Nutrition As an Intervention to Enhance Performance in COPD

Nutrition as an Intervention to Enhance Performance in COPD

Michael Steiner

Leicester, UK

Introduction

The importance of nutrition to enhance performance and training has long been recognised in the fields of sports and athletics. A detailed description of the literature in this field is beyond the scope of this paper but there is evidence for the benefits of ensuring adequate carbohydrate and protein intake (depending on the athletic discipline) in optimising performance and evidence that some specific nutrients (eg creatine) may enhance performance for some activities.

Enhancing physical performance is a key therapeutic goal in COPD and therefore there are theoretical reasons for hypothesizing that nutritional intervention might improve performance in this population or enhance the outcome of exercise training, an intervention that is of proven clinical and physiological benefit in COPD.

This paper will describe studies that have addressed these questions in COPD and draw conclusions from the available literature to date.

Methodology

Medline and Embase were searched using the strategy outlined in Appendix I. Retrieved papers were selected on the basis of the following criteria:

1. The study involved a nutritional intervention.
2. Exercise capacity was measured in response to the intervention.

29 papers met these criteria. Of these, 5 were excluded because they only assessed the acute effects of nutrition on a single bout of exercise(1-5). Seven studies were excluded because the nutritional intervention was provided as part of a multimodal package which included exercise and as a result, the impact of the nutritional component on exercise performance could not be assessed(6-12). 17 studies were considered in more detail.

Findings

Trials of nutritional intervention without exercise or training

Six studies were identified. Most were conducted over 15 years ago reflecting current opinion that nutritional therapy will be most effective when combined with an anabolic stimulus such as exercise. Similarly, most were conducted with the aim of increasing body weight rather than exercise performance. There were some indications of the potential to improve exercise capacity in undernourished patients but the findings were not conclusive and the sustainability of this effect in the longer term was not studied.

Trials of nutritional intervention provided during an exercise or training programme

Eight studies were identified(13-20). These involved a variety of interventions including carbohydrate and fat rich supplements, essential amino acids, whey protein, carnitine and polyunsaturated fatty acids (PUFA). Early macronutrient studies involving fat rich supplements did not suggest a performance advantage in the intervention groups but subsequent studies using a carbohydrate rich supplement and PUFA suggested the outcome or PR might be enhanced in selected patients. Small pilot investigations have suggested potential benefit of whey protein and carnitine but probably had insufficient statistical power for wider conclusions to be drawn.

Trials of Creatine Supplementation

Three trials have tested the effect of creatine supplementation during exercise training in COPD. Fuld et al reported greater increases in strength following training in subjects receiving creatine(21) but these findings were not replicated in subsequent trials(22;23). None of the studies identified improvements in whole body exercise capacity. A subsequent systematic review and meta-analysis supported the negative impact of the intervention(24).

Conclusions

There are a limited number of trials investigating the impact of nutritional therapies on exercise performance or training in COPD. The literature is characterised by considerable heterogeneity in the nature of the intervention, the populations enrolled and the exercise outcomes that were studied. Many studies were underpowered and most were single centre investigations. The question whether nutritional support can augment the performance outcomes of exercise training and pulmonary rehabilitation remains largely unanswered and would be a suitable topic for larger, adequately clinical trials in the future.

References

(1) Efthimiou J, Mounsey PJ, Benson DN, Madgwick R, Coles SJ, Benson MK. Effect of carbohydrate rich versus fat rich loads on gas exchange and walking performance in patients with chronic obstructive lung disease. Thorax 1992; 47(6):451-6.

(2) Engelen MP, Rutten EP, De Castro CL, Wouters EF, Schols AM, Deutz NE. Casein protein results in higher prandial and exercise induced whole body protein anabolism than whey protein in Chronic Obstructive Pulmonary Disease. Metabolism 2012; 61(9):1289-1300.

(3) Marwood S, Jack S, Patel M, Walker P, Bowtell J, Calverley P. No effect of glutamine ingestion on indices of oxidative metabolism in stable COPD. Respir Physiol Neurobiol 2011; 177(1):41-46.

(4) Rutten EP, Engelen MP, Gosker H, Bast A, Cosemans K, Vissers YL et al. Metabolic and functional effects of glutamate intake in patients with chronic obstructive pulmonary disease (COPD). Clin Nutr 2008; 27(3):408-415.

(5) Vermeeren MA, Wouters EF, Nelissen LH, van Lier A, Hofman Z, Schols AM. Acute effects of different nutritional supplements on symptoms and functional capacity in patients with chronic obstructive pulmonary disease. Am J Clin Nutr 2001; 73(2):295-301.

(6) Creutzberg EC, Wouters EF, Mostert R, Weling-Scheepers CA, Schols AM. Efficacy of nutritional supplementation therapy in depleted patients with chronic obstructive pulmonary disease. Nutrition 2003; 19(2):120-127.

(7) Farooqi N, Nordstrom L, Lundgren R, Sandstrom T, Haglin L. Changes in body weight and physical performance after receiving dietary advice in patients with chronic obstructive pulmonary disease (COPD): 1-year follow-up. Arch Gerontol Geriatr 2011; 53(1):70-75.

(8) Kubo H, Honda N, Tsuji F, Iwanaga T, Muraki M, Tohda Y. Effects of dietary supplements on the Fischer ratio before and after pulmonary rehabilitation. Asia Pac J Clin Nutr 2006; 15(4):551-555.

(9) Pison CM, CanoNJ, Cherion C, Caron F, Court-Fortune I, Antonini MT. Multimodal nutritional rehabilitation improves clinical outcomes of malnourished patients with chronic respiratory failure: a randomised controlled trial. Thorax 2011; Epub ahead of print:10.1136/thx.2010.154922.

(10) Slinde F, Gronberg AM, Engstrom CR, Rossander-Hulthen L, Larsson S. Individual dietary intervention in patients with COPD during multidisciplinary rehabilitation. Respir Med 2002; 96(5):330-336.

(11) Sugawara K, Takahashi H, Kasai C, Kiyokawa N, Watanabe T, Fujii S et al. Effects of nutritional supplementation combined with low-intensity exercise in malnourished patients with COPD. Respir Med 2010; 104(12):1883-1889.

(12) van Wetering CR, Hoogendoorn M, Broekhuizen R, Geraerts-Keeris GJ, De Munck DR, Rutten-van Molken MP et al. Efficacy and costs of nutritional rehabilitation in muscle-wasted patients with chronic obstructive pulmonary disease in a community-based setting: a prespecified subgroup analysis of the INTERCOM trial. J Am Med Dir Assoc 2010; 11(3):179-187.

(13) Broekhuizen R, Wouters EF, Creutzberg EC, Weling-Scheepers CA, Schols AM. Polyunsaturated fatty acids improve exercise capacity in chronic obstructive pulmonary disease. Thorax 2005; 60(5):376-382.

(14) Broekhuizen R, Creutzberg EC, Weling-Scheepers CA, Wouters EF, Schols AM. Optimizing oral nutritional drink supplementation in patients with chronic obstructive pulmonary disease. Br J Nutr 2005; 93(6):965-971.

(15) Borghi-Silva A, Baldissera V, Sampaio LM, Pires-DiLorenzoVA, Jamami M, Demonte A et al. L-carnitine as an ergogenic aid for patients with chronic obstructive pulmonary disease submitted to whole-body and respiratory muscle training programs. Braz J Med Biol Res 2006; 39(4):465-474.

(16) Baldi S, Aquilani R, Pinna GD, Poggi P, De Martini A, Bruschi C. Fat-free mass change after nutritional rehabilitation in weight losing COPD: role of insulin, C-reactive protein and tissue hypoxia. Int J Chron Obstruct Pulmon Dis 2010; 5:29-39.

(17) Laviolette L, Lands LC, Dauletbaev N, Saey D, Milot J, Provencher S et al. Combined effect of dietary supplementation with pressurized whey and exercise training in chronic obstructive pulmonary disease: a randomized, controlled, double-blind pilot study. J Med Food 2010; 13(3):589-598.

(18) Schols AM, Soeters PB, Mostert R, Pluymers RJ, Wouters EF. Physiologic effects of nutritional support and anabolic steroids in patients with chronic obstructive pulmonary disease. A placebo-controlled randomized trial. American Journal of Respiratory & Critical Care Medicine 1995; 152(4 Pt 1):1268-74.

(19) Steiner MC, Barton RL, Singh SJ, Morgan MD. The Nutritional Enhancement of Exercise Performance in Chronic Obstructive Pulmonary Disease. A Randomised Controlled Trial. Thorax 2003; 58:745-751.

(20) Sugawara K, Takahashi H, Kashiwagura T, Yamada K, Yanagida S, Homma M et al. Effect of anti-inflammatory supplementation with whey peptide and exercise therapy in patients with COPD. Respir Med 2012; 106(11):1526-1534.

(21) Fuld JP, Kilduff LP, Neder JA, Pitsiladis Y, Lean ME, Ward SA et al. Creatine supplementation during pulmonary rehabilitation in chronic obstructive pulmonary disease. Thorax 2005; 60(7):531-537.

(22) Deacon SJ, Vincent EE, Greenhaff PL, Fox J, Steiner MC, Singh SJ et al. Randomized controlled trial of dietary creatine as an adjunct therapy to physical training in chronic obstructive pulmonary disease. Am J Respir Crit Care Med 2008; 178(3):233-239.

(23) Faager G, Soderlund K, Skold CM, Rundgren S, Tollback A, Jakobsson P. Creatine supplementation and physical training in patients with COPD: a double blind, placebo-controlled study. Int J Chron Obstruct Pulmon Dis 2006; 1(4):445-453.

(24) Al Ghimlas F, Todd DC. Creatine supplementation for patients with COPD receiving pulmonary rehabilitation: a systematic review and meta-analysis. Respirology 2010; 15(5):785-795.

Appendix I

Search Strategy

Medline and Embase search

Limited to human studies and English language

Additional retrieval from systematic reviews

Terms:

Chronic Obstructive Pulmonary disease

Emphysema

Chronic Bronchitis

CORD/COAD/CAL/COLD

Diet Therapy

Nutrition Therapy (nutrition OR "nutritional supplement*" OR supplement* OR modulation OR protein* OR leucine OR "amino acid*" OR "fatty acid*" OR "PUFA" OR vitamin* OR creatine OR antioxidant* OR glutamate OR glutamine OR "vitamin D" OR carbohydrate)

Exercise Tolerance

Physical Exertion

Physical Fitness

Exercise capacity" OR "physical capacity" OR "exercise tolerance" OR "physical tolerance" OR "exercise intolerance" OR "exercise performance" OR "physical performance" OR "Pulmonary rehabilitation" OR rehabilitation