Our aim with these pages is to provide appropriate and reliable resources for people with respiratory conditions. We want to educate and empower people so they can improve their nutrition and manage their health care more effectively.
We hope to help them do this by:
• improving their understanding of the impact nutrition and diet can have on their health
• making them more aware of malnutrition and the impact it can have on their quality of life and disease progression
• encouraging them to discuss nutritional issues with their health professionals and be proactive about getting support when needed
Diet and nutrition is a fascinating and often confusing subject as not everything you read about nutrition on the internet or social media is accurate. As explained in more detail on our website, Dietitians must follow a code of practice which means the information and nutrition advice they provide is based on scientific evidence.
Malnutrition rates are high in people with respiratory conditions
It has been reported that approximately 20% of people with COPD – Chronic Obstructive Pulmonary Disease (one of the most common respiratory conditions) have malnutrition. This rate could in fact be much higher, as the methods used to diagnose malnutrition often rely on BMI (Body Mass Index) which does not take into account changes in body composition that commonly occur in those with chronic respiratory disease.
Malnutrition impacts negatively on the health of people with respiratory conditions
Scientific studies show that malnutrition negatively influences the course of respiratory disease because it:
• reduces muscle strength
• reduces exercise ability
• causes lung function to deteriorate
• Increases exacerbation rates
• increases the time it takes to recover from illness
• increases length of hospital stay
Malnutrition is both a cause and consequence of worsening respiratory disease. It becomes a downward spiral as declining health further effects appetite, dietary intake and nutrition. Malnutrition rates are known to increase as the severity of respiratory disease worsens.
Treating malnutrition can improve the health of people with respiratory conditions
There is scientific evidence treating malnutrition in people with COPD can improve strength, including respiratory muscle strength, promote muscle and weight gain and improve quality of life.
It is important that all health professionals understand the importance of nutrition in the holistic care of people with respiratory disease. Malnutrition needs to be identified and treated before it has a chance to seriously impact on the progression of disease.
Nutrition screening is an essential aspect of care for people with respiratory conditions
Regular nutrition screening is the first aspect of good nutrition care, followed by appropriate resources to be able to treat and monitor those with malnutrition or at high risk of malnutrition effectively.
Empowering patients to participate in managing their own health is one of the key NHS strategies. Educating those with respiratory conditions to understand the importance of nutrition and what they should expect from their health care professionals will enable them to manage their health condition more effectively.
References
Gattermann Pereira, T., Lima, J. and Silva, F.M., 2022. Undernutrition is associated with mortality, exacerbation, and poorer quality of life in patients with chronic obstructive pulmonary disease: A systematic review with meta‐analysis of observational studies. Journal of Parenteral and Enteral Nutrition, 46(5), pp.977-996.
Ferreira, I.M., Brooks, D., White, J. and Goldstein, R., 2012. Nutritional supplementation for stable chronic obstructive pulmonary disease. Cochrane Database of Systematic Reviews, (12).
Keogh, E. and Williams, E.M., 2021. Managing malnutrition in COPD: a review. Respiratory medicine, 176, p.106248.
Matkovic, Z., Cvetko, D., Rahelic, D., Esquinas, C., Zarak, M., Miravitlles, M. and Tudoric, N., 2017. Nutritional status of patients with chronic obstructive pulmonary disease in relation to their physical performance. COPD: Journal of Chronic Obstructive Pulmonary Disease, 14(6), pp.626-634.
BMI stands for Body Mass Index. It is calculated by dividing a persons weight (in kilograms) by their height (in metres) squared (multiplied by itself).
BMI is a simple calculation and commonly used within healthcare settings as a measure of health, to check if your weight falls within a healthy range. For most adults the ideal BMI range is between 18.5 to 25. But this varies with age, sex, ethnicity.
BMI ranges
BMI less than 18.5 = Underweight
BMI 18.5 to 24.9 = Healthy weight
BMI 25 to 29.9 = Overweight
BMI 30 to 39.9 = Obese
BMI 40 and over = Severely obese
If you want to calculate your BMI go to:
https://www.nhs.uk/health-assessment-tools/calculate-your-body-mass-index/calculate-bmi-for-adults
Having a BMI in the underweight range increases the likelihood or risk of being malnourished. However BMI on its own does not provide enough information and malnutrition can also be present in people who have a higher BMI (in the overweight or obese range). Weight loss is a common sign of malnutrition but may not always be apparent as weight is affected by fluid shifts. Some medical conditions cause the body to hold onto fluid which can mask weight loss and result in inaccurate calculation of BMI and malnutrition risk.
BMI is used as a quick way of assessing for malnutrition in people with lung conditions. Guidelines on the Management of Chronic Obstructive Pulmonary Disease developed by The National Institute for Health and Care Excellence (NICE) and used to guide and commission NHS services, advises BMI should be assessed as part of ongoing routine care and states nutritional supplements should be given to those with low a BMI.
Neither weight or BMI assess body composition as they do not distinguish between fat and muscle tissues. Many lung conditions are associated with ongoing inflammation which can increase the bodies requirement for protein. If dietary protein intake is inadequate, muscle protein will be broken down to meet the body’s needs. This can lead to accelerated muscle loss, malnutrition and frailty. These can be present in those with a BMI within what is considered the normal, overweight or obese weight range.
A weight and BMI in the ‘healthy’ range does not necessarily equate to good nutrition. People with lung conditions who are not underweight but have accelerated muscle loss, due to inadequate nutrition intake, may not be identified resulting in delays in nutrition treatments. See our learning pages on frailty and sarcopenia for further information.
The foods we eat provide our body with the essential nutrients: carbohydrates, fat, protein, vitamins and minerals.
The foods we eat provide our body with essential nutrients: carbohydrates, fat, protein, vitamins and minerals. It needs all these nutrients to keep working properly and stay healthy. Malnutrition happens when the body does not get enough of the right nutrients in the right amounts, causing changes that affect the ability of the body to function. There is extensive scientific evidence to show malnutrition impacts on clinical outcomes (health consequences). These include needing more visits to GP, longer recovery times from illness and increased chances of being admitted to hospital. Malnutrition can cause long term health problems for otherwise healthy and independent people.
Weight loss is the most common symptom of malnutrition. It occurs when the diet does not contain enough energy. This results in the body using its own energy stores leading to fat and muscle loss. The body needs more than just energy foods to stay healthy. Not getting eating enough protein foods in the diet can cause loss of muscle which leads to reduced strength and ability to perform everyday tasks. For further information see our ‘Learn More’ pages on protein and frailty.
Malnutrition can be present without being underweight or having obvious weight loss. If the diet contains mostly high fat and high sugar foods it tends to be less nutritious (nutrient dense) and may not provide the body with enough vitamins and minerals (micronutrients) needed to keep it functioning and stay healthy. A varied and balanced diet that includes foods from each of the four essential food groups should provide the right amount of nutrients needed for most people. For further information see our ‘Learn More’ page on micronutrients.
The Patients Association nutrition checklist (for patients)
There is a nutrition checklist you can complete for yourself or a friend/relative, to help identify signs of malnutrition. When you complete the checklist it provides some basic advice depending on the answers given. It also gives good suggestions for other suitable sources of information.
Copy and paste the following into your web browser
https://www.patients-association.org.uk/Handlers/Download.ashx?IDMF=5c3ffa5e-e774-44e3-9d27-79857cadcaaa
People with respiratory conditions are at a greater risk of malnutrition for a variety of reasons. If malnutrition is not identified and treated early on, it negatively affects lung function, health, wellbeing and quality of life.
Screening is used in medicine to look for undiagnosed health conditions and help find problems early on. By doing this they can be treated earlier so they cause less health complications.
Nutrition screening is an evaluation of your nutritional status to determine your risk of being malnourished. This is done using a validated screening tool, which just means a standardised method that has been studied to confirm it works in the way intended and has approved research evidence to show this. It highlights those who would benefit from more detailed nutrition assessment and nutrition treatment.
It needs to be a simple and quick so most nutrition screening methods involve measuring height and weight to calculate BMI and also asking about unintentional weight loss.
The National Institute of Clinical Excellence (NICE) is an organisation who provide recommendations on appropriate treatments and care within the NHS. NICE (Clinical Guideline CG32 – Nutrition Support for Adults) recommends nutritional screening should be carried out on patients attending hospital as an inpatient or outpatient:
“All inpatients should be screened for malnutrition on admission to hospital and weekly”
“All outpatients should be screened for malnutrition at their first clinic appointment and when there is clinical concern”.
NICE also advises:
“Screening should take place on initial registration at general practice surgeries and when there is clinical concern”.
NICE state clinical concern should include: unintentional weight loss, fragile skin, poor wound healing, apathy, wasted muscles, poor appetite, altered taste sensation, impaired swallowing, altered bowel habit, loose fitting clothes and prolonged intercurrent illness. This would include long term health conditions such as respiratory disease.
Nutrition screening is sometimes not done as often as recommended. If you are concerned you are becoming malnourished you can access an online malnutrition self-screening calculator by visiting malnutritionselfscreening.org
Use the self-screening calculator to calculate your risk of malnutrition by putting in your height, weight and weight history. It then assesses if you are low, medium or high risk of malnutrition and provides you with appropriate advice depending on your malnutrition risk. The website also provides information about malnutrition and has useful guidance you can download: “5 steps to help yourself” and “Your guide for making the most of your food”.
If nutrition screening identifies that you are at risk of malnutrition you should consult a health professional, either at your GP surgery or within your specialist respiratory team. If you are at risk of malnutrition your health professional should discuss a nutrition treatment plan with you. This may include prescribing nutrition supplement drinks (see learning section for further information on these) and/or referring you to see a dietitian for more individualised dietary advice.
Nutritional screening is not always sensitive enough to identify malnutrition as it does not assess for muscle loss and frailty, which are often associated with lung disease. Nutrition screening does not identify malnutrition that occurs due to a lack of nutrients because of unvaried and/or unbalanced diets unless this is also associated with weight loss.
Frailty is a state of increased vulnerability resulting from age associated decline
There is no actual agreed standard definition of frailty. NHS England describes frailty as a loss of resilience that means people don’t bounce back quickly after a physical or mental illness, accident or other stressful event.
Frailty is associated with ageing but is not an inevitable consequence of ageing. It is generally characterised by issues like reduced muscle strength and fatigue.
Frailty can have a huge impact on health and quality of life. Older people living with frailty are at greater risk of having:
• falls
• disability and need for long term care
• anxiety and depression
• unplanned hospital admissions
• difficulty recovering from illness and surgery
The causes of frailty are various and complex. It develops from age related changes that occur in multiple organs throughout the body. Resulting in a cumulative effect of decline in function and reserve capacity.
Malnutrition is one of the modifiable risk factors for the development of frailty. The consequences of malnutrition and frailty on health are well understood, however, despite plenty of NHS guidance, screening and treatment interventions are not fully integrated into all NHS services. The NHS long term plan states there are intentions to improve identification and coordination of care for those with frailty, to improve outcomes and avoid unnecessary harm.
Sarcopenia is a muscle disorder characterised by progressive and degenerative loss of muscle. It affects the skeletal muscles in the body, including muscles in the upper and lower limbs. The loss and decline in muscle performance leads to reduced strength and weakness. Because of this, sarcopenia is associated with poorer health outcomes. Sarcopenia is considered a component of frailty and both significantly impact on quality of life. For further information on frailty see our ‘Learn More’ pages.
Multiple factors contribute to the development of sarcopenia including increasing age, inactivity, the presence of disease and poor nutrition. A diet that does not contain enough energy or protein can contribute to the development of sarcopenia but not all people who have sarcopenia are underweight. There are a variety of screening methods that can be used to identify those at risk of sarcopenia but making a diagnosis requires the measurement of muscles using a DEXA scan (a type of X-ray). This procedure is not always practical or available and instead muscle strength tests, such as hand grip strength (HGS) measurements are recommended to assess for the likely presence of sarcopenia. We use HGS measurements as part of our nutritional assessment and have more information on HGS in our ‘Learn More’ pages.
Factors contributing to sarcopenia are common issues in people with respiratory conditions. The actual incidence of sarcopenia in those with respiratory conditions varies depending on the criteria used to diagnose sarcopenia and the populations studied.
Sarcopenia can impair respiratory muscle strength and affect lung function. It becomes a vicious cycle as reduced lung function can then further impact on the ability to exercise and on food choices, potentially worsening sarcopenia.
Strength exercises combined with adequate amounts of energy and protein in the diet are proven to be beneficial for the prevention and treatment of sarcopenia.
The following is an excellent resource for health professionals wanting to learn more about sarcopenia:
https://www.malnutritionpathway.co.uk/library/factsheet_sarcopenia.pdf
Hand Grip Strength (HGS) is the muscular power and force generated by the hand and forearm muscles and is measured using a hand dynamometer. HGS measurements are quick and easy to perform and provide a good indicator of overall muscle strength, as HGS correlates with arm and leg strength measurements. HGS is therefore recommended method to assess for the likely presence of frailty and sarcopenia (further information on both of these can be found in our ‘Learn More’ pages).
Reduced muscle strength is a common sign of malnutrition. However HGS is not widely used to screen for malnutrition because it takes extra time to perform and requires specialist equipment. Measuring weight and unintentional weight loss is the usual way of screening for malnutrition but this does not always give accurate results as it does not account for body composition and changes occurring that mask weight loss. HGS is therefore starting to be used to identify malnutrition in groups of patients who have medical conditions that cause their body weight to be affected by significant fluid losses and gains.
Dietitians often use HGS as part of their initial malnutrition assessment and to monitor progress with nutritional treatments. HGS increases as malnutrition improves and a deterioration in HGS without any further health issues can show that the body’s nutrition needs are still not being met.
HGS can also be used as a way of identifying sarcopenia in people with a higher BMI. Sarcopenic obesity is a more recently recognised term and refers to the loss of muscle in the presence of excessive fat stores. Our ‘Learn More’ pages on sarcopenia and high BMI might be helpful if you want to know more about this. This is likely because the factors contributing to the development of sarcopenia are common in people with respiratory conditions. Sarcopenia in those with higher BMI can be less obvious than in those with a lower BMI as fat stores can sometimes ‘hide’ muscle loss. However in both circumstances sarcopenia can limit mobility and have a detrimental effects on health. Scientific studies looking at sarcopenic obesity are just starting to emerge and although there is still a lot more to discover about its impact on health, it is recognised to be an important health condition in older age.
MEASUREMENT OF HGS
We measure hand grip strength as part of our nutritional assessment. We use the Jamar plus hand dynamometer as it is validated (has evidence for its reliability and validity) and is widely used in health care settings.
The measurement is taken while you are sitting down. You have your arm bent at the elbow and held out to your front. The dynamometer will be placed in your left hand and will continue to be gently supported at the base by the dietitian taking the measurement. You hold the HGS in one hand and when told to do so, grip as hard as you can for about 3-5 seconds until told to stop. The measurement is then performed on your right hand. The process is repeated two more times until you have three measurements for each hand. Your grip strength is the average of the three readings for each hand. Your dietitian will record these and discuss the significance of the results when the full nutritional assessment has been completed.
Unintentional weight loss is not a normal part of ageing but can occur when you get older for a variety of reasons. It can become a serious issue if not addressed as it could lead to the development of malnutrition and frailty. See our ‘Learn More’ pages for further information on both of these.
A reduction in appetite is one of the main reasons for unintentional weight loss. There are several changes that occur with ageing that can impact on your appetite:
• hormonal changes
• reduction in senses (sight, smell and taste)
• increased health problems
• increased number of medications taken (increasing potential for side effects)
• being less active
• poorer oral health and/or poor dentition
• increased risk of low mood and depression
• reduced saliva production*
• taste changes*
• constipation*
*these can occur for medical reasons but are also side effects of some medications
Ageing is associated with physiological changes that cause a gradual decline in the structure and function of body organs. This increases the possibility of developing chronic disease and the need to take medication. Many common medications can have side effects of reduced appetite or they can cause other adverse effects such as nausea, reduced saliva production or taste disturbances, which in turn reduce appetite and food intake. Ageing increases the likelihood of medication side effects as a decline in gut, kidney and liver function affect how medications are absorbed (get into the body), distributed (moved around the body), metabolised (broken down) and eliminated (removed from body). Polypharmacy (taking five or more different medications) is more common as you get older and increases the chance of getting side effects.
It is important to highlight appetite issues to your health professionals as soon possible so any modifiable cause can be identified and treated without delay. If appetite and food intake remain reduced for long periods, malnutrition and frailty can develop resulting in harmful effects on your health and wellbeing.
Appetite is strongly influenced by environment and mood. Living and eating alone with little social contact can play a big part in reducing your appetite. If either of these is likely to be a contributing factor to you having a poor diet, it is crucial you proactively seek help and advice to make positive changes to try and improve issues. Talk to your health professionals or find your own solutions by arranging more regular contact with family or friends for meals together, or alternatively seek information on local day clubs or lunch clubs. Age UK provide guides and services that may help and the British Dietetic Association has information on how diet influences mood.
Determination to eat for the purpose of keeping healthy and remaining independent is one of the most important factors to overcoming issues with appetite. It is therefore important that those with poor appetites fully appreciate the importance that diet (food and nutrients) play in health and disease. Malnutrition is a treatable medical condition that impacts significantly on your health. Getting help and making changes could really make a difference to your wellbeing and quality of life.
SUGGESTIONS TO HELP PREVENT YOU BECOMING MALNOURISHED
1. Eat at regular times throughout the day and do not rely on your appetite to tell you when to eat. Although you may not feel hungry your body still needs energy and nutrients for it to function properly. Skipping meals can actually worsen your appetite. So, try and stick to a regular meal pattern and avoid missing meals.
2. Weigh yourself regularly (at least monthly) if you can and keep a record of these weights. If your weight starts to reduce unintentionally speak to a health professional from your GP team or respiratory team. They should be able to complete nutrition screening using their usual method and be able to establish if you are at risk or high risk of malnutrition. If you are at risk, there should be an established treatment pathway and your health professional can go through this with you. It may include one or more of the following to prevent you malnutrition risk becoming more serious:
• Repeating nutrition screening again within a set timeframe
• Advice on ways to improve your diet
• Prescribing nutritional supplements
• Referral to a dietitian
3. Eat better for better health
If you are unwell and eating much less than usual, food fortification is a way of getting more energy (calories) into your diet. It involves adding additional calories to drinks and meals by including high fat and high sugar foods (butter, cream, cheese and sugar or honey) to meals and drinks. There are numerous resources about how to fortify your diet online for those with poor appetites (see additional resources listed below).
However if you are only managing to eat small amounts on a longer term basis, it is important that the foods you eat are nourishing (packed full of nutrients). Just adding high energy foods to your diet may not be appropriate if malnutrition is severe or long term. Getting enough protein, vitamins and minerals from foods is just as important for preventing malnutrition. See our ‘Learn More’ pages on Malnutrition, Protein and Micronutrients for further information.
Include nutrient dense foods in your meals such as eggs, tinned fish, beans, hummus, nuts, nut butters, full fat milk products (cream, cheese, yoghurts, powdered milk), milk based puddings (rice pudding, semolina, blancmange, mousse, panna cotta, yoghurt, custard and ice cream. Dairy free plant based milk puddings can be good alternatives for anyone following plant based diet.
Instead of snacking on sweets or biscuits try having more nutritious snacks between meals such as nuts or nut based snacks (nutty chocolates or muesli bars), non diet yoghurts, custard or mousse puddings, cheese and crackers or small bowl of breakfast cereals with milk.
Nutritious drinks are a convenient and good way to get extra energy and nutrients.
Instead of drinking fizzy drinks, water, tea or coffee try more nutritious drinks, such as full fat milk, milkshakes, milky coffee, malted milk drinks (Ovaltine, Horlicks or non branded versions) made with full fat hot milk or readymade vitamin and mineral fortified milkshakes. If you don’t drink milk, try plant based milks, milkshakes and smoothies made from either soya, coconut, oat, almond or cashew milk. Make sure you buy fortified versions of the plant based milks as these have added nutrients such as calcium and vitamin D. Alternatively you can try multivitamin juices or fruit smoothies.
4. If you’re finding it difficult to shop or cook for yourself, get some help!
If you don’t have relatives or friends nearby that can help, talk to a health professional (from your GP surgery or respiratory team) or contact your local adult social services department directly and explain the problems you are having.
Alternatively, consider a meal delivery service such as Wiltshire farm foods or Oakhouse foods by searching on the internet for “ready meal delivery services”. These and other companies deliver a range of ready-made meals and puddings that you can simply just put in the microwave or oven. They also have special energy dense, high protein meals for smaller appetites.
If you are able to and keen to carry on cooking for yourself try cooking in bulk so you can freeze portions to have available for times when you are feeling less well or unmotivated to cook. Also keep a store of ready-made frozen meals and suitable nutritious cupboard foods for when you need a quick meal or nutritious snack.
5. Staying active will help to improve your appetite.
Try to be as active as you can every day. If you are unable to go out for a short walk every day, find another activity you enjoy that keeps you active. If you are struggling to find something suitable ask your GP surgery team for advice about local activities suitable for your level of mobility and fitness.
Other resources you might also find helpful:
malnutritionpathway.co.uk Managing malnutrition in COPD – patient and carer resources:
The green leaflet – Eating well for your lungs
The yellow leaflet – Improving your nutrition in COPD
The red leaflet – Nutrition support in COPD
British Dietetic Association Food and Mood
bda.uk.com Depression and Diet
Eating Drinking and Remaining Well
Spotting and Treating Malnutrition
malnutritionselfscreening.org Nutrition screening online calculator
5 steps to help yourself
Your guide for making the most of your food
Asthma and Lung UK Help with eating and drinking
asthmaandlung.org.uk Why have I lost weight?
The Patients Association Nutrition checklist (for patients)
Age UK Tips to help prevent malnutrition
ageuk.org.uk
NHS England Malnutrition – Treatment
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Protein is an essential nutrient and foods high in protein make up one of the four essential food groups of a healthy diet. The protein in food gets broken down during the digestion process into chains of amino acids. These get absorbed into the blood and transported around the body so they can be used to make proteins and other molecules needed to:
• build and repair muscles
• help the immune system function
• repair and build other body tissues
Protein rich foods include meat, fish, eggs, milk and dairy products (foods made from milk). Protein is also available from plant based sources such as nuts, legumes (includes lentils, peas, beans, broad beans, chick peas) and seeds (including hemp, pumpkin, sunflower, flax, sesame and chia seeds) and some whole grains (such as quinoa and wild rice).
On average, we need approximately 0.8grams of protein per kilogram of our body weight per day. The amount needed does vary and depends on a variety of factors including age, Body Mass Index (BMI) and body composition. Protein needs can be much higher with the presence of illness, disease or malnutrition.
When the demand for amino acids is high, our body breaks down muscle to keep up the necessary supply. On average most people eat more protein foods than they actually need but sometimes protein intake becomes inadequate because appetite reduces or food choices change or because the bodies protein needs increase. If protein intake is inadequate for a prolonged period, it can lead to loss of muscle (muscle wasting) and malnutrition and frailty can develop. This can also sometimes happen if we do not eat enough energy foods, as this causes our body to break down muscle protein to use the amino acids as a source fuel.
It is vital to eat enough protein rich foods to prevent or reduce muscle loss and maintain muscle strength. Reduced muscle strength makes it harder to carry out normal daily activities and can result in a loss of independence and reduced quality of life. Muscle loss, malnutrition and frailty from deficient protein intakes can impact on lung function because it can weaken breathing muscles and reduce the ability to exercise. These and other effects negatively influences the course of respiratory disease.
As you get older the body becomes less efficient at using the protein from your diet. You should therefore spread the protein intake throughout the day by having at least one protein rich food with each meal. If you have a poor appetite you can get additional protein from having nutritious drinks and snacks containing protein between meals.
Although getting enough protein is important, having too much protein in your diet is not good for your health. If you have medical issues that involve your kidney or liver you will need to be more careful with the amount of protein you have in your diet and should therefore seek advice from a health professional before increasing your protein intake.
Further resources
Further information on protein can be found by searching on the internet for ‘malnutrition pathway’. They have two useful information sheets that you can download on protein and protein foods.
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The micronutrients we get from foods are essential for good health as they perform a wide range of important functions in the body. These include supporting the immune system, making bones strong and enabling the body to produce and regulate enzymes and hormones.
No single food or meal will provide all the vitamins and minerals needed by the body to keep healthy. Eating a good variety of foods and having a healthy balanced diet by eating the right amount of foods from each of the four essential food groups should provide most people with the vitamins and minerals they need. Further information on eating a healthy balanced diet can be found on the NHS website by searching for “How to eat a balanced diet” or going to the gov.uk website and searching for “Eatwell Guide”.
When the amount of food you eat reduces, either because you start to miss meals or eat smaller portion sizes, it can mean you do not get an enough of some essential micronutrients. This can also happen when you mostly eat foods that are high in calories (from high fat and/or sugar content) but low in other nutrients.
A diet lacking in micronutrients may mean the body cannot perform its functions sufficiently. Initially this will cause subclinical (‘hidden’) symptoms, such as weakness, lack of energy and low mood. Subclinical micronutrient deficiencies are often difficult to accurately detect but can increase the risk of diseases such as cancer and cardiovascular disease. They have also been associated with cognitive deficit (reduced mental functioning) and an impaired immune system (a reduction in the body’s ability to fight infections and disease). Over time inadequate micronutrient intakes can cause overt (more obvious) vitamin and mineral deficiencies that have specific symptoms making the deficiency easier to diagnose, such as anaemia and osteoporosis. More useful information and advice on each individual micronutrient can be found on the NHS UK website, under vitamins and minerals.
Testing for certain micronutrient deficiencies (iron, vitamin B12, folate and vitamin D) is available and performed within the NHS. Although other micronutrient blood testing is available privately, the results provided do not necessarily give accurate indications of body nutrient levels. The blood levels of some micronutrients are closely regulated and remain within a normal range despite inadequate intakes or deficiency. The levels of some micronutrients can also change in response to infections and inflammation or because of a decline in kidney and liver function, making it quite difficult to interpret blood test results.
Micronutrient status is usually assessed by dietitians as part of the overall nutritional assessment they perform. They will first review medical and surgical history to establish if any risk factors for micronutrient deficiencies are present, as well as assessing:
• Presence of malnutrition from rapid/long term weight loss
• Symptoms of malabsorption
• Drug nutrient interactions (certain medications interact with nutrients in diet)
They will often look for signs of deficiency in their clinical examination and then review usual dietary intake to assess micronutrient intakes. Accurately estimating the intake of each micronutrient is difficult even with detailed food diaries and nutritional analysis computer software. Dietitians instead tend to look at the intake of foods from each of the essential food groups. Generally, if there are no risk factors for deficiency and usual dietary intake is varied and balanced (contains the right amount of foods from each of the four essential food groups) micronutrient needs will likely be met.
Malnutrition rates are known to be high in people with respiratory conditions increasing the risk of inadequate micronutrient intakes and the subclinical and overt effects resulting from micronutrient deficiencies.
Scientific studies suggest fruit and vegetables (rich in micronutrients) are beneficial for lung health. It is thought that the reason for this is the antioxidant properties of certain vitamins and minerals that they contain. Feasible explanations of how antioxidants could benefit those with lung disease have been proposed. However, although several scientific studies have been carried out to examine the proposed benefits (by supplementing with various antioxidant nutrients taken as a tablet), the results have been variable. Further studies are needed before recommendations for antioxidant nutrient supplementation can be made to people with lung diseases. Fruit and vegetables contain many other substances in addition to vitamins and minerals and it therefore maybe one or more of these other substances that are beneficial to lung health. In view of the known benefits and potential benefits fruit and vegetables have on health, it is important to eat a variety of these and aim for the recommended amount of five portions every day.
The well known role of vitamin D is to keep bones healthy by increasing the absorption of calcium. There is emerging scientific evidence that vitamin D may also have other important functions in the body, including roles that enhance the immune system. This has led to an increased focus on vitamin D deficiency and its association with various chronic diseases.
Although we get vitamin D from some foods in our diet, our body also makes its own vitamin D through the action of sunshine on exposed skin. However, during winter months this occurs much less, and because of this vitamin D deficiency is common in northern European populations. Even those eating a healthy balanced diet will unlikely get enough vitamin D during the winter months. This is why there are government recommendations on taking vitamin D supplements:
“During the autumn and winter everyone (adults and children over 4 years old) should consider taking a daily supplement containing 10 micrograms of vitamin D as the sun is not strong enough for the body to make vitamin D and it’s difficult to get enough vitamin D from your diet”
“In spring and summer most people can make all the vitamin D they need through sunlight on their skin and from a balanced diet. However those with little or no sunshine exposure are at risk of vitamin D deficiency. The Department of Health and Social Care recommends that adults and children over 4 take a daily supplement containing 10 micrograms of vitamin D throughout the year if they are not often outdoors or in a care home or usually wear clothes that cover up most of their skin when outdoors or have dark skin (as they will not make enough vitamin D from sunlight exposure.”
Vitamin D deficiency is reported to be common in those with Chronic Obstructive Pulmonary Disease (one of the most common respiratory conditions). There is increasing scientific evidence for the protective effects of vitamin D supplementation, including evidence that it has a protective effect against respiratory infections in those with chronic respiratory conditions who were previously vitamin D deficient. It would be beneficial to follow the Government’s vitamin D recommendations unless you have a medical condition that means you are not able to take vitamin D supplements or your doctor has advised that you should be taking a different vitamin D supplement dose.
Further resources
The British Dietetic Association (BDA) has a good resource on vitamin D for those who would like to know more about this important vitamin. You can find this online by searching for ‘BDA Vitamin D’. Further information on vitamin D and the recommendations for supplementation can also be found on the NHS UK website.
References
Jolliffe, D.A., Greenberg, L., Hooper, R.L., Mathyssen, C., Rafiq, R., de Jongh, R.T., Camargo, C.A., Griffiths, C.J., Janssens, W. and Martineau, A.R., 2019. Vitamin D to prevent exacerbations of COPD: systematic review and meta-analysis of individual participant data from randomised controlled trials. Thorax, 74(4), pp.337-345.
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