Energy Expenditure 2006

8/22/2019 Energy Expenditure 2006

1/7

ORIGINAL ARTICLE

Energy expenditure in underweight chronicobstructive pulmonary disease patients before andduring a physiotherapy programme

F Slinde1, K Kvarnhult2,3, AM Gronberg2, A Nordenson2, S Larsson2 and L Hulthen1

1Department of Clinical Nutrition, Institute of Internal Medicine, Sahlgrenska Academy at Goteborg University, Goteborg, Sweden;2Department of Respiratory Medicine and Allergology, Institute of Internal Medicine, Sahlgrenska Academy at Goteborg University,

Goteborg, Sweden and3Department of Physiotherapy, Sahlgrenska University Hospital, Goteborg, Sweden

Objective: To investigate how total daily energy expenditure (TEE) changes when underweight patients with chronicobstructive pulmonary disease (COPD) enters a physiotherapy programme.Design: Prospective intervention study.Setting: Sahlgrenska University Hospital, Goteborg, Sweden.Subjects: Fifteen patients with severe COPD and BMIo21 kg/m2 were recruited consecutively at the outpatient COPD unit atthe Department of Respiratory Medicine. Fourteen patients completed the whole study.Intervention: TEE was assessed by the doubly labelled water method in a 2-week control period and during 2 weeks ofphysiotherapy. Energy intake was assessed using 7-day dietary record during control and physiotherapy period.Results: Mean TEE during physiotherapy period was 500 kJ (6%) lower than during control period but the difference was notstatistically significant. Ten of the 14 patients had lower and four had higher TEE. Mean energy intake during the physiotherapyperiod did not change from the control period (7700 vs 7600 kJ/day).Conclusions: Since underweight patients with COPD may show variable TEE during physiotherapy compared to a controlperiod, an assessment of individual energy requirements is recommended.Sponsorship: The Swedish Heart Lung Foundation, The Swedish Heart and Lung Association, The Swedish Nutrition

Foundation, The Ingabritt and Arne Lundberg Foundation.European Journal of Clinical Nutrition (2006) 60, 870876. doi:10.1038/sj.ejcn.1602392; published online 1 February 2006

Keywords: doubly labelled water; underweight; energy intake; nutrition; rehabilitation

Introduction

Chronic obstructive pulmonary disease (COPD) is a disease

of complex nature in which not only primary impairment of

the lungs and the airways have been demonstrated. Physio-

logic abnormalities in the structure and metabolism of

the skeletal muscles have also been shown (Maltais et al.,

1996; Casaburi, 2000). Rehabilitation programmes, includ-

ing physiotherapy (mobility training, breathing exercises

and physical exercise), nutritional support, psychotherapy

and education, are recommended in international treatmentguidelines for COPD patients (Siafakas et al., 1995; Ries et al.,

1997). Lacasse et al. (2002) concluded in a Cochrane review

that rehabilitation relieves dyspnea and fatigue, increases

exercise capacity and improves quality of life. Physical

exercise comprises activities aiming at maintaining and

improving physical and psychological functions and restor-

ing the physiologic balance in the skeletal muscles. Both

aerobic exercise and peripheral muscle training are recom-

mended for COPD patients (Cherniack, 1987). Aerobic

exercise could be walking, stair climbing and cycling whileReceived 26 April 2005; revised 18 November 2005; accepted 9 December

2005; published online 1 February 2006

Correspondence: Dr F Slinde, Department of Clinical Nutrition, Sahlgrenska

Academy at Goteborg University, PO Box 459, SE-405 30 Goteborg, Sweden.

E-mail: [email protected]

Guarantor: F Slinde.

Contributors: FS was responsible for the practical managing of all parts of the

project and drafted the manuscript, KK was responsible for the physiotherapy

program, AN was responsible for the medical surveillance and follow-up of the

patients. All authors took part in the design of the study, interpretation of the

results and writing the paper.

European Journal of Clinical Nutrition (2006) 60, 870876& 2006 Nature Publishing Group All rights reserved 0954-3007/06 $30.00

www.nature.com/ejcn


2/7

peripheral muscle training could contain exercising with

weights, pulleys and elastic rubber bands (Hodgkin, 1987).

COPD rehabilitation programmes often include some

kind of nutritional support or dietary intervention. A recent

Cochrane review, including 11 studies, concluded that

nutritional support had no significant effects in anthro-

pometric measures, lung function or exercise capacity in

patients with stable COPD (Ferreira et al., 2005). One of the

explanations for this lack of effect was described to be that the

judgement of energy expenditure might have been incorrect.

We have shown slight, but uniform, indications of positive

effects on body weight and physical performance of dietary

intervention during multidisciplinary rehabilitation in a

group of patients with severe COPD (Slinde et al., 2002).

However, in the underweight patients, where one of the goals

is to increase body weight, we found that the extra intake of

energy was not sufficient to provide both an increase in

physical performance and a gain in body weight. This fact

raised the question concerning how much extra energy that is

expended during a rehabilitation programme. To our knowl-edge, only one study has examined this thoroughly. Tang

et al. (2002) compared 1 single day without rehabilitation

exercise to 1 day including exercise using the bicarbonate

urea method. In the 10 patients studied, the total daily energy

expenditure (TEE) increased from a mean of 1508 to

1568 kcal/day (ns). A limitation of that study, as the authors

state, was the short measurement time period, mainly

dependent on the principles of the bicarbonateurea method.

The doubly labelled water (DLW) method has made it

possible to determine the TEE in free-living subjects. The

technique is well established and validated both in animals

and humans (Schoeller and van Santen, 1982; Schoeller,

1988), and is today considered to be the reference standardfor assessment of TEE which is assessed with high precision

without limiting the subjects way of life. The result

represents energy expenditure for a relatively long period

of time, in contrast to short-term measurements with major

limitations in way of life using direct calorimetry.

Baarends et al. (1997) studied 10 male COPD patients

admitted to a pulmonary rehabilitation centre, using the

DLW method, and found that the ratio between TEE and

resting energy expenditure (REE) ranged from 1.5 to 2.0

compared with a range from 1.3 to 1.6 in healthy free-living

controls. None has however studied the effect on energy

expenditure before and during rehabilitation in COPD

patients using the DLW technique.The aim of this study was therefore to investigate how TEE

changes when underweight patients with COPD enters a

physiotherapy programme using the DLW technique.

Subjects and methods

Study design

Prior to the study pulmonary function tests were performed.

A 2-week control period preceded a physiotherapy period

which lasted for 4 weeks. Measurement of energy expendi-

ture and assessment of energy intake was performed in both

periods.

Control period. At day 1, patients underwent measurements

of body composition, resting energy expenditure andreceived a first dose of DLW for assessment of TEE. They

were also instructed to record dietary intake during 7

consecutive days. Physical activity was assessed by an

activity monitor (ActiReg) during the same 7 days as the

dietary record. A visit at home was performed by the

dietitian (FS) at day 8, to discuss and collect the food record,

to check the use of medications and nicotine and to collect

the activity monitor. On day 15, the patient delivered the

urine samples for DLW analysis to the hospital and body

weight was measured.

Physiotherapy period. Measurements in the physiotherapy

period were performed during the last 2 weeks of the 4-weeklong intervention. After 2 weeks of physiotherapy, the

patient received the second dose of doubly labelled water

at day 1 in the measurement period. They were instructed to

record dietary intake during 7 days and the ActiReg

recording was started. A visit at home was performed by

the dietitian at day 8, to discuss and collect the food record

and to collect the ActiReg. On the last day of the

physiotherapy period (day 15 in the measurement period),

the patient underwent measurement of body weight and

delivered the urine samples.

Subjects

Fifteen patients (five men and 10 women) with severeand stable COPD were included in this study. Severe COPD

was diagnosed as forced expiratory volume in one second

(FEV1)o50% predicted, as determined by criteria from The

European Respiratory Society (Siafakas et al., 1995). All

patients were recruited consecutively from the outpatient

COPD unit at the Department of Respiratory Medicine,

Sahlgrenska University Hospital, Goteborg, Sweden. Inclu-

sion criteria was body mass index (BMI)o21 kg/m2, as

suggested as definition of underweight in COPD (Celli

et al., 2004) and exclusion criteria were earlier performed

rehabilitation, oxygen treatment, cancer, diabetes mellitus,

hypothyreoidism, heart failure and angina pectoris during

exercise test or other major diseases. The patients wereinformed of the nature and purpose of the study and gave

written informed consent. The study was approved by the

Ethics Research Committee of the University of Goteborg.

Pulmonary function tests

Spirometry was performed with a Vitalograph spirometer

(Selefa, Buckingham, Ireland) before and 15min after

inhalation of 1 mg terbutaline to reach optimal standardiza-

tion. The European Coal and Steel Community (ECSC)

Energy expenditure in underweight chronic obstructive pulmonary disease patientsF Slinde et al

871

European Journal of Clinical Nutrition


3/7

reference values were used for prediction (Quanjer et al.,

1993). Arterial blood gases (partial pressure of oxygen (PO2)

and partial pressure of carbon dioxide (PCO2)) were mea-

sured in all patients.

Resting energy expenditureREE was measured by indirect calorimetry using a ventilated-

hood system. The equipment used was a Deltatract II

Metabolic Monitor (Datex, Helsinki, Finland). The equip-

ment was calibrated with Quick Calt calibration gas (Datex-

Ohmeda, Helsinki, Finland) constituting of 95% O2 and 5%

CO2 according to the manufacturers instructions before

each measurement. The subjects were instructed to limit

their physical activity the evening before the measurement.

All subjects were measured after an overnight fast and they

arrived from their home by car or public transport. After a

30 min rest in the supine position, REE was measured during

30 min when the subjects were awake in the supine position.

The measurements were performed in an environmentaltemperature between 22 and 231C. The presented mean REE

for each patient is based on the last 25min of the

measurement.

Body composition

Body weight was measured, with subjects wearing light

clothing without shoes to the nearest 0.1 kg on a System 31

electronic scale (The Advanced Weighing Co. Ltd, New

Haven, East Sussex, UK). Height was measured and deter-

mined to the nearest centimeter using a horizontal head-

board with an attached wall-mounted metric rule (Hultafors,

Sweden). BMI was calculated as weight (kg) divided by

height2 (m). Body composition was measured with dualenergy X-ray absorptiometry (Lunar Prodigy, GE Lunar

Corp., Madison, USA) and fat-free mass index was calculated

as fat free mass (kg) divided by height2 (m).

Doubly labelled water

TEE was determined by the DLW technique. TEE from the

DLW method was measured over two 14-day periods (control

and physiotherapy period). Sample analysis and calculation

procedures have been described elsewhere (Slinde et al.,

2003). Prior to dosing, a voiding was collected for determi-

nation of background isotope enrichment. The patients

ingested a weighed mixture of deuteriated and oxygen-18-enriched water, corresponding to 0.05 g of deuterium oxide

(2H2O) and 0.10 g of oxygen-18-water (H218O) per kilogram

body weight. The dose was flushed down the throat with a

glass of tap water. The exact time of dosing was recorded, an

the subjects were equipped with 21 screw-capped glass vials

to be filled with the second voiding from days 2, 3, 4, 8, 13,

14 and 15. Exact voiding times were recorded, and the urine

samples were stored in the patients freezer before delivery to

the laboratory. Samples were analysed in triplicates on a

Finnigan MAT Delta Plus Isotope-Ratio Mass Spectrometer

(ThermoFinnigan, Uppsala, Sweden). TEE was calculated

by the multi-point method by linear regression from the

difference between elimination constants of deuterium

and oxygen-18, with the assumptions for fractionating as

suggested by IAEA (International Dietary Energy Consul-

tancy Group, 1990). The energy equivalence of the CO2excreted was calculated from the macronutrient intake using

estimated food quotient from the 7-day dietary record (Black

et al., 1986). The relationship between pool size deuterium

(ND) and pool size oxygen-18 (NO) was used as a quality

measurement of the DLW analysis as proposed by IAEA

(International Dietary Energy Consultancy Group, 1990).

Dietary intake

During the first 7 days of each measurement period, the

patients recorded their total food and beverage intake with

the help of household measures. On the home visit at day 8,

the dietitian checked the food record and weighed the

patients usual glasses, cups, pieces of bread etc. in order tocalculate energy intake as accurate as possible. At the same

time a list of drugs they used was collected for each patient.

For nutrient calculation we used the nutrient program

Dietist (Kost och Naringsdata AB, Bromma, Sweden) using

the Swedish Food Data Base from the National Food

Administration (updated 31 March 2005). Data on the

nutrient content of dietary supplements were added to the

database.

Physical activity

During the first 7 days of each measurement period, an

ActiReg was used to monitor physical activity in the patients.

The ActiReg is using combined recordings of body positionand motion to measure physical activity (Hustvedt et al.,

2004) and consists of two pairs of position and motion

sensors connected by cables to a storage unit fixed to a

waist belt. ActiReg has been shown to have good validity

in patients with severe COPD (Arvidsson et al., 2005). Sensors

were attached by medical tape to the chest and the right

thigh and the patients were requested to use ActiReg

continuously during 7 days, except during night and during

bathing or taking a shower. The results were analysed in the

computer program ActiCalc that enables calculation of the

physical activity level (PAL) (Hustvedt et al., 2004).

The physiotherapy programme

The physiotherapy programme took place at the Depart-

ment of Physiotherapy, Sahlgrenska University Hospital. It

comprised eight individual 90-min sessions (twice a week)

of education and physical exercise plus a home-exercise

programme. Education included some elements of basic

anatomy, respiratory physiology and pathophysiology of

COPD. Moreover, instructions on disease management and

practical-coping skills were given. Physical exercises com-

posed of mobility training, aerobic exercise on a treadmill


872



4/7

and peripheral muscle training. All patients but two were

managed by the same physiotherapist (KK).

Practical-coping skills focused on managing breathlessness

by breathing exercises and sputum removal techniques.

Breathing exercises included the pursed-lip-breathing tech-

nique, breathing exercises with positive expiratory pressure

using a BA tube and postural drainage. Instructions on

coughing techniques were also given. Mobility training

consisted of mobility exercises for the thoracic, shoulder

girdle and neck muscles. Aerobic exercise was conducted on

a treadmill (Power Jog, Sport Engineering Ltd, UK). Intensity

and duration of exercise were based upon symptom scores,

arterial oxygen saturation (SaO2) and the current level

of physical activity. Degree of perceived breathlessness was

assessed by the modified Borg-scale, scores 010 and the

degree of perceived fatigue was assessed by the Borg-scale,

scores 620. SaO2 was to be equal to or above 90%. If the

SaO2 fell below 90%, supplemental oxygen was given. The

speed and duration of the aerobic exercise was each session

based upon symptom scores and SaO2. In peripheral muscletraining muscle endurance was emphasized. Exercises were

focused on the lower extremities and were related to

functional activities. The intensity was set to 4080% of

the repetition maximum. The 6-min walking distance test

with assessment of perceived breathlessness and SaO2 every

minute was performed at the first and last appointment with

the physiotherapist and all patients had one training test

before the study started.

The home exercise programme was individualized and

based on each patients needs, as judged by the physio-

therapist. All patients were instructed to do breathing

exercises, mobility training and peripheral muscle training.

Statistics

Calculation of statistical power showed that inclusion of 15

patients would allow detection of a statistically significant

(Po0.05) difference between periods of 650kJ (s.d. 850kJ)

(judged as clinically significant) with 80% power. Results

are described as mean and s.d. Skewed variables (number of

days between periods) are presented as median and range.

Relation between number of days between period and

change in TEE between periods was investigated using the

Spearmans rank correlation coefficient rho (r). Paired two-

sample t-test was used to compare body weight, energy

intake and total energy expenditure between control and

rehabilitation period and results were judged statistically

significant if Po0.05.

Results

Patient characteristics

Fourteen patients (five men and nine women) completed the

whole study. One patient (patient no. 10) decided to drop

out after 1 week of physiotherapy. She had 1 h travel by bus

to the hospital and found it too strenuous to travel thisdistance twice a week. All presented results are based on the

14 patients completing the whole study. One patient had a

BMI at 21.2 kg/m2. In the recruitment process the patient

had a BMIo21 kg/m2, but her body weight had increased

at inclusion to the study. We still considered her to be

representative of the patients with underweight and severe

COPD. Table 1 shows characteristics of the patients at

inclusion and during the study. A significant increase in

body weight, and hence BMI were observed during the

control period, however, at the end of the rehabilitation

period the body weight, and BMI were not statistically

different from inclusion values. Median time between day 15

in the control period and day 1 in the physiotherapy periodwas 28 days. Owing to an exacerbation, one patient had a

period of 7 months between control and physiotherapy

period, for the other patients the time between control and

physiotherapy ranged between six and 85 days.

Table 1 Patient characteristics, lung function and body composition in 14 underweight COPD patients during control (C) and physiotherapy (PT) period

Mean (s.d.) day 1 in C period Mean (s.d.) day 15 in C period Mean (s.d.) day 1 in PT period Mean (s.d.) day 15 in PT period

Age (year) 64 (8) 64 (8) 64 (8) 64 (8)Weight (kg) 52.6 (5.5) 53.1 (5.6)* 53.3 (6.0)* 53.0 (6.0)Height (m) 1.67 (0.08) 1.67 (0.08) 1.66 (0.8) 1.67 (0.8)BMI (kg/m2) 19.0 (1.9) 19.2 (1.9)* 19.3 (2.1)* 19.2 (2.0)

FEV1a (% pred) 34 (9) b b bPO2

c (kPa) 9.7 (1.3) b b b

PCO2d (kPa) 5.2 (0.6) b b b

FMe (kg) 11.6 (5.6) b b b

FFMIf (kg/m2) 14.7 (1.8) b b b

aForced expiratory volume in 1 s, as percentage of predicted.bNot examined.cArterial partial pressure of oxygen.dArterial partial pressure of carbon dioxide.eFat mass (kg).fFat-free mass index.

*Po0.05.


873



5/7

Physiotherapy

Ten of the 14 patients completing the physiotherapy

programme attended seven or more of the eight appoint-

ments with the physiotherapist. One patient attended in

four and three patients in six of the eight appointments. All

patients, except one, performed an individualized home-

exercise programme at least twice a week, but most of them

several times a week. All patients, except two, performed

both 6-min walking distance tests with a mean result of

366m. No clinical relevant change (a reduction of 6 m) in

mean distance was detected between the first and second

test, however, there was a nonsignificant improvement in

mean perceived breathlessness, assessed by the modified

Borg-scale, from 3.3 to 2.7 (n.s.). SaO2 also improved

nonsignificantly from a mean of 87% in the first test to

89% in the second test (n.s.).

Change in body weight, TEE and energy intake

As shown in Table 2, no statistically significant differencesbetween control and physiotherapy period were found in

any of the measurements. However, as presented in Figure 1,

there were large individual variations in change in TEE. Ten

of the patients had lower and four had higher TEE during

2 weeks of physiotherapy compared to the control period.

Mean difference in TEE between the periods was 6% or

500 kJ per day, the difference did not reach statistical

significance. This was not related to changes in body weight,

the mean change in TEE/kg BW was an 8% reduction (11 kJ/

kg) (Po0.05). Change in TEE was positively correlated with

number of days between period (r0.73 (Po0.01)). Mean

energy intake during the physiotherapy period did not

change from the control period.

Change in physical activity

Owing to technical problems, two of the patients had no

results from the ActiReg in the control period. The mean

(s.d.) PAL in the remaining 12 patients was 1.52 (0.16) in the

control period and 1.52 (0.25) in the physiotherapy period

(n.s). There was no relation between change in PAL from

ActiReg and change in TEE from DLW (Figure 2), and only

eight of the patients had a change in the two variables

indicating the same direction (either positive or negative

change).

Discussion

In this study, we have found unexpected results concerning

change in TEE when COPD patients were engaged in

a physiotherapy programme. Some patients expended more

energy, but most of them, contrary to our hypothesis, had

a lower TEE during the physiotherapy, compared to a control

-40 -20 0Change in percent

20 40

Figure 1 Changes (%) in total daily energy expenditure (TEE) fromcontrol to physiotherapy period for each of the 14 underweight

COPD patients, each staple represent one patient.

Table 2 Resting energy expenditure, total daily energy expenditureand energy intake in 14 underweight COPD patients during control (C)period and physiotherapy (PT) period

Mean (s.d.) C period Mean (s.d.) PT period

REEa (kJ) 5000 (700) b

TEEc (kJ) 7700 (1200) 7200 (1400)EId (kJ) 7600 (2200) 7700 (2200)TEEActiReg (kJ) 7500 (1300) 7500 (1400)TEE/REE 1.53 (0.18) 1.44 (0.24)EI/REE 1.50 (0.32) 1.53 (0.33)TEEActiReg/REE 1.52 (0.16) 1.52 (0.25)

aResting energy expenditure.bNot examined.cTotal daily energy expenditure.dEnergy intake.

-10

-10 10

10

20

20

-20

% change in TEE (DLW) from control to physiotherapy period

%c

hangeinP

AL(ActiReg)from

controlto

phy

siotherapyperiod

-20

Figure 2 Change (%) in total energy expenditure (TEE) measuredby doubly labelled water related to change (%) in physical activitylevel (PAL) measured by ActiReg between a control period and aphysiotherapy period in 12 COPD patients.


874



6/7

period. There were no statistically significant differences in

TEE between the control and physiotherapy period.

In a study in 11 healthyelderly (mean age 66 years), Goran

and Poehlman (1992) found similar findings as in the

current study. Mean TEE was not higher during a period of

cycling exercises three times per week compared to a control

period. They calculated that this was due to a compensatory

decline in physical activity during the remainder of the day.

Our finding is also consistent with the findings of Tang et al.

(2002), even if they studied only one day. Tang et al. also

suggested that lack of increase in TEE during rehabilitation

in COPD patients may be caused by a decrease in the

patients normal activity pattern. That means that the

training sessions make the patients so feeble that they do

not perform their usual activities. This does not seem to be

the main explanation in the current study since the results

from the activity monitor shows that this is not the case in

most of the patients. The decrease in PAL from DLW (1.53 in

control period to 1.44 in physiotherapy period) could not be

seen in PAL from ActiReg (1.52 in both periods). Five of thepatients have both a lower TEE and a lower PAL, indicating a

lower physical activity as the reason for the lower TEE, while

three patients have a higher TEE and a higher PAL, indicating

increasing physical activity as the reason for the higher TEE.

Three patients had a decrease in TEE and an increase in PAL

while one patient had an increase in TEE and a decrease in

PAL, indicating that other factors than physical activity

might be the reason for the observed change in TEE. Other

explanations must therefore be sought.

One part of the physiotherapy is breathing exercises. The

patients do exercise aiming at reducing breathlessness and

learn techniques to cope with the experienced dyspnea.

Oxygen cost of breathing has been shown to be elevated inCOPD patients, especially underweight patients (Donahoe

et al., 1989; Palange et al., 1995). When underweight COPD

patients do breathing exercises, this could reduce the

elevated oxygen cost of breathing and thereby could limit

the increase in energy expenditure, one would expect to

occur during a period of increased load of physical exercise.

To our knowledge, this remains to be studied. Another

possible explanation could be the effect of exercise on

muscle metabolism. Studies have demonstrated that exercise

training in COPD patients increase concentrations of

enzymes facilitating oxidative metabolism, a smaller in-

crease in blood lactic acid level after exercise, and a faster

kinetics of oxygen uptake indicating a better aerobicfunction of the muscles (Casaburi, 2000). One could also

argue that some of the patients did not fulfil all of the

appointments with the physiotherapist, reducing the possi-

bility to detect an increase in TEE. There was however no

relation between compliance of physiotherapy and change

in TEE between the periods. There was a significant

correlation between change in TEE and number of days

between control and physiotherapy period. The patients

with a short period between control period and physio-

therapy had the largest decrease in TEE. No apparent

explanation for this could be found. This study was performed

over relatively long time on patients having a severe chronic

disease, so time between periods had to be made with

consideration to each patients daily life, holidays, etc.

TEE measured by doubly labelled water does not give

information about day-to-day variation in TEE or time and

intensity of physical activities performed, which is a

limitation with the method. However, compared to measures

like the bicarbonateurea method, which only give results

from one day, DLW gives a long-term result. Owing to the

design of this study, we cannot exclude the possibility that

the patients have changed their activity pattern from the

control period to the physiotherapy period, but the results

from the ActiReg indicate that this is not the case.

Furthermore, we have to bear in mind, that the patients

had a severe COPD, hence they were sedentary in both

periods. Sixty percent of the patients had a ratio between TEE

and REE lower than 1.5, indicating a lower level of physical

activity than the mean in a sample of healthy elderly (475

years old) men (Fuller et al., 1996).It might be surprising that we in the current study with

a rather homogenous patient group from many aspects

found a large variation in the relation between TEE and REE

ranging from 1.24 to 1.90 in the control period preceding the

period including physiotherapy. This is however in consis-

tency with earlier findings of similar patient groups (Goris

et al., 2003; Slinde et al., 2003).

The main advantage in this study is the long study period

and the use of reference standard techniques such as doubly

labelled water and DXA. Since one of the main findings

was the large variation between subjects in effect on TEE of

physiotherapy, individual assessment of each patients

energy requirement should be wished for in the future. Evenif doubly labelled water is considered to be the reference

standard method for assessment of TEE, the cost of the

method limits its use in the clinical setting. Other methods

have therefore to be considered. Alternatives currently

available are subjective (e.g. activity recalls) or motion

detectors (e.g. accelerometers). Steele et al. (2000) found no

correlation between the outcome of a physical activity recall

and a triaxial accelerometer in their study in COPD patients.

They suggested that this could be due to the fact that motion

detectors like accelerometers are able to cover all periods of

physical activity, including low-intensity activities, which

are difficult to recall, and these activities are dominating in

patients with chronic diseases. The large variation inphysical activity and energy expenditure shown in the

present study and in other studies (Goris et al., 2003; Slinde

et al., 2003) emphasize the importance of using methods

which are precise in low-intensity activities as well as in

moderate-to-high intensity activities.

To conclude, inclusion in a physiotherapy programme

is not necessarily followed by an increase in TEE. Contrary

to what we expected, 10 out of 14 patients had a lower TEE

during a period of physiotherapy compared to a control

period. Hence, underweight patients with COPD may show


875



7/7

a stable, increased or decreased TEE during a period with

physiotherapy compared to a control period. This calls for

individual assessment of each patients energy requirements.

Acknowledgements

We acknowledge the assistance of Mrs Elisabeth Gramat-

kovski for performing the DLW analysis in the mass spectro-

meter and Mr Daniel Arvidsson for valuable advice

concerning the ActiReg.

References

Arvidsson D, Slinde F, Nordenson A, Larsson S, Hulthen L (2005).Validity of the ActiReg system in assessing energy requirement inchronic obstructive pulmonary disease patients. Clin Nutr 2005Oct 17; [Epub ahead of print].

Baarends EM, Schols AM, Pannemans DL, Westerterp KR, Wouters EF(1997). Total free living energy expenditure in patients with severe

chronic obstructive pulmonary disease. Am J Respir Crit Care Med155, 549554.Black AE, Prentice AM, Coward WA (1986). Use of food quotients

to predict respiratory quotients for the doubly- labelled watermethod of measuring energy expenditure. Hum Nutr Clin Nutr40,381391.

Casaburi R (2000). Skeletal muscle function in COPD. Chest 117,267S271S.

Celli BR, MacNee W, Agusti A, Anzueto A, Berg B, Buist AS et al.(2004). Standards for the diagnosis and treatment of patients withCOPD: a summary of the ATS/ERS position paper. Eur Respir J23,932946.

Cherniack RM (1987). Physical therapy techniques. In: Hodgkin J,Petty T (Eds). Chronic Obstructive Pulmonary Disease: CurrentConcepts. Saunders: Philadelphia, pp 113119.

Donahoe M, Rogers RM, Wilson DO, Pennock BE (1989). Oxygenconsumption of the respiratory muscles in normal and in

malnourished patients with chronic obstructive pulmonary dis-ease. Am Rev Respir Dis 140, 385391.

Ferreira IM, Brooks D, Lacasse Y, Goldstein RS, White J (2005).Nutritional supplementation for stable chronic obstructivepulmonary disease (Review). The Cochrane Database of SystematicReviews Issue 2. Art. No.: CD000998.pub2. DOI: 10.1002/14651858.CD000998.pub2.

Fuller NJ, Sawyer MB, Coward WA, Paxton P, Elia M (1996).Components of total energy expenditure in free-living elderlymen (over 75 years of age): measurement, predictability andrelationship to quality-of-life indices. Br J Nutr75, 161173.

Goran MI, Poehlman ET (1992). Endurance training does notenhance total energy expenditure in healthy elderly persons. AmJ Physiol 263, E950E957.

Goris AH, Vermeeren MA, Wouters EF, Schols AM, Westerterp KR(2003). Energy balance in depleted ambulatory patients with

chronic obstructive pulmonary disease: the effect of physicalactivity and oral nutritional supplementation. Br J Nutr 89,725731.

Hodgkin JE (1987). Exercise testing and training. In: Hodgkin J, PettyT (Eds). Chronic Obstructive Pulmonary Disease: Current Concepts.Saunders: Philadelphia, pp 120127.

Hustvedt BE, Christophersen A, Johnsen L, Tomten H, McNeill G,

Haggarty P et al. (2004). Description and validation of ActiRegs a novel instrument to measure physical activity and energyexpenditure. Br J Nutr92, 10011008.

International Dietary Energy Consultancy Group (1990). The doubly-labelled water method for measuring energy expenditure Technicalrecommendations for use in humans, International AtomicEnergy Agency (IAEA), Vienna.

Lacasse Y, Brosseau L, Milne S, Martin S, Wong E, Guyatt GH et al.(2002). Pulmonary rehabilitation for chronic obstructive pulmon-ary disease (Cochrane Review). The Cochrane Library UpdateSoftware: Oxford.

Maltais F, Simard AA, Simard C, Jobin J, Desgagnes P, LeBlanc P(1996). Oxidative capacity of the skeletal muscle and lactic acidkinetics during exercise in normal subjects and in patients withCOPD. Am J Respir Crit Care Med153, 288293.

Palange P, Forte S, Felli A, Galassetti P, Serra P, Carlone S (1995).

Nutritional state and exercise tolerance in patients with COPD.Chest107, 12061212.Quanjer P, Tammeling G, Cotes J, Pedersen O, Peslin R, Yernault J

(1993). Lung volumes and forced ventilatory flows. Report Work-ing Party Standardization of Lung Function Tests, EuropeanCommunity for Steel and Coal. Official Statement of the EuropeanRespiratory Society. Eur Respir J16, 540.

Ries AL, Carlin BW, Carrieri-Kohlman V, Casaburi R, Celli BR, EmeryCF et al. (1997). Pulmonary rehabilitation: joint ACCP/AACVPRevidence-based guidelines. Chest 112, 13631396.

Schoeller D, van Santen E (1982). Measurement of energy expendi-ture in humans by doubly labeled water method. J Appl Physiol 53,955959.

Schoeller DA (1988). Measurement of energy expenditure infree-living humans by using doubly labeled water. J Nutr 118,12781289.

Siafakas NM, Vermeire P, Pride NB, Paoletti P, Gibson J, Howard P

et al. (1995). Optimal assessment and management of chronicobstructive pulmonary disease (COPD). The European RespiratorySociety Task Force. Eur Respir J8, 13981420.

Slinde F, Ellegard L, Gronberg AM, Larsson S, Rossander-Hulthen L(2003). Total energy expenditure in underweight patients withsevere chronic obstructive pulmonary disease living at home. ClinNutr22, 159165.

Slinde F, Gronberg AM, Engstrom CP, Rossander-Hulthen L, Larsson S(2002). Individual dietary intervention in patients with COPDduring multidisciplinary rehabilitation. Respir Med96, 330336.

Steele BG, Holt L, Belza B, Ferris S, Lakshminaryan S, Buchner DM(2000). Quantifying physical activity in COPD using a triaxialaccelerometer. Chest117, 13591369.

Tang NL, Chung ML, Elia M, Hui E, Lum CM, Luk JK et al. (2002).Total daily energy expenditure in wasted chronic obstructivepulmonary disease patients. Eur J Clin Nutr56, 282287.


876


Documents

Energy Expenditure 2006