Adequate calories to exceed basal energy expenditure slightly
Small, frequent meal
Timing the main meal to corresponed to the time requiring high energy
More protein and fat and less carbohydrate
Meal requiring little preparation
Rest before and after meals
10.4.2 Oral Nutritional Supplements
In 2012, the meta-analysis reported including the Cochrane Airways Group register showed nutritional support is effective to improve anthropometric measures and exercise capacity in patients with COPD [2, 3]. COPD is treatable disease, but its airflow limitation is not fully reversible. Therefore, nutritional therapy preventive to COPD is warranted. In 2015, Varraso, et al. reported that the Alternate Healthy Eating Index 2010 (AHEI-2010) diet score was associated with a lower risk of newly diagnosed COPD [12]. AHEI-2010, a measure of diet quality, is based on 11 components (Table 10.2): six components for which the highest intakes were supposed to be ideal (vegetables, fruit, whole grains, nuts and legumes, long-chain omega-3 fats, and polyunsaturated fatty acids), one component for which moderate intake was supposed to be ideal (alcohol), and four components for which avoidance or lowest intake were supposed to be ideal (sugar-sweetened drinks and fruit juice, red and processed meat, trans fat, and sodium). Each component is given a minimal score of 0 and a maximal score of 10, with intermediate values scored proportionally, and has the potential to contribute 0–10 points to the total score. All the component scores are summed to obtain a total AHEI-2010 score, which ranges from 0 to 110, with a higher score representing a healthier diet. Varraso, et al. investigated 73,228 female from 1984 to 2000 and 47,026 men from 1986 to 1998. Over the study period, 723 cases of newly diagnosed COPD occurred in women and 167 in men. In the pooled analysis, a significant negative association was seen between the risk of newly diagnosed COPD and fifths of the AHEI-2010: hazard ratios were 0.81 for the second fifth, 0.98 for the third fifth, 0.74 for the fourth fifth, and 0.67 for participants who ate the healthiest diet according to the AHEI-2010, compared with those who ate the less healthy diet (Table 10.3) [12]. In this section, components of AHEI-2010 and amino acids, vitamins, and antioxidants are reviewed as oral nutritional supplements.
Table 10.2
11 components of AHEI-2010
Highest intakes to be ideal |
Vegetables |
Fruits |
Whole grains |
Nuts and legumes |
Long-chain omega-3 fats |
Polyunsaturated fatty acids |
Moderate intake to be ideal |
Alchol |
Lowest intake to be ideal |
Suga-sweetened drinks and fruit juice |
Red and processed meat |
Trans fat |
Sodium |
Table 10.3
Association between AHEI-2010 and risk of newly diagnosed COPD
AHEI-2010 | Women | Men | Total | |||||||
|---|---|---|---|---|---|---|---|---|---|---|
No | Person years | Hazard ratio (95 % CI)a | No | Person years | Hazard ratio (95 % CI)a | No | Hazard ratio (95 % CI)a | P valueb | I2c | |
Lowest fifthd | 198 | 221 312 | 1.00 (referent) | 53 | 103 567 | 1.00 (referent) | 251 | 1.00 (referent) | ||
Second fifth | 168 | 226 830 | 0.98 (0.80–1.21) | 27 | 104 165 | 0.61 (0.38–0.97) | 195 | 0.81 (0.51–1.29) | 0.07 | 81.0 |
Third fifth | 161 | 228 007 | 1.01 (0.81–1.25) | 34 | 104 398 | 0.85 (0.55–1.33) | 195 | 0.98 (0.80–1.18) | 0.50 | 0.0 |
Fourth fifth | 104 | 229 754 | 0.70 (0.54–0.89) | 33 | 104 817 | 0.90 (0.57–1.43) | 137 | 0.74 (0.59–0.92) | 0.33 | 0.0 |
Highest fifthd | 92 | 231 204 | 0.69 (0.53–0.90) | 20 | 104 818 | 0.60 (0.34–1.03) | 112 | 0.67 (0.53–0.85) | 0.63 | 0.0 |
P for trend | <0.001 | 0.27 | <0.001 | |||||||
10.4.2.1 The Highest Intakes Were Supposed to Be Ideal
Vegetables
Two hundred seventy-eight patients with COPD diagnosed within the past 4 years and 340 community-based controls were investigated in Japan. The mean vegetable intakes of patients with COPD were significantly lower than healthy controls (155.62 vs 199.14 g/day). A substantial reduction in COPD risk was found by increasing daily total vegetable intake. This study provided evidence of an inverse association between vegetable consumption and the risk of COPD [13].
Whole Grains, Fruit, Nuts, and Legumes
Whole grains including cereal, fruit, and food grains contain many fibers and antioxidant components. A study from Japan showed fruit intake is lower in COPD patients compared with healthy individuals (248.32 vs 304.09 g/day), and less consumption of dietary fiber is associated with more prevalence of COPD [13]. Investigation of fiber intake with risk of COPD in 11,897 US men and women showed odds ratios of COPD for the highest versus lowest quintiles of intake were 0.85 for total fiber, 0.83 for cereal fiber, and 0.72 for fruit fiber. Dietary fiber in whole grains and fruit is independently associated with reduced risk of COPD [14].
Investigation of 832 cases of COPD showed total dietary fiber intake was negatively associated with risk of newly diagnosed COPD. Particullarly, cereal fiber was significantly associated with newly diagnosed COPD independently of other fiber sources, indicating a diet high in fiber, and possibly specifically cereal fiber, may reduce risk of developing COPD [15].
Long-Chain Polyunsaturated Fatty Acids
The anti-inflammatory activity of long-chain n-3 polyunsaturated fatty acids (PUFAs) has been established. In the cross-sectional associations between the dietary intake of n-3 fatty acid and risk of COPD in 8960 current or former smokers, higher fish consumption, and especially higher intake of PUFAs, was associated with lower odds for COPD. In this study, three case definitions of COPD were used: symptoms of chronic bronchitis, physician-diagnosed emphysema reported by the subject, and spirometrically detected COPD. The adjusted odds ratio for the highest quartile of intake as compared with the lowest quartile was 0.66 for chronic bronchitis, 0.31 for physician-diagnosed emphysema, and 0.50 for spirometrically detected COPD [16].
10.4.2.2 Moderate Intake Was Supposed to Be Ideal
Alcohol
One thousand eighty-two COPD patients completed baseline alcohol questionnaires and were included in analysis mainly to evaluate the relationship between alcohol consumption and COPD. In this study, there were small but statistically significant differences in FEV1 among the alcohol intake categories. Heavy alcohol users (>60 drinks/month) have more FEV1, though a higher mean smoking pack-year history. This data suggested some protective role of alcohol in patients with COPD, though the number of patients reporting heavy alcohol intake was small and further study is needed to determine the effect of heavy alcohol intake [17].
10.4.2.3 Lowest Intake Were Supposed to Be Ideal
Sugar-Sweetened Soft Drinks
There was a statistically significant correlation between intake of soft drinks and prevalence of chronic bronchitis. Intake of soda ≥5 times a week was associated with nearly twice the likelihood of having chronic bronchitis. Since this study is cross-sectional analysis for adults aged 20–55 y, soft drink intake may contribute to the risk of future COPD [18].
Red and Processed Meat
In 111 self-reported cases of newly diagnosed COPD among 42,915 men, the consumption of cured meats was positively associated with the risk of newly diagnosed COPD for highest versus lowest intake (relative risk = 2.64). Interstingly, the consumption of cured meats was not associated with the risk of adult-onset asthma [19]. Cured meats contain a lot of nitrites which generate reactive nitrogen species and may worsen the adverse effects of smoking on risk of COPD.
Sodium
In a study from Japan with participants including 278 COPD patients, FEV1 and FEV1% predicted were positively correlated with calcium, iron, potassium, and selenium but negatively correlated with sodium. This data suggested sodium intake may have some deleterious effect in patients with COPD [20].
10.4.2.4 Essential Amino Acid
Protein depletion is a hallmark of cachexia. Whole-body protein breakdown and synthesis is elevated in patients with stable severe COPD compared with healthy individuals. Eighty-eight COPD outpatients were randomized to receive essential amino acid (EAA) or placebo for 12 weeks. After 12 weeks, the physical performance and muscle strength were significantly increased versus baseline only in patients who received EAA. Similarly, the SGRQ score improved significantly in patients who received EAA, and changes were significantly different from those measured in the placebo group [21]. These data suggested intake of EAA may be benefical in patients with COPD.
10.4.2.5 Vitamins
Vitamin D deficiency is associated with reduced lung function. A cross-sectional survey using data from the Third National Health and Nutrition Examination Survey that included 14,091 people found that the mean FEV and mean FVC were 126 and 172 mL greater, respectively, for the highest quintile of serum 25-hydroxy vitamin D level compared to the lowest quintile [22]. In 50 patients with COPD who followed a rehabilitation program randomized to comparing a monthly dose of 100.000 IU of vitamin D with placebo, Vitamin D intervention resulted in significantly larger improvements in inspiratory muscle strength (−11 ± 12 cmH2O vs 0 ± 14 cmH2O). However, improvements in quadriceps strength or 6-min walking distance were not significantly different from the effects in the placebo group [23]. Further studies are necessary to determine whether supplementation with vitamin D is of any benefit in patients with COPD.
Vitamin E is important of dietary antioxidants. As a fat-soluble antioxidant, Vitamin E stops the production of oxidative stress formed when fat undergoes oxidation. A post hoc analysis of 38,597 women without chronic lung disease at baseline was randomized double-blind placebo-controlled factorial trial of vitamin E (600 IU every other day) and aspirin (100 mg every other day). The effect of randomized vitamin E assignment on self-reported physician-diagnosed chronic lung disease including COPD was evaluated. During 10 years of follow-up, 760 first occurrences of chronic lung disease were reported in the vitamin E arm compared with 846 in the placebo arm (HR 0.90; 10 % reduction in the risk of incident chronic lung disease) [24]. This study suggested intake of Vitamin E may have protective effect in the risk of COPD.
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