栄養とCOPDの新知見

今日も、5th Cachexia Conferenceの資料の中から、栄養とCOPDの新知見の抄録を紹介します。それだけこの資料にはネタが多いということです。

http://www.lms-events.com/19/5th_Cachexia_Conference_2009_Abstracts.pdf

この抄録にはnutritional rehabilitationという言葉が何度か出てきます。これは日本語にすると「栄養リハ」となり、栄養状態をどう改善・回復させるかという意味になります。このブログの「リハ栄養」とは意味が異なります。

COPDは単なる呼吸器疾患ではなく、多臓器に影響を及ぼす代謝疾患であると記載されています。実際、多彩な症状・障害を認めますので、全身炎症性疾患と捉える事が重要です。

COPDに対する栄養療法は悪液質による栄養障害が主な対象だったため、なかなか有効だというエビデンスを出せませんでした。最近、運動療法などを組み合わせた包括的呼吸リハとしてのアプローチであれば有効という報告が出ています。

脂肪乳剤の使用が推奨されていますが、個人的にはPFCバランスの中で脂肪の割合を増やすよりも、EPA・エイコサペンタエン酸を1日2g投与することのほうが重要ではないかと感じています。もちろん1日エネルギー必要量を投与した上での話ですが。

臨床現場でも栄養療法単独ではなく、包括的呼吸リハとしてアプローチすることが多いかと思います。COPD以外の悪液質を生じる疾患に対しても、やはり包括的アプローチが重要だと考えます。

New insights on nutrition and COPD
Annemie Schols
Maastricht University Medical Centre, The Netherlands

Research during the past two decades has consistently shown that COPD is not only a chronic inflammatory lung disease but also a metabolic disorder affecting multi-organ systems. Weight loss, skeletal muscle wasting and a decreased muscle oxidative phenotype are well documented in advanced COPD and have been a target for multimodal intervention strategies. Promising results have yet been obtained by nutritional supplementation, in particular when combined with physical exercise although a recent RCT by Weekes et al also showed long-term effects on body weight and quality of life by nutritional intervention alone whereas the control group lost weight during the 12 months follow-up. Furthermore experimental research rapidly advances in understanding the molecular mechanisms of altered muscle plasticity in COPD progression providing new leads for nutritional modulation that may even extend beyond skeletal muscle as nicely illustrated for poly-unsaturated fatty acids.

Scarce data is available in literature about the rationale and effectiveness of nutritional rehabilitation in less advanced COPD. Furthermore no data is available on the feasibility of multimodal intervention strategies in a community-based setting as well as on the long-term clinical outcome and cost-effectiveness. We recently completed a two-year randomized controlled trial evaluating the effect of an INTERdisciplinary COMmunitybased COPD management program (INTERCOM) compared to Usual Care. The INTERCOM program aimed to provide tailored care by physiotherapists, dieticians and COPD nurses working outside but in conjunction with the hospital. All patients in the intervention group received exercise training, education and smoking cessation when applicable while muscle wasted patients received additional standardized nutritional supplementation. Over the total two-year period, there were significantly better effects in the INTERCOM group compared to Usual Care in health status, exercise capacity and perceived effectiveness but no differences were found for exacerbations, muscle function and body composition. The trial was designed to enable a subgroup analysis in muscle wasted COPD patients on body composition and functional performance. After 4 months, the wasted intervention group significantly increased in fat free mass index, muscle strength and exercise performance compared to the wasted Usual Care group. Within group differences in body composition and muscle function sustained after 24 months in the intervention group while wasted patients receiving Usual Care showed a pronounced decline in walking distance and experienced significantly more severe exacerbations. Cost analysis revealed higher costs in the nutritional intervention group after 4 compared to Usual Care that disappeared after 24 months due to significantly higher costs related to hospital admissions in the wasted Usual Care group. In conclusion, new insights provide a strong rationale to broaden the scope of nutritional rehabilitation in COPD a) from modulation of muscle mass to muscle oxidative metabolism and b) from severe COPD to less advanced disease.

References:
1. Broekhuizen R, Wouters EFM, Creutzberg EC, Weling-Scheepers CAPM, Schols AMWJ. Polyunsaturated fatty acids improve exercise capacity in chronic obstructive pulmonary disease. Thorax 2005;60:376–382.
2. Calvert LD, Shelley R, Singh SJ, Greenhaff PL, Bankart J, Morgan MD, Steiner MC. Dichloroacetate enhances performance and reduces blood lactate during maximal cycle exercise in chronic obstructive pulmonary disease. Am J Respir Crit Care Med. 2008 May 15;177(10):1090-4.
3. Deacon SJ, Vincent EE, Greenhaff PL, Fox J, Steiner MC, Singh SJ, Morgan MD.
4. 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 Aug 1;178(3):233-9.
5. Mercken EM, Calvert LD, Singh SJ, Hageman GJ, Schols AM, Steiner MC. Dichloroacetate Modulates the Oxidative Stress and Inflammatory Response to Exercise in COPD. Chest 2009 Chest. 2009 Sep;136(3):744-51.
6. Schols AM. Nutritional rehabilitation: from pulmonary cachexia to sarcoPD. Eur Respir J. 2009;33:949-50.
7. Weekes CE, Emery PW, Elia M. Dietary counceling and food fortification in stable COPD. A randomized trial. Thorax. 2009;64:326-31
8. van Wetering CR, Hoogendoorn M, Mol SM, Rutten-van Mölken MP, Schols AM. Short- and long-term efficacy of a community-based COPD management program in less advanced COPD: a Randomized Controlled Trial. Thorax. 2009 Aug 23. [Epub ahead of print]