Body Composition Abnormalities Body Composition Abnormalities and Nutrional Support in and Nutrional Support in

ChronicPulmonary DisseasesChronicPulmonary Disseases

Doç.Dr. Pınar ErgünDoç.Dr. Pınar ErgünAtatürk Chest Diseases and Chest Surgery Atatürk Chest Diseases and Chest Surgery Center/ Pulmonary Rehabilitation- Home Care Center/ Pulmonary Rehabilitation- Home Care UnitUnit

RATIONALERATIONALE

Am J R Crit Care Med 1999;160: 1854-61

Weight is a reversible Weight is a reversible factor in the prognosis of factor in the prognosis of COPD COPD

Tissue wasting pattern: Tissue wasting pattern: body compositionbody composition

CachexiaCachexia SemistarvationSemistarvation SarcopeniaSarcopenia ObesityObesity Sarcopenic Sarcopenic

obesityobesity

Body composition modelsBody composition models

BloodBlood

Fat: SubcutaneousFat: Subcutaneous

Fat: IntraabdominalFat: Intraabdominal

Skeletal muscleSkeletal muscle

Muscle-OrgansMuscle-Organs

BoneBone

Anatomical

Body composition modelsBody composition models

Body w

eig

ht

Fat

free

mass

Lipids

Waters

Minerals

Fat

Proteins

Lipids

Extracellular water

Body c

ell

mass

İntracellular water

Proteins

Minerals

Measurement of body Measurement of body composition composition

Regional

•MRI Scan } muscle, fat distribution

•Dexa Scan } lean, FM, bone mass

(trunc, extremities)

Whole body

•Dexa scan } lean, FM, bone mass

•Skinfold thickness } FM

•Bioelectrical impedance } TBW > FFM

Body composition and Body composition and COPD subtypesCOPD subtypes

Body composition and COPD Body composition and COPD subtypes and healty volunteerssubtypes and healty volunteers

Am J Clic Nutr 2000; 71:733-8

Conclusion; skeletal muscle weakness i associated with wasting of extremity FFM in COPD patients, independent of air-flow obstruction and COPD subtype

Semistarvation

Sarcopeni

cachexia

Wasting pattterns and Wasting pattterns and survivalsurvival

Schols AJCN 2005

•Cachexia= Low BMI + Low FFMI

•Sarcopeni=Low FFMI

•Semistarvation= Low BMI

Body composition, disease Body composition, disease severity and mortalityseverity and mortality

Loss of FFM despite a Loss of FFM despite a normal BMI in(Gold stage normal BMI in(Gold stage 2+3)2+3)

Highest prevelance of Highest prevelance of cachexiain Gold stage 4cachexiain Gold stage 4

Differances between Differances between emphysema and chronic emphysema and chronic bronchitis = Fat massbronchitis = Fat mass

FFM is a better predictor FFM is a better predictor of survival than BMIof survival than BMI

Am J Clin Nutr 2005; 82:53-9

In patients with COPD In patients with COPD weight loss and muscle weight loss and muscle atrophyatrophy

Respiratory and peripheral muscle Respiratory and peripheral muscle functions,functions,

Exercise capacity Exercise capacity Health Related Quality of LifeHealth Related Quality of Life Mortality rates Mortality rates

effected negativelyeffected negatively1-Eur Respir J 1994;7:1793-972-Eur Respir J 1997;10:2807-133-Eur Respir J 1997;10:1575-804-Am J Clin Nutr 2005;82:53-9

FFMI and Bone mineral density in FFMI and Bone mineral density in COPDCOPD

Osteoporosis

Osteopenia

No bone loss

AJRCCM 2004

Weight and fat lossWeight and fat loss

Dietary intake

Energy metabolism

Protein sentezi

Muscle Muscle wastingwasting

Protein syntesis

Protein breakdown

Weight lossWeight loss

Muscles

Energy expenditure

Resting energy expenditure

Systemic inflamation

Energy requirement in physical activity

Lungs

RehabilitationRehabilitation

Exercise Exercise trainingtraining

Electrical Electrical muscle muscle stimulationstimulation

PharmacologicPharmacological interventional intervention

Nutritional Nutritional supportsupport

Body composition

High intensity training in COPD patients is feasible High intensity training in COPD patients is feasible and effective despite ventilatory limitationand effective despite ventilatory limitation

Endurance Endurance training:training:

↑ ↑ muscle oxidative capacitymuscle oxidative capacity

↑↑ exercise exercise performanceperformance

Strength training:Strength training: ↑ ↑ muscle massmuscle mass

↑ ↑ Quadriceps strengthQuadriceps strength

Endurance + Strength

■ ↑↑ Exercise performance

■ ↑↑ Muscle strength

■ ↑↑ Muscle mass,

↓Fat mass

Suboptimal training intensity in Suboptimal training intensity in advance COPDadvance COPD

Patients are unable to participate in Patients are unable to participate in training program due to;training program due to;– Severe dyspnea or gase exchange disturbances,Severe dyspnea or gase exchange disturbances,– Too disabled,Too disabled,– Fear, anxietyFear, anxiety

Weigth loss and muscle catabolism associated with Weigth loss and muscle catabolism associated with exacerbation or episodes of respiratory failure lead exacerbation or episodes of respiratory failure lead to major functional declineto major functional decline

exercise is difficult or imposibleexercise is difficult or imposible

Despite high exercise Despite high exercise intensity:intensity:

No effect of exercise traning per No effect of exercise traning per se on body weight and muscle se on body weight and muscle mass in COPD patients with mass in COPD patients with cachexiacachexia

Schols AJRCCM 1995

Additional Additional StrategiesStrategies

Body composition

Exercise Exercise trainingtraining

Electrical Electrical muscle muscle stimulationstimulation

PharmacologicPharmacological interventional intervention

Nutritional Nutritional supportsupport

Home based neuromuscular electrical stimulation as a new rehabilitative strategy for severely disabled patients with chronic obstructive pulmonary disease (COPD)

Thorax 2002; 57: 333-337

Additional Additional StrategiesStrategies

Body composition

Exercise Exercise trainingtraining

Electrical Electrical muscle muscle stimulationstimulation

PharmacologicPharmacological interventional intervention

Nutritional Nutritional supportsupport

Classifying muscle disease in Classifying muscle disease in COPDCOPD

COPD Muscle COPD Muscle DysfunctionDysfunction

COPD COPD Cachexia Cachexia SyndromeSyndrome

Srength and Srength and endurance endurance reducedreduced

YesYes YesYes

Muscle Muscle inflamation inflamation prominentprominent

No (?)No (?) YesYes

Responds well Responds well to exercise to exercise trainingtraining

YesYes ??

Pulmonary Cachexia Pulmonary Cachexia Syndrome; Pharmacologic Syndrome; Pharmacologic

InterventionsInterventions

Help!

What is the target of therapy?

•Undernutrition ?

•Inflamation ?

Pharmacological interventions Pharmacological interventions in weight loss and muscle in weight loss and muscle atrophyatrophy Restore energy balanceRestore energy balance

Megesterol acetate Fat massFat mass

GhrelinGhrelin Stimulate muscle metabolismKas Stimulate muscle metabolismKas

anabolizmasının stimülasyonuanabolizmasının stimülasyonu

Anabolic steroidsAnabolic steroids

Testesteron Testesteron Fat free mass Fat free mass

GhrelinGhrelin ? ? Decrease muscle catabolismDecrease muscle catabolism

Infliximab (Remicade) ?Infliximab (Remicade) ?

•Chest 2002; 121: 1070-78

•Chest 2005;Ghrelin……Nagaya …

•J Clin Endocrinol Metab 2005;90:268

•İnflixi için…….

Additional Additional StrategiesStrategies

Body composition

Exercise Exercise trainingtraining

Electrical Electrical muscle muscle stimulationstimulation

PharmacologicPharmacological interventional intervention

Nutritional Nutritional supportsupport

Nutritional Nutritional supplementationsupplementation

Restore energy balance and stimulate anabolism

•Balance (elevated) energy requirements

•Stimulate protein synthesis

Enhance efficacy of other interventions;

Exercise, anabolic steroids

Nutrional Support for induviduals with Nutrional Support for induviduals with stabil COPDstabil COPD

Ferreira Im, et al. Cochrane Library 2006

Nutrional support is feasible and effective during Nutrional support is feasible and effective during rehabilitation to improve weight and body compositionrehabilitation to improve weight and body composition

Schols (AJRCCM 1995)Schols (AJRCCM 1995) Positive effects on Positive effects on weight, FM and FFM relative to rehabilitation weight, FM and FFM relative to rehabilitation

alonealone Creutzberg (Nutrition 2000)Creutzberg (Nutrition 2000)

Gains in weight, fat, FFM, muscle functions, exercise capacity Gains in weight, fat, FFM, muscle functions, exercise capacity Patients using systemic steroids less responsivePatients using systemic steroids less responsive

Steiner (Thorax 2004)Steiner (Thorax 2004) Positive effects on weight, FM and exercise capacity relative to rehabilitation Positive effects on weight, FM and exercise capacity relative to rehabilitation

alone, particularly in normal weight subjectsalone, particularly in normal weight subjects Broekhuizen (Thorax 2005)Broekhuizen (Thorax 2005)

Gains in weight, FM, FFM, muscle functions, exercise capacity Gains in weight, FM, FFM, muscle functions, exercise capacity

Body weight

FFM

0

2

4

6

8

-2

P

NS

P

NS

Plasebo

Nutritional support

Is Pulmonary rehabilitation alone sufficient to Is Pulmonary rehabilitation alone sufficient to improve body weight and composition in improve body weight and composition in depleted COPD patients ?depleted COPD patients ? Creutzberg et al. Nutrition 2003

No effect of exercise No effect of exercise traning per se on body traning per se on body weight and muscle mass weight and muscle mass in COPD patients with in COPD patients with cachexiacachexia

Respons for Nutritional support Respons for Nutritional support isn’t same in all COPD patientsisn’t same in all COPD patients

AJRCCM 2000;161:745-52

•AgeAge

•Oral intake/resting energy Oral intake/resting energy expenditureexpenditure

• sTNF-receptor 55sTNF-receptor 55

•Extracellular/intracellular Extracellular/intracellular waterwater

Uneffective

Respiratory functions and BMI similar

For maximum efficacy in For maximum efficacy in nutritional treatment;nutritional treatment;

Caloric contant and amount of oral Caloric contant and amount of oral nutritional supportnutritional support

Macronutrient (CH, Fat)Macronutrient (CH, Fat) Anti-inflamatory modulationAnti-inflamatory modulation

Content, amount and Content, amount and macronutrients in oral nutritional macronutrients in oral nutritional supportssupports

Am J Clin Nutr 2001;73:295-301

•Metabolic and ventilatory response to low caloric nutrients are much more better,

•High CH content provide improvements in respiratory functions, and reduced dyspnea

Postprandial süre

VA

S S

koru

(m

m)

Maximal efficiencyMaximal efficiencyNutrional support; amountNutrional support; amount

Grup A;(3X125ml)

•Predicted=3.4 kg

•Measured =3.3± 2.3 kg

Grup B;(3X200ml)

•Predicted:4.8 kg

•Measured= 1.9± 1.9 kg

Broekhuizen, EJCN 2005

Anti-inflamatory contentAnti-inflamatory content Brockheuzen Brockheuzen

Thorax 2005Thorax 2005

Anti-inflamatory content: Polyunsaturated fatty acids (n3/n6)

•No effect on body weight and skeletal muscle strength on top of exercise and nutritional support

•No effect on systemic inflamation

•Effect on pulmonary inflamation ? (n3 PUFAs can downregulate the activity of NFkB )

•↑ Exercise capacity

Micronutrients

Muscle mass

Muscle metabolism

Strength Endurance

Exercise

Amino acids, Creatine, Antioxidants, PUFA

Creatin supplementation and Creatin supplementation and pulmonary rehabilitation in COPDpulmonary rehabilitation in COPD

Thorax 2005;60:531-37

Effects; Effects; Stimulates appetite in depleted COPD patients with Stimulates appetite in depleted COPD patients with

improvements in body composition improvements in body composition ↑ ↑ FMFM, no effect on FFM, no effect on FFM Reductions in exercise capacityReductions in exercise capacity Reductions in plasma cortisol ve testesteroneReductions in plasma cortisol ve testesterone

Results; not very encouragingResults; not very encouraging

Chest 2002;121:1070-78

Whole body protein breakdown Whole body protein breakdown has increased in cachectic has increased in cachectic

COPD patientsCOPD patients

Rutten, AM J Clin Nutr

Conclusion; losses in myofibriller proteins must be the target in nutritional and pharmacological interventions

Anabolic nutritional Anabolic nutritional modulation; Amino acidsmodulation; Amino acids

Branched-chain amino Branched-chain amino acids; acids; Leucine,Leucine, isoleucine, valineisoleucine, valine

PrecursorPrecursorUpregulates protein Upregulates protein

syntesis in skeletal syntesis in skeletal musclesmuscles

Anabolic nutritional Anabolic nutritional modulation; modulation;

GLUTAMAT;GLUTAMAT; - An important precursor for antioxidant - An important precursor for antioxidant

glutathione and glutamine in musclesglutathione and glutamine in muscles- Decreased Glutamat and glutathione levels Decreased Glutamat and glutathione levels

were found in skeletal muscles of patients with were found in skeletal muscles of patients with emphysema emphysema

- İntermediates to preserve high-energy İntermediates to preserve high-energy phosphates at rest .Lactic asidosis may occur phosphates at rest .Lactic asidosis may occur in the absencein the absence

Am J Respir Crit Care Med 2001; 163:859-64

●Placebo +no training

○Testesteron +no training

▲Placebo + Resistance

Δ Testesteron + Resistance

Am J Respir Crit Care Med ‘004

Under weight; <21 kg/m²

Normal;

21-25 kg/m²

Over weight;

25-30 kg/m²

Obese; >30 kg/m²

Unvoluntory weight loss

Nutritional support

weight stable

↓ BMI Normal BMI

Maintance theraphy 3

moths

Yeterli

FOLLOW-UP

Unsufficient

Compliance?Anabolic stimulation Anti-catabolic

intervention

6 months

Conclusions;Conclusions;

Weight loss and reductions in FFM are important predictors of disease progression, resulted in reductions in exercise capacity, increases in mortality and morbidities in COPD patients .

Nutritional support reverses the effects of hypermetabolism and negative energy balance that resulted weight loss.

With the addition of high caloric main menu,enteral nutrients must be used small sized porsions but frequantly in stable COPD patients.

ESPEN Guidelines .Clinical Nutrition 2006;25:311-318

Thank you