COVER STORY
COPD: NUTRITION AND WEIGHT MANAGEMENT Alice Lunt, Health Advisor for BLF and Cardiorespiratory Dietitian at Royal Brompton Hospital, London
This article has been put together by British Lung Foundation (BLF), Charity that promotes lung health and supports those affected by lung disease.
For full article references please email info@ networkhealth group.co.uk
One of the many lung conditions that good nutritional management is important for is chronic obstructive pulmonary disease (COPD). COPD can have an effect on the whole body. It is, therefore, vital that people living with the condition maintain a healthy weight and eat a balanced varied diet. This will help with maintaining strength and fitness, as well as supporting the body with fighting infections.1 Food provides the body with energy, including energy to breathe. At rest, COPD patients need to use up to an additional 15% of energy compared with a healthy person, to compensate for the extra physical effort required to breathe. This equates to an estimated additional 430-720 calories per day. Should these additional calories not be consumed, the patient will experience significant weight loss and be at an increased risk of cachexia.2 It has been estimated that around 21% of individuals with COPD (up to 630,000 people) are at risk of malnutrition.3 Conversely, COPD can lead to weight gain due to patients becoming less physically active. Carrying additional body weight increases their risk of cardiovascular disease, high blood pressure, high cholesterol and diabetes. Despite this, most current guidelines and evidence focus on being underweight and malnutrition, rather than general optimal health or being overweight. Facts about COPD in the UK: • It is a group of lung conditions where inflammation and damage cause the airways to be narrowed, making it difficult to empty air out of the lungs. • This includes emphysema and chronic bronchitis. • After asthma, COPD is the second
most common lung disease. • Estimated 1.2 million people, or 2% of the population, are living with diagnosed COPD (2011). • Research from BLF also suggests that prevalence is growing. • There is higher prevalence in the North and Scotland than the South of the UK. • Someone is newly diagnosed with COPD every five minutes.4 MAINTAINING A HEALTHY WEIGHT
Someone with COPD may find their weight increases due to being less physically active and, in those needing steroidal medications, their appetite may increase. If a COPD patient is overweight they will require more effort to breathe and move around. Stored fat compresses the lungs making physical activity harder. Bending also becomes very difficult and leads to breathlessness. A Body Mass Index (BMI) of between 20 and 30kg/m2 is a healthy weight for someone with COPD. Alternatively, waist circumference measurement may be more useful (see Figure 1 overleaf). There are a number of practical tips to help patients make dietary changes. Recommend that they: • check portion sizes and try using a smaller plate; • fill up on vegetables or salad - these should cover about half the plate; www.NHDmag.com June 2017 - Issue 125
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FROM HOLDING BACK.. . .TO HOLDING JACK
. .In a shot SOMETIMES PATIENTS CAN’T MEET THE ENERGY REQUIREMENTS THEY NEED THROUGH NORMAL DIET AND ONS ALONE.1
IT’s BEEN SHOWN TO:
Little wonder it helps so much
55% 92% 67%
Increase calorie intake by 55% IN ADDITION TO NORMAL diet 2 HAVE 92% COMPLIANCE OF THE PRESCRIBED DAILY AMOUNT3 Reduce ‘MUST’ scoreS IN 67% OF PATIENTS*3,4
Pro-Cal shot is a food for special medical purposes and should be used under strict medical supervision. ® Reg. Trademarks of Société des Produits Nestlé S.A.
®
Vitaflo International Ltd, Suite 1.11, South Harrington Building, 182 Sefton Street, Brunswick Business Park, Liverpool L3 4BQ, UK. Tel: 0151 709 9020 vitaflo.co.uk abbottnutrition.co.uk A Nestlé Health Science Company
References 1. Wright C. CN Focus 2012;4(3):17-19. 2. Sharma M et al. Colorectal Disease 2013;15: 885-891. 3. Data on file. 4. Malnutrition Advisory Group (MAG) 2011.Malnutrition Universal Screening Tool. www.bapen.org.uk/pdfs/must/must_full.pdf. Accessed September 2016. *Of those who were at medium or high risk of malnutrition at baseline, 67% were at low risk of malnutrition on study completion.
All information correct at the time of print. December 2016
Figure 1: Ideal waist circumference measurement
• avoid frying foods; instead they should try to grill, steam, boil, bake, dry roast or microwave; • choose low-fat options such as skimmed or semi-skimmed milk, low-fat spread and low-fat yoghurts; • choose ‘diet’, or ‘no added sugar’ drinks and puddings; • try sweeteners or gradually reduce the amount of sugar added; • check food labels; • exercise as able, often pulmonary rehabilitation groups are appropriate. In addition, try to get patients to think about why they eat: • Why do they snack between meals? • Are they really hungry? • Is this hunger or actually thirst? • Are they bored and eating out of habit or for comfort? • Have they tried distracting themselves with another activity? SPECIFIC NUTRIENTS
Eating a well-balanced diet, with the right portions of the five key food groups, will not only help patients maintain a healthy weight, but will ensure that they get the right nutrients
to keep them strong and well. The Eatwell Guide is a helpful overview not only for those with COPD, but also friends and family (see Figure 2 overleaf).5 Each of these food groups will contribute to keeping patients healthy: Fruit and vegetables contain vitamins and minerals which boost the immune system and help fight off chest infections.6 Most people can get everything they need by eating a varied well-balanced diet and, therefore, do not need to take a multivitamin. They’re also a great source of fibre, which can help you feel full if trying to lose weight. Starchy carbohydrates give the body energy to perform a range of tasks including breathing. Patients should aim for high fibre or wholegrain versions, which can help them to feel full, keep bowels moving and contain more nutrients including B vitamins and folic acid. Protein helps to keep muscles strong, including the muscles in the chest that help the ribs expand when breathing. It’s also important for the immune system and blood cells.7 Due to the time it takes to digest protein, it helps us to feel full and when taken from a variety of sources, i.e. fish, pulses and lean meats, it can help with balancing intake of fat, fibre and omega-3. www.NHDmag.com June 2017 - Issue 125
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MY COPD MEANS MY APPETITE HASN’T BEEN VERY GOOD...
Figure 2: Eatwell Guide
Eatwell Guide
Check the label on packaged foods
Use the Eatwell Guide to help you get a balance of healthier and more sustainable food. It shows how much of what you eat overall should come from each food group.
Each serving (150g) contains Energy 1046kJ 250kcal
13%
Fat
Saturates Sugars
3.0g 1.3g LOW
LOW
4%
7%
Salt
34g 0.9g HIGH
38% 15%
of an adult’s reference intake Typical values (as sold) per 100g: 697kJ/ 167kcal
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Whole grain cereal
Bagels Whole wheat pasta
Porridge
Limit fruit juice and/or smoothies to a total of 150ml a day.
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Tuna
Plain s
Beans lower salt and s ugar
Chick peas
Spaghetti
L o w f at s o f t ch e es e
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Crisps
Eat less often and in small amounts
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Frozen peas
Sauce
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s, p Ea ulse s, fis so t mor h, eg gs, mea red urced e beans t and other proteins and and fish p proc er we pulses, 2 portions of sustainably ek, one esse of which is oily. Eat less d mea t
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Per day
2000kcal
Oil & spreads
Choose unsaturated oils and use in small amounts
2500kcal = ALL FOOD + ALL DRINKS
Source: Public Health England in association with the Welsh Government, Food Standards Scotland and the Food Standards Agency in Northern Ireland
© Crown copyright 2016
Foods that contain protein are also a good source of important minerals, including: selenium (keeps the immune system healthy), iron (helps carry oxygen around the body) and zinc (which helps the body’s ability to heal). Dairy foods are a good source of proteins, vitamins and minerals, including calcium which helps to keep your bones healthy. When taking steroids or becoming less active, the mineral calcium is especially important. This is because steroids can weaken bones and increase the risk of brittle bones or osteoporosis.8 Dairy foods can be high in fat causing patients to put on weight. If overweight, they should be advised to choose lower fat alternatives where possible (i.e. lower-fat and lower-sugar products like 1% fat milk, reduced-fat cheese or plain lowfat yoghurt).
this. Generally, dairy should be included unless diagnosed with a food allergy. If someone reports that dairy makes their mucus stickier or harder to shift, suggest rinsing the mouth or drinking a little water following consumption of milk products. If cows’ milk causes problems, other calcium enriched non-dairy products, such as dairyfree milks, yoghurts, desserts or cheese are recommended to help maintain bone strength.
Crown copyright. Source: Public Health England in association with the Welsh government, Food Standards Scotland and the Food Standards Agency in Northern Ireland.
FACT OR FICTION? MILK AND MUCUS9,10,11
Some people worry that if they eat dairy foods they’ll produce more mucus. However, currently there’s not enough scientific evidence to support
OILS
Oils in small amounts in a diet are important to provide certain vitamins: vitamins A and E (for fighting infections), vitamin D (for healthy, strong bones) and vitamin K (for regulating blood clotting and healing wounds). These are found in certain foods, such as nuts, oily fish, avocado and sunflower and olive oils. However, eating too much animal and saturated fat can make it harder to maintain a healthy body weight and can increase the risk of high cholesterol and heart disease. www.NHDmag.com June 2017 - Issue 125
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CONDITIONS & DISORDERS
Many people with a lung condition have a dry mouth. This can be caused by breathing through the mouth, taking certain inhaled medications and using oxygen treatment. Food and drinks high in fat, salt and sugar, such as cakes, crisps and sugary soft drinks, which are not needed in a diet, have minimal nutritional value and should be eaten less often in small amounts.
A good aim would be for a patient to drink a minimum of six to eight cups of fluid a day. This can include water, tea, coffee, milk, squash or fruit juice.13
VITAMIN D
Having a lung condition can have a number of adverse effects on someone’s diet. Patients may experience dry mouth, taste changes, or be too breathless to eat, for example. In these situations, there are a number of steps which can help them maintain a healthy weight and balanced diet. Sometimes people with lung conditions feel too breathless to eat, chew or swallow. Recommend that they: • choose softer, moist foods that are easier to chew and swallow;14 • have nourishing liquids such as milk, smoothies, juice, and soups; • try eating smaller, more frequent meals and snacks; • take time when eating and try to swallow every mouthful before going onto the next.
COPD patients are at risk of being deficient in vitamin D. Vitamin D works with calcium and phosphorous from dairy foods in the body for healthy bones, muscles and teeth. Vitamin D comes from sunshine, not food, therefore, eating a healthy balanced diet is unlikely to provide enough vitamin D. People should consider taking a daily supplement of vitamin D (10 micrograms), especially the following who are at higher risk of becoming vitamin D deficient: • People over 65 years old: this is because their skin is not as good at making vitamin D. • People with darker skin tones: this includes people of Asian, African, Afro-Caribbean and Middle Eastern descent. • People who always cover most of their skin when they’re outside. • People who spend very little time outside during the summer: this includes people who are housebound, shop or office workers and night shift workers. • Pregnant women and breastfeeding mothers. • The further north you live, the more at risk you are of becoming vitamin D deficient and you’re also more at risk if you live somewhere where the air is polluted.12 KEEP DRINKING WATER
It is very important for COPD patients to drink plenty of fluid. This helps to keep them hydrated and keeps mucus moving. If mucus sits in the airways and lungs, they are more likely to get an infection. 16
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HOW CAN FOOD AFFECT SYMPTOMS?
Many people with a lung condition have a dry mouth. This can be caused by breathing through the mouth, taking certain inhaled medications and using oxygen treatment. Recommend the following: • Make sure the patient is drinking enough fluids - at least six to eight cups a day. Ice cold drinks can be refreshing. • Aim for them to eat more soft foods, use more sauces such as gravy and cheese sauce and eat dishes that are moist such as stews. • After using inhalers, they must try to remember to rinse their mouth out and gargle with water. • Make sure they look after their teeth and mouth by brushing regularly and using dental floss. • Let them try sugar-free gum or mints, frozen grapes, pineapple or orange segments to help produce more saliva.
• Smoking and alcohol can irritate a dry mouth. These should be reduced to limit any discomfort. • If a dry mouth is causing soreness or problems with eating then they should speak to a doctor. Products that help produce saliva are available on prescription. A dry mouth can mean that a patient’s sense of taste changes. This is very common. They can try experimenting with different herbs, spices, chutneys and pickles, but should avoid adding extra salt. The feeling of breathlessness can make people gulp air when eating which leads to bloating or trapped wind. Recommend that they: • eat in a relaxed environment and sit in an upright position; • don’t rush and make sure food is chewed well; • limit fizzy drinks; • watch out for some foods which can produce more gas than others, such as cabbage, sprouts, broccoli, cauliflower and beans; • try using peppermint which can help some people with bloating and trapped wind. This can be in the form of tea, a cordial or a capsule. UNINTENTIONAL WEIGHT LOSS
At the opposite end, patients with COPD may lose weight because eating makes them breathless. They may also find it more difficult to shop and prepare meals if they are tired or out of breath.2 This puts patients at risk of malnutrition, which can in turn weaken the breathing muscles and lead to chest infections.13 Patients who find they are losing weight or have lost their appetite can be advised to do the following:
• Eat little and often, for example, having snacks between meals throughout the day. • Have nourishing drinks such as full-fat milk, hot chocolate, malted drinks, flavoured milk and milkshakes or smoothies. • Avoid drinking before a meal instead drink after eating and between meals. • Fortification of meals, i.e. having full-fat items, adding cheese or milk to foods. • They may need nutritional supplements, or add three to four tablespoons of dried skimmed milk powder to a pint of milk. Local meal delivery services may be beneficial, or referral to a social services team which might be able to provide an occupational therapy assessment and equipment around the house to make life easier.
Summary check list: • Working towards an optimal weight and waist circumference • Balanced and varied diet in line with Eatwell Guide • Adequate protein • Sources of calcium • Vitamin D supplement may be required • Well hydrated • Is lack of food or too much food affecting their symptoms? SUMMARY
In summary, being a healthy weight and having good nutritional intake are very important for people living with COPD. If a patient is very overweight, it becomes harder for their heart and lungs to supply oxygen to the body. Likewise, if they are too thin they are at an increased risk of infections. Eating a balanced and varied diet will aid them in fighting infections. When patients are feeling strong and well, healthy eating will also help keep them stay this way.1
For further information: • British Lung foundation at www.blf.org.uk. The BLF Helpline on 03000 030 555 have a friendly helpline team who can offer advice on healthy eating and answer questions on any aspect of living with a lung condition. • For more information on healthy eating go to www.nhs.uk or the British Dietetic Association food facts website www.bda.uk.com/foodfact ; • For details of local food delivery services go to www.gov.uk www.NHDmag.com June 2017 - Issue 125
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