Dietary approaches are shaping up as a key aspect of chronic obstructive pulmonary disease (COPD) management.
COPD encompasses both extremes of weight. Obesity affects some 54% of patients in the U.S., but underweight is also an issue, affecting anywhere from 4% to 40% across populations, with particularly high rates in severe (grade 3 and 4) COPD due to a procatabolic state contributing to weight loss and muscle wasting.
Overweight or obesity in COPD is linked with a higher prevalence of comorbid diseases, including hypertension, diabetes, osteoarthritis, and heart failure compared with normal weight. Obesity is also associated with worse dyspnea, lower quality of life, and poorer exercise capacity as well as more COPD exacerbations, although with a paradox of a survival advantage due to reduction in static volume.
"Certainly, that's only making things harder for those who have chronic lung disease if they're carrying excessive weight," noted Christopher Mosher, MD, MHS, of Duke University in Durham, North Carolina.
Impact of Diet
An unhealthy diet may increase risk of developing COPD. A 2022 systematic review pointed to intake of fruit, vegetables, dietary fibers, vitamins C and E, polyphenols, and β-carotene as individually associated with lower COPD risk, whereas risk rose with consumption of processed meat.
Once developed, COPD patients' diet can affect the decline in pulmonary function and respiratory symptoms, although the review noted data are "limited and inconsistent" for specific dietary components other than a clear benefit from vitamin D intake. High adherence to the Mediterranean diet, for example, was associated with decreased fatigue and increased independence in activities of daily living in older COPD patients in an observational study from Turkey.
"Compared with other chronic diseases with similar burdens on quality of life and healthcare costs, such as cancer and cardiovascular disease, less is known about how lifestyle factors other than -- and independent of -- smoking influence pulmonary function and the development of COPD," another 2019 review agreed.
Nutritional screening, though, shouldn't just rely on a one-time weight or body mass index check, which are "insufficient to identify the presence of nutritional disorders and do not provide detailed body composition information to inform treatment choices," according to a 2023 review. Thoracic CT, dual energy X-ray absorptiometry, and bio-electrical impedance can provide a better picture of nutritional status.
The review concluded that physicians should promote consuming a healthy diet to their COPD patients, although exactly how to manage obesity with dietary or bariatric therapy needs to be better defined.
Practical Aspects
For COPD patients with a nutritional goal to lose weight, some simple approaches can do a lot of good, Mosher noted, pointing to the importance of really focusing on portion sizes and the types of food they're putting on their plate.
"It's well known -- and patients have probably heard this a lot -- but really eliminating the amount of calories that they're drinking" helps, he noted. "Any kind of juice and sodas ... eliminating those could be an easy way to shave several hundreds of calories off their daily intake."
Exercise is important but not really an effective way to lose weight, Mosher emphasized. "I tell them the battle for weight loss is won at the dinner table, not in the gym ... particularly for this patient population, which their ability to expend themselves is going to be more limited than, say, a 20-year-old."
For patients on the opposite end of the spectrum with underweight, the period during and after an acute exacerbation of COPD represents a "therapeutic window of opportunity for multimodal and personalized nutritional interventions beyond malnutrition, but optimized intervention strategies and composition of interventions needs to be elaborated in future studies," the 2023 review noted.
Especially if they are starting a pulmonary rehabilitation or exercise program, "it's going to be particularly important that they really give their body the fuel it's going to need to keep up with these metabolic demands," Mosher said. He recommends patients focus on eating enough protein and enough calories in general.
"I tell them honestly, you may not have had a doctor tell you this before, but now is not the time to be skipping ice cream. If you want to have ice cream every day, that's fine," he said. "Obviously there's some limit to that. You don't want patients to go above and beyond, but really working on getting in a sufficient amount of calories."
Disclosures
Mosher disclosed research funding from the National Institutes of Health, AstraZeneca, and the Patient-Centered Outcomes Research Institute as well as consulting for the COPD Foundation, GSK, Genentech, Guidepoint, and International Consulting Associates.
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