COPD: Research and Recommendations #COPD #Health #Nutrition

            When attempting to understand and treat disease, one’s whole lifestyle, diet, genetics, and potential risk factors should be considered before a specific treatment modality is given.  Such analysis is helpful in understanding wide-ranging conditions such as chronic obstructive pulmonary disease (COPD).  This condition often decreases one’s lung capacity, which increases breathing difficulty and can negatively impact daily activities.  Adequate, evidence-based scientific research should be used to discover methods for targeting the underlying roots of this disease and restore health.

COPD refers to conditions which deteriorate the lungs over time.  This respiratory illness covers two long-term lung diseases, including chronic bronchitis, where the bronchial tubes are inflamed and emphysema, when the air sacs (alveoli) of the lungs become damaged.  These two conditions may occur separately or exist simultaneously with those who have COPD.  Smoking is the primary factor contributing to this condition with frequent inhalation of dust chemicals and air pollution listed as additional causes.  It has also been noted in a few cases that a protein known as alpha 1 antitrypsin (AAT) may be helpful in warding off COPD; as a result, those lacking this protein may be at an increased risk (1).  Those who contain lower levels of AAT are usually afflicted with emphysema at an early age such as their thirties or forties.  Furthermore, those with a family history of chronic bronchitis are twice as likely to develop the disease at some stage during their lives.  Poor results on pulmonary function tests can often be seen in the parents and siblings of someone with COPD (2). 

Common signs and symptoms of COPD include wheezing, frequent respiratory infections, blueness of lips and nail beds, persistent coughing, coughing up mucous and shortness of breath with daily activity (2).  These symptoms increase or decrease in severity according to the specific stage COPD is in.  Weight loss and rapid, shallow breathing may also be observed in individuals with emphysema; possibly associated with increased energy used to breathe (2).  Early detection of exactly what’s going wrong can be difficult to achieve.  Since many individuals with COPD are smokers, the coughing associated with bronchitis can easily be dismissed as smoker’s cough, without further examination.  The shortness of breath, seen in emphysema patients, can also be attributed to other factors such as poor cardiovascular health, smoking and lack of physical fitness. Spirometry, one of the most common diagnostic tests used in COPD, reveals how much air is going into and out of the lungs.  This test is crucial in determining if there is an obstruction of one’s airwaves and is often used in combination with a bronchial provocation test.  Other tests such as arterial blood gas, exercise tolerance and exercise for desaturation analyze levels of oxygen (O2) and carbon dioxide (CO2) in the blood with and without physical activity (3). 

         

   A combination of individual signs and symptoms, family history, relevant medical conditions, and different lung function test is used to diagnose COPD (4).  There are four stages of COPD, with each stage requiring more intensive forms of treatment as internal conditions worsen.  A lung function test known as forced expiratory volume (FEV1) is used to determine which stage of COPD exists.  Stage one is known to be mild, with irregular coughing present.  Here, FEV1 is around eighty percent of ideal levels; and a fast-acting bronchodilator is used to allow for normal opening of airwaves.  At stage two, there is often moderate to severe shortness of breath while exhaling.  This is often the stage where people begin seeking treatment.  FEV1 levels are between fifty and seventy nine percent of normal lung function, with a possible cough or sputum present.  Stage three sees an increase in symptoms with more severe shortness of breath.  Cough and/or sputum may be present as well, with FEV1 between thirty and fifty percent of adequate functioning levels.  In the final stage of COPD (stage four), the severe shortness of breath could be life-threatening.  FEV1 levels at this stage plummet to below thirty percent of normal lung function (5). 

            In 2011, COPD was the third leading cause of death in the U.S.  Fifteen million Americans report being diagnosed with COPD, however, over 50% of adults with low pulmonary function were not aware they had COPD.  As a result, the actual percentage of COPD patients is likely to be significantly higher than what’s reported.  This condition most affected people aged 65-74, and is more likely to occur in women.  People who were unemployed, retired or unable to work, those with low wages, those who were divorced, widowed, or separated and those with a history of asthma also appeared to exhibit higher rates of COPD (6)

            The treatment of COPD may vary considerably, depending on what stage it’s in and other health conditions which may accompany the disease.  Due to the fact that this disease primarily manifests itself in smokers, cessation is critical to any successful treatment plan (7).  Bronchodilators are used to relax muscles around the lungs and bronchial tubes.  These medications are often taken with an inhaler and may be short or long-acting, depending on the stage of COPD (7).  Inhaled corticosteroids (ICS) are one of a few primary medications often used in COPD treatment.  These act by combatting inflammation, reducing the swelling and excess mucus in one’s airwaves which is caused by inflammation.  A few local side-effects may occur with the use of corticosteroids.  Potential reactions include a yeast infection, in the presence of white spots on the mouth, tongue or throat, along with occasional hoarseness.  One can avoid side-effects by rinsing their mouth after treatment and using a spacer with a metered dose inhaler (8). 

Long-acting beta2-antagonists (LABA) may also be used for this condition; resulting in wider airways by relaxing surrounding muscles.  These drugs are fairly new, compared to other COPD medications and, as a result, only two currently exist (formoterol and salmeterol).  LABAs may last up to twelve hours, resulting in better sleep for some patients.  However, they may also affect heart and skeletal muscles, causing shakiness and cramping of the feet, legs and hands.  As with the use of ICS, using a spacer/chamber device as an inhaler and practicing good rinsing habits decreases the likelihood of such side-effects.  LABAs are often taken using DPI and MDI inhalation devices at a rate of one or two puffs every twelve hours (9).  A third category of drugs often used for COPD are known as long-acting muscarinic antagonists (LAMAs).  These are often used in treating moderate to severe COPD (stage two and higher).  LAMAs stimulate the β2-adrenergic receptors, relaxing smooth muscles around one’s airway. Furthermore, they block the effects which acetylcholine has on muscarinic receptors, the main end receptors for acetylcholine.  As a result, LAMAs help to reverse airway obstruction (10).  One specific LAMA known as Aclidinium Bromide has shown some promise with improving FEV1 levels and other lung-function tests when used twice daily at 200 and 400 µg (10). 

One should carefully monitor their diet, while taking COPD medications, as they may have noticeable interactions.  The β2-adrenergic meds albuterol and salmetrol may cause the body to excrete more potassium than normal.  Including adequate potassium in one’s diet should suffice for this, as the loss is usually not long term.  Metylxanthines (theophylline, aminophylline, oxtriphylline) may have different responses to certain nutrients.  High fat meals, for example, may increase theophylline levels, while high carbohydrate intake may result in lower levels.  Caffeine containing foods such as chocolate, energy drinks, coffee, tea, and sodas should be limited, as they may increase the severity of methylxanthine medicine.  One should also strive to drink little, if any, alcohol, especially if they’re nauseous or vomiting.  Corticosteroids promote sodium and water retention as well as increased appetite.  Careful diet planning with medical professionals should take place while on corticosteroids.  Diuretics, which are sometimes used to combat excess fluid buildup, often cause losses of potassium, sodium and calcium (11).  Again, one should consult medical professionals regarding food and drug interactions. 

The herb, Thyme contains beneficial oils which, researchers have shown to assist the clearing of mucous in animals.  Additionally, these oils may have an anti-inflammatory effect, which can result in improved airflow to the lungs.  English ivy seems promising in relieving airway restriction and improving lung function in those with COPD, however this plant can be allergenic to people, thus caution is advised.  Panax ginseng has also shown additional promise in healing COPD symptoms compared to treatment with standard medication or no treatment at all.  Curcumin, the active compound in turmeric has been shown to reduce airway inflammation, fight oxidative stress and block cellular inflammation.  Red sage has shown to alleviate inflammation in the airways of people with COPD, these benefits perhaps being due to the antioxidant compounds present this herb (12).  Additional research, ideally randomized, controlled trials on humans is needed to help confirm, deny or clarify these findings.    

Whole, minimally processed foods offer the most benefits for those with COPD. The nutrition care manual recommends consuming 5-6 small meals or large snacks throughout the day, and drink enough fluids, throughout the day and evening.  It’s also recommended that one drinks, high-calorie, high-nutrient beverages such as milkshakes, whole-milk, fortified  and flavored milk and commercial nutritional products.  High-calorie and high-nutrient foods like healthy oils, margarines, butters, nut-butters, regular cheeses, sour cream, ice cream and cold cuts, yogurt or cottage cheese, meats, poultry, fish, beans and nuts.  Whole grains and fruits and vegetables with are also recommended to ensure patients get adequate fiber, vitamins and minerals.  One may need to take medical food supplements or use supplemental oxygen around mealtimes, if prescribed by a physician (13).  A one day sample menu for COPD could include half a cup of oatmeal with one tablespoon of ground flaxseed, two slices of whole wheat toast with butter or margarine, half a grapefruit and six ounces of milk or non-dairy drink for breakfast.  For a mid-morning snack, one could have half a cup of Greek yogurt.  Lunch could consist of a black bean burger with lettuce, tomato and onion on a whole grain bun with an apple and a handful of prunes.  For an afternoon snack, one may have a smoothie with 1/2 cup of grape juice, one banana, 1/2 cup of frozen strawberries, and 1/4 cup of fat-free dried milk. For dinner, one can have one cup of whole grain pasta, 3/4 cup tomato sauce, and 1 and ½ cups of salad greens with two tablespoons of beans, sliced onion, tomato and two tablespoons of olive oil.  As an evening snack, they can have one cup of yogurt with one tablespoon of walnuts and a quarter teaspoon of cinnamon. 

It’s important to note what extent prevention (quitting smoking, reducing chemical exposure) along with diet and exercise intervention can help reduce one’s dependency on medication.  The Mediterranean diet, in particular has shown to have benefits in the protection against and treatment of respiratory diseases.  This diet is rich in whole foods, nuts, seeds, legumes, whole grains, olive oil, fresh fruits and vegetables with low to moderate intake of low- fat meats and dairy.  The Mediterranean diet has been found to have protective effects for allergic respiratory diseases in epidemiological studies.  Additionally, it has been inversely associated with atopy and has a protective effect on atopy, wheezing and asthma symptoms (14).  Perhaps this is due to the many antioxidants and anti-inflammatory properties associated with the fruits, vegetables and healthy fats in this diet.  Epidemiological evidence reviewed by Saadeh et al. showed that fruit intake was associated with a low prevalence of wheezing and that cooked green vegetable intake was associated with a low prevalence of wheezing and asthma in school children aged 8–12 years old. Furthermore low vegetable intake in children was related to current asthma (15).  Both dietary vitamin E intake and vitamin E supplements were shown to improve FEV1 and FEC levels.  At least one study has shown vitamin E to be protective against COPD mortality.  This is likely due to vitamin E’s antioxidant properties, preventing peroxidation of lipid molecule and providing an anti-inflammatory effect.  More research is needed to better understand the relationship between vitamin E and lung disease as there have been conflicting results (16). 

Vitamin C may also assist those with COPD, as it has been shown to improve vascular function and structure.  Glutathione-S-transferase (GST) has been shown to reduce oxidative damage and convert vitamins C and E back to their active forms (17).  Spirulina has shown to help improve patient outcomes when combined with COPD medication.  Research has indicated both improved FEV1% (61 +,- 14) to (67 +,- 16) over a span of four months.  Also, a significant decrease in FEV1%, FVC%, and FEV1/FVC% was shown for the next two months when the spirulina supplements were withdrawn and the medication was continued  (18).  In patients with COPD, energy insufficiency due to decreased dietary intake caused by appetite loss associated with diminished general physical activity, a tendency toward depression, or dyspnea while eating is speculated to contribute to under-nutrition.  In the Cochrane Review updated in 2012, the results of a meta-analysis of data from 17 randomized controlled trials revealed that nutritional supplement therapy induced body weight recovery and increased the FFM index with consequently improved exercise tolerance (6-minute walking distance) in undernourished patients with COPD  (19).  Research also indicates fish intake at four or more servings a week to be inversely associated with COPD symptoms.  Again, the anti-inflammatory effect is perhaps what we can attribute these benefits towards.  Zinc has shown to have protective effects against cadmium, a toxic metal that accumulates in the alveolar macrophages of smokers.  Additionally, zinc deficiency has been observed with impaired lung function, and oxidative stress may be improved by zinc supplementation (20).  These dietary components should be carefully considered, specific to each patient with regards to their medication and potentially confounding conditions.  They may be used in combination with medication or perhaps to reduce the extent of medication.  As more studies emerge, professionals will gain crucial insight to the importance different dietary components play in managing COPD. 

             

The extent to which oxidative damage plays a role in the development of COPD is significant.  Studies indicate oxidative stress with measurements like lipid peroxidation product, MDA, and other oxidants.  At the same time, there is often a decrease in vitamins C, E, catalase and superoxide dismutase.  Cigarette smoke, biomass fuel burning, dust, pollution, etc., as well as endogenously produced oxidants from activated inflammatory cells are related to oxidation status.  Additionally, low BMI and malnutrition occurs in 20-70% of COPD patients, suggesting the importance of nutritional supplementation and weight management (21).  As a result, one should attempt to limit oxidants and increase antioxidants as much as possible.  A diet rich in whole, minimally-processed foods, along with adequate exercise and healthy weight management appears to offer the most substantial benefits to COPD patients.  Certain co-morbidities, like osteoporosis, present further nutritional problems when dealing with COPD.  Osteoporosis can occur in 9-69% of COPD patients, depending on the population studied, and may lead to decreased functional lung capacity, independent of lung function.  In this case, calcium and vitamin D supplementation may be useful to help correct osteoporosis symptoms.    Other common co-morbidities include heart disease, diabetes, chronic kidney disease, sleep apnea, anemia, depression, lung cancer and skeletal muscle weakness (22).  Tailoring patient-specific diets to deal with COPD and its underlying conditions is essential for improved recovery outcomes in COPD patients.  Having professional, research-driven nutritional therapy may help heal COPD by combating underlying symptoms, such as inflammation and oxidative damage.

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2.      ALA Staff.  COPD: Symptoms, Diagnosis and Treatment.  American Lung Association.  Available at http://www.lung.org/lung-disease/copd/about-copd/symptoms-diagnosis-treatment.html.  Accessed March 29, 2015.

3.      Bowler, R.  COPD: diagnosis.  National Jewish Health.  Available at http://www.nationaljewish.org/healthinfo/conditions/copd-chronic-obstructive-pulmonary-disease/diagnosis.  Accessed February 28, 2015. 

4.      National Heart, Lung and Blood Institute.  How is COPD diagnosed?  National Institutes of Health.  Available at http://www.nhlbi.nih.gov/health/health-topics/topics/copd/diagnosis. Accessed February 28, 2015. 

5.      Jovinelly, J.  COPD symptoms and stages.  Healthline.  Available at http://www.healthline.com/health/copd/stages#Overview1.  Accessed February 5, 2015.

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http://www.thoracic.org/professionals/clinical-resources/copd-guidelines/for-patients/what-kind-of-medications-are-there-for-copd/what-are-beta-agonists.php

Accessed March 10, 2015.

10.  Maltais, François and Julie Milot.  The Potential for Aclidinium Bromide, a New Anticholinergic, in the Management of Chronic Obstructive Pulmonary Disease.

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Accessed March 10th 2015

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Available at http://www.webmd.com/lung/copd/the-relationship-between-drugs-and-nutrients

Accessed March 12, 2015.

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Accessed March 31, 2015.

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Accessed April 6, 2015.

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17.  Md. Ismail, et al.  Effect of Spirulina Intervention on Oxidative Stress, Antioxidant Status and Lipid Profile in Chronic Obstructive Lung Disease Patients.  Biomed Research International.  Available at http://www.hindawi.com/journals/bmri/2015/486120/

Accessed April 7, 2015

18.  Seung Hee Seo.  Medical Nutrition Therapy based on Nutrition Intervention for a Patient with Chronic Obstructive Pulmonary Disease.  The Korean Society of Clinical Nutrition. Available at http://e-cnr.org/DOIx.php?id=10.7762/cnr.2014.3.2.150

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19.  Ferreira IM, et al.  Nutritional supplementation for stable chronic obstructive pulmonary disease.  Cochrane.  Available at https://www.youtube.com/watch?v=jCG_i9lnBFc

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20.  Jessica R. Napolitano, et al.  Cadmium-mediated toxicity of lung epithelia is enhanced through NF-κB-mediated transcriptional activation of the human zinc transporter ZIP8.

Available at http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3362162/

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21.  Niraj Dhakal, et al.  Oxidative Stress and Nutritional Status in Chronic Obstructive Pulmonary Disease.  Am J Physiol Lung Cell Mol Physiol.

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22.  Nele Cielen, et al.  Musculoskeletal Disorders in Chronic Obstructive Pulmonary Disease.  Biomed Res Int.

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