*8.3.3 Nutritional education*

Body composition in COPD patients may change as the disease severity progresses. While obesity predominates in the milder stages of the disease, patients with advanced disease and emphysema tend to be underweight and have generalized muscle wasting [114, 115]. Factors other than the lung disease itself, which can lead to this shift, includes inactivity, systemic inflammation, osteoporosis and glucocorticoids use. Studies have shown an increase in mortality in COPD patients who are underweight, independent of their disease severity [116, 117]. These patients with decreased fat free mass have higher limitation to exercise tolerance and thereby reported a decreased HRQoL status in comparison to COPD patients with normal weight [118–121]. Various studies have shown a survival benefit with weight gain as low as 2 kg or by increase in one body mass index unit [116, 117]. This is why nutritional education are particularly essential in rehabilitation of COPD patients.

Every pulmonary rehabilitation program should include nutritional screening with measurement of BMI at the least. A more comprehensive program may also include fat free mass estimate using skinfold anthropometry or bioimpedance analysis. Estimation of osteoporosis can be done using dual energy X-ray absorptiometry (DEXA) scanning. Improvement of nutritional status requires a multi-pronged approach with utilization of both physiologic and pharmacological interventions. Endurance and strength training as described previously in this chapter can improve muscle mass as well as bone strength. Nutritional interventions include adding nutritional supplementation to patient's diet with emphasis on adequate protein intake to maintain or restore lean body mass. Patients who are unable to eat large meals due to dyspnea can switch to frequent small meals. It has been shown that a 6-month intervention involving dietary counseling, nutritional supplementation and positive reinforcement led to a significant weight gain in advanced COPD patients [60].
