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Body Composition Abnormalities and Nutrional Support in ChronicPulmonary Disseases. Doç.Dr. Pınar Ergün Atatürk Chest Diseases and Chest Surgery Center/ Pulmonary Rehabilitation- Home Care Unit. RATIONALE. Am J R Crit Care Med 1999;160: 1854-61. - PowerPoint PPT Presentation
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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
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