February 2009 Issue

Nutrition and COPD - Dietary Considerations for Better Breathing

By Ilaria St. Florian, MS, RD
Todays Dietitian
Vol. 11 No. 2 P. 54

A recent survey conducted by the National Heart, Lung, and Blood Institute
suggests that despite a growing awareness of chronic obstructive pulmonary
disease (COPD), only 64% of respondents had ever heard of it. Yet, according to the
Global Initiative for Chronic Obstructive Lung Disease, COPD is the fourth leading
cause of chronic morbidity and mortality in the United States and an estimated 24
million Americans are affected.1

COPD is a progressive lung disease that makes breathing difficult due to partially
obstructed airflow into and out of the lungs. It results from an inflammatory and
destructive process in the lungs stimulated by exposure to toxins, primarily due to a
history of smoking cigarettes.

Healthy peoples bronchial tubes and alveoli are elastic; thus, when they breathe in
and out, they inflate and deflate much like a balloon. In contrast, patients with
COPD experience limited airflow through their airways due to either a loss of
elasticity and/or inflamed, damaged, or mucous-clogged airways. Because the
airways are partially blocked or damaged, breathing becomes difficult, and the
lungs begin to lose their ability to effectively take up oxygen and remove carbon
dioxide.2,3 Expiratory airflow limitation is the hallmark of COPD, and the gold
standard for diagnosis is spirometry, which is a simple lung function test that
measures how well the lungs exhale.1

Symptoms of COPD include chronic cough, often referred to as smokers cough;

excessive mucous production; wheezing; shortness of breath; tightness in the chest;
and a decrease in exercise capacity.2,4 The leading cause of COPD is cigarette
smoking; in fact, most patients with COPD are either current smokers or have a
history of smoking. According to the American Lung Association, an estimated 80%

to 90% of COPD deaths are attributed to smoking, and smoking cessation is the
most effective
According to the ADAs 2008 practice guidelines for COPD, at-risk patients should
take at least 1,200 milligrams of calcium and 800 to 1,000 international units of
vitamin D daily to minimize bone loss.

A healthy diet for patients with COPD can lead to better breathing and possibly
facilitate weaning from mechanical ventilation by providing the calories necessary
to meet metabolic needs, restore FFM, and reduce hypercapnia. Carbon dioxide is a
waste product of metabolism and is normally expelled via the lungs. However,
patients with COPD who have limited and obstructed airflow have a compromised
ability to take in oxygen and eliminate carbon dioxide. In patients with COPD, this
impaired gas exchange increases patients ventilatory demands, as the lungs must
work harder to clear excess carbon dioxide. In healthy individuals, increased carbon
dioxide levels are easily eliminated.7

The Importance of Proper Nutrition

Proper nutrition can help reduce carbon dioxide levels and improve breathing.
Specifically, it is important to focus on the percentages of total carbohydrate, fat,
and protein that patients consume to see how their diet composition impacts their
respiratory quotient (RQ), which is defined as the ratio of carbon dioxide produced
to oxygen consumed. To put it simply, following metabolism, carbohydrate, fat, and
protein are all converted to carbon dioxide and water in the presence of oxygen.
However, the ratio of carbon dioxide produced to oxygen consumed differs per
macronutrient; the RQ for carbohydrate is 1, fat is 0.7, and protein is 0.8. From a
nutritional standpoint, this means that eating carbohydrates will yield the most
carbon dioxide, while eating fats will yield the least carbon dioxide. That said,
prescribing a high-fat, low-carbohydrate diet would reduce patient RQ levels and
carbon dioxide production. In fact, patients who have difficulty increasing ventilation
following a carbohydrate load or patients with severe dyspnea or hypercapnia may
benefit from a high-fat diet.6

A July 1993 study in Chest found that a high-fat diet (55% fat) would be more
beneficial to patients with COPD than a high-carbohydrate diet (55% carbohydrate)
because it would decrease carbon dioxide production, oxygen consumption, and RQ,
as well as improve ventilation. However, there is not a general consensus in the
literature to universally recommend a high-fat, low-carbohydrate diet, as it may not
be necessary for stable patients and not all patients may be able to tolerate the

potential side effects (eg, gastrointestinal and abdominal discomfort, belching,

diarrhea). In addition, some patients may have a coexisting heart condition, which
could make a high-fat diet contraindicated.6 In fact, 25% of COPD patients develop
pulmonary hypertension due to low oxygen levels, which results in enlargement and
thickening of the right ventricle of the heart, a condition known as corpulmonale.

Therefore, according to the ADAs Manual of Clinical Dietetics, it is best to replete

energy needs but avoid overfeeding as excess calories are more significant in the
production of carbon dioxide than the