Nutrition is increasingly recognized as contributing to chronic disease development and progression. For COPD patients, weight loss, low body weight, and muscle wasting are common in advanced disease and associated with worse outcomes. Malnutrition in COPD can be caused by the inflammatory process, energy imbalance, medications, and reduced physical activity. The Mediterranean diet may benefit COPD as it is high in antioxidants from fruits and vegetables and anti-inflammatory omega-3 fatty acids. Nutritional supplements can help COPD patients gain weight and increase muscle strength. For acute COPD exacerbations, small, frequent doses of oral nutritional supplements are recommended to avoid discomfort and improve compliance.

1. Nutrition In Respiratory Diseases
Dr KUMAR UTSAV
MD – Respiratory Medicine
Director – Agrim Pulmonology
Chest Clinic & Agrim Hospital

2. Brain Triggers
• How my lecture should
affect your practice?
• Diet and nutrition are
increasingly becoming
recognised as modifiable
contributors to chronic
disease development and
progression.

3. Learning from the
past, educating the
Present
for a better future.
• Our Ancient knowledge is proven right
over and over.
• Western Civilization is adopting our
methods, understanding its
importance and using it to make their
life better.
• We sadly are forgetting the treasure of
knowledge our elders left for us.

4. • A Local Disease with systemic Side effects.
• There is an increase in Systemic Inflammation leading to increase in Energy
expenditure and due to multifactorial reasons there is decrease in energy
intake(decreased appetite, depression, lower physical activity and dyspnoea
while eating) leading to Negative energy balance
• Weight loss, low body weight and muscle wasting are common in COPD
patients with advanced disease and are associated with reduced survival
time and an increased risk of exacerbation.
• COPD has profound effects on skeletal muscle (sarcopenia and cachexia)
and bone (osteoporosis).
• Weight loss and being underweight are associated with poor prognosis and
increased mortality
undernutrition is most commonly
recognised as a feature of COPD

5. MALNUTRITION in COPD
• Reported prevalence rates vary considerably from 9% to 63%,
• MALNUTRITION IN COPD can be attributed to a number of factors,
including the disease process itself (systemic inflammation), energy
imbalance (positive or negative), medication treatment (oral
corticosteroids) and lifestyle (inactivity). Loss of FFM(fat free Mass),
which often occurs with ageing, can be accelerated in the presence of
chronic inflammatory disease

6. • The progressive nature of COPD disease, leading to worsening
respiratory function and nutrition impact symptoms, is one cause for
worsening nutritional status. Conversely, poor nutritional status
resulting in fat‐free mass (FFM) losses and weakness, particularly in
muscles associated with breathing, could result in an impaired ability
to expectorate. This could increase the risk of recurrent pulmonary
infections and hasten the progression of Disease.
• social deprivation has also been found to be a significant predictor of
malnutrition in COPD

7. HOW TO CHECK FOR MALNUTRITION IN OPD
• A mid‐upper‐arm circumference (MUAC) of < 23 cm often indicated a
• BMI of < 20 kg/m2
• Bioelectrical impedance analysis is increasingly being used in COPD to
assess changes in FFM and as an illness indicator to help predict
prognosis.
• Patient hydration status, clinical condition (e.g. raised C‐reactive
protein, white cell count and low serum albumin levels), history of
excessive alcohol consumption, and low phosphate, potassium,
calcium and magnesium levels should be reviewed.

9. Dietary Patterns
Beneficial to COPD
patients –
Mediterranean
diet
A diet of a type traditional in
Mediterranean countries, characterized
especially by a high consumption of
vegetables and olive oil and moderate
consumption of protein, and thought to
confer health benefits.

10. Diet Description
• The Mediterranean diet has been found to have protective effects for
allergic respiratory diseases in epidemiological studies. This dietary
pattern consists of a high intake of minimally processed plant foods,
namely; fruit, vegetables, breads, cereals, beans, nuts and seeds, low
to moderate intake of dairy foods, fish, poultry and wine and low
intake of red meat & avoidance of Fast food.
• The Mediterranean diet is inversely associated with atopy and has a
protective effect on atopy, wheezing and asthma symptoms. A high
Mediterranean diet score during pregnancy was protective for
persistent wheeze and atopic wheeze in children at 6.5 years of age,
again there is a strong association in its adherence & Asthma Control.

11. WHAT TO AVOID IN COPD
• The “western” dietary pattern, prevalent in developed countries, is
characterised by high consumption of refined grains, cured and red
meats, desserts and sweets, french fries, and high-fat dairy products.
• a diet low in fruit and vegetables and high in meat and potatoes has
been associated with an increased likelihood of developing COPD.

12. Fruits & Vegetables
• Increased fruit and vegetable intake may be protective against COPD
development, with consumption of a “prudent” diet including
increased fruit and vegetables being protective against lung function
decline, However a long term intervention is needed to provide
therapeutic effects.

13. Omega 3 Fatty
Acids (PUFA)
• Omega-3 polyunsaturated fatty acids (PUFA) from marine sources and
supplements have been shown to be anti-inflammatory through several
cellular mechanism.
• Long chain omega-3 PUFA’s decrease inflammatory cell production.
• PUFA reduce production of ROS in Neutrophils. Hence reducing
inflammation.
• Omega-3 PUFA may have positive effects in COPD, as higher levels of DHA
in serum were found to decrease the risk of developing COPD.
• Omega-3 found lower levels of TNF-α [45] and improved rehabilitation
outcomes.

14. Role of Anti-Oxidants
• . Antioxidants including vitamin C, vitamin E, flavonoids and
carotenoids are abundantly present in fruits and vegetables, as well
as nuts, vegetable oils, cocoa, red wine and green tea.
• α-tocopherol is a form of vitamin E, helps maintain integrity of
membrane fatty acids, hence prevents Lipid peroxidation.
• Carotenoids - ; α- and β-carotene, lycopene, lutein and β-
cryptoxanthin; shown to benefit respiratory health due to their ability
to scavenge ROS and reduce oxidative stress.
• lycopene intake has been positively correlated with FEV1 in both
asthma and COPD. Lycopene supplementation could suppress
neutrophilic airway inflammation

15. Vitamin C & Vitamin E
• Adequate dosing of Vitamin C, Reduces incidence of Wheezing in
Animal models.
• Vitamin E works synergistically with vitamin C, as following
neutralisation of ROS; Supplementation α-tocopherol( VITAMIN E ) in
Animal Models reduced allergic airway inflammation and AHR.
Vitamin E has been shown to reduce biomarkers of oxidative stress in
adults with COPD

16. Vitamin D -
• Vitamin D appears to have a protective role against the susceptibility to and
severity of these infections.
• Production of antimicrobial cathelicidins and defensins that kill bacteria and
induce wound repair.
• Activated vitamin D also decreases the expression of Viral disease receptors in
endothelial cell cultures and PBMC’s
• active vitamin D inhibits airway smooth muscle (ASM) cell proliferation &
deficiency impairs normal lung development
• vitamin D can inhibit Th1 and Th2 cell cytokine production
• LOW vitamin D levels in COPD patients were found to be a risk factor for COPD
• Its deficiency is associated with negative respiratory and immune outcomes.

17. Minerals
• Dietary magnesium may have beneficial bronchodilator effects in
asthma & COPD. Low dietary magnesium intake has been associated
with negative effects on bronchial smooth muscle in severe asthma.
• Low levels of Calcium & Potassium also are detrimental towards
patient health.

18. Systemic Inflammation & Cigarette Smoking
systemic inflammation which is a hallmark of COPD, may influence energy
intake and expenditure. Cigarette smoke may also have deleterious effects
on body composition in addition to the systemic effects of COPD. Smoking
causes muscle fibre atrophy and decreased muscle oxidative capacity shown
in cohorts of non-COPD smokers.
• Increased oxidative stress, due to increased mitochondrial ROS production,
occurs both systemically and in muscle tissue in cachectic COPD patients
and is negatively associated with fat free mass (FFM) and muscle strength
in COPD patients
• An average weight gain of 3.8 kg in females and 2.8 kg in males has been
observed in individuals who successfully stopped smoking for >1 year

19. ROLE OF NUTRITIONAL SUPPLEMENTS.
• Nutritional supplementation therapy in undernourished COPD
patients has been shown to induce weight gain, increase fat free
mass, increase grip strength and exercise tolerance as well as improve
quality of life.
• macronutrient composition of the nutritional supplement along with
Respiratory Rehabilitation Exercise is beneficial to the patient.
• Branched chain amino acid supplementation in COPD is associated
with positive results including increases in whole body protein
synthesis, body weight, fat free mass and arterial blood oxygen levels

20. ESPEN recommendation of Oral Nutritional Supplements(
ONS) in COPD
Subject Recommendations
Indication Nutrition in combination with exercise and anabolic pharmacotherapy has the
potential to improve nutritional status and function
Application Frequent small amounts of oral nutritional supplements (ONS) are preferred to avoid
postprandial dyspnoea and satiety and to improve compliance.
Type of Formula In stable COPD there is no additional advantage of disease specific low carbohydrate,
high fat ONS compared to standard high protein or high energy ONS.
Anker, S.D., John, M., Pedersen, P.U., et al. (2006). ESPEN Guidelines on Enteral Nutrition: Cardiology and pulmonology. Clin Nutr, 25(2):311-8.
Based on the available evidence it is concluded that in clinically stable COPD patients, optimal efficacy of
ONS is best achieved not by manipulating macronutrient composition but by giving EN in small frequent
doses thereby avoiding complications and improving compliance composition.

21. HELGA SAUDNY-UNTERBERGER, JAMES G. MARTIN, and KATHERINE GRAY-DONALD
Results: Forced vital capacity (% predicted) improved in the
treatment group as compared with the control group
(+8.7% versus -3.5%, p=0.015). Change in FEV1 was in the
same direction but not significantly different (p= 0.099).
Conclusion: An important increase in oral intake in patients
hospitalized with an acute exacerbation is possible using
ONS.
Saudny-Unterberger, H., Martin, J.G., Gray-Donald, K. (1997). Impact of nutritional support on functional status during an acute exacerbation of chronic obstructive pulmonary disease. Am J Respir Crit Care Med, 156(3 Pt
1):794-9.
Impact of nutritional support on functional status during an
acute exacerbation of chronic obstructive pulmonary disease

22. Benefits of ONS1,2
Improve hand grip strength
Improve respiratory muscle strength
Improve exercise performance
Improve patients’ nutritional intake
1Cramer, J.T., Cruz-Jentoft, A.J., Landi, F., et al. (2016). Impacts of High-Protein Oral Nutritional Supplements Among Malnourished Men and Women with Sarcopenia: A Multicenter, Randomized, Double-Blinded, Controlled
Trial. J Am Med Dir Assoc, 17(11):1044-1055. 2Alibakhshi E, Shirvani H. (2015). Nutritional Status in Patients with Chronic Obstruction Pulmonary Disease (COPD) - Review Article. EC Nutrition, 2(1): 267-274.
Improve weight
Improve quality of life
Increase energy and protein
without affecting dietary
intake

23. WHAT TO DO IN ACUTE EVENT OF COPD
LUNG ATTACK
• Patient to khayega nai.. Tab Kya karenge?? ICU mein hai..
• Generally patients aise hi milte hain pehli baar
• Maintain a decent protein Intake of around 1.5 gm / KG / day by way
of nutritional supplements. Don’t make the patient Over-eat, it
doesn’t help too (REFEEDING SYNDROME). Just decent
supplementation helps.

24. MALNUTRITION IN TUBERCULOSIS
• Poverty and food insecurity are both causes and consequences of TB
• An adequate diet, containing all essential macro- and micronutrients, is
necessary for the well-being and health of all people, including those with
TB infection or TB disease.
• Concerns about weight loss or failure to gain weight during
TB treatment should trigger further clinical assessment (e.g.
resistance to TB drugs, poor adherence, comorbid conditions) and nutrition
assessment of the causes of undernutrition, in order to determine the
most appropriate interventions
• TB is commonly accompanied by comorbidities such as HIV, diabetes
mellitus, smoking and alcohol or substance abuse, which have their own
nutritional implications, and these should be fully considered

25. What to give in
a TB patient?
• At OPD :
• Patient comes to you,
• U prescribe AKT, Advise sputum
test , get xray done.
• Agla sawal 1 crore rupaiye ke liye
Dewiyon aur Sajaanoon
“Dr sahab kaa khaaiyin … “

26. What to prescribe apart from a protein rich
diet
• Protein intake Upto 1.5 gm / kg / day. In form of fish, eggs, paneer,
Chainaa, chicken, mungfalii, chana, Protein powders...
• Prescribe Vitamin D supplemants, Multivitamins(vitamins C and E,
retinol, zinc, iron and selenium). Advise Calcium too.
• Check for Iron MCV levels – kam hai toh IRON ki goli ; jyada hai toh
Vitamin b12 ki goli.
• Advise decent PUFA / Omega 3 Fatty acid intake.

27. Thank You