CC BY
19
Liverko Irina Vladimirovna, MD, professor, deputy director, of the Scientific Center of Physiology and Pulmonology Ubaydullaeva Naima Nabikhanovna, PhD., in medicine, associate professor, of the Departmen of Pulmonology of the Tashkent Institute of Postgraduate Medical Education, Tashkent, Uzbekistan E-mail: [email protected]
ASSESSMENT AND ORIGINS OF MALNUTRITION, AND POTENTIALITIES OF NUTRITIONAL SUPPORT IN PATIENTS WITH CHRONIC OBSTRUCTIVE PULMONARY DISEASE
Abstract: Nutritional status was assessed in 105 elderly patients with chronic obstructive pulmonary disease (COPD) (mean age 51.5 ± 2.3 years, disease duration 20.5 ± 1.5 years) by means of the Mini Nutritional Assessment Short-Form (MNA®-SF). According to interview findings, malnutrition was registered in 42.8% patients with COPD, 33.3% of the patients needed the nutritional support. The malnutrition ofpatients with COPD is a multifactorial disorder with the nutritive factor playing a significant role in its onset and progression; a third of the patients were found not to have proper intake of protein, fruits and vegetables, and fluids. 6.7% of patients with COPD found it difficult to eat without assistance due to shortness of breath when eating. The patients with COPD tended to overestimate both their nutrition status and health status. The nutraceuticals used in the combination therapy for patients with COPD were shown to produce tonic, and what is more significant, anabolic action, to facilitate tolerance to physical loading and to reduce the extent of the effect COPD produced on a patient's life.
Keywords: chronic obstructive pulmonary disease, malnutrition, nutritional support, nutraceuticals.
According to the European Society of Parenteral and En- The findings from multiple studies demonstrate that
teral Nutrition (ESPEN), malnutrition among elderly persons nutritional disorders are associated with various structural
occurs in 15% of community-dwelling ones, in 30% of those and functional changes in a human organism, as well as with
living at the nursing houses, in 48% of those under continuous disturbances of metabolism, homeostasis and its adaptive re-
care and in 50% of those hospitalized at health-care facilities of serves. Nutritional supply of seriously ill patients and their
various specialties, to name, surgery (27-28%), internal medi- mortality have been found to correlate positively; the harder
cine (46-49%), eldercare (26-57%), orthopedics (39-45%), the energy failure, the more frequently multiple organ system
oncology (46-88%), infection (42-59%), pulmonology (33- failure and lethal outcome occurs (Popova T. S. et al., 2000;
63%), gastroenterology (46-60%) and chronic kidney disease Gray-Donald K. et al., 1996; Landbo C. et al., 1999) [5; 7; 8]. (31-59%) [3; 4]. It is beyond argument that in addition to oxygen supply,
The malnutrition is considered clinically significant the nutritional homeostasis is the mainstay for an organism's
when the weight loss is < 10%. 20% protein malnutrition functioning and a key condition to overcome pathologies.
drastically increases the likelihood of fatigue, depression, Next to its intrinsic factors, to a considerable extent, main-
perioperative morbidity, sepsis and wound infection, and tenance of a human organism's nutritional homeostasis is de-
mortality (Gray-Donald K. et al., 1996; Schols A. M. et al., termined by availability ofthe nutritious substrates necessary
1998; Allison S. P., 2000) [1; 5; 9]. for life support.
Typically, the malnutrition is undiagnosed and untreat- The aim of the work was initiated to assess the nutritional
ed, specifically in the in-patients. Essentially, this is due to status in elderly patients with chronic obstructive pulmonary
(i) absence of the medical staff's proper training in meth- disease (COPD) and to choose the modus operandi for the
ods of nutritional therapy, (ii) lack of expert knowledge, nutritional support.
(iii) scarcity of appropriate protocols for examination and Materials and methods. Nutritional status was identified
assessment of malnutrition, and (iv) inadequacy of measures in 105 elderly patients with COPD (mean age 51.5 ± 2.3 years,
taken [2; 6]. disease duration 20.5 ± 1.5 years) by means of the most simple
and practical tool, the Mini Nutritional Assessment Short-Form (MNA®-SF), consisting of a screening (a 6-parameter first step) and an assessment (a 12-parameter second step) (Supplement 1).
Maximum composite screening score is 14 points. 12-14 points imply normal nutritional status, no risk of malnutrition and no necessity of the second step. 9-11 points imply risk of malnutrition and necessity of the second step.
Maximum composite score at the second step is 16 points. Composite score for two steps is 30 points. 17-23.5 points imply risk of undernutrition; > 17 points imply clinical undernutrition (CU).
The patients with COPD and initial signs of undernutrition, and thus, needing nutritional support (n=60) were divided into two groups. In the course of combination therapy for the disease exacerbation, 35 patients (1st group) additionally received 4 courses of kuvatin (Institute of the Chemistry of Plant Substances, Uzbekistan Academy of Sciences, Tashkent, Uzbekistan) (a tablet thrice a day for 3 months) and ekdisten (Institute ofthe Chemistry of Plant Substances, Uzbekistan Academy of Sciences, Tashkent, Uzbekistan) (two tablets twice a day for 15 days with 10-day intervals), 25 patients (2nd group) were prescribed with kuvatin only (a tablet thrice a day 20 minutes before meals for 3 months). 15 patients with COPD prescribed with a specific diet were included into the control group. To process the data, we used the Statistical Analysis System (SAS), a software suite that can mine, alter, manage and retrieve data from a variety of sources, and perform statistical analysis.
Results and discussion. According to interview findings, malnutrition was registered in 42.8% patients with COPD. 57.1% of patients reported the decline in food intake over previous 3 months due to low appetite, 14.3% and 42.8% among them specified the loss as the strong and moderate, respectively. Weight loss between 1 and 3 kg during previous 3 months was reported by 28.6%. Equivalent proportions of patients with COPD, 14.3%, (i) could not go out due to mobility restriction, (ii) reported irritability, anger and memory disorders and (iii) had BMI < 19 kg/m2. As the findings from assessment of quality of nourishment demonstrated, only 66.7% of patients had two proper meals a day. According to findings from assessment of markers for consumption of protein, 33.3% of patients with COPD answered "yes" one time, 66.7% answered "yes" two times and no one chose the whole list of markers. 66.7% of patients with COPD consumed two or more vegetable or fruit dishes a day, 33.3% were deprived of the possibility to do it. As to fluid intake (including water, juice, coffee, milk, tea) a day, 33.3% of patients had 3-5 glasses; 6.7% found it difficult to eat without assistance due to shortness of breath when eating. According to 66.7% of patients, there were no problems with food intake; the nutri-
tion status was regarded as poor only by 6.7%. Self-scoring their health status, 66.7% of patients estimated it as better than other people's health; 33.3% of patients regarded their health status as good as the one of people of the same age. Patients with COPD tended to overestimate both their nutrition status and health status. Our findings demonstrated that 33.3% of patients with COPD needed a nutritional support.
Active nutritional support is to be prescribed in case of:
1. Relatively rapid progress ofweight loss in consequence of the disease: > 2% a week, > 5% a month, > 10% a quarter or > 20% per six months.
2. Presence of signs of initial undernutrition, including BMI < 19 kg/m2, upper arm circumference < 90% on the standard (< 26 cm for men and < 25 cm for women), hypo-proteinemia < 60 g/l (or) hypoalbuminemia < 30g/l and lymphocytopenia < 1200.
3. Hazard of progressing nutritional deficiency, including impossibility of natural oral feeding when a patient cannot, does not want or should not take food naturally, and presents with hypermetabolism and hypercatabolism.
Proper nutritional intervention should be based upon (i) promptitude, implying that the therapy should start as early as possible avoiding severe undernutrition resisting treatment, (ii) adequacy, implying that the patient should get nutrient materials to cover for his/her organism expenditures and (iii) optimality, implying that the therapy should last until complete normalization of somatometric and clinical-laboratory parameters.
Nutritional intervention should include prescribing of a high-calorie diet, and formulas for enteral and parenteral feeding. The diet should contain high amounts of easily digested proteins, have sufficient caloric value and be rich in macro- and microelements and vitamins. Practical expertise demonstrates that there is a limited choice of food products with the properties above.
We have managed to consider approaches to nutritional support for patients with COPD by means of nutraceuticals as represented by kuvatin, an oral nutritional supplement (ONS), and ecdisten, a phytoecdysterone.
Kuvatin is an oral nutritional supplement (ONS) with a composition of natural protein containing amino acids, such as asparagine, threonine, serine, glutamine, proline, glycine, alanine, cysteine, valine, methionine, isoleucine, tyrosine, phe-nylalanine, histidine, tryptophan, lyzine and arginine, and microelements, such as sodium, bromine, magnesium, potassium, argentum, chrome, iron, titan, calcium, manganese and copper.
Ecdisten is a phytoecdysterone with tonic and significant anabolic action extracted from rhizomes and roots of Rhaponticum carthamoides (Willd) Iljin, a herbaceous perennial plant from the family Asteraceae. Its molecular
mechanism of action is similar to the one of anabolic steroids. It binds to the receptors on the myocyte membrane to be transferred with the cytoplasmic receptors to the cell nucleus to regulate synthesis of nucleic acids which regulate the biosynthesis of protein. Like anabolic steroids, ecdysterones are substances of cumulative effect.
The findings from the follow-up of patients with COPD in the course of therapy with kuvatin and ecdisten and those in the control group can be seen in
By the end of a 3-month therapy with nutraceuticals, frequency of manifestations of asthenization, lack of appetite, physical activity restriction and changes in myocardial metabolism reduced to be more significant in patients who received a combination of kuvatin and ekdisten (Table 1). The nutraceuticals facilitated more significant weight gain, up to 750g and 450g averagely in the 1st and 2nd group of patients, respectively, making the difference in parameters of physical tolerance test and increasing the distance in 6-minute walk test (6MWT) up to 82m and 59m, respectively. No changes in the parameters under study could be seen in the controls.
The nutraceuticals under study had a favorable effect on the clinical course of COPD. Episodes of reinfection and exacerbations could be observed significantly less frequently in patients receiving nutritional support. Thus, the findings from the 3-month therapy demonstrated that episodes of reinfection and exacerbation were registered in 5.7% of patients receiving a combination of kuvatin and ecdisten, in 16% of patients receiving kuvatin only, and in 53.3% of the controls. Duration of clinical symptoms of exacerbation was found reducing to 16.5 and 19.5 days in groups of patients receiving a combination of kuvatin and ecdisten, and only kuvating, respectively, versus 29 days in the control group. Nutraceu-ticals were found to produce positive effect on the frequency of rehospitalization. Thus, in the group of patients receiving a combination of kuvatin and ecdisten, 2.8% needed hospital-
ization due to exacerbation of the disease; while it was necessary for 12.0% of patients in the group receiving kuvatin and for 40% of those in the control one.
Three-month follow-up of patients with COPD receiving kuvatin and ecdsiten demonstrated significant increase in absolute lymphocyte count to be the evidence for restoration of immune hemostasis.
As a whole, nutraceuticals had a favorable effect on the health of patients with COPD. As the findings from COPD assessment test (CAT) demonstrated, by the end of 3-month intervention 52% of patients with COPD receiving a combination of kuvatin and ecdisten changed their opinion of the effect COPD produced on a patient's life from significant to insignificant one (10 points), while according to 48% of the patients, the change was from significant to moderate one (20 points). Most patients receiving only kuvatin changed their opinion of the effect from significant to moderate one, while only 5% of the controls did so.
Conclusions:
1. The malnutrition was registered in 42.8% of patients with COPD, 33.3% of the patients needed the nutritional support.
2. The malnutrition of patients with COPD is a multifacto-rial disorder with the nutritive factor playing a significant role in its onset and progression; a third of the patients were found not to have proper intake of protein, fruits and vegetables, and fluids. 6.7% of patients with COPD found it difficult to eat without assistance due to shortness of breath when eating.
3. As the patients with COPD tended to overestimate both their nutrition status and health status, higher awareness of pulmonologists in diagnosis of malnutrition is mandatory.
4. The nutraceuticals used in the combination therapy for patients with COPD were shown to produce tonic, and what is more significant, anabolic action, to facilitate tolerance to physical loading and to reduce the extent of the effect COPD produced on a patient's life.
References:
1. Allison S. P. Malnutrition, disease, and outcome // Nutrition. 2000; 16 (7/8): 590-3.
2. Detsky A. S., McLaughlin J. R., Baker J. P. et al. What is subjective global assessment of nutritional status // Journal of parenteral and enteral nutrition. 1987; 11 (1): 8-13.
3. ESPEN Guidelines on enteral nutrition. 2007.
4. Ferreira I. M., Brooks D., Lacasse Y., Goldstein R. S. Nutritional support for individuals with COPD: a meta-analysis // Chest. 2000; 117: 672-8.
5. Gray-Donald K., Gibbons L. O., Shapiro S. H. et al. Nutritional status and mortality in chronic obstructive pulmonary disease // Am J Respir Crit Care Med. 1996; 153: 961-6.
6. Kostyukevich O. I. Current approaches to diagnosis and treatment of wasting syndrome from a therapist's point of view // The Russian Medical Journal. 2011; 6: 66. (In Russian). Popova et al. Contemporary views of metabolic response to system impairment.
7. Landbo C., Prescott E., Lange P. et al. Prognostic value of nutritional status in chronic obstructive pulmonary disease // Am J Respir Crit Care Med. 1999; 16:1856-61.
8. Popova T. S., Shestopalov A. E., Tamazashvili T. Sh., Leiderman I. N. Nutritional support of patients in critical conditions // - M.: M-Vesti. 2002; 319 p. (In Russian).
9. Schols A. M., Slangen J., Volovics L., Wouters E. F. Weight loss is a reversible factor in the prognosis of chronic obstructive pulmonary disease // Am. J. Respir. Crit. Care Med. 1998; 157: 1791-7.
