What are the recommendations for a person with chronic obstructive pulmonary disease (COPD) who is underweight?

From the Guidelines

For someone who is underweight with COPD, I strongly recommend a comprehensive approach focusing on both nutrition and respiratory management to improve morbidity, mortality, and quality of life. This approach should include increasing caloric intake by eating smaller, more frequent meals (5-6 per day) that are nutrient-dense and high in protein, as low body weight and muscle wasting are associated with increased mortality and poor clinical outcomes 1.

Key Recommendations

• Increase caloric intake by eating smaller, more frequent meals (5-6 per day) that are nutrient-dense and high in protein, aiming for 1.2-1.5 grams of protein per kilogram of body weight daily, incorporating foods like eggs, dairy, lean meats, and plant proteins.
• Consider nutritional supplements like Ensure Plus, Boost Plus, or Pulmocare which are specifically formulated for respiratory patients.
• Consume healthy fats from sources like avocados, nuts, and olive oil to increase calorie intake without adding volume.
• Stay well-hydrated but limit fluids with meals to prevent feeling full too quickly.
• For COPD management, use prescribed bronchodilators such as albuterol (2 puffs every 4-6 hours as needed) and maintenance inhalers like tiotropium (Spiriva) once daily or fluticasone/salmeterol (Advair) twice daily.
• Pulmonary rehabilitation is essential to improve exercise capacity while conserving energy, as it has been shown to improve health status, quality of life, and exercise capacity in patients with COPD 1.
• Oxygen therapy may be necessary if prescribed by your doctor.

Rationale

The rationale behind these recommendations is based on the evidence that weight loss and underweight status are associated with increased mortality, independent of the degree of airflow obstruction, whereas weight gain in those with a BMI below 25 kg/m2 appears to be associated with decreased mortality 1. Additionally, muscle mass constitutes the major part of fat-free mass, and a simple field test to estimate FFM in clinically stable individuals is bioimpedance analysis (BIA) using a validated prediction equation that is appropriate regarding age, sex, and race 1.

Important Considerations

It is also important to consider that nutritional intervention in COPD generally begins with dietary supplements once alternative causes of weight loss are excluded, and that systematic reviews provide conflicting information on the effectiveness of nutritional supplementation on anthropometric measures, lung function, and exercise capacity 1. However, the most recent and highest quality study suggests that a comprehensive approach focusing on both nutrition and respiratory management is essential to improve morbidity, mortality, and quality of life in patients with COPD and underweight status.

From the Research

Recommendations for Underweight Individuals with COPD

• Assessing and monitoring body weight is crucial, as being underweight is a poor prognostic sign in COPD 2
• Medical nutrition therapy by a registered dietitian nutritionist can help maintain and improve outcomes, such as lung function, mortality, and quality of life 3
• Individualizing calorie prescription and macronutrient composition of the diet may be beneficial, although more research is needed to support this recommendation 3
• Nutritional supplementation can lead to weight gain and improvements in respiratory muscle function and exercise performance, but long-term effects are unclear 2, 4
• Dietary interventions and targeted single or multi-nutrient supplementation can be beneficial when optimal timing is considered, such as during and recovering from an acute exacerbation 5

Management of Malnutrition in COPD

• Measuring body mass index is recommended, and healthcare professionals should ensure that COPD patients are achieving their nutritional requirements 4
• Malnutrition can cause negative effects on exercise and muscle function, lung function, and increase exacerbations, mortality, and cost 4
• Nutrition management should be included in clinical practice, and nutritional education may have short-term improvements 4
• The role of novel forms of treatment, such as androgens or appetite stimulants, needs to be further studied to increase fat-free mass and improve outcomes 2