Nutritional Supplementation during Pulmonary Rehabilitation in Chronic Obstructive Pulmonary Disease

Abstract

Introduction: Pulmonary rehabilitation (PR) is a cost-effective management strategy in chronic obstructive pulmonary disease (COPD) patients which improves exercise performance and health-related quality of life. However, adherence to PR is common issue and this may be compounded by reduced muscle mass and/or malnutrition. The use of nutritional supplementation to overcome malnutrition and enhance outcomes for COPD patients during PR has been limited by the absence of rigorous evidence. Aim: To investigate relationships between malnutrition, nutritional supplementation, and PR in COPD. Specifically, to investigate the effect of protein-supplementation (Fortisip Compact Protein, FCP) during a COPD PR program on exercise capacity, peripheral muscle strength, anthropometrics measurements, anxiety and depression, health related quality of life, and physical activity. To assess whether any changes in exercise capacity, peripheral muscle strength, anthropometrics measurements, anxiety and depression, health related quality of life, and physical activity associated with nutritional supplementation are maintained at six weeks following PR. Methods: A systematic review was conducted to summarise the current evidence for using nutritional supplementation during PR in stable COPD to enhance PR outcomes. The systematic review facilitated the development of the research questions and main hypothesis. To identify the prevalence of malnutrition in our population, we conducted a study in a COPD population referred to PR, examining relationships between nutrition and disease severity. We then conducted a double-blind randomised controlled trial using FCP as an intervention and preOp (a carbohydrate supplement) as control in COPD patient who participated in a six-week PR programme. Participants were required to consume the intervention twice a day and attended PR sessions two hours long, twice each week for six weeks, with complete pre- and post-measures, including incremental shuttle walk test (ISWT) as the primary outcome. We conducted a follow-up study to identify if changes in exercise capacity and other outcomes were maintained six-week following completion of PR. Finally, participants’ experience using both products was assessed in a survey. Results: It was impossible to draw definitive conclusions in the systematic review due to heterogeneity, but nutritional supplements may enhance the benefit of PR with a need for further well-designed and rigorous research to address this area. In our PR population, the prevalence of malnutrition was 17% and lower BMI was significantly associated with lower FEV1, FEV1% and FEV1/FVC. There were no statistically significant differences between intervention and control groups in exercise capacity measured by ISWT at the end of the PR, however, there was a clinically meaningful difference favouring the intervention group (intervention: 342 m ±149 vs. control: 305 m ±148, p >0.05). Individuals who reached that improvement had larger mid-thigh circumference (responder: 62 cm ±4.5 vs. non-responder: 55 cm ±6.2; p <0.05). Appetite did not change and the majority of participants were satisfied with product Conclusion: Malnutrition is common in stable COPD patients referred for PR and lower BMI is associated with lower lung function (FEV1). Using a high protein nutritional supplementation in individuals with COPD who were enrolled in PR resulted in a clinically meaningful difference favouring the intervention in exercise capacity measured by ISWT, and that improvement was maintained least six weeks later. A larger study would be necessary to demonstrate statistical significance. Individuals who reached that improvement had larger mid-thigh circumference. Nutritional supplements are acceptable to patients.