting for all variables the only treatable trait that remained significant was 6MWD.

Conclusion

Patients without paid work are more likely to have treatable traits with 6MWD revealing the most significant association.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12931-021-01736-6.

Self-management interventions for adults living with Chronic Obstructive Pulmonary Disease (COPD): The development of a Core Outcome Set for COMPAR-EU project

BACKGROUND

A large body of evidence suggests that self-management interventions (SMIs) may improve outcomes in chronic obstructive pulmonary disease (COPD). However, accurate comparisons of the relative effectiveness of SMIs are challenging, partly due to heterogeneity of outcomes across trials and uncertainty about the importance of these outcomes for patients. We aimed to develop a core set of patient-relevant outcomes (COS) for SMIs trials to enhance comparability of interventions and ensure person-centred care.

METHODS

We undertook an innovative approach consisting of four interlinked stages: i) Development of an initial catalogue of outcomes from previous EU-funded projects and/or published studies, ii) Scoping review of reviews on patients and caregivers' perspectives to identify outcomes of interest, iii) Two-round Delphi online survey with patients and patient representatives to rate the importance of outcomes, and iv) Face-to-face consensus workshop with patients, patient representatives, health professionals and researchers to develop the COS.

RESULTS

From an initial list of 79 potential outcomes, 16 were included in the COS plus one supplementary outcome relevant to all participants. These were related to patient and caregiver knowledge/competence, self-efficacy, patient activation, self-monitoring, adherence, smoking cessation, COPD symptoms, physical activity, sleep quality, caregiver quality of life, activities of daily living, coping with the disease, participation and decision-making, emergency room visits/admissions and cost effectiveness.

CONCLUSION

The development of the COPD COS for the evaluation of SMIs will increase consistency in the measurement and reporting of outcomes across trials. It will also contribute to more personalized health care and more informed health decisions in clinical practice as patients' preferences regarding COPD outcomes are more systematically included.

Treatable traits qualifying for nonpharmacological interventions in COPD patients upon first referral to a pulmonologist: the COPD sTRAITosphere

Introduction

The present study assessed the prevalence of nine treatable traits (TTs) pinpointing nonpharmacological interventions in patients with COPD upon first referral to a pulmonologist, how these TTs co-occurred and whether and to what extent the TTs increased the odds having a severely impaired health status.

Methods

Data were collected from a sample of 402 COPD patients. A second sample of 381 patients with COPD was used for validation. Nine TTs were assessed: current smoking status, activity-related dyspnoea, frequent exacerbations <12 months, severe fatigue, depressed mood, poor physical capacity, low physical activity, poor nutritional status and a low level of self-management activation. For each TT the odds ratio (OR) of having a severe health status impairment was calculated. Furthermore, a graphic representation was created, the COPD sTRAITosphere, to visualise TTs prevalence and OR.

Results

On average 3.9±2.0 TTs per patient were observed. These TTs occurred relatively independently of each other and coexisted in 151 unique combinations. A significant positive correlation was found between the number of TTs and Clinical COPD Questionnaire total score (r=0.58; p<0.001). Patients with severe fatigue (OR: 8.8), severe activity-related dyspnoea (OR: 5.8) or depressed mood (OR: 4.2) had the highest likelihood of having a severely impaired health status. The validation sample corroborated these findings.

Conclusions

Upon first referral to a pulmonologist, COPD patients show multiple TTs indicating them to several nonpharmacological interventions. These TTs coexist in many different combinations, are relatively independent and increase the likelihood of having a severely impaired health status.

Food Pyramid for Subjects with Chronic Obstructive Pulmonary Diseases

Nutritional problems are an important part of rehabilitation for chronic obstructive pulmonary disease (COPD) patients. COPD patients often present with malnutrition, sarcopenia, and osteoporosis with possible onset of cachexia, with an inadequate dietary intake and a poor quality of life. Moreover, diet plays a pivotal role in patients with COPD through three mechanisms: regulation of carbon dioxide produced/oxygen consumed, inflammation, and oxidative stress. A narrative review based on 99 eligible studies was performed to evaluate current evidence regarding optimum diet therapy for the management of COPD, and then a food pyramid was built accordingly. The food pyramid proposal will serve to guide energy and dietary intake in order to prevent and treat nutritionally related COPD complications and to manage progression and COPD-related symptoms. The nutrition pyramid described in our narrative review is hypothetical, even in light of several limitations of the present review; the main limitation is the fact that to date there are no randomized controlled trials in the literature clearly showing that improved nutrition, via the regulation of carbon dioxide produced/oxygen consumed, inflammation and oxidative stress, improves symptoms and/or progression of COPD. Even if this nutritional pyramid is hypothetical, we hope that it can serve the valuable purpose of helping researchers focus on the often-ignored possible connections between body composition, nutrition, and COPD.

Imbalance in zinc homeostasis enhances lung Tissue Loss following cigarette smoke exposure

Cigarette smoke exposure is a major cause of chronic obstructive pulmonary disease. Cadmium is a leading toxic component of cigarette smoke. Cadmium and zinc are highly related metals. Whereas, zinc is an essential metal required for normal health, cadmium is highly toxic. Zrt- and Irt-like protein 8 (ZIP8) is an avid transporter of both zinc and cadmium into cells and is abundantly expressed in the lung of smokers compared to nonsmokers. Our objective was to determine whether disturbed zinc homeostasis through diet or the zinc transporter ZIP8 increase susceptibility to lung damage following prolonged cigarette smoke exposure.

METHODS

Cigarette smoke exposure was evaluated in the lungs of mice subject to insufficient and sufficient zinc intakes, in transgenic ZIP8 overexpressing mice, and a novel myeloid-specific ZIP8 knockout strain.

RESULTS

Moderate depletion of zinc intakes in adult mice resulted in a significant increase in lung cadmium burden and permanent lung tissue loss following prolonged smoke exposure. Overexpression of ZIP8 resulted in increased lung cadmium burden and more extensive lung damage, whereas cigarette smoke exposure in ZIP8 knockout mice resulted in increased lung tissue loss without a change in lung cadmium content, but a decrease in zinc.

CONCLUSIONS

Overall, findings were consistent with past human studies. Imbalance in Zn homeostasis increases susceptibility to permanent lung injury following prolonged cigarette smoke exposure. Based on animal studies, both increased and decreased ZIP8 expression enhanced irreversible tissue damage in response to prolonged tobacco smoke exposure. We believe these findings represent an important advancement in our understanding of how imbalance in zinc homeostasis and cadmium exposure via tobacco smoke may increase susceptibility to smoking-induced lung disease.

The Underappreciated Role of Low Muscle Mass in the Management of Malnutrition

Preserving muscle is not only crucial for maintaining proper physical movement, but also for its many metabolic and homeostatic roles. Low muscle mass has been shown to adversely affect health outcomes in a variety of disease states (eg, chronic obstructive pulmonary disease, cancer, cardiovascular disease) and leads to an increased risk for readmission and mortality in hospitalized patients. Low muscle mass is now included in the most recent diagnostic criteria for malnutrition. Current management strategies for malnutrition may not prioritize the maintenance and restoration of muscle mass. This likely reflects the challenge of identifying and measuring this body composition compartment in clinical practice and the lack of awareness by health care professionals of the importance that muscle plays in patient health outcomes. As such, we provide a review of current approaches and make recommendations for managing low muscle mass and preventing muscle loss in clinical practice. Recommendations to assist the clinician in the optimal management of patients at risk of low muscle mass include the following: (1) place muscle mass at the core of nutritional assessment and management strategies; (2) identify and assess low muscle mass; (3) develop a management pathway for patients at risk of low muscle mass; (4) optimize nutrition to focus on muscle mass gain versus weight gain alone; and (5) promote exercise and/or rehabilitation therapy to help maintain and build muscle mass. The need to raise awareness of the importance of screening and managing 'at risk' patients so it becomes routine is imperative for change to occur. Health systems need to drive clinicians to treat patients with this focused approach, and the economic benefits need to be communicated to payers. Lastly, further focused research in the area of managing patients with low muscle mass is warranted.

Nutritional supplementation during pulmonary rehabilitation in COPD: A systematic review

Uptake of nutritional supplementation during pulmonary rehabilitation (PR) for people with chronic obstructive pulmonary disease (COPD) has been limited by an absence of rigorous evidence-based studies supporting use. The objective was to report and summarise the current evidence supporting the use of nutritional supplementation to improve outcomes during PR in stable COPD patients. A systematic search was conducted up to 7 August 2019 (registration number CRD42018089142). The preferred reporting items for systematic reviews and meta-analyses guidelines were used. Six databases were included: Medical Literature Analysis and Retrieval System Online or MEDLARS Online, Allied and Complementary Medicine Database, the Cochrane Database of Systematic Reviews, Excerpta Medica dataBASE, Cumulative Index of Nursing and Allied Health Literature and Web of Science. This systematic search generated 580 initial matches, of which 22 studies (917 COPD participants) met the pre-specified criteria and were included. Sixteen of 19 studies that used nutritional supplements in addition to PR did not show additional benefit compared to PR alone when measuring exercise capacity. Nutritional supplements significantly increased body weight in 7 of 11 studies. Body mass index increased significantly in two of six studies. Handgrip strength did not improve, while quadriceps muscle strength significantly improved in 3 of 11 studies. Four of eight studies showed a significant improvement in inspiratory muscle function. Only 2 of 14 studies demonstrated a significant improvement in quality of life with supplementation in addition to PR. There remains insufficient evidence on the effect of nutritional supplementation on improving outcomes during PR in patients with COPD due to heterogeneity in supplements, outcome measures and PR programmes. Therefore, controversy remains and further research is needed.

‘Mind the gap’: the importance of managing malnutrition in chronic obstructive pulmonary disease

Malnutrition is linked to poor outcomes in patients with chronic obstructive pulmonary disease (COPD), and reduced fat free mass and low BMI are independent risk factors for increased mortality. However, weight loss is not inevitable and can be prevented or reversed so screening for malnutrition is essential. The latest guidelines for managing malnutrition in COPD recommend first-line nutritional support. In particular, patients with a BMI <20 kg/m2 should be prescribed oral nutritional supplements (ONS), which have been shown to significantly improve outcomes. However, this guidance is often not implemented locally, increasing the likelihood of malnutrition, hospital admission and increased healthcare costs. Ready-prepared, low-volume, high-protein, high-energy drinks can improve compliance with ONS, particularly in people who are unable to tolerate high volumes. ONS therefore play an important role in managing malnutrition in COPD, helping to reduce its physiological and economic effects.

Effectiveness of Tailored Dietary Counseling in Treating Malnourished Outpatients with Chronic Obstructive Pulmonary Disease: A Randomized Controlled Trial

BACKGROUND

Malnutrition in patients with chronic obstructive pulmonary disease (COPD) is common and associated with poor prognosis. Nutrition interventions are necessary, but there is a lack of evidence regarding the effectiveness of tailored nutrition advice.

OBJECTIVE

This study investigated whether tailored nutrition counseling could improve dietary intake, nutritional status, functional outcomes, and health-related quality of life (QoL) of malnourished outpatients with COPD.

DESIGN

We conducted a randomized controlled trial in which participants were randomly assigned to either the intervention group (IG) or the control group (CG).

PARTICIPANTS/SETTING

One hundred and twenty malnourished outpatients with COPD participated in the study between May and November 2017 at the National Lung Hospital, Hanoi, Vietnam.

INTERVENTION

The IG received tailored nutrition counseling once per month for 3 months based on a specifically developed written nutrition resource for COPD. The CG received the same educational resource at baseline without any discussion.

MAIN OUTCOME MEASURES

The main outcome measures were energy and protein intakes, body weight change, nutritional status (Subjective Global Assessment score), muscle strength, and QoL.

STATISTICAL ANALYSES

Differences between groups before and after the intervention were assessed using two-way repeated measures analysis of variance. Generalized estimating equation modeling was used to investigate the differences between groups over time.

RESULTS

At baseline, there were no significant differences in outcomes of interest between the two groups. After 3 months of intervention, time-intervention interactions for energy intake, protein intake, and body weight change were significant (945 kcal/day, 95% CI 792 to 1,099 kcal/day, P<0.001; 50.0 g protein/day, 95% CI 43.9 to 56.1 g protein/day, P<0.001; and 1.0 kg, 95% CI 0.5 to 1.5 kg, P<0.001, respectively). Subjective Global Assessment scores improved in the IG and worsened in the CG. Significant improvements were found in inspiratory muscle strength in the IG (5.4 cmH₂O, 95% CI 2.3 to 8.6 cmH₂O, P=0.001) and significant decreases in handgrip strength were found in the CG after 3 months of the intervention (1.4 kg, 95% CI 0.4 to 2.4 kg, P=0.007). There was a significant interaction effect for all QoL scores (analysis of variance two-way repeated, P≤0.003). The IG also significantly improved all QoL scores from baseline to 3 months (P<0.004).

CONCLUSIONS

Tailored nutritional counseling has the potential to improve dietary intakes, nutritional status, functional outcomes, and QoL in malnourished outpatients with COPD.

The prognostic significance of weight loss in chronic obstructive pulmonary disease-related cachexia: a prospective cohort study

BACKGROUND

Cachexia is an important extra-pulmonary manifestation of chronic obstructive pulmonary disease (COPD) presenting as unintentional weight loss and altered body composition. Previous studies have focused on the relative importance of body composition compared with body mass rather than the relative importance of dynamic compared with static measures. We aimed to determine the prevalence of cachexia and pre-cachexia phenotypes in COPD and examine the associations between cachexia and its component features with all-cause mortality.

METHODS

We enrolled 1755 consecutive outpatients with stable COPD from two London centres between 2012 and 2017, stratified according to European Respiratory Society Task Force defined cachexia [unintentional weight loss >5% and low fat-free mass index (FFMI)], pre-cachexia (weight loss >5% but preserved FFMI), or no cachexia. The primary outcome was all-cause mortality. We calculated hazard ratios (HRs) using Cox proportional hazards regression for cachexia classifications (cachexia, pre-cachexia, and no cachexia) and component features (weight loss and FFMI) and mortality, adjusting for age, sex, body mass index, and disease-specific prognostic markers.

RESULTS

The prevalence of cachexia was 4.6% [95% confidence interval (CI): 3.6-5.6] and pre-cachexia 1.6% (95% CI: 1.0-2.2). Prevalence was similar across sexes but increased with worsening Global Initiative for Chronic Obstructive Pulmonary Disease spirometric stage and Medical Research Council dyspnoea score (all P < 0.001). There were 313 (17.8%) deaths over a median (interquartile range) follow-up duration 1089 (547-1704) days. Both cachexia [HR 1.98 (95% CI: 1.31-2.99), P = 0.002] and pre-cachexia [HR 2.79 (95% CI: 1.48-5.29), P = 0.001] were associated with increased mortality. In multivariable analysis, the unintentional weight loss feature of cachexia was independently associated with mortality [HR 2.16 (95% CI: 1.31-3.08), P < 0.001], whereas low FFMI was not [HR 0.88 (95% CI: 0.64-1.20), P = 0.402]. Sensitivity analyses using body mass index-specific, age-specific, and gender-specific low FFMI values found consistent findings.

CONCLUSIONS

Despite the low prevalence of cachexia and pre-cachexia, both confer increased mortality risk in COPD, driven by the unintentional weight loss component. Our data suggest that low FFMI without concurrent weight loss may not confer the poor prognosis as previously reported for this group. Weight loss should be regularly monitored in practice and may represent an important target in COPD management. We propose the incorporation of weight monitoring into national and international COPD guidance.

Coexistence of malnutrition, frailty, physical frailty and disability in patients with COPD starting a pulmonary rehabilitation program

BACKGROUND & AIMS

Malnutrition, frailty, physical frailty, and disability are common conditions in patients with chronic obstructive pulmonary disease (COPD). Insight in the coexistence and relations between these conditions may provide information on the nature of the relationship between malnutrition and frailty. Such information may help to identify required interventions to improve the patient's health status. We therefore aimed to explore whether malnutrition, frailty, physical frailty, and disability coexist in patients with COPD at the start of pulmonary rehabilitation.

METHODS

For this cross-sectional study, from March 2015 to May 2017, patients with COPD were assessed at the start of a pulmonary rehabilitation program. Nutritional status was assessed with the Scored Patient-Generated Subjective Global Assessment (PG-SGA) based Pt-Global app. Frailty was assessed by the Evaluative Frailty Index for Physical activity (EFIP), physical frailty by Fried's criteria, and disability by the Dutch version of World Health Organization Disability Assessment Schedule 2.0 (WHODAS). These variables were dichotomized to determine coexistence of malnutrition, frailty, physical frailty, and disability. Associations between PG-SGA score and respectively EFIP score, Fried's criteria, and WHODAS score were analyzed by Pearson's correlation coefficient. Two tailed P-values were used, and significance was set at P < 0.05.

RESULTS

Of the 57 participants included (age 61.2 ± 8.7 years), malnutrition and frailty coexisted in 40%. Malnutrition and physical frailty coexisted in 18%, and malnutrition and disability in 21%. EFIP score and PG-SGA score were significantly correlated (r = 0.43, P = 0.001), as well as Fried's criteria and PG-SGA score (r = 0.37, P = 0.005).

CONCLUSIONS

In this population, malnutrition substantially (40%) coexists with frailty. Although the prevalence of each of the four conditions is quite high, the coexistence of all four conditions is limited (11%). The results of our study indicate that nutritional interventions should be delivered by health care professionals across multiple disciplines.

The Effects of a Nurse-Led Education and Counseling Program on Dyspnea, Health Status, and Care Dependency in Patients With Chronic Obstructive Pulmonary Disease: A Feasibility Study

The aim of this feasibility study was to determine the effects of a nurse-led education and counseling program for chronic obstructive pulmonary disease (COPD-ECP) on dyspnea, health status, and care dependency in patients. A quasi-experimental, pre-posttest research design without a control group was performed on 30 COPD patients. The patients received an 8-week COPD-ECP via home visits during the first 4 weeks and via phone interviews in the subsequent 4 weeks. After completion of COPD-ECP and a 4-week break, a final follow-up was conducted at the end of 12th week. The Dyspnea-12, COPD Assessment Test (CAT), and Care Dependency Scale (CDS) scores were calculated during the first interview, and on the 4th, 8th, and 12th week of the study. The patients completed all sessions of COPD-ECP without side effects. There was a significant decrease in the total Dyspnea-12 scores at the end of the study period. Compared to the baseline assessment, CAT total scores significantly decreased in the 4th, 8th, and 12th week ( p < 0.05), and CDS scores showed a significant reduction at the 12th week ( p < 0.05). In conclusion, COPD-ECP is feasible in regular clinical practice and well accepted by patients, and it seems to improve health status and decrease dyspnea, and care dependency. Future randomized controlled studies are warranted to explore the effects of COPD-ECP on fatigue, cough and sleep problems, and the best innovative strategies to improve the efficiency of COPD-ECP.

Relationship Between Performance Improvement in Activities of Daily Living and Energy Intake in Older Patients With Hip Fracture Undergoing Rehabilitation

Objective

To analyze whether sufficient energy intake (EI) improves performance of activities of daily living (ADL) in patients with hip fracture admitted to rehabilitation hospitals. The adequate amount of EI for improving performance of ADL in patients with hip fracture remains unknown.

Methods

This retrospective cohort study included all patients with hip fracture (n=234) admitted to rehabilitation hospitals in Japan. The inclusion criteria for this study were age >65 years and body mass index <30.0 kg/m². Patients who were transferred to an acute hospital and those with missing case data were excluded. According to the amount of EI, the patients were classified into energy sufficiency and shortage groups (EI/total energy expenditure ≥1.0 and <1.0, respectively). The Functional Independence Measure (FIM) and FIM gain were used to evaluate the patient disability level and change in patient status in response to rehabilitation. Finally, FIM gain was calculated as the discharge FIM score minus the admission FIM score.

Results

The final analysis targeted 202 patients—53 (26.2%) were in the energy shortage group and 149 (73.8%) were in the energy sufficiency group. The energy sufficiency group had a greater FIM gain than the energy shortage group (mean, 25.1±14.2 vs. 19.7±16.4; p=0.024). Furthermore, sufficient EI in the first week since admission (β=0.165; 95% confidence interval, 0.392–5.230; p=0.023) was an independent factor of FIM gain.

Conclusion

Among elderly patients with hip fracture admitted to rehabilitation hospitals in Japan, the amount of EI during the first week after admission was an independent factor of FIM gain.

Nutritional support in chronic obstructive pulmonary disease (COPD): an evidence update

Chronic obstructive pulmonary disease (COPD) primarily affects the lungs but due to the accompanying chronic systematic inflammation and the symptoms associated with the disease there are many extrapulmonary effects which include complex physical and metabolic adaptations. These changes have been associated with reduced exercise capacity, increased nutritional requirements, altered metabolic processes and compromised nutritional intake. As a result, nutritional depletion in COPD is multi-faceted and can involve imbalances of energy (weight loss), protein (sarcopenia), and periods of markedly increased inflammation (pulmonary cachexia) which can increase nutritional losses. As a result, depletion of both fat-mass (FM) and fat-free mass (FFM) can occur. There is good evidence that nutritional support, in the form of oral nutritional supplements (ONS), can overcome energy and protein imbalances resulting in improved nutritional status and functional capacity. However, in order to treat the aetiology of sarcopenia, frailty and cachexia, it is likely that targeted multi-modal interventions are required to address energy and protein imbalance, specific nutrient deficiencies, reduced androgens and targeted exercise training. Furthermore, interventions taking a disease-course approach, are likely to hold the key to effectively managing the common and costly problem of nutritional depletion in COPD.

Anti-inflammatory nutrition with high protein attenuates cardiac and skeletal muscle alterations in a pulmonary arterial hypertension model

Pulmonary arterial hypertension (PAH) is characterized by remodelling of the pulmonary arteries and right ventricle (RV), which leads to functional decline of cardiac and skeletal muscle. This study investigated the effects of a multi-targeted nutritional intervention with extra protein, leucine, fish oil and oligosaccharides on cardiac and skeletal muscle in PAH. PAH was induced in female C57BL/6 mice by weekly injections of monocrotaline (MCT) for 8 weeks. Control diet (sham and MCT group) and isocaloric nutritional intervention (MCT + NI) were administered. Compared to sham, MCT mice increased heart weight by 7%, RV thickness by 13% and fibrosis by 60% (all p < 0.05) and these were attenuated in MCT + NI mice. Microarray and qRT-PCR analysis of RV confirmed effects on fibrotic pathways. Skeletal muscle fiber atrophy was induced (P < 0.05) by 22% in MCT compared to sham mice, but prevented in MCT + NI group. Our findings show that a multi-targeted nutritional intervention attenuated detrimental alterations to both cardiac and skeletal muscle in a mouse model of PAH, which provides directions for future therapeutic strategies targeting functional decline of both tissues.

Disease-related malnutrition in hospitalized chronic patients with complex needs

BACKGROUND AND AIMS

Disease-related malnutrition is a prevalent condition that can be associated with multimorbidity. The purposes of this study were to assess the prevalence of disease-related malnutrition in a cohort of chronic patients with complex needs (CPCN) admitted to two University hospitals, and to evaluate the impact of malnutrition in their hospitalization outcomes.

METHODS

All CPCN admitted on a previously agreed day in non-critical services of two University hospitals in Catalonia were included. Nutritional risk was evaluated with Mini-Nutritional Assessment Tool and Nutritional Risk Screening 2002. Hospitalization outcome data were evaluated, including length of the hospital stay, mortality during admission and placement when discharged. After five months, a new evaluation was performed to assess mortality and readmissions.

RESULTS

A total of 101 patients were included, 83% of which were at nutritional risk when screened with NRS-2002; when using MNA, 86% of them were found to be either at nutritional risk or malnourished. Malnourished patients had a greater need for home care/intermediate care hospital at discharge (41.8% vs 22.9%, p < 0.01), and a higher mortality rate during admission (16.7% vs 1.6%, p < 0.01). Mortality at 5 months was also higher in the malnourished group (30.5% vs 9.8%, p < 0.01). Factors associated with malnutrition were BMI and gender (malnutrition was more prevalent in women). In our cohort, malnutrition was the sole independent predictor of mortality at 5 months.

CONCLUSIONS

The prevalence of both malnutrition and risk of malnutrition is very high in hospital-admitted CPCN, and has a profound impact on placement at discharge and mortality. This high prevalence is not explained by the multimorbidity pattern. Other factors need to be evaluated in this group of high-need, high-cost patients.

β-Hydroxy-β-methylbutyrate and its impact on skeletal muscle mass and physical function in clinical practice: a systematic review and meta-analysis

BACKGROUND

Loss of skeletal muscle mass and muscle weakness are common in a variety of clinical conditions with both wasting and weakness associated with an impairment of physical function. β-Hydroxy-β-methylbutyrate (HMB) is a nutrition supplement that has been shown to favorably influence muscle protein turnover and thus potentially plays a role in ameliorating skeletal muscle wasting and weakness.

OBJECTIVES

The aim of this study was to investigate the efficacy of HMB alone, or supplements containing HMB, on skeletal muscle mass and physical function in a variety of clinical conditions characterized by loss of skeletal muscle mass and weakness.

METHODS

A systematic review and meta-analysis of randomized controlled trials reporting outcomes of muscle mass, strength, and physical function was performed. Two reviewers independently performed screening, data extraction, and risk-of-bias assessment. Outcome data were synthesized through meta-analysis with the use of a random-effects model and data presented as standardized mean differences (SMDs).

RESULTS

Fifteen randomized controlled trials were included, involving 2137 patients. Meta-analysis revealed some evidence to support the effect of HMB alone, or supplements containing HMB, on increasing skeletal muscle mass (SMD = 0.25; 95% CI: -0.00, 0.50; z = 1.93; P = 0.05; I2 = 58%) and strong evidence to support improving muscle strength (SMD = 0.31; 95% CI: 0.12, 0.50; z = 3.25; P = 0.001; I2 = 0%). Effect sizes were small. No effect on bodyweight (SMD = 0.16; 95% CI: -0.08, 0.41; z = 1.34; P = 0.18; I2 = 67%) or any other outcome was found. No study was considered to have low risk of bias in all categories.

CONCLUSION

HMB, and supplements containing HMB, increased muscle mass and strength in a variety of clinical conditions, although the effect size was small. Given the bias associated with many of the included studies, further high-quality studies should be undertaken to enable interpretation and translation into clinical practice. The trial was registered on PROSPERO as CRD42017058517.

Differences in plasma amino acid levels in patients with and without bacterial infection during the early stage of acute exacerbation of COPD

PURPOSE

No consensus has been reached regarding appropriate nutritional intervention and rehabilitation during early acute exacerbation of COPD (AECOPD). Given the individual differences in symptoms of AECOPD, patients should be classified by their pathology. For example, it is known that there are differences in the inflammatory response between AECOPD with and without bacterial infection. However, there have been few reports on AECOPD from a nutritional perspective. The aim of this study was to investigate amino acid levels in patients with AECOPD.

PATIENTS AND METHODS

Blood was collected from patients who were hospitalized with AECOPD and from patients with COPD that was in a stable state. We divided the patients with AECOPD into those without bacterial infection (group A) and those with bacterial infection (group B). The patients with COPD that was stable served as controls (group C). The plasma levels of 9 essential amino acids, 13 nonessential amino acids, and total amino acids were compared between the three groups.

RESULTS

In the early stages of AECOPD, differences in plasma levels of only three amino acids (glycine, phenylalanine, and arginine) were observed between groups C and A. Differences in total amino acids and 13 amino acids were observed between groups C and B. Group B had lower levels of total amino acids and of seven amino acids (asparagine, citrulline, glutamine, histidine, methionine, serine, and threonine) compared with the other study groups.

CONCLUSION

The findings of this study show that amino acid levels in plasma differ in patients with AECOPD depending on whether or not bacterial infection is present. Our results suggest that specific amino acids (ie, asparagine, citrulline, glutamine, histidine, serine, and threonine) have potential utility as diagnostic markers to distinguish between bacterial and nonbacterial AECOPD.

Nutritional status, dietary intake, and health-related quality of life in outpatients with COPD

Background

Malnutrition is common in patients with COPD; however, little is known about its impacts on health-related quality of life (QoL) among patients with COPD. This study aimed to explore the nutritional status and dietary intake among outpatients with COPD in Vietnam and its possible associations with QoL.

Methods

A cross-sectional study was carried out in COPD outpatients visiting the COPD management unit at the National Lung Hospital, Hanoi, Vietnam between May 2017 and July 2017. Consecutive outpatients with a confirmed diagnosis of COPD were recruited with written inform consent. The nutritional status of participants was assessed using Subjective Global Assessment (SGA), and dietary intake via a 24-hour recall interview. The St George Respiratory Questionnaire (SGRQ) for COPD was used to investigate the participants’ QoL. Sociodemographic and clinical data were extracted from hospital records.

Results

Of 168 COPD outpatients involved in the study, three-quarters (74.4%) were diagnosed as malnourished (SGA B/C) and 81.5% reported unintentional weight loss. Most of the patients did not meet their estimated energy and protein requirements (85.7% and 89.9%, respectively). Malnutrition was significantly associated with disease severity (P=0.039) and ratio of protein intake to estimated requirement (P=0.005). QoL was low for all levels of malnutrition or disease severity, with well-nourished participants and those with less disease severity having better QoL (P=0.006 and P<0.001, respectively). With an extra meal per day, the odds of having malnutrition decreased 5.6 times (P<0.05) and the total SGRQ reduced 3.61 scores (P<0.05) indicating a better QoL.

Conclusion

Malnutrition and weight loss are prevalent among COPD outpatients. Most of the patients had inadequate dietary intake and low QoL. Nutrition counselling including increasing the number of meals per day with a focus on energy- and protein-rich foods may help improving nutritional status and QoL of patients with COPD in Vietnam.