The Breathe Better Blog

Resistance training boosts smoking cessation success

2011-05-18T13:59:00.000-04:00

Every year, over two thirds of U.S. current smokers express a desire to permanently quit. Yet despite this broad desire, only about 40% actually try to quit in any given year and of this 40% who attempt to quit less than 10% are ultimately successful in abstaining from cigarettes for more than six months even with the most effective of treatment options. In fact according to research findings it takes the average smoker up to ten attempts to finally kick the habit permanently.

People who attempt to quit on their own without any medical assistance are the least successful with low single digit success rates. Those who combine long-term counseling with nicotine replacement therapy tend to be the most successful with between 8-17% success rates although some of these reported success rates seem dubious because many rely primarily on self-reported abstinence confirmation versus chemical verification.

Pharmaceutical companies pour many millions of dollars into research each year to find new drugs to boost success rates but so far no major breakthrough. Alarmingly though, a number of the newer pharmaceuticals prescribed by doctors for smoking cessation (anti-depressants) have received Food and Drug Administration warnings for some pretty scary side effects. Meanwhile many other companies tout all manner of other products or services to aid in boosting cessation rates ranging from hypnosis to acupuncture to electronic cigarettes (but with little success in moving the needle).

It is a reminder of how addictive nicotine can be and of how challenging it can be to eliminate a long-term habit.

So what’s a smoker to do?

Well, a simple answer that might just double your odds of success and produce positive side effects versus negative ones is…exercise. Seems hard to believe doesn’t it? Not much research has been done on combining exercise with smoking cessation but the research that has been done has shown some promise. Why is exercise a possible valuable addition to a smoking cessation program? According to the exercise researchers, exercise has been shown in other research to improve mood, assist in weight loss and reduce cravings – all three big-time cigarette smoking withdrawal symptoms.

As a case in point, a new study was published online ahead of print last month in the journal Nicotine & Tobacco Research that demonstrated that study subjects undergoing a 12-week resistance training program (weight lifting) boosted abstinence at 3-month and 6-month follow-up checkpoints by 100% over study subjects who did not exercise during the study. Both the control and resistance training groups received one 15-20 minute smoking cessation counseling session and both groups received nicotine patches during the study period so the only differentiating variable between the two groups was the resistance training program. The absolute abstinence success rate for the resistance training group was 15-16% at both the 3-month and 6-month follow-up checkpoints compared to 8% at both time intervals for the control group. These abstinence results were determined by both self-reported questionnaires and by chemical analysis of each subject’s carbon monoxide levels. [1]

The 12-week resistance training program followed by the exercise group was described the researchers as follows, “Participants engaged in two 60-min RT sessions/week for 12 weeks. The full-body routine (ACSM, 2009b), involved 10 exercises, with set intensity and volume adjusted every 3 weeks. For the first 3 weeks, participants completed one set (10 repetitions) of each exercise at 65%–75% of their estimat¬ed maximal strength. From weeks 4–12, participants complet¬ed two sets per exercise. Weight was systematically increased by a researcher to match gains in strength and maintain inten¬sity at weeks 7–10. Researchers monitored exercise for safety, interactions were minimized, and smoking was not discussed. Participants exercised alone and could attend up to three ses¬sions/week to make up for one missed session in the prior week, with no more than one session/day. All were asked not to engage in RT beyond the supervised sessions or change their other exercise.”

To be fair, the study population was small (25 total subjects) and only 50% of the subjects participated all the way through to the 6-month follow-up checkpoint. So one might argue the success rates of both approaches were actually lower if all subjects were tracked the full way through. That said, those engaged in a resistance training program who did make it all the way through this novel study (novel because it examined resistance training versus aerobic training in conjunction with smoking cessation) did achieve higher abstinence, greater weight loss and lower body fat measurements than the control group.

Other studies probing the addition of an exercise component to a smoking cessation program have also shown promise. In one such 2010 study, researchers found 34% of women participating in the study who participated in a 150 minute per week moderate intensity aerobic exercise program achieved chemically verified abstinence at 6-month follow-up compared to 20% for the control group. In this study, both groups also received one smoking cessation counseling session and nicotine patches for the duration of the study. [2]

In yet another 2010 study examining the effect of either high-intensity (running) or moderate intensity (walking) aerobic exercise on craving to smoke, researchers reported, “Significant group x time interactions were identified, demonstrating significant reductions in craving items after the walking and running conditions compared with the passive control. No significant differences in craving reductions were found between walking and running conditions. Post hoc comparisons found that running condition cravings to smoke scores were reduced for a longer duration post-treatment than post-walking condition scores. The decline in cortisol concentration was attenuated in the running group only. Vigorous exercise has a similar effect to moderate exercise in terms of the magnitude of craving reduction. However, performing bouts of moderate-intensity exercise may be a better recommendation for reducing cravings.” [3]

It therefore seems that adding an exercise program (resistance training and/or aerobic training) to a smoking cessation attempt is worthy of your consideration. Not only might exercise improve your odds of kicking the habit permanently, it has also been shown to notably improve heart rate variability (a risk factor in cardiovascular disease), reduce the risk of lung cancer, and reduce chronic shortness of breath – even among smokers who continue to light up!

For smokers interested in experimenting with an exercise program but who aren’t sure where to start or what specific exercises to do, we have three suggestions for your consideration. First, consider asking your doctor to recommend a specific exercise program. Alternatively, consider visiting a local fitness center and ask to speak to a certified fitness instructor. Associations such as the American College of Sports Medicine create recommended exercise protocols for different health conditions and a fitness instructor should be able to help construct one appropriate for you. They will likely charge for their services but most provide an initial consultation free of charge.

If neither of those options appeals to you, I created the Breathe Better for Life guidebook and companion CD-ROM to assist people with poor respiratory health (smokers and people with lung disease) access the principles and practices of the respiratory medical treatment pulmonary rehabilitation. This treatment option combines aerobic exercise, resistance training, breathing technique training, airway clearing technique training and guidance on other respiratory related topics.

In the Breathe Better for Life guide/CD, I developed an exercise program based on guidelines established by the American Thoracic Society, European Respiratory Society and the American College of Sports Medicine to assist people with poor respiratory health start and maintain an aerobic and resistance training program if they cannot access such a program elsewhere. The CD provides narrated, pictorial step-by-step instructions for the specific resistance training exercises in addition to many other valuable education elements geared to help improve one’s ability to breathe. Click here to learn more about Breathe Better for Life.

Regardless of what exercise program you choose, it is always advisable to review the program prior to starting with your physician to ensure it is appropriate for your particular health status.

[1] Ciccolo JT, et al. Resistance Training as an Aid to Standard Smoking Cessation Treatment: A Pilot Study. Nicotine & Tobacco Research. April 18, 2011 [Epub ahead of print].

[2] Williams DM, et al. Moderate intensity exercise as an adjunct to standard smoking cessation treatment for women: a pilot study. Psychol Addict Behav. 2010 June:; 24(2): 349-354.

[3] Scerbo F, et al. Effects of exercise on cravings to smoke: the role of exercise intensity and cortisol. J Sports Sci. 2010 Jan;28(1):11-9.

Antioxidants for oxidative stress in COPD patients revisited

2011-05-06T13:22:00.000-04:00

Regular readers of our Breathe Better for Life e-letters and Breathe Better Blog are well aware we are strong advocates of antioxidants for people with chronic shortness of breath. Our perspective - we view antioxidants as an excellent addition to a regular exercise program, a Mediterranean-style diet and smoking cessation to reduce inflammation and oxidative stress.

We do not believe that antioxidants will cure, reverse lung disease or improve lung function. However, there is substantial and growing evidence that oxidative stress (an imbalance in damaging pro-oxidant molecules known as free radicals and protective anti-oxidant molecules) is a key contributing factor to the sensation of breathlessness and that most COPD patients are significantly deficient in antioxidants compared to those without persistent shortness of breath.

We are not alone in this belief as a new research paper echoes many of our sentiments. This research review article, published in the journal Current Drug Targets, examines the role of oxidative stress in COPD and the potential of antioxidants as a supportive therapy. In fairness to the review authors, they acknowledge that while antioxidant therapy seems a key area for further exploration there are conflicting study results on the effectiveness of antioxidants for COPD patients. Further, they acknowledge there are few definitive guidelines regarding the optimum human daily dosages for the most promising antioxidants. [1]

Still we’re concerned that it will be decades before enough researchers and practitioners determine these criteria to their own satisfaction. Meanwhile, millions of COPD patients will not learn of the potential benefits that have already been reported in peer reviewed published research for over the past decade.

So, we thought it would be helpful to share some snippets of this research review paper so that readers have access to the emerging potential of antioxidants as a supporting therapy to other traditional COPD treatments.

First, some observations about oxidative stress and COPD offered in the paper’s introduction, “The lung is the organ with the highest exposure to ambient air in the entire human architecture. Due to its large surface area and blood supply, the lung is susceptible to oxidative injury in the form of myriads of reactive oxygen species (ROS) and free radicals. ROS may be produced endogenously by metabolic reactions or have exogenous origins, such as air pollutants or cigarette smoke. Airborne pollutants may result in direct lung damage as well as in activation of inflammatory responses in the lungs. Tobacco smoke is a mixture of over 4700 chemical compounds, including high concentrations of oxidants. Inflammatory cells recruited in airspaces become activated and generate ROS in response to appropriate stimuli.”

“Chronic obstructive pulmonary disease (COPD) is a chronic inflammatory disease which is characterized by an abnormal inflammatory response of the lungs to external stimuli, the most common being tobacco smoke. This abnormal inflammatory response is attributed to many underlying pathophysiologic mechanisms and one of the most important is the imbalance of oxidative stress and antioxidant defenses.”

For a layman’s understanding of the above process, we recommend readers check out our War of the Worlds in Your Lungs article.

Regarding antioxidants, the review authors explain, “In order to provide defense against the oxidative burden, the lungs produce various endogenous agents called antioxidants. The antioxidant species help the lungs ward off the deleterious consequences of a wide variety of oxidants/reactive oxygen species and reactive nitrogen species, either of endogenous or environmental origin. The major nonenzymatic antioxidants of the lungs are glutathione, vitamins C and E, beta-carotene, uric acid, whereas the major enzymatic antioxidants are superoxide dismutases, catalases and peroxidases. These antioxidants are the first lines of defense against oxidants and usually act at a gross level.”

As a side note, the most powerful of these antioxidants is glutathione. That said the human body does not absorb glutathione well when administered directly. Our bodies are much better at producing our own glutathione when we are provided precursors of the antioxidant. The most effective precursor in assisting the body’s production of glutathione is N-Acetyl Cysteine (NAC).

“Oxidative stress is intimately associated with the progression and the development of exacerbations in COPD. A rational approach for the treatment of COPD would therefore be to consider antioxidant intervention not only aiming to neutralize the increased oxidative stress and the subsequent inflammatory response, but also in an attempt to identify the source of oxidants and overwhelm their generation. This can be achieved through two approaches, either by increasing the endogenous antioxidant enzyme defences or by enhancing the non-enzymatic defences through dietary or pharmacological means. To date, however, most clinical trials of antioxidants for COPD have yielded conflicting or disappointing results.”

Despite these conflicting and disappointing results, however, the study authors conclude, “There is now solid evidence for the role of oxidative stress in the development and evolution of COPD. Several biomarkers of oxidative stress have been evaluated by invasive and non-invasive means in patients with COPD. However, further standardization of methods is imperative for the application of such biomarkers in clinical practice. An effective wide-spectrum antioxidant therapy with bioavailability is urgently needed to control the local and systemic oxidative burst in COPD. In that direction, several antioxidant agents have been evaluated as potential candidates for the management of COPD. However, despite some encouraging results, clinical trials so far have failed to elaborately define the type of antioxidant, the regimen and the time period of treatment that may improve clinically meaningful outcomes in patients with COPD. This may be largely due to the incomplete understanding of the pathophysiology of COPD and the differences within COPD phenotypes. Moreover, some of the antioxidants may not reach the correct cellular/tissue compartment where the oxidative damage is taking place. Well-designed clinical trials investigating the potential role of new antioxidants and combinations of antioxidants with existing anti-inflammatory agents may provide new insights in COPD management."

So the takeaway – not enough evidence yet to satisfy researchers and practitioners regarding efficacy and not enough clear guidance on dosages, but clearly an area that will receive great attention in the future due to the unambiguous connection between shortness of breath, inflammation and oxidative stress.

By the way, the antioxidants with most encouraging study results highlighted by the authors:

• N-Acetyl Cysteine
• Resveratrol
• Curcumin
• Vitamin C
• Vitamin E
• Beta Carotene
Attentive readers will note the above mentioned antioxidants, with the exception of Beta Carotene, are key ingredients of our Resplenish anti-oxidant respiratory support dietary supplement. We’ve further bolstered the formula with other antioxidants that have recently demonstrated promising results in respiratory health studies (including Vitamin D, Quercetin, Coenzyme Q10 and Baicalin). If you are interested to learn more about Resplenish, click here.

Whether our Resplenish supplement is of interest to you or not, we recommend you consider bolstering your daily diet with an antioxidant rich dietary supplement and antioxidant rich foods. While it’s true there is no “gold-standard” when it comes to antioxidant dosages for respiratory health it is also true and undeniable that the primary weapons at the disposal of physicians to combat oxidative stress are the natural agents our bodies already use and/or produce – antioxidants.

[1] Loukides S, et al. Oxidative Stress in Patients with COPD. Current Drug Targets. 2011; 12: 469-477.

Exercise reduces shortness of breath and improves heart rate variability in COPD patients

2011-03-22T10:33:00.000-04:00

When we think of respiratory health we often concentrate our thoughts on the lungs and the act of breathing. However, respiratory health also encompasses the heart and our circulatory vessels that pump blood carrying oxygen inhaled through the lungs to all parts of our bodies.

Often the impact of chronic shortness of breath therefore is not just seen in lung function tests but in tests to evaluate the efficiency/health of the heart and circulatory system. One such measure is called heart rate variability (HRV). In simple terms, HRV is the amount of time between heartbeats. In general, if there is a large gap in time between heartbeats the HRV is considered to be good. On the flip side, if there is a short gap in time between heartbeats, the HRV is considered bad.

When physicians evaluate HRV, they are most interested to see whether a person’s heartbeats are getting closer together or farther apart. When they are getting closer together, physicians become concerned as this indicates the heart is working harder than it did before. Poor HRV (meaning shorter and shorter gaps of time between heartbeats) is a significant predictor of cardiovascular events such as heart attacks and strokes.

For COPD patients, heart rate variability tends to be poor which makes sense given that the lungs have to work harder to breathe which places greater stress on the heart and therefore the heart has to beat faster/more often in order to help the rest of body perform normal every day functions. As a result, COPD patients experience a greater incidence of cardiovascular events compared to non-COPD populations.

Exercise has been shown in previous studies in non-COPD populations to improve HRV (meaning exercise helps the heart slow down or said another way it helps the heart beat less frequently). Exercise has also been shown in previous studies to reduce COPD patient shortness of breath. So a group of Brazilian researchers recently decided to evaluate whether exercise could also help COPD patients specifically improve heart rate variability. [1]

The study authors described the purpose of their research project as follows,” Nowadays, exercise training is a well-recognized method to treat symptomatic patients with COPD. Its objective is to improve impaired disease outcomes such as exercise capacity, functional status, health-related quality of life and peripheral muscle force, as well as physical activity in daily life. However, little is known about the effects of exercise training programs on HRV changes in patients with COPD.”

In their study, the research team divided 40 COPD patients into two groups. One group of 20 patients participated in a high intensity exercise program patterned on principles and practices of the COPD treatment pulmonary rehabilitation (high intensity group). The other group of 20 patients engaged in a low intensity exercise program that did not push patients as much as a traditional rehab program does (low intensity group). The researchers desired to see whether either program made a notable difference in heart rate variability and whether one level of intensity was more effective in improving HRV than the other.

The study team discovered that the high intensity exercise group experienced a notable mean improvement in heart rate variability (24% on one particular measure known as the SDNN index, and 27% on another measure known as the rMSDD) while the low intensity group saw their HRV worsen between 12-13% on these same two measures. This led the researchers to conclude that high intensity exercise (ala similar to the intensities practiced in pulmonary rehabilitation programs) not only reduce shortness of breath symptoms but also improves heart rate variability. In the researchers own words, “The present study showed that a 12-week high-intensity exercise training program including endurance and strengthening exercises was able to improve HRV outcomes such as the rMSSD and SDNN variables, whereas a low-intensity program of similar duration was not.”

So what did the two different exercise programs entail? According to the study authors, “In the HI group, circuit training including cycling, walking and strength training was performed based on a protocol previously described. For ergometry cycling, the training intensity was set at 60% of the initial maximal work rate; for treadmill walking, at 75% of the average walking speed during the baseline 6-min walking test (6MWT); and for strength training, at 70% of the baseline 1 repetition maximum test (1RM). Increase in work rates and/or duration was assured on a weekly basis, guided by a predetermined schedule and driven by the patients’ perception of their symptoms (Borg-symptom scores). In the LI group, patients progressively performed 5 different sets of exercises including breathing exercises, strengthening of the abdominal muscles (crunches) and calisthenics. Each set consisted of 12 different exercises which were repeated 15 times each. Every 7 sessions, patients began a new set of exercises with an increment on the intensity. Close supervision was provided during both training protocols, which were attended three times per week, for 12 weeks, with 1-h training sessions.”

As we have discussed in many previous articles, exercise is incredibly beneficial to COPD patients and those who otherwise suffer from chronic shortness of breath regardless of disease severity. We have many times recommended COPD patients seek entry to a pulmonary rehabilitation program in their local area if their pulmonologist will provide a referral.

For those people who cannot access a pulmonary rehab program (and unfortunately that’s about 99% of COPD patients and nearly 100% of an expanded audience of people who suffer from chronic shortness of breath but do not carry a COPD diagnosis), we created our Breathe Better for Life guidebook and CD-ROM, www.breathebetterforlife.com, to put the principles and practices of pulmonary rehabilitation directly in your hands. In the guide we created a 12 week exercise program patterned after the guidelines of the American Thoracic Society, the European Respiratory Society and the American College of Sports Medicine for those with poor respiratory health. Our accompanying CD-ROM provides narrated, pictorial step-by-step instructions for the various strength training, stretching and breathing exercises recommended in the guidebook.

Regardless of what exercise program you follow, it is vitally important for COPD patients to start and maintain an exercise program for the long haul. Many research studies have proven the benefits of a regular exercise program for COPD patients (reduced shortness of breath, fewer hospitalizations, improved quality of life, and improved physical strength and stamina to name a few). This study’s results seem to indicate that following a pulmonary rehabilitation style exercise program can also improve heart rate variability and in so doing lessen the potential for a cardiovascular event.

[1] Camillo CA, et al. Improvement of heart rate variability after exercise training and its predictors in COPD. Respiratory Medicine. 2011 February 20 [Epub ahead of print]

Breathing exercises significantly reduce fatigue intensity in COPD patients

2011-03-17T13:36:00.000-04:00

In January 2011, a group of Iranian researchers reported that COPD patients who engaged in a regimen of three breathing technique exercises four times a day over a ten day period experienced an average 27% reduction in fatigue intensity. By comparison, the control group in the study (COPD patients who received no breathing technique exercises) reported only a 4% improvement in self-perceived fatigue. [1]

In introducing their study findings, the researchers set the stage by noting, “Two significant symptoms of COPD frequently complained by the patients are dyspnea (shortness of breath) and fatigue. Any patient who feels tired for more than 1 month is considered as affected by chronic fatigue. Chronic fatigue is important and common sensation in patients with COPD that interferes with the quality of life but (is) almost neglected. As the disease advances, hard breathing followed by dyspnea and increasing limitation of the patient’s ability to perform daily activities are worsened, and even for doing simple work during the day, the patient gets out of breath and is affected with early fatigue…

Respiratory exercises such as lip-pursing (pursed-lips breathing) or diaphragm respiration (diaphragmatic breathing), are considered as a part of pulmonary rehabilitation programs, which could lead to an improvement in gas exchange, exercise tolerance and quality of life. The goal of respiratory exercises in patients with COPD is for the patients to replace their ineffective respiratory techniques with effective ones and to discharge the lungs from secretions through deep respiratory exercises and effective coughing.”

In other words, the study team speculated that employing breathing techniques that help re-train COPD patients to breathe more deeply and at a slower speed would reduce the sensation of fatigue and enable the patients to participate in more activities and thereby enjoy a higher quality of life.

A total of 60 COPD patients participated in the study (30 in the breathing exercise group and 30 in the control group). Both groups completed a “fatigue severity scale” survey upon enrollment. Then the breathing exercise group received instruction in three respiratory exercise techniques (pursed-lips breathing, diaphragmatic breathing and “effective coughing” – the technique for effective coughing was not identified in the study but was most likely the Huff Cough technique taught in many pulmonary rehab progams).

The COPD patients in the breathing exercise group received instruction and supervision of the proper breathing and coughing techniques and then were asked to practice these techniques 4 times a day for 10 consecutive days. The control group did not receive the breathing/coughing training and were not instructed to utilize such techniques over the same 10 day period. After the 10 day study period, both groups again completed the fatigue survey and the researchers compared the pre- and post- results within and across each group.

For such a short duration of breathing/coughing technique training, the breathing exercise group recorded significant improvements. For example, at the outset of the study 27 of the 30 COPD patients indicated their fatigue was “severe” (the highest level on the survey), while 3 rated their fatigue as “moderate”. At the end of the study, only 16 reported their fatigue as severe (a 41% drop in the number of COPD patients who considered their fatigue severe), 11 indicated their fatigue was moderate, and 3 reported their fatigue as mild. On average, the breathing exercise group demonstrated a 27% improvement in perceived fatigue.

The control group barely moved in their fatigue perceptions. At the outset of the study, 27 of the 30 COPD patients reported their fatigue as severe. At the end of the study, 26 still perceived their fatigue intensity as severe.

These are pretty remarkable findings especially considering the study did NOT involve the core regimen of physical exercise typically offered in a pulmonary rehabilitation program. The only element of pulmonary rehab used in the study was the training and application of breathing and coughing techniques.

The study authors concluded, “Results of the present research showed a reduction in the fatigue intensity among COPD patients under interference as well as a meaningful reverse relationship between the fatigue intensity and the rate of respiratory exercises. In other words, the higher the rate of respiratory exercise applied, the less the fatigue intensity among the samples under interference. The present research also showed that it was the change of respiratory pattern that caused the reduction of fatigue intensity in COPD patients. Patients with COPD have a shallow, fast and insufficient breathing. Through exercises, this type of respiration has improved to diaphragm respiration in which the breathing speed is reduced leading to an increase of alembic aeration. By lip-pursing respiration also, the breathing depth is increased in patients.

Training of respiratory exercises through face to face procedure while implementing treatment procedures may have significant effects on controlling and improving the symptoms, raising the level of awareness and finally, upgrading their quality of life.”

If you are unfamiliar with pursed-lips breathing, diaphragmatic breathing or the huff cough techniques, consider making an appointment with your pulmonologist or respiratory therapist to learn and practice the techniques. For those interested there is a brief overview of these techniques on our Resplenish dietary supplement web site that you can view by clicking here. In addition, our Breathe Better for Life CD-ROM which accompanies our Breathe Better for Life guidebook contains narrated, pictorial, step-by-step instructions of these techniques. To learn more about Breathe Better for Life, visit www.breathebetterforlife.com.

[1] Zakerimoghadam M, et al. The Effect of Breathing Exercises on The Fatigue Levels of Patients with Chronic Obstructive Pulmonary Disease. Acta Medica Indonesia. January 2011: 43(1); 29-33.

COPD and sleep quality

2011-02-27T09:33:00.000-05:00

Breathing difficulties can notably degrade one’s ability to enjoy a good night’s sleep and, according to a new study, poor sleep quality is a significant contributor to COPD patients’ reporting of low quality of life. [1]

As a case in point, the new study found that 74% of the 180 COPD patients enrolled in the research program reported incurring at least one sleep-disturbing respiratory symptom 3 times a week or more. The most common respiratory symptoms cited by study participants included:

• Coughing
• Wheezing
• Snoring
• Sleep apnea events
• Can’t breathe at night
• Chest pains

These symptoms affected the self-reported average amount of time it took study participants to fall asleep (30 minutes), the amount of time they slept each night (5 hours) and the percentage of patients that awoke during the night (78%) for one reason or another. If the study population is representative of the general COPD population (and there is no reason to think otherwise) then sleep quality is a huge problem for people with respiratory conditions.

To assess whether sleeping difficulties affect COPD patients overall self-reported quality of life, the researchers had the study participants complete three different quality of life surveys (a common respiratory health survey, a sleep specific health survey, and a general health survey) from which the study team conducted a statistical comparison of the correlations.

They discovered a particularly strong correlation between low reported quality of life on the respiratory health survey (St. George’s Respiratory Questionnaire) and poor sleep quality as determined by the sleep specific survey (Pittsburgh Sleep Quality Index).

Ironically, the researchers reported that only about 7% of the enrolled COPD patients indicated they felt excessively sleepy during the day (i.e. difficulty in staying awake) despite the significant percentage of sleep disturbances and quality of life correlation. With that said the researchers concluded, “Patients with COPD have poor HrQOL (self-reported quality of life) and a high prevalence of disturbed sleep. This was correlated with indices of disturbed sleep. Few patients reported daytime sleepiness in spite of severe sleep disturbances. Studies in COPD incorporating HrQOL as an outcome should take sleep quality into account.”

We previously wrote an article for COPD patients and smokers detailing strategies for improving chances for a good night’s sleep. To read that article, click here.

[1] Scharf SM, et al. Sleep quality predicts quality of life in chronic obstructive pulmonary disease International Journal of Chronic Obstructive Pulmonary Disease. 2011:6 1–12

Tai chi improves respiratory function in COPD patients

2011-02-21T10:31:00.000-05:00

A new study published online ahead of print last month in the journal Complementary Therapies in Medicine demonstrated that a 3-month tai chi qigong program improved respiratory function and activity capacity in COPD patients participating in the study. [1]

As we’ve written in many previous articles, regular physical activity is crucially important for COPD patients to reduce shortness of breath and improve quality of life. While we’ve previously discussed tai chi as one form of physical activity that has shown promise for improving quality of life among COPD patients (click here for our most recent previous tai chi article), this is the first study to demonstrate tai chi’s impact on respiratory function.

Tai chi, according to the study authors, “…is a combination of exercise and meditation. It consists of a series of slow movements and deep breathing that helps to promote circulation of ‘‘Qi’’ (vital energy) in the meridians, regulate functions of the internal organs, and improve physiological functions. The slow, controlled graceful movements of TCQ, which integrates mental concentration and deep breathing, is believed to improve circulation and breathing. Deep breathing draws the breath down into the “tantien” (the main energy center of the body) placing less pressure on lungs and increasing lung capacity.”

The design of the study was as follows: the one hundred and fifty eight COPD patients who completed the 3-month research program were divided into three groups (a tai chi group, a walking group, and a control group). The China based researchers collected baseline measurements at the outset of the program including lung function (spirometry), exercise capacity (distance walked in 6 minutes), and self-reported dyspnea (shortness of breath) among other diagnostic tests. At 6 weeks into the study, the researchers again recorded measurements on these tests. Finally, at the end of the 3-month study, the COPD patients completed one more battery of these diagnostic evaluations. The researchers then compared the results of the baseline, 6-week and 3-month readings to assess whether there had been any significant improvements or declines since the outset of the study.

The tai chi group (60 COPD patients) practiced 13 movement forms of tai chi qigong twice a week for one hour each group session over the 3-month period. The sessions were held at an outpatient hospital center and led by a qualified tai chi instructor. Additionally, patients were asked to practice tai chi on their own at home one further hour each day during the study and were given a tai chi DVD to help facilitate their at-home practice.

The walking group (50 patients) was asked to walk for one hour daily during the study. In addition, during their one hour sessions the walking group COPD patients were also asked to practice two breathing techniques (pursed lips breathing and diaphragmatic breathing).

The control group received no instruction on breathing techniques and was not requested to engage in exercise during the course of the study (48 patients).

The results of the study showed significant improvement (7%) in forced vital capacity (a measure of respiratory function) in the tai chi group while the control group experienced a 4% decline in the same measure. The walking group showed a 4% improvement in FVC.

With regard to exercise capacity, the tai chi group exhibited an 11% jump in distance walked in 6 minutes while the control group and walking group’s distance walked rose only 2%.

The study authors concluded, “TCQ did contribute noticeable improvement in health outcomes with respect to lung functions and activity tolerance. Due to reduced physical abilities, people with COPD may not be able to carry out exercises at high-intensity levels. Despite the fact that much of the evidence pertaining to the physiological benefit of exercise is based on conventional physical exercise, such as walking, jogging, swimming and cycling, the role of other complementary and alternative modes of exercise also deserves attention. TCQ has been selected in this study because it has a number of potential advantages for health promotion among people with chronic illnesses. Studies have shown that practicing TCQ in a supportive atmosphere can foster feelings of self-efficacy. Through continuous practice, the subjects gradually developed mastery, which may have the effect of increasing their confidence in disease management and treatment compliance. In addition, through the TCQ program, subjects could increase their abilities to be more independent in terms of self-care and decrease their feelings of physical dysfunction due to the disease. TCQ was also well tolerated and enjoyed by the subjects. This might be the reason for the higher compliance rate and less attrition due to ‘‘no interest to continue’’ in the TCQ group (n = 2) than in the exercise (n = 10) and the control groups (n = 11).”

Regarding the authors’ final point, it has been shown in previous respiratory health studies that COPD patients participating in tai chi programs tend to stick with the programs for longer periods of time than other forms of conventional exercise. This current study seems to echo those findings.

If you are interested in trying a tai chi class, most fitness and community centers offer group classes for all levels of skill (beginner, intermediate, expert) and the movements can be adapted so that people with limited mobility/poor balance can participate while seated in a chair. Alternatively, there are many tai chi DVDs available through retail and online stores that you can use to practice at home. These DVDs also come in beginner, intermediate and expert versions and there are a few that are geared for practicing tai chi while seated. We’ve selected a sampling of the top selling beginner DVD’s from amazon.com on our Breathe Better Marketplace site for those who are interested.

[1] Chan AWK, et al. Tai chi Qigong improves lung functions and activity tolerance in COPD clients: A single blind, randomized controlled trial. Complementary Therapies in Medicine (2011) 19, 3—11.

Pulmonary rehabilitation effective even for severe COPD patients

2011-02-17T19:30:00.000-05:00

One of the most valuable steps anyone who suffers from chronic shortness of breath can undertake is to engage in a regular program of physical activity (including those diagnosed with chronic obstructive pulmonary disease or COPD).

Often the biggest challenge to become more physically active among those with pronounced breathing difficulties is a poor level of conditioning. Shortness of breath often leads people to rest more (meaning sitting or lying for larger segments of the day). The trend towards a more sedentary existence weakens muscles, bones, and the body’s cardiovascular function.

To help COPD patients “kick start” a physical activity program, pulmonology professionals can prescribe a treatment option known as pulmonary rehabilitation. In these programs, respiratory therapists and physicians first assess the baseline physical condition of each patient and then they design a somewhat customized 8-12 week exercise program that includes aerobic exercise (typically walking on a treadmill, riding a stationary cycle, or utilizing a device known as a cycle ergonometer) and strength training (weight lifting). Patients typically visit an outpatient rehab center 2-3 days per week for the 1 hour exercise sessions, and at various points along the way the therapists increase the duration and/or intensity of the exercise to help patients build back strength and endurance. Most rehab programs also include counseling and education sessions regarding breathing techniques, nutrition, smoking cessation, proper use of medications and social support.

Sounds great, right? Well, it is. Literally thousands of studies have been conducted on the effectiveness of pulmonary rehabilitation in reducing COPD patient shortness of breath, improving physical conditioning (strength and endurance), reducing exacerbations (shortness of breath attacks), shortening hospital stays and reducing overall health care costs. You’d think pulmonary rehab would be offered to every COPD patient…but it isn’t. In fact, only 1-2% of COPD patients are admitted to pulmonary rehab programs each year for a variety of reasons (none of them compelling).

At particular disadvantage are COPD patients considered “severe” cases. You see, there is a bit of a goldilocks mentality when it comes to doling out access to pulmonary rehab. If you have mild COPD (Stage I), you are unlikely to be admitted. If you have very severe COPD (Stage IV), you are also unlikely to be admitted. Why? Because Medicare and insurance companies will only reimburse rehab clinics for moderate to severe COPD patients (Stage II and III). And hospitals are not in the business of offering services for which they do not get paid.

Further, there is somewhat of an unspoken bias against admitting severe and very severe patients to begin with among pulmonology professionals. There seems to be an undercurrent that offering pulmonary rehab to severe patients is a waste of resources since their condition is unlikely to improve.

But research studies counter such notions. For example, a recent Nigerian study designed a 6-week pulmonary rehab program for 42 severe/very severe COPD patients. In particular, the study team desired to see whether the program would boost both the physical condition of patients as well as improve quality of life. [1]

Their results were remarkable in that the 6 week program (2 visits weekly for 2 ½ hours each session) delivered clinically significant improvements in distance walked on a timed test (21% improvement). Further, quality of life ratings for dyspnea (perceived shortness of breath), fatigue, emotional support and mastery all improved above the clinically significant threshold established in past research studies. Further still, the percentage of study participants acknowledging depression (40%) and anxiety (32%) both fell to 27% by the end of the study. More remarkable is the fact that the vast majority of these improvements were maintained 4 months after the 6 week program ended.

The study authors concluded, “This study has shown that a successful outpatient based rehabilitation programme is feasible and possible in patients with very severe COPD. Significant improvements can be achieved in shuttle walking distance, quality of life and psychological measurements, and the improvement is maintained for at least three more months without further intervention.”

If you are a COPD patient, we highly recommend you speak to your pulmonologist about gaining entry to a pulmonary rehab program in your area. If they won’t refer you, if you get rejected for admission, or there is no program in your area, we suggest you consider purchasing our Breathe Better for Life guidebook and companion CD-ROM.

We devised a pulmonary-rehab style exercise program based on guidelines established by the American Thoracic Society and the European Respiratory Society. We then augmented these guidelines with the exercise protocol recommended by the American College of Sports Medicine for those with chronic respiratory conditions. The guide and the CD were reviewed and edited by prominent respiratory care professionals, and both resources cover elements of a pulmonary rehab program that go beyond exercise (breathing techniques, airway clearing techniques, nutrition, proper use of inhaler medications, and other topics). To learn more about Breathe Better for Life, visit www.breathebetterforlife.com.

If you decide to follow our exercise program please consult your physician first to ensure the program is appropriate for your particular situation. While we did create two different programs based on condition severity (with different starting points, intensities, durations), it is important to include your doctor in your plans to begin an exercise program.

[1] Ige OM, et al. Outpatient Pulmonary Rehabilitation in Severe Chronic Obstructive Pulmonary Disease. Indian J Chest Dis Allied Sci. 2010 Oct-Dec; 52(4)

Incorrect use of inhalers common among COPD patients

2011-02-11T09:33:00.000-05:00

Bronchodilators are common treatment options prescribed by physicians treating patients suffering from chronic shortness of breath. Despite their widespread use, however, a significant percentage of COPD patients do not use their inhalers properly. The result of the misuse is inhalation of either too-little or too-much medication. In either case, patients can become frustrated with the effectiveness and/or side effects of the medications.

This widespread misuse is somewhat understandable given that there are different types of inhalers which carry different usage instructions (dry powder inhalers, metered dose inhalers) and some incorporate nebulizers while others don’t. Further, despite the best efforts of respiratory care professionals, many patients report they do not receive adequate instruction on how to use them properly.

As a case in point, a new study abstract published online ahead of print in the Journal of General Internal Medicine, examined the inhaler use of 40 COPD and 60 asthma patients who had been hospitalized due to their conditions at one of two Chicago area hospitals. The researchers discovered that 86% of the study subjects were improperly using metered dose inhalers while 71% were misusing Diskus brand dry powder inhalers. [1]

The study authors cited two main reasons for the poor rate of correct usage – difficulty with vision, and low health literacy. 43% of the COPD patients in the study had vision worse than 20/50 in both eyes. 61% of COPD patients in the study scored “less-than-adequate” health literacy on a test called The Short Test of Functional Health Literacy in Adults (S-TOFHLA for short).

After administering the vision and health literacy tests, the researchers taught patients the correct methods for using the inhalers (and presumably practiced with them). At the end of the study 100% of the participants correctly used their inhalers. The research team concluded the abstract by acknowledging, “Inhaler misuse is common, but correctable in hospitalized patients with COPD or asthma. Hospitals should implement a program to assess and teach appropriate inhaler technique that can overcome barriers to patient self-management, including insufficient vision, during transitions from hospital to home.”

If you think you might be using your inhaler improperly, the simplest of solutions is to visit your physician/pulmonologist/respiratory therapist and ask them to demonstrate the proper technique. Practice it in front of them to ensure you’ve got it down right and in future office visits, every now and then ask them to evaluate your inhaler technique.

Here is a brief excerpt from our Breathe Better for Life guidebook regarding proper use of metered dose inhalers:

“Many COPD medications need to be inhaled deeply into the lungs. Most people, over 90%, misuse their inhalers. To help you do this effectively, you will most likely need to use a metered-dose inhaler (MDI). If you have an MDI without a spacer, you need to shake the inhaler to prime it. Remove the cap and exhale deeply. Hold the inhaler one to two inches from your mouth (do NOT put it in your mouth). Press down to discharge the medication as you breathe in as deeply as you can. One depression (spray) per breath. Close your mouth and hold your breath for 5–10 seconds (ideally). Then exhale slowly.

If your MDI has a spacer, you want to shake the inhaler to prime it, then attach the spacer. Exhale deeply, then put the spacer between your teeth and seal your lips around it. With your chin up, pump one puff into the spacer. Slowly inhale through your mouth for three to four seconds. (Too rapid of an inhalation will likely result in less medication getting to the lungs, where it is absorbed and utilized by the airways.)

Remove the spacer from your mouth, and with your mouth closed, hold your breath for 10 seconds (ideally). Then exhale slowly. If you take a second puff, wait at least 30 seconds before doing so.”

If you’d like a more robust explanation and demonstration of the proper use of inhalers, our Breathe Better for Life companion CD-ROM includes easy-to-understand pictorial, narrated, step-by-step instructions on the proper use of metered dose inhalers, dry powder inhalers and nebulizers. As many of you know the Breathe Better for Life guidebook and CD-ROM also contains specific exercise, nutrition, breathing technique and airway clearing technique recommendations and demonstrations. You can learn more about Breathe Better for Life by visiting www.breathebetterforlife.com.

[1] Press VG, et al. Misuse of Respiratory Inhalers in Hospitalized Patients with Asthma or COPD. J Gen Intern Med. 2011 Jan 20 [Epub ahead of print]

Vitamin E supplementation reduces risk of lung disease by 10% among women in new study

2011-02-08T08:52:00.000-05:00

A new study published online ahead of print in the respiratory journal Thorax showed that healthy women who consumed 600 IU of vitamin E every other day had a 10% lower risk of developing lung disease. [1]

The study examined the past health records of nearly 40,00 women who enrolled in a large, ongoing health study called the Women’s Health Study. The researchers split the 40,000 women into two groups of roughly 20,000 – those who consumed 600 IU of vitamin E every other day, and those who received a placebo (100 mg of aspirin every other day). The mean age, weight, smoking status, alcohol use, multivitamin use and other health factors between the two groups were largely the same (a purposeful selection by the researchers to eliminate variables that might skew the study results).

During 10 years of follow up from study enrollment, 760 women receiving vitamin E were diagnosed with lung disease. By way of comparison, 846 of the study participants receiving the placebo were diagnosed with a chronic respiratory condition. From this data, the study authors concluded that those receiving vitamin E had a 10% lower risk of developing lung disease.

As an aside, the researchers pointed out that the strongest contributing health factor in developing lung disease among the study participants was cigarette smoking. Smokers in the study had 4.2 higher odds of developing lung disease than non-smokers. This is not a novel finding as other studies have produced similar results but we offer it as a reminder of the strong correlation between cigarette smoking and lung disease.

In addressing the implications of the lower lung disease risk from consumption of vitamin E, the study authors did not speculate on the mechanisms involved but did relate the findings of other vitamin E/COPD studies, “Observational studies investigating the association of dietary intake and pulmonary function consistently report that higher intake of nutrients with antioxidant properties is associated with better pulmonary outcomes, but causal inferences are limited by concerns about confounding and other biases. Studies comparing patients with COPD with healthy individuals report lower plasma and peripheral skeletal muscle vitamin E (alpha-tocopherol) concentrations in patients and a lower risk of death from respiratory disease with higher serum alpha-tocopherol concentration, but whether nutrition contributed to the onset of COPD is less clear.”

In other words, even though previous studies have hinted at vitamin E’s potential value for people who already have lung disease, there is not yet overwhelming, definitive evidence of its effectiveness. Further, the Thorax study was conducted on healthy women not COPD patients and therefore one cannot necessarily extend vitamin E’s benefits to those who already have respiratory disease.

With that in mind, however, there is a strong and growing body of evidence linking depressed levels of antioxidants (including vitamin E) with oxidative stress and inflammation in humans and laboratory animals with diagnosed respiratory conditions. And many of these studies demonstrate the power of boosting antioxidant blood levels in lowering oxidative stress and inflammation (whether through diet or dietary supplements). For additional articles we've written on antioxidants for healthy respiratory function, type in the keyword "antioxidant" in the search box in the left hand column of this page.

The dosage level consumed by the women in the Thorax study, 600 IU every other day, is well within the tolerable upper daily limits as reported by the National Institutes of Health Office of Dietary Supplements. For more information about vitamin E and potential counter-indications, click here to visit the aforementioned NIH information page on vitamin E. Please also consult your physician to determine whether adding vitamin E to your daily regimen is appropriate.

[1] Agler AH, et al. Randomized vitamin E supplementation and risk of chronic lung disease in the Women’s Health Study. Thorax. 2011 January 21. [Epub ahead of print]

Physical activity level best predictor of mortality in COPD patients

2011-02-04T14:44:00.000-05:00

The official journal of the American College of Chest Physicians, Chest, just published an abstract of a new study evaluating a range of potential predictors of mortality among COPD patients. Though the contents of the full study are embargoed until the article has gone to press, the abstract provides some interesting insights worth sharing.

First, as regular readers of our blog and e-letters well know, we are strong proponents for daily physical activity among COPD patients and anyone who suffers from chronic shortness of breath. We favor an exercise program based on the principles and practices of the COPD treatment pulmonary rehabilitation but acknowledge that even a simple walking program can confer conditioning benefits for smokers and those with respiratory conditions.

Many previous respiratory health studies have clearly and unambiguously demonstrated that regular physical activity reduces shortness of breath symptoms, increases cardiovascular conditioning, heightens muscle strength, improves self-reported quality of life, reduces hospital admissions and reduces severe shortness of breath attacks known as exacerbations.

When physicians act to address shortness of breath symptoms they typically favor smoking cessation, inhaler-based medications and antibiotics. These are reasonable and prudent treatment options. Smoking cessation confers significant health benefits in both the short and long run but a minority of smokers achieves successful permanent smoking cessation. Inhaler-based bronchodilators, steroids, and antibiotics offer short-term relief of immediate shortness of breath symptoms but their track record in conferring long term health benefits are spotty at best.

Regular physical activity, on the other hand, can deliver both short-term and long-term benefits provided one begins and maintains a regular program of activity. Previous studies have shown that COPD patients who are the most active (whether they exercise the most or simply are up and walking/moving around more frequently) report the highest quality of life, demonstrate the best exercise capacity and record the lowest sensations of breathlessness compared to those who are the least active.

In the new Chest study abstract, the researchers offered one more compelling reason to become more physically active – COPD patients in their study who were the most active reported the best survival rates over the four year follow up period after study enrollment. In fact, of all the diagnostic measures evaluated by the study team, the level of physical activity was considered the strongest predictor of patients likely to survive. [1]

According to the abstract, the Germany based researchers enrolled 170 stable COPD patients in their study. At the outset, they conducted a battery of diagnostic tests on the patients and recorded their respective readings. Tests included evaluations of respiratory function, cardiovascular function, body mass index, nutrition status, blood levels of inflammation markers, exercise capacity and levels of physical activity.

Forty-eight months after enrolling the patients and conducting the diagnostic tests, the researchers followed up with the patients to determine which were still alive and which had passed away (26 of the 170 patients died during the four year follow up period, roughly 15%).

The researchers then compared the mean diagnostic readings for the survivors and non-survivors and determined that among all the diagnostic measures, physical activity level was the measure with the highest inverse correlation between the two groups (meaning the people who did not survive the four year follow up period had recorded the lowest levels of physical activity in the diagnostic tests).

In fact, the study abstract mentioned that each 8-10% increase in physical activity level was associated with approximately 50% lower risk of death! Pretty compelling reason to get up off the couch and get moving, wouldn’t you say?!

Note: Physical activity level (PAL) in the study was measured by attaching a device to patients called a multisensory armband which records energy expenditure from movement over a defined period of time (typically a number of days). The World Health Organization has established that PAL levels between 1.7 and 2.0 are indicative of moderately active adults based on data accumulated over time utilizing this device and associated energy expenditure/metabolism calculations. Those considered sedentary or inactive have PAL levels between 1.4 and 1.7. In the Chest abstract, each .14 increase in PAL yielded 54% lower hazard ratio of death, hence our approximation of 8-10% movement in PAL (.14/1.7 or .14/1.4).

If you are a COPD patient and spend most of the day sitting or lying down, it is strongly worth your while to consider becoming more active (standing, walking, exercising). Not only will doing so improve how you feel and breathe each and every day, it may also help extend your life!

We realize getting started on a physical activity program may feel daunting. For those of you who feel that way, you are likely concerned about your balance, potential shortness of breath episodes, and lack of current energy. All are reasonable concerns but none of these issues will go away by simply sitting or lying down. They will only get worse.

To address these concerns, respiratory care professionals offer a treatment option known as pulmonary rehabilitation which assists COPD patients get started on a regular exercise program by starting slow and gradually increasing the intensity and duration of exercise for each patient based on their respective individual starting conditioning levels. These programs are highly effective and we strongly recommend you ask your pulmonologist for a referral to a program in your area.

One thing to keep in mind, however. Entry into these programs can be challenging. There are not enough pulmonary rehab programs around the country to serve all the COPD patients who could benefit from the treatment. Further, Medicare and insurance reimbursement only applies to Stage II and Stage III COPD patients in most cases (moderate to severe COPD), and the programs only last 8-12 weeks.

If you can’t gain entry into a pulmonary rehab program in your area, we recommend you consider purchasing our Breathe Better for Life guidebook and companion CD-ROM. We have created an at-home (or fitness center) exercise program based on pulmonary rehabilitation guidelines published by the American Thoracic Society and European Respiratory Society. We augmented these guidelines by incorporating exercise recommendations for people with chronic respiratory problems from the American College of Sports Medicine. Whether you follow our program or simply use the guide as a resource to discuss structuring an exercise program with your physician, we believe Breathe Better for Life provides excellent education for COPD patients and smokers on exercise, nutrition, breathing technique and airway clearing techniques to improve how you breathe and live. You can learn more about Breathe Better for Life by visiting www.breathebetterforlife.com.

[1] Waschki B, et al. Physical activity is the strongest predictor of all-cause mortality in patients with chronic obstructive pulmonary disease: a prospective cohort study. Chest. 2011 Jan 27 [Epub ahead of print].

New study shows N-acetylcysteine’s effect on oxidative stress from cigarette smoke

2011-02-02T12:54:00.000-05:00

Each puff of cigarette smoke contains massive numbers of molecules known as free radicals that damage the lining of the airways and allow the toxic chemicals present in cigarette smoke to enter lung tissues. Over time, these toxins damage the tissue’s immune response to invading bacteria and fungi. This results in inflammation of lung tissue, and inflammation is believed to be a prime cause for chronic shortness of breath.

Normally, the body has a supply of neutralizing molecules known as antioxidants that bond to free radicals and essentially render them harmless. Antioxidants are in foods we eat (primarily fruits and vegetables) and can also be consumed in the form of dietary supplements.

But in the vast majority of cigarette smokers, the body’s supply of antioxidants is severely depressed for two reasons. On one hand, the significant counts of free radicals inhaled in cigarette smoke are far larger than even the healthiest of eater’s consumption of antioxidant rich foods. On the other hand, previous research has shown that the average smoker’s diet is low in antioxidant-rich food to begin with. The combination of these two factors (too many free radicals and too few antioxidants) leads to a condition known as oxidative stress.

Respiratory researchers have increasingly turned their attention to the impact of supplementing antioxidants in smokers and those with chronic shortness of breath to see if they can reduce oxidative stress and inflammation (and thereby contribute to improving shortness of breath symptoms).

We have previously written a number of articles regarding a number of recent studies regarding antioxidants that have shown promise in reducing oxidative stress and inflammation among those exposed to cigarette smoke and those with respiratory health conditions, including COPD. One such antioxidant is n-acetylcysteine (often referred to as NAC). NAC has been studied extensively for its anti-inflammatory properties and has also shown effectiveness in boosting exercise tolerance among COPD patients participating in a pulmonary rehabilitation exercise program.

A new research paper published this month online ahead of print in the journal International Immunopharmacology showed further evidence of NAC’s ability to significantly reduce oxidative stress and inflammation due to exposure to cigarette smoke. [1]

In the study, lung tissue from four groups of laboratory mice were examined for differences in oxidative stress and inflammation markers (proteins and white blood cells known to be present in high numbers as a result of oxidative stress and inflammation).

A control group of mice lung tissue received a normal diet and was not exposed to nicotine, NAC or another antioxidant compound known as eugenol. A cigarette group received exposure to nicotine in addition to a normal diet. Another group received nicotine and eugenol and the final group received nicotine and NAC.

The researchers then examined the four groups’ lung tissue counts of cytokines (proteins) and macrophages (white blood cells) to evaluate the relative influence of nicotine, eugenol and NAC.

First, they discovered that nicotine dramatically increased the number of cytokines and macrophages compared to the control group (approximately 3 fold increase), proving once again the impact of the chemicals in cigarette smoke in generating oxidative stress and inflammation.

Further the researchers reported dramatic decreases in the same oxidative stress and inflammation markers in lung tissue treated with nicotine and either NAC or eugenol (the relative performance between NAC and eugenol was about the same). In fact, the study results showed that NAC (and eugenol) lowered the counts of cytokines and macrophages to nearly the same level as the control group, implying that NAC and eugenol effectively negated the impact of nicotine in the mice lung tissue samples.

The researchers concluded, “…we have also demonstrated that, the importance of eugenol and N-acetylcysteine to exert a new anti-inflammatory [effect] to combat against nicotine-induced immune disorder, as our results clearly established that, co-treatment of eugenol or N-acetylcysteine with nicotine can diminish the nicotine-induced enhanced Th1 cytokines (TNF-α and IL-12) release and in mRNA level, as well as, boost up the Th2 (IL-10 and TGF-β) cytokine release and mRNA level up to more or less control level . In summary, our study has enhanced our understanding of the molecular steps leading to nicotine induced weaken of immune functions by murine [mouse] macrophages, and provided additional rationale for the application of anti-inflammatory therapeutic approaches by eugenol and N-acetylcysteine for different inflammatory [condition] prevention and treatment during nicotine-induced toxicity.”

Respiratory health care professionals will caution that these results may or may not translate to humans exposed to nicotine/cigarette smoke. However, there have been promising live human studies involving NAC therapy as an effective treatment option for chronic inflammation and therefore we believe NAC is worth your consideration.

NAC is an amino acid that helps the body produce glutathione – the most abundant antioxidant found in the human body (including lung tissues). NAC is widely available as a stand-alone dietary supplement or in combination with other antioxidant ingredients. As an aside, NAC is the lead ingredient in our respiratory support antioxidant-rich dietary supplement, Resplenish at a daily dosage of 1200mg. To learn more about Resplenish, please visit www.resplenish.com.

[1] Kar Mahapatra S, et al. Alteration of immune function and Th1/Th2 cytokine balance in nicotine-induced murine macrophages: Immunomodulatory role of eugenol and N-acetylcysteine. Int Immunopharmacol. 2011 Jan 13 [Epub ahead of print].

Gold Kiwi – Powerful Fruit for a Healthy Heart

2011-01-27T12:52:00.000-05:00

So you know the old adage – “an apple a day helps keep the doctor away”, right? Well, when it comes to heart health it appears the better option is gold kiwi fruit by a long-shot, so says a new study published this month in the journal Biological and Pharmaceutical Bulletin.

In their study, the Japanese research team examined seven fruits that are known to have high antioxidant content: gold kiwi, green kiwi, navel orange, mandarin orange, white grapefruit, ruby grapefruit, and apple (the researchers did not specify the apple type tested). ¹

In particular, the study team desired to know which of the fruits had the highest concentration of polyphenols (powerful antioxidants that offset the effects of molecules known as free radicals), which were most effective in reducing lipid oxidation (the process whereby fatty acids are turned into free radicals that damage cells), and which were most effective in eliminating free ranging hydrogen peroxide (another type of free radical produced as a byproduct of the body’s process to create and use energy at the cellular level).

People with high levels of unhealthy lipids (LDL cholesterol) in their blood serum (oxidized LDL in particular) are considered at high risk for cardiovascular conditions such as atherosclerosis, heart attacks, strokes and other maladies. By reducing the amount of oxidized lipids and the number of other free radicals in blood serum, physicians believe people can significantly reduce their risk of heart disease. A common way to reduce free radicals and oxidized lipids is to consume more antioxidant rich food, hence the interest of the researchers in these fruits.

The short takeaway – gold kiwi crushed the competing fruits on all measures. In fact, apples came in dead last on every measure!

For example, to assess polyphenol content, the researchers cut equal weight pieces of each fruit flesh and blended in a mixer for about 30 seconds. The blended fruit juices were then processed through a centrifuge for 10 minutes and subsequently strained through a filter. The strained juice was centrifuged again – this time for one hour - and then samples were taken of the remaining, centrifuged juice.

Using this method, the researchers found that gold kiwi’s polyphenols content was approximately 1.04 milligrams per milliliter, green kiwi was second with 0.85 mg/ml, navel oranges were third at 0.80 mg/ml, while apples were dead last at 0.13 mg/ml!

To assess the antioxidant properties of these polyphenols, the researchers then mixed a 1% concentration of the fruit juice solutions with lipids from egg yolk and then irradiated the mixture for various time intervals (irradiation via UV rays causes the lipids to oxidize). After irradiation, the study team examined the counts of oxidized lipid molecules remaining in the respective fruit juice mixtures. They found gold kiwi and navel orange both inhibited oxidation of 60% of the lipids. Again, apples were dead last at 23%.

To further evaluate the antioxidant properties of the various fruits, the researchers mixed a 5% concentration of the fruit juice solutions with hydrogen peroxide and let the mixture sit for two hours. Then the researchers measured the amount of hydrogen peroxide eliminated by the fruit juices. Once again, gold kiwi significantly outperformed the other fruits, eliminating over 60% of the hydrogen peroxide. No other fruit achieved greater than 30% elimination and apples again lagged the field at less than 10%.

The study authors concluded, “Therefore, we propose the novel possibility that daily consumption of kiwi fruit is effective on decrease of oxidative stress and further prevention of disease by excessive oxidation…All these indicators showed the highest activity for gold kiwi, demonstrating that gold kiwi has strong anti-oxidant effects. Overall, green kiwi had lower anti-oxidant effects than gold kiwi, but had stronger effects than the other fruits.”

So, if you’d like to add an easy, tasty and heart healthy fruit to your daily diet, consider gold kiwi. It’s a little more challenging to find in a retail grocery store (and a little more expensive to buy) so you may need to look for it in a specialty/gourmet food store.

According to the prime producer of gold kiwi fruit, a New Zealand company called Zespri, the biggest difference between the green and gold kiwi is taste, “ While green kiwifruit has a tangier, more tart flavor, gold kiwifruit is mellow and tropical, a mixture of mango, melon and citrus flavors. People who find green kiwifruit too tart usually love gold. As for other differences, the color is gold, instead of green, and it is tear-drop shaped, with a smooth skin and a crown on the top. Finally, while you might need to wait a few days for green to ripen, gold kiwifruit is always ready to eat.” ²

(Article by Kevin P. Donoghue originally published on January 13, 2011 for Peak Health Advocate, www.peakhealthadvocate.com)

¹ Iwasawa H, et al. Anti-oxidant Effects of Kiwi Fruit in Vitro and in Vivo. Biol Pharm Bull. 2011;34(1):128-34.

² Zespri Kiwifruit North America web site, http://www.zesprikiwi.com/faqs.htm, accessed January 12, 2011.

Pulmonary rehabilitation increases exercise capacity and reduces shortness of breath

2011-01-24T12:27:00.000-05:00

This month, a new study published in the journal Archives of Physical Medicine and Rehabilitation, clearly demonstrated again the physical gains achieved by COPD patients participating in a pulmonary rehabilitation program.

As regular readers of our articles can attest, we believe strongly in the COPD treatment, pulmonary rehabilitation, and its proven ability to reduce shortness of breath, improve physical endurance and strength, as well as its impact in improving COPD patient quality of daily living. Still, it remains an under-prescribed treatment by physicians and an underutilized resource by COPD patients.

As further evidence of pulmonary rehab’s effectiveness, a group of Dutch researchers examined the impact of a 12 week pulmonary rehab program in 18 moderate-to-severe COPD patients. They discovered the 12 week program of aerobic exercise and strength training improved cycling endurance of the study participants by 160% and walking distance achieved in a 6-minute timed test improved by 14%. In addition, at the end of the program, self-reported dyspnea (shortness of breath) during the activities tested had declined by 9-17%. [1]

The study was intended to assess whether conditioning tests traditionally used to validate pulmonary rehab’s effectiveness are better measures than observed improvements in training performance. In other words, is a comparison of 6 minute walk test distances recorded at the beginning and end of a rehab program a better way to determine whether COPD patients derived benefit from the program versus measuring increases in how much weight a patient could lift or how much more resistance a patient could withstand during cycling.

The researchers ultimately concluded that the traditional conditioning tests are better measurements of COPD patient improvement, but to us the value of the study was in reaffirming the benefits of pulmonary rehab in general – regardless of measurement preference.

The pulmonary rehab program in the study involved 1.5 hour exercise sessions, 3 days per week over a 12 week period. The exercises included in each session (with intermittent rest breaks) included:

• 20 minutes of interval cycling (alternating sessions of heavy and light intensity cycling),
• 5 minutes of unsupported arm dumbbell lifting exercises (2.5 minutes for each arm)
• 5 minute sit/walk slalom course designed to simulate everyday sit/walk activities at home
• 6-12 minutes of endurance walking exercise on a treadmill
• Additional strength resistance training of abdominal, shoulder, and leg muscle groups

Prior to beginning the rehab program, and again following the last rehab session, the researchers had the study participants perform three conditioning tests (constant work-rate cycling, 6-minute walk test and maximal incremental cycling). To determine the rehab program’s effectiveness, researchers evaluated the pre- and post- rehab conditioning test results of the study subjects. They also assessed improvements in the amount of weight lifted in the arm exercise and resistance load achieved during the interval cycling from the beginning of the program to the end.

While the patients did see significant improvements in amount of weight lifted, number of repetitions performed, and resistance load achieved during interval cycling, the researchers found the traditional conditioning tests to be a better gauge of the pulmonary rehabilitation program’s impact.

The study authors concluded, “Indeed, in the current study, exercise duration and walking distance during submaximal exercise tests (constant workrate cycling, 6-min walk test) increased by 160% and 14%, respectively, and both of these have been reported to be of clinical relevance…The current study also included the training activities in the evaluation. During the 12 weeks of training, all patients were able to perform training activities with higher loads and weight for a longer duration, and with a trend toward less dyspnea and fatigue.”

Pulmonary rehabilitation works and if you are a COPD patient interested in improving how you feel, you owe it to yourself to discuss pulmonary rehabilitation with your pulmonologist. If you can’t gain entry to a rehab program in your area (or if one is not offered), we recommend asking your doctor to recommend an exercise program appropriate for your particular circumstance.

Alternatively, we have created a pulmonary-rehab style exercise program based on guidelines established by the American Thoracic Society and European Respiratory Society that is available in our Breathe Better for Life guidebook, www.breathebetterforlife.com. Our program also incorporates guidelines established by the American College of Sports Medicine for those with chronic respiratory conditions.

[1] Hanneke A, et al. Exercises Commonly Used in Rehabilitation of Patients With Chronic Obstructive Pulmonary Disease: Cardiopulmonary Responses and Effect Over Time. Arch Phys Med Rehabil. 2011;92:111-117.

Skipping breakfast is bad medicine for smokers

2011-01-21T10:23:00.000-05:00

In researching an article about the dangers of skipping breakfast we wrote recently for a different publication, we came across a 2009 study that examined the breakfast eating habits of current smokers. Though the research is not hot off the presses, we thought the results were worth sharing with you knowing that many of you are active smokers. The most startling finding in the study - current smokers who regularly omitted a morning meal were 4.7 times more likely to develop diabetes than current smokers who ate breakfast every day. ¹

The Japan-based research team also found that 63% of current smokers in their study regularly skipped breakfast, evidently echoing previous studies that have shown a strong correlation between smokers and breakfast skipping tendencies.

In other studies, skipping breakfast has been shown to increase fasting lipids (fats in the blood stream), elevate blood sugar, and impair insulin control. All of these impacts are considered contributing factors in the development of diabetes. The researchers in this study speculated that smoking seems to accelerate these effects of breakfast skipping leading to a pronounced increase in the odds of developing diabetes.

How strong is the influence of breakfast skipping combined with smoking in the risk of developing diabetes? Well, the results of this study indicated that smokers who regularly ate breakfast had the same, low odds of developing diabetes as never smokers who regularly ate breakfast. But when compared with smokers who never or rarely eat breakfast, the odds ratio of developing diabetes were 4.7 times higher than both groups of regular breakfast consumers.

In addition to diabetes risk, there are a host of other studies that have been published over the past few years that highlight other significant health risks associated with eschewing a morning meal including increased risk for cardiovascular disease and obesity. Further, a number of previously reported papers have shown strong correlations between breakfast skipping and poor mental focus, poor sleep quality and persistent fatigue.

In fact, in the Japanese smoker/breakfast skipping study, the paper’s authors also noted that smokers who skipped breakfast were more than 2 times likely than regular breakfast eaters (both smokers and non-smokers) to report poor sleep quality.

If you are interested in adding a morning meal to your daily routine, a number of breakfast-oriented studies have determined the healthiest choice is ready-to-eat cereal made from whole grains combined with low-fat milk. For those wishing to spice it up a bit, add a piece of fruit into the mix.

Cereals made with whole grains typically have a higher fiber content, lower glycemic index value (glycemic index is a measure applied by dieticians to assess the blood sugar raising effects of various foods), and less harmful fats/oils. Before you start to groan imagining eating tasteless, coarse cereals, check out this list of healthy and unhealthy cereal choices developed by Dr. Diane Mirkin.

If you can’t see your way chomping on bran flakes to start your day, at least try to avoid breakfast foods that have been shown to possess a high glycemic index. High glycemic index foods are strongly correlated with obesity, diabetes, high blood pressure and other cardiovascular risk factors. Some of the biggest breakfast offenders on this list include doughnuts, waffles, bagels, and toast made from white bread.

However, this study points out smokers would be well served to add a regular meal to begin the day (regardless of breakfast food choice) so as to avoid the risk of adding insult to injury by compounding the respiratory effects of smoking by increasing the odds of contracting diabetes.

¹ Nishiyama M, et al. The Combined Unhealthy Behaviors of Breakfast Skipping and Smoking Are Associated with the Prevalence of Diabetes Mellitus. Tokohu J. Exp. Med. 2009;218:259-264.

...

Mate tea reduces inflammation caused by cigarette smoke

2011-01-17T12:54:00.000-05:00

On many occasions we have written about the power of antioxidants in reducing oxidative stress and inflammation among smokers and those with respiratory conditions such as COPD. We’ve discussed studies examining dietary antioxidant supplements, foods with high antioxidant content, and even cigarettes laced with antioxidants. Now comes a new study about an antioxidant rich beverage, Mate tea, and its ability to reduce inflammation caused by cigarette smoke. (1)

Mate tea is a beverage made by brewing the dried leaves and twigs of the herb yerba mate. Once steeped, it can be served hot or cold and is a popular beverage in many Latin American and Arabian countries. Yerba mate is known to be a rich source of an antioxidant form called xanthines. Interestingly, caffeine is considered one of the more powerful xanthines.

The research article, published online ahead of print in the journal Experimental Lung Research, investigated supplementing Mate tea to cigarette smoke-exposed laboratory mice. The researchers divided 60 laboratory mice into four groups. The control group received no exposure to cigarette smoke and Mate tea. A second group received the Mate tea but no cigarette smoke. A third group was exposed to cigarette smoke but received no Mate tea. The last group was exposed to both cigarette smoke and Mate tea.

The groups exposed to cigarette smoke received the equivalent of 12 cigarettes a day over a 60 day period. The groups receiving Mate tea received 500 milligrams per kilogram of body weight daily over the same 60 day period. At the end of the study, the mice were euthanized, their lungs removed and analyzed. The researchers evaluated both statistical measures of inflammation (counting certain white blood cells known to be present in high numbers in inflamed lung tissue), and observational differences in lung tissue samples examined under a microscope.

They found dramatic differences in both evaluation sets. For example, counts of inflammation related white blood cells known neutrophils were measured at 8.7 squared millimeters in the control group while the cigarette smoke exposed group measured 71 (a huge difference and a clear indication of the impact of cigarette smoke’s ability to inflame lung tissue). By comparison, the neutrophil count in cigarette smoke exposed mice who also received Mate tea was only 27. In other words, while the cigarette/Mate group showed some inflammation, it was significantly lower than the mice exposed to cigarette smoke only (61% lower). Similar results were found for other inflammation related white blood cell types measured by the study team.

When looking at samples of lung tissue under a microscope, the researchers found significantly enlarged air spaces in the cigarette smoke exposed mice in comparison to the control group (enlarged air spaces are indicative of emphysema and are a by-product of persistent inflammation). On average, the volume density of the air spaces in the cigarette group was 16% higher than the control. By comparison, the volume density of the cigarette/Mate group was only 6% higher than the control group. Again, this shows that the antioxidant properties of Mate tea were effective in reducing inflammation associated with cigarette smoke.

The researchers concluded, “This study examined Mate tea in response to CS (cigarette smoke) exposure in the mouse. The protection observed, by both histological and biochemical analyses, leads us to suggest that Mate tea provides beneficial effects against lung damage caused by CS exposure in the mouse. In the CS+Mate group, few alterations to the alveolar spaces were observed, elastic fibers were preserved, and there were fewer macrophages and neutrophils recruited to alveoli compared to the CS group... Our results point to Mate tea as a nutritional antioxidant against lung injury in mice exposed chronically to CS and support efforts to investigate the beneficial effects of Mate tea on CS related lung injury in other animal models and humans.”

While many pulmonology professionals will be reluctant to recommend consuming Mate tea to COPD patients and smokers based on a mouse study, we think it is of value to share the study results with you. In the pursuit of better breathing, it is clear that regular consumption of antioxidants by any means possible is beneficial to those who smoke and have respiratory conditions. And certainly, there is no harm in adding a cup of Mate tea to your daily routine.

If you don’t think Mate is your cup of tea (sorry for the bad pun) to receive antioxidants, we recommend you either consider adding an antioxidant-rich multi-nutrient such as our Resplenish dietary supplement, www.resplenish.com, and/or adding antioxidant rich foods to your daily diet – an excellent choice is gold kiwi (check out our new article on gold kiwi in our e-letter Breathe Better for Life News). For other articles we’ve written regarding inflammation, oxidative stress, and antioxidants studied by respiratory health researchers, visit our Breathe Better Blog.

(1) Lanzetti M, et al. Mate tea ameliorates emphysema in cigarette smoke-exposed mice. Experimental Lung Research. 2011 Jan 6. [Epub ahead of print].

Calcium deficiency and COPD

2010-12-29T10:54:00.000-05:00

A new Japanese research study published in the Asia Pacific Journal of Clinical Nutrition points to dietary calcium deficiency as a risk factor for developing COPD. In particular, their research findings showed that study subjects who consumed the most dietary calcium had a 35% lower risk of developing COPD than those who consumed the least amount of calcium-rich food.

The goal of the study was to determine if there were correlations between the dietary consumption of certain key minerals and prevalence of COPD. To assess these correlations, the researchers analyzed the dietary habits of 278 Japanese COPD patients and 340 healthy Japanese adults. The researchers surveyed the study participants regarding their eating habits and then used standard nutritional content tables to calculate the mineral content of the foods consumed by study participants. (Hirayama F, et al. Dietary intake of six minerals in relation to the risk of chronic obstructive pulmonary disease. Asia Pac J Clin Nutr. 2010;19(4):572-7)

Of the six minerals examined, only two showed correlations between low mineral levels and high prevalence of COPD – calcium and iron. Of the two, calcium was the most pronounced.

Calcium deficiency is also a known contributor to the development of osteoporosis. We’ve previously written about the high incidence of osteoporosis among COPD patients (estimated to exist in 50-65% of COPD patients). In those previous articles we’ve highlighted the root causes as a combination of sedentary lifestyle, Vitamin D deficiency (from lack of exposure to direct sunlight), and prolonged exposure to cigarette smoke. Click here and here to read these previous articles. It is likely therefore that calcium deficiency plays a role in the development of osteoporosis among COPD patients as well.

Foods that are naturally rich in calcium content include certain fish such as salmon, tuna, sardines and mackerel. Additionally, soy beans and other soy based products (such as tofu) contain high levels of calcium. Dairy products such as milk, cheese, egg yolks, and yogurt are also good sources of calcium.

New study shows acai berry helpful for smokers

2010-12-28T12:54:00.000-05:00

A novel study published online ahead of print in the journal Food and Chemical Toxicology explored injecting the extract of a potent antioxidant known as acai berry into cigarettes that were in turn inhaled by laboratory mice. The researchers discovered that the acai berry treated cigarettes produced far less inflammation in mice receiving the antioxidant compared to mice exposed to cigarette smoke alone.

The purpose of the study was to determine whether providing a powerful antioxidant along with cigarette smoke would lessen the likelihood of lung tissue damage and associated inflammation. The researchers chose acai berry extract (specifically the extract of the acai berry stone [seed]) because previous research studies involving plant-based antioxidants known as proanthocyanidins have shown similar anti-inflammatory effects.

In this study, the researchers divided the 60 mice in the study into three groups. One group, the control group, received neither exposure to cigarette smoke or acai berry extract. A second group, the cigarette group, was exposed to cigarette smoke from 12 cigarettes daily over a 60 day period. The third group, the acai group, was exposed to cigarette smoke in the same manner as the cigarette group but received the cigarette smoke from cigarettes injected with the acai berry extract. (de Moura RS, et al. Addition of acai (Euterpe oleracea) to cigarettes has a protective effects against emphysema in mice. Food Chem Toxicol. 2010 Dec 10. [Epub ahead of print])

At the end of the 60 day period, all mice were euthanized and lung tissue samples were extracted. The researchers viewed lung tissue samples via microscope to assess the size of alveolar spaces between the three groups (in emphysema, alveolar spaces enlarge). In addition, the lung tissue was analyzed for counts of proteins and white blood cells that are known to be present in large numbers in inflamed airway tissue.

The study team discovered that the cigarette group had 38% greater alteration to alveolar tissue in comparison to the control group. The acai group had 25% lower alteration compared to the cigarette group (meaning the acai group’s lung tissue samples showed less alteration than the cigarette group but more alteration in comparison with the control group).

When analyzing the inflammation markers, researchers found 400% more leukocytes in the cigarette group compared to the control group. The acai group had 65% fewer leukocytes than the cigarette group (again showing the acai group lessened the impact of cigarette smoke). Similar findings were found for other markers such as macrophages and neutrophils.

The study team concluded, “This study demonstrated for the first time that adding a hydro-alcoholic extract of acai stone to cigarettes significantly reduced pulmonary inflammation, oxidative stress, and CS-induced emphysema in mice… Because lung damage induced by CS is mainly due to inflammation and oxidative stress, it seems likely that acai’s anti-inflammatory and antioxidant properties underlie these protective effects…The present study demonstrated that acai extract in cigarettes has a preventive action; that is, the harmful effects of CS can be significantly reduced when the smoke also contains antioxidant compounds.”

Now, what to make of this finding? First, it is unlikely you will find acai-injected cigarettes offered by cigarette companies any time soon. The medical community will object vociferously to such additives because they fear such additives will give consumers the false impression that adding antioxidants to cigarettes reduces their negative health effects.

Second, the study results echo those of other recent studies on different antioxidant ingredients. There is a clear, growing body of evidence in pulmonology research that antioxidant supplementation (whether through consumption of antioxidant rich foods or from dietary supplements) confers significant anti-inflammatory benefits in smokers and people with COPD.

Currently, there is no consensus view as to what antioxidants are most appropriate for smokers and people with lung disease. Further, there is no consensus among researchers as to the appropriate human dosage levels to achieve significant inflammation reduction (most recent studies have been conducted on either human tissue samples or laboratory animals).

That said, the antioxidants that have received the most attention from pulmonology researchers over the past few years include Vitamin D, Vitamin A, Vitamin C, Vitamin E, N acetyl cysteine, reseveratrol, curcumin, quercetin, Chinese skull cap (baicalin), and now acai berry.

As an aside, all of the above antioxidants, with the exception of acai berry, are included in our respiratory support dietary supplement, Resplenish. To learn more about Resplenish, visit www.resplenish.com.

For more information about acai berry, click here for a WebMD.com summary.

For a sampling of dietary supplements that include acai berry, visit our Breathe Better Marketplace hosted by amazon.com.

Systemic inflammation in ex-smokers

2010-12-22T10:33:00.000-05:00

A new research article reveals that 54% of ex-smoking COPD patients involved in a Chile based COPD study still exhibited signs of systemic inflammation despite their commitment to permanent smoking cessation.

These results echo the findings of another research study we wrote about last month that found airway inflammation persists for an extended period of time in ex-smoking COPD patients. Click here to read that article.

The new study examined 104 ex-smokers with mild to very severe COPD and 52 healthy non-smoking adults to see if there were differences in the blood serum levels of know inflammation markers. In particular, the research team evaluated counts of certain proteins and white blood cells that are typically found in large numbers in the presence of systemic inflammation (C-Reactive protein, Interleukin-6, fibrinogen, neutrophils).

The research investigators found notably higher counts of two of these inflammation markers among 54% of the COPD patients participating in the study (C-Reactive protein and interleukin-6). The counts of these two proteins were high enough for the researchers to conclude systemic inflammation still existed for 56 of the 104 ex-smoking COPD patients. (Morales SA, et al. Systemic inflammation among stable ex smokers with chronic obstructive pulmonary disease. Rev Med Chil. 2010 Aug;138(8):957-64. Epub 2010 Nov 26).

Why is inflammation such a big deal for smokers and COPD patients? In short, prolonged exposure to cigarette smoke alters the functioning of lung cells by disrupting the lungs normal response to the presence of bacteria and fungi. This disruption causes the body to produce massive amounts of fluid containing proteins and white blood cells seeking to counteract the presence of bacteria and fungi. The fluid build-up causes lung tissues to swell and harden, thus narrowing airways and resulting in persistent shortness of breath. For a more detailed description of inflammation and steps you can take to reduce inflammation, read our War of the Worlds In Your Lungs.

For many years, pulmonology researchers hypothesized that permanent smoking cessation would lead to a pronounced decline in airway inflammation. While that may be in the case for some smokers, it does not seem to be true in a majority of patients who’ve already been diagnosed with COPD.

In the interim, researchers and practitioners have focused the majority of their attention on corticosteroids, bronchodilator delivered prescription medication, and antibiotics as the main weapons to fight inflammation. While all three of these pharmaceutical solutions do offer relief for shortness of breath/inflammation related symptoms, the vast majority are short-acting in nature. In other words, they are band-aids for short-term relief. They offer no long-term cures for inflammation. Several exotic combinations of bronchodilating medications have shown increased promise for longer-term inflammation relief but their potential side effects concern some respiratory care professionals.

Therefore, COPD patients, current smokers and ex-smokers are wise to consider additional avenues to help combat inflammation. These other avenues include exercise, dietary changes, antioxidant supplementation and increased exposure to direct sunlight. To learn more about these inflammation fighting actions you can employ, read our 5 Steps to Feel Better NOW Plan.

Cigarette smoking and a good night’s sleep

2010-12-19T13:31:00.000-05:00

According to a new study published online ahead of print in the journal Sleep Medicine, current cigarette smokers are more than twice as likely to report insufficient sleep as non-smokers.

As the study authors explain, “The mechanism through which active smoking affects sleep has been established. Nicotine, the active component of cigarette smoke, stimulates the release of sleep regulating neurotransmitters including dopamine and serotonin, resulting in sleep disturbance. Cigarette smoking is associated with disturbances in sleep architecture including lighter sleep, long latency in sleep initiation, decreased sleep efficiency and increased daytime sleepiness. Nicotine dependence and nightly withdrawal are associated with anxiety and stress disorders. Further, cigarette smoking impacts sleep by exacerbating respiratory symptoms or contributing to sleep disordered breathing.”

In other words, nicotine disrupts the chemical processes in the brain that help us fall asleep and stay asleep. Further, during sleep smokers do not ingest nicotine at the same rate as they do when awake and so sleep is further compounded by anxiety and stress associated with nightly nicotine withdrawal symptoms. It’s a bit of damned if you do, damned if you don’t cycle every single night.

In the Sleep Medicine study, a group of West Virginia University researchers examined questionnaire results provided by over 80,000 respondents participating in the 2008 Behavioral Risk Factor Surveillance System - a large behavioral health study based on random, nation-wide phone surveys conducted in 2008. (Sabanayagam C, et al. The association between active smoking, smokeless tobacco, second-hand smoke exposure and insufficient sleep. Sleep Med. 2010 Dec 6. [Epub ahead of print])

Their particular aim was to confirm previous study results connecting insufficient sleep/chronic insomnia and current cigarette smokers, and to verify whether similar sleep disturbances were present in people who use smokeless tobacco and non-smokers regularly exposed to cigarette smoke.

The research team discovered that approximately 18% of current cigarette smokers suffered from insufficient sleep (defined by the researchers as not getting enough rest or sleep everyday in the preceding 30 days). By comparison, only 9% of non-smokers reported insufficient sleep when completing the survey. This led the researchers to conclude that current smokers have 100% higher odds of experiencing insufficient sleep compared to non-smokers.

With regard to smokeless tobacco, the study investigators found 67% higher incidence of insufficient sleep among current smokeless tobacco users compared to never smokeless tobacco users. While this level was lower than the odds ratio for current cigarette smokers, it is still statistically significant.

Among non-smokers exposed to second hand cigarette smoke, the study results showed 41% higher odds of insufficient sleep compared to non-smokers not exposed to second hand cigarette smoke.

It appears from these results that regardless of consumption source (inhaling cigarette smoke, chewing tobacco, inhaling snuff, or inhaling second hand cigarette smoke), nicotine exposure is disruptive to a good night’s sleep. As the article authors concluded, “Consistent with previous studies, active smoking was associated with insufficient rest/sleep in the current study. Effect of smokeless tobacco on sleep has not been studied before. To our knowledge this is the first study showing an association between smokeless tobacco and insufficient rest/sleep.”

So short of permanent smoking cessation, what can people regularly exposed to cigarette smoke do to improve their odds of a good (or at least better) night’s sleep?

From our reading of sleep related research, we have several suggestions to offer:

1. Exercise – multiple studies have shown that adults of various ages and physical condition enjoy better sleep latency (the amount of time it takes for one to fall asleep), sleep duration and self-reported sleep quality from engaging in a regular exercise program. In fact, a separate study published this month online ahead of print in the journal Sleep Medicine showed that elderly study subjects who engaged in 30-40 minutes of sub-maximal aerobic exercise 3-4 times each week over a 16 week period reported a 1.25 hour increase in sleep duration, a 21% drop in the time it took them to fall asleep, and a significant jump in self-reported sleep quality.

2. Caffeine – avoid consuming products with caffeine after 2 p.m. each day. Much like nicotine, caffeine is a brain chemical stimulant that disrupts the body’s normal sleep cycle. If you can’t give up nicotine, then at least avoid compounding the problem by eliminating caffeine after 2 p.m. each day in order to give your body a chance to flush the caffeine consumed earlier in the day before bedtime.

3. Alcohol – thought alcohol is not a stimulant (it’s considered a depressant), consuming too much alcohol does disrupt the normal release of sleep inducing chemicals in the brain. Research suggests that consuming more than 2-3 alcoholic beverages within 4 hours of attempting to sleep does affect the body’s ability to fall asleep.

4. Television/Internet usage – though many people unwind at night by watching television or surfing the web, research has shown that cutting off television viewing/Internet surfing 1 hour or more before bedtime enhances the body’s ability to drift off to sleep.

5. Snack – studies have shown that consuming a light snack prior to bedtime enhances the body’s ability to fall asleep and stay asleep. Note, we said light snack, not full meal.

6. Sleep environment – scientists have found that odds of a good night’s sleep are enhanced by sleeping under warm bedding in a dark, cold room. Further, retiring to your bed only when ready to sleep (versus reading a book or watching TV in bed for a prolonged period before sleep) has been shown to improve the time it takes one to fall asleep.

7. Wake-time – an effective way of shocking your body to accept sleep more readily is to set your alarm clock to wake 30 minutes before your current waking time for at least a week. When you combine this technique with avoiding naps during the day during the same reset period, you effectively reset your body’s sleep clock (meaning at night your body is more receptive to sleep).

While there are surely other techniques for improving the time it takes one to fall asleep, stay asleep and wake up feeling well rested and full of energy, these techniques are the ones most often cited by sleep advocates such as the American Academy of Sleep Medicine.

Perceived quality of life a strong predictor of COPD exacerbations

2010-12-15T09:46:00.000-05:00

A COPD exacerbation is typically defined as a shortness of breath episode significant enough that a patient seeks physician intervention and can often lead to an emergency room visit or hospitalization. Exacerbations commonly occur in COPD patients as a result of significant airway inflammation most often caused by some combination of prolonged exposure to cigarette smoke, upper respiratory infections and/or dramatic increases in the production of sputum.

Many recent pulmonology research efforts have explored ways to treat exacerbations, reduce the number and severity of future exacerbations and to find ways to identify patients who are likely to be most susceptible to exacerbations (with an eye towards heading off the problem before it occurs).

The most common solutions prescribed by physicians to address exacerbation symptoms are in the form of antibiotics, corticosteroids, and bronchodilator medications. The antibiotics help suppress respiratory infections and clear sputum. The corticosteroids and bronchodilators typically help suppress airway inflammation. Sounds like an easy set of solutions, right? Well, it is true that these medications do help reduce exacerbation symptoms but unfortunately most are effective in relieving immediate symptoms and do not produce lasting benefit or protection against future exacerbations.

For those thinking proactively (i.e. trying to avoid future exacerbations) the treatment option that offers the best, longer-term protection is smoking cessation. Prolonged exposure to cigarette smoke damages the integrity of lung tissues over time as the pro-oxidant free radical molecules present in cigarette smoke in massive quantities nick away at the protective lining of the airways, exposing underlying cells to the toxic chemicals in cigarette smoke. Those toxic chemicals eventually disrupt the normal lung cell function and stimulate inflammation.
Beyond smoking cessation, another effective method for reducing exacerbations is a COPD treatment known as pulmonary rehabilitation. Pulmonary rehab is an exercise centered treatment program designed to build patient physical endurance and strength. Research studies have shown that an 8-12 week pulmonary rehab program is effective in reducing COPD patient shortness of breath, reducing the frequency and severity of exacerbations, reducing future hospitalizations, improving physical conditioning, and improving patient quality of life.

There is also growing research evidence that many COPD patients are deficient in vital nutrients known as antioxidants. In studies where certain antioxidants are supplemented (through food or dietary supplements) in human COPD patients and smokers, human lung tissue samples exposed to cigarette smoke, and laboratory animals exposed to cigarette smoke, there have been many published results showing a significant reduction in lung tissue inflammation. So there appears to be growing sentiment for supplementing antioxidants as a proactive ongoing measure against lung inflammation (and by extension future exacerbations).
But what about methods to predict or identify those most susceptible to COPD exacerbations? Well, a new research article examined several potential “leading indicators” and concluded that among the leading indicators self-reported quality of life ratings seem to be a strong potential predictor of those most likely to have frequent future exacerbations.

The study, published online ahead of print in The Clinical Respiratory Journal, followed 121 COPD patients in a year-long study. The Sweden based research team selected several potential “leading indicators” to measure at the outset of the study including previous 3-month corticosteroid use (signaling a recent previous exacerbation episode), self-reported quality of life survey ratings, inflammation-related markers in sputum samples, body-mass-index scores, and a set of diagnostic test measures of physical condition (6 minute walk test) and lung function (spirometry).

During the course of the 1 year study, the COPD patients and their physicians reported subsequent exacerbations to the study team. At the end of the study period, the researchers divided the 121 COPD patients into two groups. In one group, study subjects who had 2 or more exacerbations during the study were denoted as “frequent exacerbators”. The other group, those who experienced less than 2 exacerbations during the study period were classified as “infrequent exacerbators”.

Then the researchers examined the differences in the “leading indicators” measured at the outset of the study to determine which, if any, indicators were substantially different between the two groups. The only two indicators that delivered statistically significant differences were “past 3-month corticosteroid use” and low self-reported quality of life survey ratings. (Brusse-Kaizer MGJ, et al. Clinical predictors of exacerbation frequency in chronic obstructive pulmonary disease. The Clinical Respiratory Journal. Accepted Article; doi: 10.1111/j.1752-699X.2010.00234.x)

The past 3-month corticosteroid use makes intuitive sense. The steroids were most likely prescribed for a previous exacerbation event and therefore indicative of someone susceptible to future exacerbations.

The quality of life survey ratings were more intriguing as a potential predictor in our opinion (especially in alerting COPD patients of potential quality of life warning signs to keep an eye on). Two particular questions on the Health Quality of Life survey used in the study showed strong correlation as predictive of future exacerbations. As the researchers explained, “The factors “being in control of health”, “panic”, and “disturbance of daily life” could be worse in less stable patients and these patients could therefore be identified as being at higher risk of being frequent exacerbators, something that to our knowledge has not been analyzed in this way before. Indeed, the question “I feel that I am not in control of my chest problem” was answered positively more often by frequent (35.5%) than by infrequent exacerbators (12.2%). Similarly, the question “I get afraid or panic when I cannot get my breath” was answered positively more often by frequent (38.7%) than by infrequent exacerbators (22.2%)”.

In other words, COPD patients who are increasingly concerned that they are not in control of their chest problem and/or sense a increasing degree of panic when they can’t catch their breath are among those most likely to experience a COPD exacerbation within the year.

In our opinion, if you find yourself feeling this way about either issue and you want to take proactive steps to avoid a COPD exacerbation, you would be well served to discuss your concerns with your physician and to explore smoking cessation, pulmonary rehabilitation, and antioxidant supplementation.

Smoking cessation and antioxidant supplementation will help reduce inflammation. Pulmonary rehabilitation will help boost your physical condition, reduce shortness of breath, and promote a greater sense of control of your breathing. The combination of these three treatment options combined with medications prescribed by your doctor can significantly reduce the likelihood of future exacerbations and the severity of an exacerbation if one does occur.

To learn more about inflammation and what steps you can take to reduce it, we recommend reading our article, War of the Worlds in Your Lungs, and considering following our 5 Step Feel Better NOW Plan.

Pulmonary rehabilitation reduces depression in COPD patients

2010-12-13T10:10:00.000-05:00

A new study published in the journal Chronic Respiratory Disease revealed that COPD patients who underwent an intensive 4-week inpatient pulmonary rehabilitation program reported significantly lower feelings of depression in addition to recording improved physical conditioning and higher self-reported quality of life.

This study confirms previous pulmonary rehabilitation research results with regard to its reported findings with a twist. Most past pulmonary rehab studies have examined the effectiveness of 8-12 week outpatient programs where COPD patients attend 2-3 one-hour sessions each week.

In this Norway based study, the 161 study subjects participated in a hospital-inpatient program for 4 weeks where patients attended pulmonary rehabilitation sessions 7.5 hours a day, 5 days a week over the 4 week period. The program components were similar to outpatient programs (guided/observed exercise, breathing & airway clearing training, and counseling regarding nutrition, medication use and other related health topics).

At the outset of the study, the COPD patients were tested for their exercise capacity using common a respiratory diagnostic tool known as the 6 minute walk test (where patients are asked to walk as far as they can within a 6 minute time limit – the resulting measure is called the 6-minute walk distance or 6MWD). Patients also completed health quality of life questionnaires and a depression/anxiety questionnaire commonly used by researchers to assess patient perceptions of well being (the St. George’s Respiratory Questionnaire and the Hospital Anxiety and Depression Scale, respectively). At the end of the 4 week period, the patients went through this battery of tests again and then researchers compared the pre and post study measures to judge if patients experienced improvement on some or all. (Bratas O, et al. Pulmonary rehabilitation reduces depression and enhances health-related quality of life in COPD patients - especially in patients with mild or moderate disease. Chron Respir Dis. 2010;7(4):229-37)

Not surprisingly, given past rehab study results, exercise capacity improved as measured by the 6 minute walk test. The mean improvement in 6MWD after the 4-week rehab program was 44 meters, or 12% (according to the study team, an increase of 35 meters or more is considered clinically significant).

On the Health Quality of Life survey, the COPD patients in the study showed statistically significant improvement between their pre and post study questionnaires in one particular component, the “psychosocial impact” component. According to the study team, the impact section, “measures aspects of social functioning and psychosocial disturbances caused by airway disease.” In other words, patients rate their perception of how COPD impacts their ability to interact with others.

It was in the depression/anxiety survey results where the biggest statistical improvement of the pulmonary rehab program was reported by study participants. At the outset of the study, 27% of the COPD patients in the study recorded scores on the anxiety/depression questionnaire that suggested a depression diagnosis. At the end of the 4-week pulmonary rehab program, only 16% showed results suggesting a depression diagnosis. This represented a 39% reduction in study participants with a possible depression diagnosis after completing the pulmonary rehab program.

Commenting on the improvements in the “psychosocial impact” and depression scores, the study authors commented, “In general, it is not clear which components of a pulmonary rehabilitation program specifically contribute to reduction of psychological distress. However, the components exercise, disease education and psychosocial support in the present rehabilitation program may have contributed, separately or combined to reducing depression.”

We suspect that in the process of improving physical condition through pulmonary rehabilitation-style exercise programs, COPD patients develop a greater sense of control over their breathing pattern and greater confidence in their ability to participate in everyday activities. The greater sense of control and improved confidence in turn help reduce depression (i.e. less sense of helplessness and greater participation/enjoyment of normal daily activities).

For COPD patients who haven’t tried pulmonary rehabilitation, we highly recommend you ask your physician to refer you to a program in your area. While it will not be as short/intensive as the program reported in this study, a traditional outpatient program confers many of the same benefits. For COPD patients who are unable to gain entry to a pulmonary rehab program (and sadly, that represents about 99% of COPD patients given the limited number of available programs and restrictive Medicare/insurance admission guidelines), you can achieve many of the same benefits by beginning and maintaining a regular exercise program.

Consult your physician for an exercise program that is appropriate for your individual circumstance. If your physician does not have a program to recommend, we suggest you consider purchasing our Breathe Better for Life guidebook and CD-ROM. We’ve developed an exercise program based on the principles of pulmonary rehabilitation as outlined by the American Thoracic Society and the European Respiratory Society. We’ve further tweaked these guidelines to include exercise recommendations from the American College of Sports Medicine for people with chronic respiratory conditions.

Whatever path you choose, we strongly believe that regular physical exercise is one of the best proactive steps a COPD patient (or anyone who suffers from chronic shortness of breath) can undertake. Not only will you likely benefit from improved physical conditioning and reduced shortness of breath, you may also see significant improvements in your perceived quality of life, mood and outlook.

COPD patients & smokers – winter is almost here, are you ready???

2010-12-04T09:55:00.000-05:00

For people who suffer from chronic shortness of breath, the winter months are the most trying. By way of example, previous studies have shown that COPD exacerbation events spike during the winter months often leading to increased emergency room visits and/or hospitalizations. This trend is most pronounced in northern latitude geographic locations where the combination of colder temperatures and reduced hours of sunlight lead people to pursue an unhealthy mix of lifestyle behaviors.

The cycle goes like this:

1. Colder temperatures and fewer hours of sunlight lead people to stay indoors more hours of every day during the winter.

2. While indoors, most people tend to be less physically active than when participating in outdoor activities. Lack of movement/activity weakens muscles and contributes to de-conditioning of cardiovascular function – especially in COPD patients.

3. Also while indoors, people receive less Vitamin D from exposure to direct sunlight. Vitamin D deficiency is believed a leading cause of lung inflammation (along with other antioxidant deficiencies).

4. For those who smoke cigarettes and/or those who regularly use wood burning heating sources, the toxic fumes from smoke linger in the air longer indoors given that the confined space traps smoke versus dissipating more quickly in outdoor environments (meaning more of the dangerous chemicals are inhaled while indoors).

5. Further, bacteria and viruses most often thrive in warm, moist environments and during winter months the most attractive environments for them to survive are found indoors. The more time spent indoors, the greater the exposure to bacteria and viruses that cause respiratory infections.

6. Episodes of depression are more pronounced during winter months due to prolonged confinement in indoor environments, lack of activity, and the persistent bleak inhospitable outdoor environment. Depression can lead people to smoke more, eat more and drink alcohol more.

So, winter’s nearly here (and if it hasn’t officially arrived in your area, we’re it sure feels like it already) – what can you do to improve your chances of having a healthier and happier season?

1. Increase your consumption of Vitamin D – from direct exposure to sunlight (20-30 minutes a day with multiple areas of your skin exposed and without applying sunscreen that blocks UV-B rays), foods fortified with Vitamin D (cereals, breads and dairy products are good sources of Vitamin D), and/or from Vitamin D dietary supplements (we recommend 2,000 IU’s for smokers and people with respiratory conditions). Vitamin D as a dietary supplement is inexpensive and is widely available both in retail stores and from online merchants (look for Vitamin D3 in the form of cholecalciferol). For those interested, we have included Vitamin D3 at 2,000 IU’s in our potent, antioxidant dietary supplement for respiratory support called Resplenish. To learn more about Resplenish, click here. Alternatively, we’ve listed a couple stand-alone Vitamin D products from supplement companies we find reputable on our Breathe Better Marketplace site hosted by amazon.com.

While increasing your Vitamin D consumption may sound too simple a solution for good respiratory health during the winter months it is honestly one of the most valuable steps you can take. It helps protect your immune function and reduces airway inflammation – both valuable benefits for those with respiratory health concerns, especially during winter months.

2. Exercise – 20-30 minutes of cardiovascular exercise and 20-30 minutes of strength training exercise 3-5 days a week has been shown to reduce shortness of breath, improve physical strength/stamina, improve participation in other activities, and improve sense of well being, reduce COPD exacerbations, and reduce hospitalizations related to respiratory health. These are the fundamental benefits of pulmonary rehabilitation, a highly effective COPD treatment.
If you are a COPD patient and don’t know where to start, ask your physician for a referral to a pulmonary rehab program in your area. If you cannot gain admission to a rehab program in your area (they are notoriously hard to get into), consider utilizing a fitness center in your community where you can find fitness instructors who can design an exercise program appropriate for your health circumstances. Alternatively, consider purchasing our Breathe Better for Life guidebook and CD-ROM for our recommended exercise program for those with respiratory conditions. Our program is based on pulmonary rehabilitation guidelines promulgated by the American Thoracic Society, European Respiratory Society, as well as guidelines for those who chronic respiratory conditions from the American College of Sports Medicine.

If none of those options appeal to you, consider a simple walking program of 30-60 minutes a day, 3-5 days a week. If you live in an area with snow and ice covered outdoor walkways, try walking at your local indoor mall or on a treadmill. If you live in an area where there isn’t a lot of snow or ice, it is ideal to walk outdoors to gain the additional benefit of exposure to direct sunlight. Whether indoors or outdoors, seek flat surfaces and walking courses/equipment with adequate handrail support if you suffer from poor balance. You might even consider Nordic walking (walking with ski-pole-like devices). We previously wrote about a recent research study regarding Nordic Walking for COPD patients that you can read by clicking here.
Not only is exercise beneficial for good respiratory health and physical conditioning, it also has been shown in many studies to reduce feelings of depression.

3. Join a tai chi or yoga class – these mediation based forms of exercise convey health benefits for COPD patients and others who suffer from chronic shortness of breath as we’ve previously reported. If you’re stuck indoors all winter, these classes are also great ways to get out, move around, and socialize with others. Many health clubs and community centers offer tai chi and yoga classes specifically designed for people with limited mobility or other health conditions. If you can’t or don’t want to attend a center-based tai chi or yoga class, consider buying a tai chi or yoga DVD to use at home. These videos offer step by step instructions and many are geared for people with limited mobility or other health conditions. We’ve listed a handful on our Breathe Better Marketplace hosted by amazon.com for those who are interested but tai chi and yoga DVD’s are widely available from retail and online merchants.

4. While the value of smoking cessation during winter months is particularly high given the increased exposure to smoke in confined indoor spaces, we understand the prospect of smoking cessation may feel like too much of a challenge for some. For those who can’t or won’t stop smoking, consider delaying your first cigarette of the day for 30-60 minutes after waking. Research studies have shown that smokers who light up their first cigarette within the first 5 minutes after waking have the highest level of depression among all smokers, while those who delay for at least 30 minutes after waking have the lowest depression among smokers. And the gap between the two is notable as we’ve previously reported.

5. If your primary heating and/or cooking source is a wood burning stove or fireplace, seriously consider replacing these options with electric or natural gas burning devices. Previous studies have shown that regular exposure to wood smoke can be as detrimental to respiratory health as cigarette smoke, and if you are exposed regularly to both, your chances of serious respiratory health issues are dramatically increased. Click here to read a related article.

In our opinion, you can significantly improve your chances of a healthier and happier winter season by following the above steps. The combination of increased Vitamin D consumption, regular exercise/physical activity, and reduced exposure to cigarette and wood smoke can make a world of difference for COPD patients, smokers and other who suffer from chronic shortness of breath.

Yoga for COPD patients and smokers

2010-12-01T11:30:00.000-05:00

Over the past year, we’ve published a few articles describing the benefits of tai chi for COPD patients. The combination of the slow, graceful tai chi movements with deep breathing/meditation exercises appears to hold promise for COPD patients in reducing shortness of breath, improving balance and coordination, and improving overall sense of well being. To view our past tai chi articles, visit www.breathebetterblog.blogspot.com and enter the search term “tai chi” in the search box provided in the left hand column of the page.

Tai chi has also been shown to help COPD patients extend the length of time they maintain an exercise program – an important element of successful long-term COPD self management. Researchers speculate the main factor driving this additional benefit is that many tai chi class participants find the sessions more interesting/enjoyable than limiting their exercise to stationary exercise equipment (such as walking on a treadmill). Therefore, because many COPD patients consider this form of exercise fun, they keep their programs going for longer periods of time.

Along similar lines, we recently read a new study published online ahead of print that showed interesting benefits for COPD patients from practicing another form of meditative exercise, yoga. Unlike tai chi which emphasizes balanced movement, yoga involves more stationary exercises where one sits or stands in specific positions while concentrating on deep breathing and clearing one’s mind through meditation.

In this particular study conducted by researchers at a Chicago based Veterans Administration hospital, the 22 male COPD patients who completed the study participated in yoga classes 1 hour per day, 3 days per week over a 6 week period. Patients were encouraged to practice the yoga exercises at home but were not required to do so. (Fulambarker A, et al. Effect of Yoga in Chronic Obstructive Pulmonary Disease. Am J Ther. 2010 Oct 22. [Epub ahead of print])

The researchers described the content of the yoga sessions as involving 6 specific yoga exercises, “Yoga exercises comprised pranayama, asanas, kapalabhati, sithali, and meditation during the 1-hour yoga session. The participants were encouraged to practice the same at home on a daily basis. Pranayama involves slow deep breathing, breathing through one nostril at a time, slow expiration, breath holding, and usage of abdominal muscles for expiration. Kapalabhati involves rapid abdominal contractions to force a volume of air out of the lungs. Sithali involves breathing through a curled tongue. Asanas comprise shoulder warm-ups, standing forward bend, cat and cow, downward dog with lunge, child pose, bridge, and seated twist. Meditation was done after the abovementioned exercises. Asana techniques were modified to accommodate the level of performance of the subjects with COPD.”

The researchers’ main goal in conducting the study was to understand whether yoga improved COPD patients’ sense of well being as measured by a common quality of life survey used to assess COPD patients (St. George’s Respiratory Questionnaire). The study participants completed the survey before the yoga program and again afterwards. The researchers tallied the self-reported ratings and compared the differences between the pre and post study surveys. The results showed a 19% improvement in self-reported quality of life among the COPD patients practicing yoga.

The more compelling/interesting outcomes of the COPD yoga study were statistically significant improvements in lung function. Specifically, study participants underwent diagnostic lung function tests at the beginning and end of the study. In particular the researchers tested the COPD patients for maximum inspiratory pressure, maximum expiratory pressure, forced vital capacity, and forced expiratory volume. On all of these measures, the yoga practicing COPD patients experienced statistically significant improvements. For example, maximum inspiratory pressure improved by 23% and maximum expiratory pressure improved by 14%. The improvements in forced vital capacity and forced expiratory volume were smaller but considered by the researchers to still be statistically significant.

The study authors speculated the reasons for the improvement in lung function as follows, “The beneficial effect of yoga observed in our study may be related to deep breathing (pranayama) and meditation causing a reduction in breathing frequency as in other studies. It may modulate airway reactivity, increase respiratory sensation through conditioning of the breathing pattern, reduce oxygen consumption, decrease hypoxic and hypercapnic responses with better blood oxygenation without increasing minute ventilation, increase respiratory endurance and muscle strength at least on a short-term basis, and modulate the autonomic function with a documented short-term decrease in resting heart rate and sympathetic reactivity. There is also evidence to suggest that it modulates the respiratory center and increases respiratory sensation through conditioning of the breathing pattern.”

We believe these research results show promising benefits for COPD patients participating in a yoga program and that those benefits may extend to smokers and others who suffer from chronic shortness of breath. Indeed, the yoga study authors noted that asthma patients participating in previous yoga studies have shown reduced shortness of breath symptoms and decreased use of bronchodilators (but no improvement in lung function).

Therefore, for those of you interested in adding a low impact and fun form of exercise to your weekly routine that also help relieve shortness of breath symptoms, tai chi or yoga are options worth exploring. Many community centers and health clubs offer tai chi and yoga classes specifically geared for people with chronic health conditions where the exercises are modified for people with limited mobility and other health issues. In addition, there are a wide range of videos available through retail outlets and online merchants that teach basic tai chi and yoga exercises. We’ve listed a handful of these videos on our Breathe Better Marketplace hosted by amazon.com for those who are interested.

Pulmonary rehabilitation for underweight COPD patients

2010-11-19T11:45:00.000-05:00

Over the years, respiratory medicine researchers have found that underweight COPD patients seem to exhibit the worst dyspnea (shortness of breath), report the lowest quality of life and experience the highest mortality rate among the general COPD population.

Pulmonary rehabilitation (PR) has been shown in many studies to improve both dyspnea and quality of life in the general COPD population but most PR studies have not distinguished between low body weight patients and those considered either normal weight or obese in reporting their findings. This raises the question – are their differences in PR outcomes among these three body weight classifications and if so, should PR programs be adapted to address the differing outcomes?

With those questions in mind, two recently published studies provide some insight into PR’s effectiveness for low body weight COPD patients in comparison to those of either normal weight or those considered obese.

To take a step back, the cornerstone element of pulmonary rehabilitation is observed, guided exercise where patients start at modest levels of intensity and duration and over the course of 8-12 weeks increase both intensity and duration. The goal of the exercise program is to boost aerobic endurance/stamina and to build muscle strength. By doing so, research has convincingly shown that upon program completion, PR participants demonstrate improved physical conditioning, reduced shortness of breath, lower incidence of COPD exacerbations (shortness of breath attacks), fewer hospitalizations and higher self-reported quality of life. PR programs include other elements that support this mission including breathing training, nutrition counseling and other self-management techniques.

The first of two recent pulmonary rehab studies distinguishing outcomes based on body weight classifications showed notable differences in self-reported quality of life measures depending on whether a COPD patient was considered low weight, normal weight or overweight. In the study, the Brown University based researchers examined the records of 61 male veterans who completed a pulmonary rehabilitation program at a Rhode Island based Veterans Administration medical center between October 2006 and January 2008. Fourteen of the 61 patients were considered underweight (body mass index lower than 23), 30 patients were considered middle-weight (BMI 23-33), and the remaining 17 patients were considered obese (BMI over 33). (Velasco R, et al. Influence of Body Mass Index on Changes in Disease-Specific Quality of Life of Veterans Completing Pulmonary Rehabilitation. J Cardiopulm Rehab and Prev. 2010; 30; 334-339.)

To assess the differences in PR outcomes, the Brown University study team looked at quality of life survey answers provided by the study participants prior to starting the PR program and again at the end of the PR program. They found that all three BMI groups did report improvement on all categories (mastery, fatigue, emotion and dyspnea) as a result of participating in the PR program, but that COPD patients who were obese (those in the highest weight category) experienced the greatest absolute gains across the four rated categories. By contrast, low BMI patients in the study experienced the smallest absolute gains in quality of life measures post-rehab. This led the researchers to conclude that higher BMI patients got more out of the PR program than the lower BMI patients – even though both groups achieved improvements.

In the second recent study examining PR outcomes based on weight classifications, a China-based research team evaluated low and normal weight COPD patients with regard to exercise capacity as well as quality of life ratings.

One wrinkle in this study was that all the study subjects (both low weight and normal weight patients) received supplemental oxygen during their rehab exercise sessions (3 liters/minute). Since the Chinese researchers didn’t evaluate the study subjects exercise performance without supplemental oxygen it’s difficult to discern how much of the absolute benefits were derived from the rehab program versus the use of supplemental oxygen. However, since both low body weight and normal body weight COPD patients received supplemental oxygen their relative PR outcomes to one another can be evaluated.

The Chinese study involved 44 COPD patients (22 considered underweight with a BMI lower than 20, and 22 considered normal weight with BMI greater than 20 – note that the split between weight groups in this study was significantly different than in the Brown University study described above). All 44 patients underwent a 12 week hospital based pulmonary rehab program. Diagnostic readings of exercise capacity and lung function were taken at the outset of the program and again at the end, as were quality of life surveys. (Lin CC, et al. Pulmonary rehabilitation improves exercise capacity and quality of life in underweight patients with chronic obstructive pulmonary disease. Respirology. Accepted article published online ahead of print. doi:10.1111/j.1440-1843.2010.01895)

Their results showed the low BMI group started at lower levels of physical conditioning/exercise capacity on most measures compared to the normal BMI group, but that the low BMI group achieved greater percentage gains post-rehab on a number of the exercise performance measures. For example, the low BMI group achieved a 13% increase in peak exercise work load from readings taken at the beginning of the PR program. By comparison, the normal BMI group increased peak work load by 9%. Maximum oxygen uptake during peak exercise also increased by a greater percentage in the low BMI group (9%) compared to the normal weight group (6%). On most other exercise performance measures there was little difference in improvement levels between the two groups.

In the quality of life survey results, both groups showed marked improvement post-rehab in comparison with their pre-program ratings and there were no significant differences in quality of life improvements based on body weight. However, the low BMI group did report absolute quality of life scores (both pre and post rehab) that were notably lower than the normal weight group.

The results of these two studies seem to indicate that even though low BMI COPD patients enter rehab programs at lower levels of conditioning and perceived quality of life, they do achieve meaningful gains from PR and in some cases these gains are relatively higher in comparison with normal-to-overweight COPD patients.

Given that upwards of 40% of COPD patients are considered underweight, it seems worthwhile for researchers and practitioners to take a harder look at tailoring rehab program elements for COPD patients of different body weight classifications to improve the gains of all rehab participants. To learn more about pulmonary rehabilitation, please visit www.breathebetterforlife.com.

Four new studies show connection of antioxidant levels and respiratory function

2010-11-17T22:07:00.000-05:00

Examine lung tissue and sputum samples from a COPD patient, current smoker or former smoker who reports chronic shortness of breath and compare them to people with healthy respiratory function and here is what you will find in the COPD/smoker samples:

1. Enlarged cells of the airway lining and surrounding muscles resulting in narrower airways
2. High concentrations of infection detecting/signaling proteins known as cytokines
3. High concentrations of infection fighting white blood cells known as macrophages

These are the classic indicators of what respiratory researchers call airway inflammation – believed to be a prime cause of shortness of breath.
Next, look at the chemical analysis of blood plasma from COPD patients, current smokers and former smokers who report chronic shortness of breath and compare them to people with normal respiratory function and here is what you will find in the COPD/smoker samples:

1. High concentrations of damaging pro-oxidant molecules known as free radicals
2. Low, deficient concentrations of protective anti-oxidant molecules that neutralize free radicals

These are the classic indicators of what scientists call oxidative stress – an imbalance between anti- and pro-oxidant molecules in the body. Oxidative stress is believed to be a prime cause of airway inflammation in COPD patients and smokers. Cigarette smoke and industrial pollutants are far and away the primary sources of pro-oxidative molecules consumed by those with poor respiratory health.

Four new studies published this month add to the growing number of previous studies which demonstrate the connection between antioxidant levels and healthy respiratory function:

1. A group of NIH researchers reported that of the 118 Buffalo, NY police officers evaluated in their study, those with higher blood plasma concentrations/consumption of Vitamin A and magnesium had better measures of forced vital capacity (FVC) compared to officers with low concentrations. Among police officers who are current/former smokers, the researchers found higher forced vital capacity and higher forced expiratory volume (FEV1) in those with increased intake of Vitamin E. FVC and FEV1 are common diagnostic measures of lung capacity and the quality of lung function. (Charles LE, et al. Antioxidants and Pulmonary Function Among Police Officers. J Occup Environ Med. 2010 Nov;52(11):1124-1131)

2. In Indonesia, a research team divided 108 COPD patients with upper respiratory infections into three groups. In one group, the patients received the antibiotic ciprofloxacin for 7 days. One group received cipro for 7 days and the herb Echinacea purpurea for a total of 14 days. The final group received cipro for 7 days and Echinacea plus the antioxidants zinc, selenium and Vitamin C for a total of 14 days. In particular, the researchers sought to understand if any of the three regimens were correlated with a reduced incidence and severity of post-infection COPD exacerbations (shortness of breath attacks which are strongly linked to inflammation). Their results showed significantly less severe and shorter exacerbation episodes following an upper respiratory infection among the group that received cipro/Echinacea/antioxidants compared with the other two groups. (Isbaniah F. Echinacea purpurea along with zinc, selenium and vitamin C to alleviate exacerbations of chronic obstructive pulmonary disease: results from a randomized controlled trial. J Clin Pharm Ther. 2010 Nov 10. doi: 10.1111/j.1365-2710.2010.01212.x. [Epub ahead of print])

3. In Taiwan, a study group desired to evaluate differences in blood plasma concentrations and dietary intake of antioxidants Vitamin A, C, E and carotenoids between 43 healthy Taiwanese subjects and 34 Taiwanese COPD patients. Further, the investigators examined the blood plasma concentrations of white blood cells that are markers of inflammation in the two groups. Their results definitively showed, “Compared to the healthy controls, COPD patients had significantly lower plasma concentrations of vitamins A, C, and E; alpha- and beta-carotene; and total carotenoids but significantly higher endogenous and H2O2-induced white blood cell DNA damage [inflammation]. Intakes of vitamin C and several carotenoids were lower in the COPD group, and COPD patients consumed significantly fewer vegetables and fruits than did the healthy controls. In conclusion, COPD patients in Taiwan have lower levels of antioxidative nutrients in their plasma and diet than do healthy people. Intakes of vitamin C and carotenoids are correlated with dietary habits.” (Lin YC, et al. Comparison of plasma and intake levels of antioxidant nutrients in patients with chronic obstructive pulmonary disease and healthy people in Taiwan: a case-control study. Asia Pac J Clin Nutr. 2010;19(3):393-401.)

4. At the annual conference of the American College of Chest Physicians earlier this month, a paper was presented by a group of researchers analyzing the dietary habits of 20 COPD patients for antioxidant content. They discovered that antioxidant deficiency was common (55% were deficient for Vitamin A, 45% for Vitamin C, 70% for Vitamin D, 90% for Vitamin E, and 25% were deficient in trace mineral selenium). The researchers further noted that the male COPD patients in the study who showed deficiencies in Vitamin A, C and D had poorer lung capacity than COPD patients who were not deficient in these antioxidants. (Khan MS, et al. The effect of antioxidant intake on pulmonary function in chronic disease is moderated by gender. Chest 2010; 138: 488A)

Many physicians recommend that COPD patients boost antioxidant levels through adding more antioxidant rich foods to their daily diet. Their primary concern with dietary supplements is that there are no consensus dosage recommendations for daily intake for respiratory support antioxidants at this time.

However, other researchers and practitioners recognize that the volume of pro-oxidant free radicals consumed through cigarette smoke is so significant that adding a few oranges to your daily diet is unlikely to make much of a dent in the imbalance of pro/anti oxidants. This latter group of physicians recommends complementing antioxidant rich foods with antioxidant dietary supplements. Since there are no standard recommended dosage guidelines for antioxidant consumption among those with poor respiratory health at this time, it is wise in our opinion from a safety and efficacy standpoint to consume a broad array of antioxidants in modest dosages rather than consume massive doses of one or two. This is why we incorporated a broad array of the antioxidants most studied in respiratory health studies in our Resplenish formula, www.resplenish.com.

For example, the above studied antioxidants may not be the most potent/effective for reducing inflammation/oxidative stress among those who have respiratory concerns. To wit, the most widely studied antioxidant related to airway inflammation is n-acetyl-cysteine (NAC). NAC is actually an essential amino acid that helps the body produce the most abundant antioxidant used in airway tissues, glutathione. Now you’d think that the simple solution would be to just consume glutathione directly but glutathione is not absorbed well as a stand-alone dietary ingredient. Therefore, respiratory researchers often utilize NAC to help the body boost its production of glutathione.

In our opinion, you have the power to rebalance your body’s supply of antioxidants and thereby alleviate oxidative stress and inflammation by:

1. Reduce pro-oxidant molecule intake (i.e. reduce or eliminate cigarette consumption – a massive source of pro-oxidant molecules)

2. Increase anti-oxidant molecule intake (through antioxidant rich foods such as vegetables, fruits, grain cereals, teas, legumes, and nuts - and/or dietary supplements containing antioxidants).

For more information about airway inflammation, food sources of antioxidants, and dietary supplement antioxidant ingredients that are supportive of healthy respiratory function, visit our Resplenish web site by clicking here.

Add tai chi to spice up your exercise program & improve your breathing

2010-11-15T13:38:00.000-05:00

Over the past decade, tai chi, the ancient Chinese martial arts form that emphasizes gentle, flowing movements and meditative breathing techniques has received increasing research attention for a range of benefits including stress-relief, balance/coordination, and aerobic conditioning among people with various health conditions (91 studies published in 2010 alone).

While the amount of past tai chi research related to COPD is scant (less than a handful of studies in total), there are some intrepid researchers who continue to investigate tai chi for COPD patients for some very valid and specific reasons, including:

Long-term adherence to exercise programs is a significant problem among COPD patients. Past tai chi research studies related to other health conditions have shown that including tai chi as part of an ongoing exercise program notably lengthens the span of time an exercise program is maintained. The reigning thought behind why this happens is that over time traditional exercise programs become boring/tedious and that participating in group tai chi sessions keeps exercise fun/interesting and therefore improves adherence. Thus far, however, no studies have either explored or reported such exercise compliance improvements among COPD patients.
Past studies among patients with poor heart health have shown that tai chi boosts exercise capacity and physical conditioning. While recent COPD studies have shown modest improvements in physical condition/exercise capacity among patients in a tai chi program, the improvements have not yet been shown to be clinically significant and certainly have not been tested yet head-to-head against the proven COPD treatment pulmonary rehabilitation.
Past COPD studies have shown that those participating in a tai chi program report less severe breathlessness symptoms than COPD patients that don’t exercise. For those unwilling or unable to participate in a traditional exercise program, tai chi is viewed as a potential method of boosting physical activity and reducing perceived breathlessness. Researchers believe that the meditative breathing techniques taught/practiced in tai chi programs are the prime drivers of this effect.
Poor balance and coordination is a common symptom of sedentary COPD patients. The less physically active a person is the weaker muscles and bones become. Over time, this weakness results in poor balance/coordination. Past tai chi studies among elderly patients and those with muscular dysfunction have shown a marked improvement in balance/coordination. Since one of the core principles of tai chi as a martial arts form is to maintain balance when defending oneself against an attacker, the tai chi movements taught and practiced are intended to explicitly improve balance.

On the heels of this past research and hypotheses comes a new study published this month in the journal Respiratory Care seeking to confirm whether tai chi improves exercise capacity and perceived breathlessness among COPD patients. (Yeh GY, et al. Tai Chi Exercise for Patients With Chronic Obstructive Pulmonary Disease: A Pilot Study. Respir Care. 2010;55(11):1475-1482)

The study, conducted at a Boston area hospital, involved 10 COPD patients split into two groups (5 who participated in a 12-week group tai chi program, and 5 who did not participate in an exercise program of any kind). The researchers measured all 10 patients exercise capacity at the beginning of the study and again after the 12-week tai chi program had concluded. In addition, the study participants completed standard quality of life/respiratory symptom questionnaires at the outset of research effort and again at the end. The investigators then evaluated the changes between the baseline and end-of-study measures for each of these diagnostic tools in both groups.

The 12-week tai chi program took place twice each week for one hour each session and included warm-up exercises, 5 simplified tai chi movements, visualization techniques, and traditional breathing techniques. Tai chi participants were provided a 35 minute instructional video that outlined the exercises presented in class and patients were encouraged to practice the movements at home in between sessions (most did).

At the end of the study, the researchers reported that the most pronounced difference between the two groups was in their self-reported breathlessness ratings on the respiratory symptoms questionnaire. The tai chi group rated a 33% improvement in their sense of breathlessness at the end of the program compared to their pre-tai chi ratings. This was sharply higher than the 7% improvement in perceived breathlessness reported by the control/non-exercising group.

Further, while the research team did not comment on their findings related to balance and coordination, we found an intriguing result in their data that may point to balance/coordination benefits of tai chi for COPD patients. One of the quality of life/respiratory symptom questionnaire sections completed by study participants examines mastery of activities of daily living (an evaluation of how often COPD patients participate in every-day activities and how they feel about their ability to participate these activities). The tai chi group in the study reported a 54% jump in their mastery ratings at the end of the study while the control/non-exercising group registered a 5% drop in mastery. In our opinion, the perceived improvement in mastery ratings by the tai chi group is likely driven by greater confidence in moving around as a result of improved balance and coordination gained through the tai chi sessions.

With regard to exercise capacity, the researchers found a small improvement (6%) in the distance walked by study participants in 6 minutes (a standard diagnostic test to assess physical condition in respiratory health studies) in comparison to a 10% drop in distance walked for the non-exercising/control group. These variances were not considered statistically significant enough by the study authors to declare that tai chi improves exercise capacity but they do show some benefit. We reported a similar finding in an article we wrote about a March 2010 tai chi COPD study you can read by clicking here.

So for those of you seeking to start or spice up an exercise program, tai chi may be an option worth exploring. Tai chi classes are widely offered in health clubs and in community centers across the country and are likely available in your local area (many of these classes are geared specifically for elderly and less mobile participants). Additionally, there are a range of videos in DVD/CD format that demonstrate the basic movements that you can use to try tai chi at home. We’ve highlighted a few of these instructional videos in our Breathe Better Marketplace hosted by amazon.com. Click on the link titled tai chi DVDs in the right hand side bar of the Breathe Better Marketplace site to learn more about the titles we selected.

Lung inflammation persists in ex-smoking COPD patients

2010-11-08T12:04:00.000-05:00

For many years, smoking cessation advocates have extolled the short-term and long-term benefits associated with permanently quitting cigarettes. Some of these benefits happen quite quickly while others accrue over time. Indeed the American Lung Association and U.S. Surgeon General’s office have categorized a number of these benefits that you can view by clicking here.

One such benefit is the reduction of airway inflammation – inflammation is believed to be a prime cause of shortness of breath among those with poor respiratory health. However, a new study published in the journal Chest revealed that COPD study participants with confirmed emphysema still showed significant markers of inflammation even though they had quit smoking for an average 15 years. (Miller M, et al. Persistent airway inflammation and emphysema progression on CT in ex-smokers observed for 4 years. Chest. DOI 10.1378/chest.10-0705. Epub online ahead of print)

In the study, the research team recruited 10 ex-smoking COPD patients who had an emphysema diagnosis confirmed by a CT scan. As controls, the investigators also included 8 healthy non-smokers, and 7 healthy smokers (i.e. current smokers who showed no evidence of lung disease).

The researchers collected sputum samples from each group at the outset of the study (baseline measure) and then four years later collected sputum samples again. They examined the sputum samples for the content of certain proteins and white blood cells that are present in large numbers in patients with significant lung inflammation. The researchers also chemically verified that the ex-smokers and non-smokers in the study were not active smokers at the baseline or end-study measurements.

Upon comparing the baseline and end-of-study inflammation markers between the three groups, the researchers found that the COPD-Emphysema group still showed significantly higher counts of the inflammation related proteins and white blood cells than either the non-smoking group or the healthy smoking group. Indeed, the actual inflammation marker counts in the COPD-Emphysema group were relatively unchanged between the outset measures and the end-of-study measures.

As the research team concluded, “In summary, in this study we have demonstrated that in subjects with GOLD stage IIb COPD-E (moderate COPD with emphysema), even after at least 4 years of not smoking, airway inflammation persists and that this is associated with continued airspace destruction as revealed by increased emphysema on CT-scan. This continued inflammation and airspace destruction in ex-smokers with GOLD stage IIb COPD-E could likely be more extensive if these subjects continued to smoke and thus it remains important that smokers with COPD should quit smoking. However, this study provides further evidence that once tobacco smoke initiates and causes progression as far as GOLD Stage IIb COPD-E, discontinuing smoking may slow but not necessarily halt the persistent inflammation and progression of this severity of COPD-E.”

What’s the takeaway? While smoking cessation confers many benefits for COPD patients (both those with emphysema and chronic bronchitis), it does not necessarily lead to a reduction in inflammation among emphysema patients.

As we have written previously, there are other steps that COPD patients can take to reduce inflammation including engaging in a regular exercise program, increasing dietary intake of antioxidants, complementing food antioxidant intake with dietary supplements, and increasing direct exposure to sunlight. For more information about these valuable action steps, we recommend you consider reading our Feel Better NOW Plan.

Mediterranean diet combined with physical activity boosts antioxidant levels

2010-11-05T11:49:00.000-04:00

In past articles we have extolled the benefits of regular exercise and antioxidant consumption (through food and nutritional supplementation) for COPD patients, smokers and others who experience chronic shortness of breath.

So we thought it worthwhile to bring to your attention a new study demonstrating the value of increased physical activity combined with a Mediterranean diet. While the study is not focused specifically on COPD patients or smokers, it is in our opinion relevant to anyone seeking to improve their respiratory and cardiovascular health.

In the study, the Greece based research team surveyed 3,042 Greek citizens about their daily physical activity levels, dietary consumption, and lifestyle behaviors. In addition, study participants received several diagnostic evaluations including blood pressure measurements, and blood draws to assess antioxidant levels and cholesterol levels.

The purpose of the study was to determine whether there was a positive correlation between physical activity level and the so-called “Mediterranean” diet on total antioxidant capacity (TAC). Total antioxidant capacity is a blood plasma measure of the combined antioxidant particles available to your body from all antioxidant nutrients consumed through diet or produced by the body.

Commenting on the Mediterranean diet, the study authors noted, “The dietary characteristics found in the olive growing areas of the Mediterranean region (i.e. Greece, Spain, Italy and France) have been…associated with lower incidence of cardiovascular diseases, metabolic disorders and several types of cancer.”

The foods that form the basis of a Mediterranean diet include whole grains, fruits, vegetables, olive oil, nuts and seeds combined with an emphasis on poultry and fish versus red meat. In addition, many proponents of the Mediterranean diet also suggest red wine for those who consume alcohol in moderation. For a more complete description of the Mediterranean diet, click here to read the Mayo Clinic summary.

In previous studies, it has been shown that people who regularly exercise have higher TAC levels than those who exercise less. Additionally, previous studies on the Mediterranean diet have shown that those closely following the Mediterranean diet have higher TAC levels compared to those consuming more of a Western diet (a diet that typically has higher levels of red meat versus fish/poultry, and a greater percentage of calories from refined foods with high sugar/salt content versus fruits, vegetables, and other plant based foods).

So the researchers in this investigation desired to know whether there was an additive effect on TAC from closely following a Mediterranean diet and engaging in regular physical activity as opposed to pursuing one of these two lifestyle options alone. (Kavouras SA, et al. Physical activity and Adherence to Mediterranean Diet Increase Total Antioxidant Capacity: The ATTICA Study. Cardiology Research and Practice. 2010 Oct 20;2011:248626).

Their results showed that those study participants who most closely followed the Mediterranean diet and exercised the most had mean TAC levels of 288 umol/L (umol/L is a measurement describing the total number of antioxidant molecules present in the blood plasma samples of the study participants).

Those who closely followed a Mediterranean diet but were physically inactive had mean TAC levels that were 11% lower than the combined high Med diet/high exercise group. Among study subjects who exercised heavily but did not follow a Mediterranean diet closely, TAC levels were 15% lower than the combined high Med diet/high exercise group.

By comparison, those who were the least physically active and did not consume a Mediterranean style diet had TAC levels of 230 umol/L , or 20% lower blood level concentration of antioxidants.

So the results clearly showed the additive benefit of a closely followed Mediterranean diet and high levels of regular physical activity on the body’s antioxidant reserves. It should be noted that the participants of this study were considered “healthy adults”, not people with advanced cardiovascular or respiratory conditions.

You might ask – so what?

Well, it is believed by scientists that an imbalance between pro-oxidative molecules known as free radicals and anti-oxidant molecules which neutralize the effects of pro-oxidants are significantly correlated with poor cardiovascular and respiratory health.

We’ve previously discussed such evidence related to the effects of cigarette smoke in depleting the body’s supply of antioxidants and in so doing contributing to airway inflammation. Chronic airway inflammation is believed to be the main cause of chronic shortness of breath.

As another recent dietary antioxidant study noted, “The imbalance of oxidant/antioxidant plays an important role in the development of chronic obstructive pulmonary disease (COPD). There is increasing evidence that individuals with high antioxidative nutrient levels in the diet or in blood tend to maintain better lung function.” (Lin YC, et al. Comparison of plasma and intake levels of antioxidant nutrients in patients with chronic obstructive pulmonary disease and healthy people in Taiwan: a case-control study. Asia Pac J Clin Nutr. 2010;19(3):393-401.)

Therefore, steps one can take to boost antioxidant levels in the body are beneficial to help protect the heart, lungs and other vital body organs from the damage exacted by an over-abundance of pro-oxidative molecules. This study confirms that closely following a Mediterranean diet and engaging in regular physical activity are powerful strategies that you can employ to boost your body’s supply of antioxidants.

COPD and air travel

2010-11-01T16:40:00.000-04:00

For those who contend with persistent shortness of breath, the prospect of air travel can be intimidating. In fact, many COPD patients opt not to travel by air for fear of experiencing a shortness of breath attack during the flight (known alternatively as “hypoxia”, “dyspnea” or “air hunger” among pulmonary medicine professionals).

According to a new research paper published in the journal Respiratory Medicine, this is an understandable concern given that “At maximal cruising altitude, the cabin pressure is allowed to decrease to the equivalent of 2438 meters altitude. This may cause a significant decrease in arterial oxygen tension in patients with respiratory disease, such as chronic obstructive pulmonary disease (COPD).”

However, despite the lower in-flight air pressure and anxiety regarding travel, this new study showed that a majority of COPD patients participating in the study did in fact travel by air (54%) and a minority of these flyers actually experienced dyspnea and air hunger in-flight (28%). (Edvardsen A, et al. High prevalence of respiratory symptoms during air travel in patients with COPD. Respiratory Medicine. Epub online ahead of print. Doi:10.1016/j.rmed.2010.10.006).

The Norway-based study sought to examine and compare the air travel behavior of 391 COPD patients and 184 control subjects who did not have COPD. In particular, the researchers desired to understand the prevalence of dyspnea/air hunger among COPD patients while traveling and whether there were any pre-flight factors that influenced who might experience hypoxia/air hunger.

Of the 54% of COPD patients who had traveled by air within the previous two years, 50% had flown at least twice and 33% reported having flown four or more times. The most common flight duration noted by flying COPD patients was 3-6 hours. Surprisingly, only 9% of the 46% non-flying COPD patients reported avoiding air travel due to their lung condition (the most common reason for not flying among this group was “no reason to travel” –noted by 79% of the non-flying COPD patients).

By comparison, 86% of the control subjects without COPD had flown within the previous two years with approximately 40% having flown at least two times and 55% having flown four or more times. The average flight duration was about the same for control subjects as for COPD patients.

As one can see from these findings, fewer COPD patients participating in the study traveled by air versus those without COPD, and those COPD patients who did fly took fewer flights. Further, as one will see below, COPD patients were more apt to report in-flight shortness of breath symptoms.

When looking at the percentage of both groups who experienced hypoxia-like symptoms such as air hunger, 28% of the flying COPD patients in the study reported such symptoms. By comparison, 16% of the flying non-COPD control subjects in the study reported in-flight shortness of breath symptoms. After adjusting for external influencing factors (referred to by researchers as confounders), the study team concluded that flying COPD patients were 3 times more likely to experience shortness of breath related symptoms than those without COPD.

But…

Of particular note to us were the findings that the COPD patients who reported the fewest hypoxia symptoms during flight were those patients who reported low levels of dyspnea pre-flight and/or those who walked longer distances on the 6 minute walk test pre-flight (a common diagnostic tool used by respiratory care professionals to assess overall physical condition of COPD patients).

In our view, these results seem to indicate that COPD patients who are in better pre-flight aerobic conditioning are less likely to experience significant shortness of breath when traveling by air.

While the researchers offered no recommendations for improving air travel experience for COPD patients in their paper, we think their results suggest a few proactive steps for those who would like to travel by air but have decided against it in the past because of anxiety related to a potential shortness of breath episode:

Begin and maintain an exercise program 6-8 weeks prior to flying. Many COPD research studies have conclusively demonstrated that a regular program of aerobic and strength training exercise (the foundations of the COPD treatment known as pulmonary rehabilitation) does reduce perceived shortness of breath and does improve physical stamina, strength and endurance. If you have Stage II or Stage III COPD, ask your doctor for a referral to a pulmonary rehabilitation program in your area. Alternatively, if you can’t gain entry to a pulmonary rehab program, ask your doctor to recommend an exercise program appropriate for your particular circumstance. To learn more about our recommended exercise program for COPD patients, smokers and those who suffer from chronic shortness of breath, consider purchasing our Breathe Better for Life guidebook and companion CD-ROM, www.breathebetterforlife.com. We’ve patterned our program based on guidelines published by the American Thoracic Society, European Respiratory Society and the American College of Sports Medicine.
Learn and practice the pursed-lips breathing technique leading up to the flight – and use this helpful breathing technique in-flight if you start to feel uncomfortable. This technique helps you clear old/used air out of your lungs in order to accommodate more new, oxygenated air. While a more robust description of the pursed-lips breathing technique and narrated pictorial demonstration are included on our Breathe Better for Life CD-ROM, we have posted a brief description of the technique on our Resplenish web site that you can access by clicking here. Resplenish is our new respiratory support nutritional supplement intended to help reduce inflammation/oxidative stress and improve exercise tolerance.
Consider increasing your intake of antioxidants for at least 6-8 weeks prior to traveling to help reduce inflammation/oxidative stress. Numerous respiratory health-focused studies have been published over the past decade examining the anti-inflammatory properties of a range of antioxidants given that inflammation is believed by pulmonary researchers to be caused by an imbalance between pro-oxidative and anti-oxidative molecules. To read more about what causes inflammation and how antioxidants can help, click here to read our inflammation-related article “War of the Worlds in your lungs” on our Resplenish web site.
Review our checklist recommendations for other COPD patient pre-flight preparations excerpted from the Breathe Better for Life CD-ROM by clicking here. Though many of these recommendations are for COPD patients who utilize supplemental oxygen, a number of the checklist items are useful to non-oxygen using COPD patients.

As always, please consult your physician prior to following these recommendations to ensure they are appropriate for your particular situation. Additionally, if you do decide to plan a trip involving air travel, it is advisable to discuss your travel plans with your physician prior to your departure date to determine whether your specific health status warrants special considerations.

War of the Worlds in your lungs

2010-10-27T14:38:00.000-04:00

Many of you have heard of the 1938 Orson Welles’ radio broadcast of the H.G. Wells classic novel, War of the Worlds, and the widespread panic it briefly spurred. Welles’ actors delivered chilling, live reports of invading aliens landing on Earth and causing major mayhem, death and destruction along the way. Many people listening on the radio had no idea that Welles was offering a theatric production and mistakenly believed that real aliens were indeed invading. Calls flooded police stations; people grabbed family, pets and guns and headed for the cellar, others hopped in cars and either fled in abject fear or went in search of aliens to attack. When the broadcast was over and the dust settled, Welles was forced to bashfully go on-air again to explain, NEVER MIND, it was all just an act.

Well believe it or not, a similar theatric production goes on in your lungs daily if you are a smoker or have a respiratory condition such as COPD.

Imagine invading bacteria are inhaled into your lungs (the aliens). Proteins in lung cells called cytokines that are charged with keeping a lookout for troublemakers (radio listeners) sense the invasion and panic. The cytokines start signaling other cytokines, sending out thousands of messages (calls flooding police stations). The message-receiving cytokines in turn call even more cytokines and so on…all putting out alerts for the body to produce white blood cells (policemen) to come and attack the invading aliens. The cells that produce white blood cells receive thousands, tens of thousands, hundreds of thousands, millions of messages from the cytokines to rush to the lungs as fast as possible and take care of the invaders. Soon the lung tissues, as the cytokines and white blood cells gather for the fight, become swelled with the particles and fluids from these defenders of the peace, all running around in a panic about the invading bacteria. They’ve brought enough ammo to wipe out millions of the invaders…but guess what? There may only be a hundred of the bacteria molecules…

You see – it’s a false alarm. An act. An over-reaction.

Cigarette smoke has messed up lung cells’ ability to appropriately detect and respond to invading bacteria. Instead of cytokines accurately sensing the number of invading bacteria/fungi and sending out signals for a proportional response to kill them, the cells fear there is a massive attack and respond with overwhelming force.

The problem with this over-reaction is that when lung tissues swell with fluid and become stiff, the airways narrow and it becomes harder to breathe. This circumstance is referred to as airway inflammation by pulmonology professionals.

Inflammation in the lungs is similar to inflammation in other parts of your body - tissues swell with fluid and become stiff. If you’ve ever sprained an ankle, knee or shoulder, you know how your damaged joint swelled and stiffened for a period of time after the injury. The pressure of the swelled tissue feels uncomfortable, like someone squeezing you. The stiffened joint makes it hard to move, restricting your activity. Well, now imagine those same effects happening to your airways…no wonder it’s hard to breathe!

Can inflammation be stopped or reduced?

Pulmonology researchers and practitioners are in an ongoing search to find effective ways to reduce oxidative stress, relieve inflammation, and prevent/reverse /minimize the damage done by cigarette smoke and other inhaled toxic agents.

If you currently smoke, the number one step you can take to reduce inflammation is to quit. Permanently. Plain and simple, it’s the single best first step you can take.

Outside of smoking cessation, physicians can and often do prescribe some combination of short-acting bronchodilators and corticosteroids for use when patients are experiencing uncomfortable shortness of breath. These medications force open the airways by shutting off the production of cytokines and similar signaling agents in the body…but only for a short time. These pharmaceutical solutions do very little to resolve inflammation long-term and they unfortunately come with common dissatisfying side effects such as persistent dry-mouth.

Physicians often also prescribe antibiotics to help COPD patients and others with respiratory conditions defeat upper respiratory infections caused by bacteria & fungi. Antibiotics do help relieve immediate shortness of breath symptoms by killing off infectious bacteria & fungi, but again, this is only a short-term fix. Antibiotics do not relieve inflammation over the long term.

Beyond Inhalers - Do Your Part!

There are some very specific, research-based action steps you can take on your own to reduce oxidative stress, alleviate inflammation, reduce shortness of breath, and feel better for the long run, including:

• Engage in a regular cardiovascular & strength training exercise program
• Ensure you are receiving adequate exposure to direct sunlight
• Increase antioxidant & key nutrient intake from food
• Increase antioxidant & key nutrient intake from dietary supplements
• Practice proven breathing techniques & airway clearing techniques

To be clear, in no way are these steps meant to replace advice provided by your physician. Further, these action steps will NOT reverse lung disease, repair lung cells, nor improve lung function, but combined they can help make a significant difference in how you feel and breathe, and are steps you can take that complement the medical care you receive from your physician. To learn more about each of these respiratory health self-management action steps, visit our Five Steps to Feel Better Now Plan by clicking here.

Does frequent chocolate consumption lower your risk of coronary heart disease?

2010-10-20T08:21:00.000-04:00

According to a new study published online ahead of print in the journal Clinical Nutrition…quite possibly yes! The research team leading the study found that adults who consumed at least 5 servings of chocolate per week had 57% lower odds of developing coronary heart disease (CHD) compared to those who consumed no candy at all. (Djousse L, et al. Chocolate consumption is inversely associated with prevalent coronary heart disease: The National Heart, Lung, and Blood Institute Family Heart Study. Clin Nutr. 2010 Sep 19. [Epub ahead of print])

Now I’m sure we’ve all seen the screaming headlines in supermarket tabloids that declare, “Chocolate Cures Everything!” And while for some people chocolate might indeed seem like a cure for a broken heart, stress or a craving for sweet-tasting food, does it really offer measurable health benefits?

Well, according to the new study’s authors, it turns out that a number of human subject studies conducted over the past decade have actually demonstrated notable health benefits associated with high chocolate consumption ranging from lower blood pressure, lower cholesterol levels, and lower cardiovascular disease risk in general.

In the Clinical Nutrition study, the Harvard Medical School-based lead investigator examined the medical records of nearly 5,000 adults who participated in broader heart health study known as the National Heart, Lung, and Blood Institute (NHLBI) Family Heart Study. In particular, the researchers looked at food consumption surveys completed by study participants that highlighted chocolate consumption among other foods. They then compared the incidence of coronary heart disease among the study participants at various levels of chocolate consumption (none, 1-3 times/month, 1-4 times/week, and 5+ times/week).

The study team’s results showed that people who consumed chocolate 1-3 times a month had about the same odds ratio of developing CHD as non-chocolate consumers, while the group that consumed chocolate 1-4 times/week had 26% lower risk of developing CHD, and the group devouring chocolate 5+ times/week showed a 57% lower odds ratio of a CHD diagnosis.

So what’s going on here? How can high chocolate consumption possibly lessen your risk of coronary heart disease? Well, according to the study authors, chocolate (cocoa and dark chocolate in particular), contains high amounts of powerful antioxidant compounds known as polyphenols that are believed to be helpful in reducing the damage done to the human body by molecules known as free radicals.

Free radicals are by-products of the body’s process to utilize oxygen (when cells absorb oxygen, they break off the piece of oxygen they need leaving an unstable oxygen molecule behind – this unstable oxygen molecule is known as a free radical). Free radical damage is believed to be a significant contributing factor in many diseases associated with aging. In addition to free radicals created in the human body through the normal everyday process of absorbing and using energy, free radicals can also be inhaled in massive amounts through cigarette smoke as well as environmental and industrial pollutants. Hence why we bring this study to your attention.
Generally, in non-smoking adults who consume a diet that includes foods high in antioxidant content (whole grains, fruits, vegetables, tea, and red wine to name a few) research evidence shows lower incidence of many types of cardiovascular and respiratory disease. From this study’s results it appears that chocolate can be added to this list.

It should be noted that while the study authors emphasize the value of dark chocolate over milk chocolate in reporting their findings based on previously reported study results, their study participants did not delineate their consumption between the two types of chocolate (and one would presume that most of the study subjects were consuming a fair bit of milk chocolate given that most chocolate candy is milk chocolate-based).

A parting word of caution from the study’s authors though – while chocolate may confer these protective cardiovascular benefits, other forms of candy do not. For example, the investigators evaluated the odds ratio of CHD among people who consumed 5+ servings of non-chocolate candy each week to those who consumed no candy and found the non-chocolate candy group had a 49% HIGHER risk of developing coronary heart disease (as opposed to a 57% LOWER risk among those who consumed chocolate 5+ times/week).

So, if you find yourself craving a sweet-tasting component to your daily diet one would be wise to reach for a chocolate bar instead of a fistful of jelly beans. While chocolate might be a bit messier to eat, your heart will approve of your selection!

Further evidence of undetected osteoporosis in COPD patients

2010-10-19T09:57:00.000-04:00

For the second time in less than a month, a new study has been published detailing the high rate of osteoporosis in COPD patients and revealing the low rate of testing and detection for this debilitating bone condition among those with lung disease.

For regular readers of our blog and e-letters, you will recall that we published an article earlier this month describing a new study that showed osteoporosis was present in 51% of COPD patients participating in the study. More alarming though was the presence of vertebral fractures in a significant percentage of these patients – many of whom had no idea they had such fractures! Click here to read the article.

Now comes a study published last week online ahead of print in the journal Osteoporosis International that demonstrates both the high incidence of osteoporosis in COPD patients and the poor rate of testing and detection of bone disease in this population – only on a significantly larger scale.

In this new study, a group of researchers from the Dartmouth Medical School examined the records of close to 90,000 male veterans who were newly diagnosed with COPD between 1999 and 2003 and who were receiving medical care through the Veterans Administration. (Morden NE, et al. Skeletal health in men with chronic lung disease: rates of testing, treatment, and fractures. Osteoporos Int. 2010 Oct 9. [Epub ahead of print]).

In particular the research team sought to determine whether the presence of osteoporosis was higher among male COPD patients in comparison to men of similar age in the U.S. population. Their results showed that the male COPD patients in the study had 256% higher incidence of hip fractures and 38% higher incidence of wrist fractures compared to males of similar age in the general U.S. population.

According to the study authors, “The fracture rate in this population was much higher than that reported in the literature for men in the general population between the ages of 65 and 69… The high fracture rate likely results from a confluence of risks that include medication exposure, inactivity, smoking, hypogonadism, underweight or weight loss as well as inadequate nutrition and effects of the chronic inflammation that characterizes COPD.”

Further, the investigators sought to understand the prevalence of bone mineral density testing and treatment for low bone density in the male COPD patients. They found that only 4% of the nearly 90,000 COPD patients had received a bone density test (either concurrent with their COPD diagnosis or thereafter). Of the 4% COPD patients who were tested for low bone density, approximately 75% were prescribed an osteoporosis-related medication – but that still means that only 3% of the total COPD study subjects were prescribed helpful medication.

We ask ourselves, if pulmonologists know that well over 50% of COPD patients likely have osteoporosis, why are they only testing 4% of newly diagnosed patients?

How can this be? It’s probably best to let the researchers speak for themselves, “Juxtaposed to the high rate of fragility fracture, the low rate of bone densitometry [testing] and anti-resporptive treatment in this population is striking. The association between osteoporosis and COPD was recognized as early as 1972, and confirmation of this association has repeatedly appeared in the literature since then. The low rate of treatment observed in this cohort [population] likely reflects the low rate of bone density testing which commonly prompts treatment. Of particular note is the fact that more COPD exacerbations were strongly associated with both higher probability of fracture and lower probability of testing or treatment. This may reflect physician and patient distraction as lung disease is prioritized over bone health or simply a lack of understanding of the association between COPD severity (and related treatments) and fracture.”

In other words, physicians seem more focused on treating lung disease and miss the opportunity to test COPD patients for osteoporosis. While one can understand the prioritization of care when a patient has experienced a COPD-related exacerbation, it is less understandable why there isn’t standard osteoporosis screening as part of the follow up process related to an exacerbation. This is especially puzzling given the observations of the Dartmouth study team, “In addition to being at high risk for osteoporosis and consequent fragility fractures, men with COPD may suffer particularly high mortality following a hip fracture…In addition to higher mortality, patients with COPD may suffer greater morbidity from osteoporosis as vertebral compression fractures may diminish lung volume and compromise already limited respiratory function.”

Therefore, my good friends, you appear to be in the driver’s seat on this topic. If you have COPD and you have not been tested/screened for osteoporosis, we would highly recommend that you asked to be tested. The study highlighted four different screening tests available for assessing osteoporosis risk including: dual energy X-ray studies, ultrasound for bone density measure, CT scan bone density, and bone mineral, single or dual photon.

Separately, you can help support both your respiratory function and bone density by altering your lifestyle by taking these valuable steps:

1. Start and maintain a regular exercise program that includes both cardiovascular training and strength training. Our Breathe Better for Life guide/CD, www.breathebetterforlife.com, provides a specific exercise program regimen formulated specifically for COPD patients and smokers based on the principles and practices of the COPD treatment pulmonary rehabilitation. Even a simple walking program that involves 20-40 minutes of walking 3-5 days each week will provide some protective value for both COPD symptoms and osteoporosis.

2. Increase your exposure to direct sunlight (without sunscreen lotion on that blocks UV-B rays)…meaning get outside with multiple parts of your body exposed to direct sunlight for 20-30 minutes a day (combine that with your walking program and you’re knocking off two important steps in one action!) Sunlight helps your body produce Vitamin D, an important nutrient in supporting healthy respiratory function and bones. COPD patients and smokers are known to be significantly deficient in Vitamin D.

3. Supplement your diet with foods rich in Vitamin D (and/or fortified with Vitamin D). For a good listing of Vitamin D rich foods, click here.

4. Consider adding a Vitamin D3 dietary supplement to your daily routine – we recommend 2,000 IU daily dosage (make sure your Vitamin D3 comes in the form of cholecalciferol). For those interested, we have included this dosage level in our new respiratory support supplement, Resplenish. To learn more about Resplenish, click here.

5. Increase protein sources to your daily diet – three particularly good sources that have been shown in previous studies to be associated with better respiratory function are soy isoflavones (soy bean sprouts, tofu, soy beans), fish and dairy products (both dairy products and fish are also rich sources of Vitamin D). Many COPD patients and smokers are underweight due to lack of adequate protein/nutrient intake. Protein is helpful in maintaining a healthy weight and healthy muscles – which are supportive of healthy bones.

New study shows value of combining aerobic exercise with strength training among COPD patients

2010-10-17T09:09:00.000-04:00

This week, a new Portuguese research study revealed that moderate to severe COPD patients who underwent an exercise program including both strength resistance training and aerobic exercise training reported higher levels of perceived health status compared to COPD patients who participated in either aerobic training alone or respiratory physiotherapy.

A number of previous studies have shown that the combination of aerobic exercise and strength/resistance training produces higher levels of overall physical conditioning in COPD patients than either of these two forms of exercise alone (i.e. greater endurance, greater muscle strength, greater exercise capacity). This is a key reason why most pulmonary rehabilitation programs include both strength training and aerobic/cardiovascular training in their exercise regimens.

Instead of evaluating objective, physical measures of performance between these three potential COPD treatment options (strength & aerobic exercise, aerobic exercise, physiotherapy), the new Portuguese based research study aimed to understand how COPD patients perceive their own health status through two “quality of life” surveys (the St. George’s Respiratory Questionnaire (view sample survey form by clicking here) and the Short Form [36] Health Survey (view sample survey form by clicking here).

In other words, the study team desired to know, outside of physical performance measures (e.g. did you walk farther, did you walk faster, could you lift more weight), do COPD patients actually feel differently about their own health status depending on which method of rehabilitation they receive?

To test their hypothesis, the research team divided 50 moderate to severe COPD patients into two groups (25 who participated in a 10-week combined strength/aerobic exercise program, 25 in a 10-week aerobic-only exercise group) and compared their survey results to each other and to an additional 50 moderate to severe COPD patients who received 10 weeks of respiratory physiotherapy (essentially physical therapy accompanied by breathing technique and airway clearing technique training – but no explicit exercise program). They administered the two surveys mentioned above prior to the respective treatment programs and then again at the end of the programs. They then measured the differences in the patients’ responses from their pre-program surveys and their post-program surveys and compared the mean (average) results between the three different treatment options. (Pereira AM, et al. Impact of combined exercise on chronic obstructive pulmonary patients' state of health. Rev Port Pneumol. 2010 Sep-Oct;16(5):737-57)

The results clearly showed that COPD patients who received both the strength training and aerobic exercise training reported significantly higher ratings of their perceived health status at the end of their exercise program as compared to the other two groups ON ALL SECTIONS OF BOTH SURVEYS.

For example, in the St. George’s Respiratory Questionnaire, the combined exercise group reported a 64 point increase in their “activity” rating (a section of the questionnaire designed to understand a patient’s ability to participate in activities of daily living) versus a 19 point increase for the aerobic-only exercise group and a 1 point increase for the physiotherapy group.

As another example, on the SF-36 survey, COPD patients receiving both strength and aerobic exercise training reported an 83 point jump in their perceived vitality (a section of the test designed to assess quality of daily living), versus a 14 point rise for the aerobic-only group. On this measure the physiotherapy group showed flat response between pre and post treatment.

These results reinforce the basic underlying principles and practices of COPD treatment pulmonary rehabilitation. Combined strength and aerobic exercise is highly valuable for those who suffer from chronic shortness of breath on two fronts – on physical performance measures and on quality of life perceptions.

If you are a COPD patient and you’d like to try an exercise program, consider asking your pulmonologist for a referral to an outpatient pulmonary rehabilitation program in your area. A note of upfront warning – these programs have very limited admission rates despite their proven effectiveness due to lack of available medical resources to help meet the demand for program participation. Additionally, Medicare and insurance guidelines limit reimbursement for pulmonary rehabilitation to moderate and severe COPD patients only (meaning mild and very severe COPD patients are not eligible for reimbursement – and hence are rarely admitted).
Alternatively, ask your physician to recommend an exercise program appropriate for your situation. If they don’t have such a program to offer you, consider visiting a local fitness center in your area and ask to speak with a fitness instructor certified in structuring exercise programs for people with chronic health conditions.

If none of those options appeal to you but you’d like to learn more about what a pulmonary rehabilitation-style exercise program looks like, we’d recommend you consider purchasing our Breathe Better for Life guide and companion CD-ROM, www.breathebetterforlife.com.

We’ve created an at-home or at-fitness center strength and aerobic exercise program based on pulmonary rehabilitation guidelines published by the American Thoracic Society and the European Respiratory Society. We’ve also tweaked the program to include exercise guidelines issued by the American College of Sports Medicine for elderly patients with chronic respiratory conditions. Our guide provides explicit exercise recommendations and our CD provides explicit, narrated step-by-step instructions for common strength training movements. If you do elect to purchase our guide and follow our exercise program recommendations, we recommend you discuss your plan with your physician prior to engaging in the exercise program to ensure it is appropriate for your particular situation.

Antioxidant Quercetin shown to reduce inflammation & oxidative stress

2010-10-15T11:42:00.000-04:00

A new study published in the pulmonology journal Respiratory Research demonstrated the effectiveness of the potent antioxidant Quercetin in reducing oxidative stress and inflammation in laboratory mice exposed to a toxic chemical commonly found in cigarette smoke.

Quercetin, a flavinoid found in many plants, has long been studied for its antioxidant properties. Over the past few years, Quercetin has garnered more and more attention from pulmonology researchers seeking methods to help alleviate oxidative stress and inflammation in smokers and people with respiratory health concerns. In several laboratory animal studies and in a few human tissue studies, Quercetin has been shown to reduce inflammation and oxidative stress associated with prolonged exposure to cigarette smoke.

In this new study, the University of Michigan based-investigators sought to confirm previous Quercetin study results by using a different method of exposing laboratory mice to a toxic chemical found in cigarette smoke. (Ganasen S, et al. Respiratory Research. 2010, 11:131)

Instead of exposing laboratory mice to cigarette smoke itself, the investigators instead introduced a specific chemical found in cigarette smoke called lipopolysaccharide (LPS) into the mice via their nasal openings. According to the study authors LPS is, “a cell wall component of gram negative bacteria, is a potent inflammatory molecule and is present in appreciable amounts in cigarette smoke. It is also an active component in environmental and occupational exposures…”

The researchers divided the mice into three groups. One group (the control group) received no exposure to LPS or Quercetin. One group received LPS but no Quercetin (the LPS group). The third group was exposed to LPS and orally fed daily doses of Quercetin at 10mg per kg of body weight (the Quercetin group).

The 8-10 week old mice in the two groups who were exposed to LPS (LPS group & Quercetin group) received the exposure one day a week over a 4 week period. After the 4 week LPS exposure period, mice in the Quercetin group received the potent antioxidant once a day for 10 days. Then the mice were euthanized and their lung cells examined.

To assess the degree of inflammation and oxidative stress, the research team evaluated counts of certain proteins and white blood cells known to be present in high amounts in lung tissue inflamed due to cigarette smoke (e.g. cytokines, chemokines, TBARs). They first discovered that the LPS group mice did indeed evidence a significant degree of inflammation from the 4 week exposure to LPS thus validating their method of exposing lung cells directly to a toxic chemical contained in cigarette smoke.

They further discovered that Quercetin significantly reduced the degree of inflammation and oxidative stress in the Quercetin group when comparing counts of the inflammation/oxidative stress markers mentioned above to mice in the LPS group. As the study authors concluded, “In summary, we have demonstrated that quercetin, a plant polyphenol, reduces oxidative stress, inflammation and MMP levels in elastase/LPS treated mice which show typical features of [poor respiratory function].”

While these results support previous respiratory health studies evaluating the potential of Quercetin as a helpful antioxidant and anti-inflammatory dietary ingredient, there have yet to be live human studies conducted that provide definitive guidance regarding efficacious dosages in humans desiring better respiratory health. That said, Quercetin is readily available in dietary supplement form in daily recommended dosages ranging from 100mg to 500mg. There are also a wide variety of fruits and vegetables that contain high concentrations of Quercetin that can be viewed by clicking here.

We have also included Quercetin at 200mg in our new respiratory support supplement formula, Resplenish along with a dozen other potent antioxidants studied for their respiratory support properties. To learn more about Resplenish, visit www.resplenish.com.

High level of physical activity, even at advanced ages, is extremely beneficial

2010-10-11T17:23:00.000-04:00

In researching articles for our current e-letter editions, we ran across an interesting snippet in Respiratory Report (an e-letter targeted at pulmonology professionals) regarding a new study that shows that maintaining an ongoing regular exercise program late into life provides significant conditioning benefits.

Quoting the Respiratory Report article, “In looking at seniors who ski well into the so-called "golden years," investigators discovered they have twice the oxygen-uptake capacity of same-aged adults who do not exercise.

The research, conducted at Mid Sweden University, was presented at last week's American College of Sports Medicine: Integrative Physiology of Exercise conference.

The results for the active seniors are comparable to values for men who are 40 to 50 years younger but do not exercise to improve their stamina. Analyses of muscle samples at the molecular and cell level reveal a profile similar to what is found in younger men.”

Pretty amazing to discover that in your 60’s, 70’s and 80’s, you can exhibit stamina and strength of non-exercising adults who are 40 and 50 years younger so long as you keep physically active! Not only that, as we previously reported, other studies have shown that starting and maintaining an active exercise program in your 50’s and 60’s, doubles the odds of you reaching age 85! Click here to read the article.

While the study referenced in the Respiratory Report is not specifically related to COPD patients, we thought it worth sharing because we often run into reports of COPD patients and smokers feeling like, “why start an exercise program now. It’s too late.”

Au contraire mon amis! (sorry if that’s improper French diction for…on the contrary my friends). Beginning and maintaining an exercise program for smokers and COPD patients at any age and at any stage of disease is HIGHLY beneficial. Many COPD and smoker research studies prove it. Not only does it improve physical & cardiovascular conditioning, it strengthens muscles, improves balance/coordination, reduces shortness of breath, reduces hospitalizations related to COPD exacerbations, and improves sense of well being/quality of life.

True, exercise will NOT reverse the damage done to your lungs from prolonged exposure to cigarette smoke (nothing can unfortunately) but it can make you feel significantly better nonetheless and help you become more mobile and active and thereby enjoy a more fulfilling life.

To get started, for COPD patients who have been diagnosed with Stage II or Stage III COPD, ask your doctor for a referral to a pulmonary rehabilitation program in your area. The cornerstone element of these programs is guided/observed exercise in which therapists adjust your starting point based on their assessment of your physical condition at admission, and then increase the duration/intensity of your exercise program based on your progress on specific diagnostic measures.

Unfortunately, for Stage I and Stage IV COPD patients, and others concerned with persistent shortness of breath who have not been diagnosed with COPD (such as current/former smokers), entry into an outpatient pulmonary rehab program is next to impossible.

If you fall into this latter category (or if you are Stage II or Stage III and can’t/won’t go to a pulmonary rehab program), we recommend you consider purchasing our Breathe Better for Life guide/CD, www.breathebetterforlife.com. We’ve created a home-based or fitness-center based exercise program based on the same principles and practices that respiratory care professionals use in pulmonary rehabilitation programs. Of course, if you do decide to purchase and follow our exercise program, we recommend you first discuss your exercise plan with your physician to ensure the program is appropriate for your particular circumstance.

The point is – whatever exercise program you follow – start one and keep it going. Next to smoking cessation, it’s the very best thing you can do on your own to improve how you feel and breathe no matter what age you are!

New study shows 51% of COPD patients likely have Osteoporosis

2010-10-08T09:06:00.000-04:00

Osteoporosis is a degenerative bone disease that results in low bone density which weakens bones and ultimately leads to frequent bone fractures. It has long been considered a condition that is often found in COPD patients. A new Dutch study published online ahead of print reveals that the prevalence of osteoporosis in COPD patients is likely much higher than previously reported – as high as 1 of every 2 COPD patients!

Why? According to the research team, “Most studies in COPD patients use dual energy absorptiometry (DXA) scan only to determine osteoporosis, therefore microarchitectural changes without a low BMD are missed. Aim of the current study was to determine the prevalence and correlates of osteoporosis in COPD patients based on DXA-scan, X-ray of the spine (X-spine) and the combination thereof.” (Graat-Verboom L, et al. Osteoporosis in COPD outpatients based on bone mineral density and vertebral fractures. Journal of Bone and Mineral Research. 2010 Sep 27. [Epub ahead of print])

In other words, in previous studies only one testing method (dual energy absorptiometry) has been typically used to make a diagnosis of osteoporosis in COPD patients and the researchers desired to know whether there would be an increase in diagnosed cases of osteoporosis in COPD patients by utilizing an alternative method (X-ray of the spine to identify vertebral fractures), and then by using both methods.

The study team discovered that dual energy absorpitometry only identified osteoporosis in 24% of the 255 COPD patients participating in the study, while spine X-rays identified osteoporosis in 37% of study subjects. When both methods were used in combination, the diagnosis of osteoporosis among the COPD patients in the study rose to 51%. As an interesting but frightening side note, 93 of the COPD patients in the study had spine fractures detected by X-Ray, but only 8 of these patients were aware prior to the X-Ray that they had fractured vertebrae.

Even more stunning was their discovery that the percentage of osteoporosis diagnosis was relatively consistent across the spectrum of mild, moderate, severe and very severe COPD patients – implying that osteoporosis is present early on in the development of COPD.

What leads to osteoporosis in COPD patients? Ironically, many of the same factors that tend to worsen shortness of breath…the combination of prolonged exposure to cigarette smoke, a sedentary lifestyle, inadequate exposure to sunlight, and low body weight due to poor/low nutritional intake.

As case in point, the researchers discovered that Vitamin D deficiency was present in over 86% of COPD patients in the study (when using the same deficiency cut-off level employed in diagnosing osteoporosis in post-menopausal women)! Vitamin D, as regular readers of our blog and e-letters well know, is typically produced in the body by skin-cell receptors that utilize UV-B rays from direct sunlight as a catalyst. Vitamin D is essential for the production and maintenance of healthy bones. Many COPD patients lead sedentary, indoor lifestyles and therefore do not get adequate exposure to sunlight. In addition, cigarette smoke has been shown to leach Vitamin D from the body. For COPD patients who don’t get adequate exposure to sunlight, a double whammy happens – it increases airway inflammation and leads to bone density loss. Click here to see our recent article about Vitamin D deficiency and airway inflammation.

Further, many COPD patients are physically inactive. Not only does this weaken the cardiovascular function and muscle strength/function, it also significantly weakens bones. You see, bone strength is reinforced by engaging in weight bearing tasks (walking and lifting weights for example). Because many COPD patients do not regularly exercise and instead spend significant portions of each day sitting/lying down, bone loss from lack of direct sunlight is compounded by lack of physical activity.

Further still, many COPD patients are significantly underweight. This is most often due to the combination of depressed appetite caused by the body’s chemical reaction to cigarette smoke, poor dietary caloric intake of protein & vital nutrients (including Vitamin D fortified foods), and a higher-than-normal metabolism due to the fact that COPD patients burn significantly more calories to take in/expel each breath – even at rest. Low body weight is highly correlated with osteoporosis – again because it means that less weight/load is placed on bones in the body.

So what can you do if you are concerned about the possibility that you might have osteoporosis? Well, first, it’s a good idea to ask your doctor to order both of the above mentioned diagnostic tests to determine if you have osteoporosis or osteopenia (a term doctors apply to low bone density that isn’t quite bad enough to call osteoporosis yet) – especially given the prevalence of previously undetected fractured vertebrae discovered in the Dutch study.

There are prescription drugs available that purportedly increase bone mass but they come with some significant and unpleasant side effects (as a side note, approximately 87% of the Dutch study subjects were NOT taking prescribed bone medication). In our opinion, your first best defenses to improve bone density are the same recommendations we make for improving shortness of breath in our Breathe Better for Life guide/CD, www.breathebetterforlife.com.

1. Start and maintain a regular exercise program that includes both cardiovascular training and strength training. Our Breathe Better for Life guide/CD provides a specific exercise program regimen formulated specifically for COPD patients and smokers based on the principles and practices of the COPD treatment pulmonary rehabilitation. Even a simple walking program that involves 20-40 minutes of walking 3-5 days each week will provide some protective value for both COPD symptoms and osteoporosis.

2. Increase your exposure to direct sunlight (without sunscreen lotion on that blocks UV-B rays)…meaning get outside with multiple parts of your body exposed to direct sunlight for 20-30 minutes a day (combine that with your walking program and you’re knocking off two important steps in one action!)

3. Supplement your diet with foods rich in Vitamin D (and/or fortified with Vitamin D). For a good listing of Vitamin D rich foods, click here.

4. Consider adding a Vitamin D3 dietary supplement to your daily routine – we recommend 2,000 IU daily dosage (make sure your Vitamin D3 comes in the form of cholecalciferol).

5. Increase protein sources to your daily diet – three particularly good sources that have been shown in previous studies to be associated with better respiratory function are soy isoflavones (soy bean sprouts, tofu, soy beans), fish and dairy products (both dairy products and fish are also rich sources of Vitamin D).

Zinc reduces inflammation due to cigarette smoke

2010-10-04T16:15:00.000-04:00

A new study published in late August showed that laboratory mice fed a diet high in zinc had 50-60% lower markers of inflammation in lung tissue samples than mice fed a diet low in zinc. The study authors suggest that supplementing zinc in COPD patients, asthmatics and smokers may be helpful in reducing inflammation associated with airway diseases (inflammation is believed to be a leading cause of breathlessness in COPD patients).

According to the study authors, “Zinc is a dietary trace metal that has been clinically and physiologically linked to airway inflammatory diseases, such as asthma and COPD. Patients with COPD have lower serum, plasma and hair zinc levels than healthy subjects. In addition, there is a negative correlation between plasma zinc and wheezing. Zinc supplementation had favorable effects on oxidant–antioxidant balance in patients with COPD.” (Lang CJ, et al. Dietary zinc mediates inflammation and protects against wasting and metabolic derangement caused by sustained cigarette smoke exposure in mice. Biometals. Published online ahead of print, August 29, 2010. (doi:10.1007/s10534-010-9370-9))

In other words, zinc seems to act as an antioxidant in lung tissue, particularly in cells of the lining of the lungs known as epithelial cells. According to the research team, zinc is naturally abundant in epithelial cells, but the effects of a diet that is low in zinc content combined with prolonged exposure to cigarette smoke depresses levels of this important nutrient and thus contributes to airway inflammation. By supplementing dietary zinc in laboratory mice exposed to cigarette smoke, the researchers hypothesized that signs of inflammation would be reduced.

As regular readers of our e-letters and blog know well, there are a host of antioxidants that have been studied (and continue to be studied) in relation to airway inflammation. You see, it’s clear from blood plasma samples that smokers and COPD patients are significantly deficient in antioxidant counts compared to healthy non-smoking adults. Scientists theorize that the pro-oxidative nature of cigarette smoke overwhelms the body’s supply of antioxidants consumed through diet or produced in the body creating a condition referred to as “oxidative stress”. Oxidative stress in simple terms is an imbalance of pro-oxidative molecules (too much of a bad thing) and anti-oxidative molecules (too little of a good thing) in the body. As a result of the imbalance, more pro-oxidative molecules get through to lung tissues and damage them, creating inflammation, which in turn leads to persistent shortness of breath.

Therefore, researchers seeking for ways to alleviate inflammation have been testing a variety of antioxidants to boost blood plasma levels of these protective nutrients to judge whether doing so has a positive effect on airway inflammation. In this particular zinc study (and in a growing number of other studies on other antioxidants) the answer appears to be yes.

But a word of reason – from the scores of studies we’ve reviewed on antioxidants and airway inflammation, it is clear that there is no single magic antioxidant. The human body absorbs, processes and produces a wide range of antioxidants and so the best advice is to eat a diet rich in foods that contain high levels of antioxidants (most often colorful fruits and vegetables) and if you desire to add additional antioxidants through dietary supplements, favor products that give you a broad base of different antioxidants rather than massive doses of a single antioxidant.

In the Biometals zinc study itself, the research team divided the laboratory mice into three groups. One group was fed a diet of whey protein that is low in zinc content, one group was fed the same whey protein supplemented by additional zinc sulfate, and a third group received the same basic diet but with a much higher level of supplemented zinc.

Then the mice were exposed to smoke from 2 cigarettes for 15 minutes, 3 times a day, 5 days a week for 8 weeks. Then the mice were euthanized and their lung tissues sampled and examined for a variety of measures.

One of the measures the researchers looked at were the number of macrophages (white blood cells) present in alveolar (lung) tissue samples – one outcome of the inflammation process is the production of white blood cells (in fact the body over-produces white blood cells because the inflammation process makes the body think there is a massive infection occurring). Here the researchers found that cigarette exposed mice who were fed the diet supplemented with high zinc content had 50-60% fewer macrophages – thus demonstrating a significant reduction in the inflammatory response to cigarette smoke.

As the study authors noted, “The 50–60% reduction in alveolar macrophages in Zn-supplemented mice supports our evolving hypothesis that Zn is an important anti-inflammatory mediator of airway inflammation. Restoring airway Zn levels through dietary supplementation may lessen the severity of lung inflammation when Zn intake is low.”

Now, unfortunately, there is no specific guidance in the study on how much supplemental zinc is beneficial for smokers/COPD patients for reducing airway inflammation, and it is not a matter of simply translating the amount fed to the mice per unit of body weight and multiplying it by your own body weight.

That said the odds are high that you have a zinc deficiency if you smoke and/or have COPD, but before you go crazy adding massive amounts of zinc to your diet, we would recommend you ask your doctor to order a blood or hair sample test to determine whether you have a deficiency and how severe your deficiency is. From there, you and your doctor can determine a supplemental zinc dosage level appropriate for your particular circumstance.

In the meantime, for a good listing of foods high in zinc content published by the National Institutes of Health’s Office of Dietary Supplements that you can access by clicking here. This same web page provides additional information about the daily recommended intake of zinc from food/dietary supplements and provides guidance on how much is too much.

12 elements of successful long-term COPD self-management

2010-09-23T10:26:00.000-04:00

In researching topics for the current edition of our e-letters, we ran across a review article examining the how to make pulmonary rehabilitation a greater success component of COPD disease management.

As readers of our blog, e-letters, and buyers of our Breathe Better for Life guide/CD know, we are emphatic supporters of the value of pulmonary rehabilitation. This treatment option has been shown in three decades worth of research studies to reduce breathlessness, improve physical conditioning, improve patient quality of life, reduce exacerbations and associated hospital stays/health care costs.

For those who are unaware, the cornerstone element of pulmonary rehabilitation is observed guided exercise (aerobic and strength training). Other elements of pulmonary rehab include training of breathing and airway clearing techniques, and counseling on nutrition, smoking cessation, and proper use of medications.

In any event, in describing ways to expand access to pulmonary rehabilitation for a wider range of COPD patients, and ways to encourage continued participation in an ongoing exercise program after rehab, the article author included a chart on self-management strategies for COPD patients (Bourbeau J, Making pulmonary rehabilitation a success in COPD. Swiss Medical Weekly. 2010;140:w13067)

We thought the chart was worth summarizing for you (see below). If your doctor has not discussed these strategies with you, or if you have not yet seen your doctor about your shortness of breath concerns, we recommend using this list as a guide to discuss your own “better breathing program” with your doctor. Alternatively, we suggest you consider purchasing our Breathe Better for Life guide/CD, www.breathebetterforlife.com, to find specific suggestions and strategies for many of the topics highlighted in the below list, including exercise, nutrition, breathing techniques, conserving energy, managing stress, and maintaining intimacy among others.

Self-management skills and healthy behaviors for COPD self-management (Table 3 in referenced review article):

1. Live in a smoke free environment - Quit smoking, remain non-smoker and avoid second-hand smoke.

2. Comply with your medication - Take medication as prescribed on a regular basis and use proper inhalation techniques.

3. Manage to maintain comfortable breathing, use according to directives:
– the pursed-lip breathing technique
– the forward body positions

4. Conserve your energy - Prioritize your activities, plan your schedule and pace yourself.

5. Manage your stress and anxiety - Use your relaxation and breathing techniques, try to solve one problem at a time, talk about your problems and do not hesitate to ask for help and maintain a positive attitude.

6. Prevention and early treatment of COPD exacerbations - Get your flu shot every year and your vaccine for pneumonia. Identify and avoid factors that can worsen your symptoms. Use your Plan of Action according to the directives (recognition of symptom deterioration and actions to perform).Contact your resource person when needed.

7. Maintain an active life style - Maintain physical activities (activities of daily living, walking, climbing stairs, etc.). Exercise regularly (according to a prescribed home exercise program).

8. Keep a healthy diet - Maintain a healthy weight, eat food high in protein and eat smaller meals more often (5–6 meals/day).

9. Have good sleep habits - Maintain a routine, avoid heavy meals and stimulants before bedtime and relax before bedtime.

10. Maintain a satisfying sex life - Use positions that require less energy. Share your feelings with your partner. Do not limit yourself to intercourse, create a romantic atmosphere. Use your breathing, relaxation and coughing techniques.

11. Get involved in leisure - Choose leisure activities that you enjoy.

12. Activities - choose environments where your symptoms will not be aggravated. Pace yourself through the activities while using your breathing techniques. Respect your strengths and limitations.

Pedometer teamed with Internet a useful tool in boosting physical activity in COPD?

2010-09-20T08:11:00.000-04:00

A significant challenge for respiratory care professionals in lifelong COPD disease management is ensuring that patients increase and maintain a higher level of daily physical activity.

The primary method for “kick-starting” physical activity in COPD patients is the treatment option known as pulmonary rehabilitation (PR). In a typical outpatient PR program, patients receive exercise training for 30-60 minutes, 2-3 days per week, over an 8-12 week period. The exercise training includes both aerobic/cardiovascular (i.e. walking on a treadmill, riding a stationary cycle or ergonometer) and strength training (lifting weights that strengthen upper and lower body muscles).

However, once a COPD patient completes a PR program, he/she is expected to self-manage an ongoing exercise program thereafter. Unfortunately, many COPD patients who’ve experienced significant gains in physical conditioning, reduced shortness of breath, and improved sense of well being during PR lose the benefits within one year because they don’t continue to exercise.

Why COPD patients who’ve experienced these health gains don’t maintain an exercise program is bedeviling to practitioners and researchers. It seems that in many cases exercise adherence falls as COPD patients leave PR because they lose their cheerleader/guider/motivator/feedback provider.

So practitioners and researchers continue to seek ways/methods to encourage exercise post-rehab and for those who are not eligible for rehab (which sadly, is about 99% of COPD patients). Researchers know it is not feasible from a cost or physical resource perspective to provide ongoing direct support ad infinitum, so they investigate ways to cost effectively provide feedback and motivation and thereby extend the length of home-based exercise programs.

One such way for encouraging greater daily physical activity might be to provide COPD patients with a pedometer to track their daily steps combined with an easy way to track progress and goals set by practitioners. That was the aim of a new research study reported in the Journal of Rehabilitation Research & Development.

In this study, the research team looked back at the results of a larger pedometer study to extract the experience of the 16 COPD patients who completed in the study (of the 205 people who completed the larger pedometer study, only 16 were identified as COPD patients).

To establish a baseline of steps taken in a given day, the study participants were asked to carry/wear a pedometer with the display screen covered during waking hours for a 7 day period. After the baseline was established, study participants were asked to carry/wear the pedometer during waking hours for 16 weeks, recording their steps taken at least once per week on an Internet-based tracking site. The Internet walking-tracking site provided feedback/motivational messages/goals for each patient based on their individual progress.

At the end of the study, COPD patients saw their daily steps taken rise by 988 over their baseline average of 3,596 (27% increase). By comparison, the non-COPD population of the larger study from which this data was extracted experienced a 60% gain in average daily steps taken over the 16 week period. (Moy ML, et al. Use of pedometer and Internet-mediated walking program in patients with chronic obstructive pulmonary disease. J Rehabil Res Dev. 2010;47(5):485-96)

While the COPD patients did indeed demonstrate a statistically significant rise in average daily steps taken, their increase was not as dramatic as the non-COPD participants. But from a practitioner perspective, a statistically significant rise in COPD patient daily activity is a huge step in the right direction.

It is not clear from the study whether the pedometer alone, or the pedometer combined with the Internet tracking service was responsible for the rise in steps taken since the study did not include test panels to evaluate the relative differences in steps taken between no intervention, pedometer alone, pedometer with Internet tracking service. However, understanding that a significant barrier to continued exercise among COPD patients is the lack of a feedback/motivation loop outside of the clinical environment, it would appear that the combination of live data from the pedometer teamed with the tracking/feedback Internet site is an interesting alternative to a traditional exercise program for COPD patients who are self-managing their disease.

If you are interested in starting a pedometer assisted walking program of your own, we’ve provided a link to our Breathe Better Marketplace where we’ve posted some of Consumer Reports top rated pedometers available through amazon.com. We’ve also included a link to Step Up To Better Health, the Internet-based walking tracking site used in the above mentioned study.

Resveratrol vs. Steroids in smokers and COPD patients

2010-09-15T11:22:00.000-04:00

A new German study published online ahead of print in the Journal of Pharmacology and Experimental Therapeutics showed that Resveratrol may be more effective in depressing inflammation in smokers and COPD patients than corticosteroids.

Resveratrol, a polyphenol compound produced in a range of plants, is a protective chemical secreted by plants to ward off infection from attacks of bacteria or fungi. Resveratrol has been studied for a wide range of health applications in humans and first garnered significant attention as the main factor behind the “French Paradox”.

The French Paradox refers to the puzzling circumstance of low heart disease prevalence in the French population despite a diet which includes significant amounts of calories from fats and oils. Given that red wine is a staple of many French diets, and Resveratrol is found in red grapes in relatively high concentration, some scientists have associated the Resveratrol with protective heart health benefits. What makes this a head scratcher is that the average glass of red wine contains only 1-2mg of Resveratrol – a dosage level which is way below dosage levels deemed effective in Resveratrol research studies. But the fact still remains that French citizens who consume red wine on a regular basis seem to have less incidence of heart disease.

Resveratrol has shown promising results in smokers and people with COPD as we described in a previous article (click here to read more). The new German study further explored Resveratrol as an antioxidant and anti-inflammatory agent for smokers and COPD specifically to understand whether it might be more effective than steroids in reducing inflammation.

It has been previously established in past research studies that corticosteroids, a common treatment option for airway inflammation in smokers and COPD patients, are not particularly effective over the long-term in relieving symptoms associated with inflammation. As the German research team noted, “The use of corticosteroids in COPD is disputed, since their anti-inflammatory properties are impaired in smoking-related COPD compared to other chronic inflammatory lung diseases such as asthma.” (Knobloch J, et al. Resveratrol impairs the release of steroid-resistant inflammatory cytokines from human airway smooth muscle cells in COPD. JPET. Epub ahead of print, DOI:10.1124/jpet.110.166843)

To understand why, it is important to understand what causes inflammation in the first place. The cycle operates like this – cigarette smoke damages the cells of the lungs lining and airway muscle cells. Over time, the volume of damage inflicted by cigarette smoke causes the affected cells to malfunction. The most notable way they malfunction is an inappropriately overwhelming response to the presence of bacteria or fungi in the lungs.

Normally, when the cells detect bacteria or fungi, they send out signals (in the form of proteins known as cytokines). These signals are intended to boost production of white blood cells (macrophages as an example) to attack and kill the invading bacteria or fungi.

In smokers and COPD patients, however, the cell response to the presence of bacteria or fungi is dramatically more intense. Huge amounts of cytokines are produced and an overwhelming number of white blood cells respond. The lung tissues fill up with both the proteins and white blood cells and swell. The combination of swelled tissue and extra fluid in the lungs is described as inflammation. This inflammation in turn makes it harder to breathe because the airways are narrowed and not as much oxygen can be inhaled.

Corticosteroids are widely prescribed for reducing inflammation as anyone who has bad knees, hips, or back can attest. They are effective in reducing the body’s response to a perceived threat or injury. However, in smokers and COPD patients, some of the proteins that signal production of white blood cells have shown to be resistant to steroid’s effects, thereby diluting their anti-inflammatory properties.

Antioxidants have been receiving greater focus as an alternative because a number of them have been shown to be effective in reducing the production of cytokines and in moderating the free radical damage inflicted by inhaling cigarette smoke.

In this study, the German research team sought to test Resveratrol versus Dexamethasone (corticosteroid) in reducing the presence of cytokines in human lung tissue samples (specifically, human airway smooth muscle cells or HASMC). They recruited 3 sets of 10 patients – 10 non-smokers, 10 smokers who were considered healthy and free of lung disease, and 10 smokers diagnosed with COPD.

The study subjects agreed to a biopsy of their lung tissue into which the research team introduced a cytokine known as TNF-alpha (tumor necrosis factor alpha). The presence of TNF-alpha in lung tissue in turn signals the cells to produce other cytokines (Interleukin-8, for example) and chemicals (GM-CSF, granulocyte macrophage-colony stimulating factor, for example) to pass the “alert…infection detected” signal on to produce white blood cells in response.

Then the researchers introduced Dexamethasone into one set of the lung tissue samples from each group (non-smokers, smokers, COPD), Resveratrol into another set of the samples, and maintained a control/baseline set of tissue samples that received no injections.

The results showed that Dexamethasone was effective in reducing the number of inflammation-related proteins and chemicals in non-smokers, and that its effectiveness by comparison in smokers and COPD patients was notably reduced. This was determined by counting the number of cytokines and other signaling chemicals in the cell samples before and after treatment with Dexamethasone.

By contrast, the smoker and COPD cells treated with Resveratrol showed significantly lower counts of cytokines and other white blood cell signaling chemicals. As the study team noted, “In contrast to dexamethasone, resveratrol reduced IL-8 release from TNFalpha-stimulated HASMCs down to baseline level in all three cohorts.” (researcher-speak meaning that Resveratrol eliminated nearly all the inflammation related protein IL-8, by the way, the same was true of the signaling chemical GM-CSF).

Further, the researchers’ results showed that repeated administration of Resveratrol at lower dosage levels provided similar benefits to a single, large dose. The reason this is interesting is related to the point discussed above related to the “French Paradox”. Red wine contains a low dosage of Resveratrol (1-2mg per glass) and so one wouldn’t think that such a low dose would provide health benefits given that past Resveratrol research studies typically have had to administer large dosage levels in order to generate statistically significant responses.

Scientists have theorized that repeated low to moderate dosage of Resveratrol over time may, in effect, improve the body’s response to the antioxidant in such a way as to provide similar benefits to single, large doses. This study seems to provide support for this point of view. That said there is no current guideline for appropriate dosage level of Resveratrol in humans for any health condition. What seems more important than the specific dosage is continually replenishing the body’s supply of it.

Resveratrol is widely available in dietary supplement form in daily dosages ranging from 20mg up to 1000mg – it is sometimes sold as Grape Seed Extract. If you decide to purchase and try Resveratrol, make sure though that you check the supplement facts box of the product you are interested in prior to purchasing. While a label might indicate that there is 200mg of Grape Seed Extract in the product, Resveratrol is typically found in concentrations of 8% to 20%. So if you bought a 200mg Grape Seed Extract thinking you were getting 200mg of Resveratrol, you might really be getting 16mg-40mg of Resveratrol. Reputable supplement marketers will clearly identify the concentration level of Resveratrol in their product – steer clear of those who don’t.

As always, please check with your doctor before consuming Resveratrol to ensure there are no counter-indications with your individual health status. If you don’t want to try a Resveratrol supplement, consider adding red grapes, peanuts and/or red wine to your diet. All three of these sources provide 1-2mg Resveratrol per serving.

B Vitamins and Lung Cancer Risk

2010-09-08T18:38:00.000-04:00

A recent study published recently in the Journal of the American Medical Association (JAMA) showed that people with higher blood levels of Vitamin B6, Folate (Vitamin B9), and the amino acid Methionine had a 67% lower odds-ratio of developing lung cancer compared to those with low levels of these nutrients.

According to the research team, the above odds ratio was largely the same among never smokers, former smokers and current smokers (meaning that in all three groups of smoking status, the odds ratio of developing lung cancer was about the same when comparing those who had high blood levels of these nutrients and those who had low levels). (Johansson M, et al. Serum B Vitamin Levels and Risk of Lung Cancer. JAMA. 010;303(23):2377-2385)

That said current smokers between the ages of 35 and 79 included in the research database analyzed by the study team had a much higher risk of lung cancer than either former smokers or never smokers. As a case in point, currently smoking men in the study with low levels of Vitamin B6 and Methionine had a 14.9% risk of developing lung cancer while currently smoking men with high levels of these two nutrients had only a 6.6% risk. On the other end of the spectrum, never smoking men in the study with low blood levels of Vitamin B6 and the amino acid Methionine had a 0.9% risk of developing lung cancer while those never smoking men with high levels of these two nutrients had a 0.3%.

To take a step back, the paper’s authors achieved their results by examining the medical records of over 500,000 Europeans who participate in a large, ongoing study (a generational study known as a cohort) called EPIC. They examined the EPIC database of patients to select those who had developed lung cancer after their initial blood draw (when their levels of B Vitamins and other nutrients were originally obtained). After eliminating some of the lung cancer patients for various confounding characteristics the researchers arrived at roughly 900 lung cancer patient records. They then selected approximately 1,800 control patient records from the database, attempting to find 2 cancer-free control patients of similar health/demographic characteristics for each of the lung cancer patients.

The researchers focused their study on B Vitamins and Methionine because, “B vitamins, including B6 and Folate (B9), as well as related enzymes in the 1-carbon pathway, are essential for DNA synthesis and methylation…Deficiencies in B vitamins may increase the probability of DNA damage and subsequent gene mutations, and may influence gene expression via aberrant methylation patterns. Given their involvement in maintaining DNA integrity and gene expression, these nutrients have a potentially important role in inhibiting cancer development, and offer the possibility of modifying cancer risk through dietary changes.”

In other words, these nutrients play a key role in healthy cell development and division. When low levels of these nutrients are present in the human body there is a greater likelihood of abnormal cell development and division (and abnormal cell development and division is at the root of cancer development).

For the paper’s authors, the puzzle arising out of the study results was the fact that there was less of a correlation between dietary intake levels of foods or nutritional supplements that contain these nutrients and lung cancer risk than there was with blood level amounts of the nutrients.

In other words, the study team did not find direct evidence to support the contention that consuming more foods and/or supplements with Vitamin B6, Folate and Methionine reduced lung cancer risk. Instead, the correlation discovered was based solely on blood levels of these nutrients.

But clearly, the main sources of these nutrients for humans are food and nutritional supplements that contain these ingredients. So if a person has higher blood levels of these nutrients it is logical to assume that they either consume more foods/supplements with these nutrients or their bodies better absorb the nutrients than people with low levels.

Despite the absence of proof that higher dietary intake of Vitamin B6, Folate and Methionine necessarily leads to higher blood levels of these nutrients, the study authors conclude, “Dietary sources of B6 are varied and include beans, grains, meats, poultry, fish, and some fruits and vegetables, whereas primary sources of methionine are from animal proteins, as well as some nuts and vegetable seeds.Given that serum levels of B vitamins and metabolites are at least partially determined by diet, and are clearly affected by vitamin supplements,low vitamin levels are therefore modifiable.” [Meaning, it seems to us, you can generate higher blood levels of these nutrients by consuming foods and supplements that contain them]

The study provided no guidance on specific dietary intake levels of Vitamin B6, Folate and Methionine. However, we have provided below links to fact sheets from the National Institutes Health’s Office of Dietary Supplements for Vitamin B6 and Folate that describe food sources and recommended daily dosage levels of dietary supplements for these nutrients. In addition, we’ve provided a link to a Wikipedia page with similar information for Methionine.

Vitamin B6
Folate
Methionine

What to do if you can’t or won’t stop smoking cigarettes?

2010-09-07T11:20:00.000-04:00

A new paper in the Journal of Clinical Nursing highlighted some of the smoking cessation challenges/barriers that exist for COPD patients who continue to smoke cigarettes. The researchers identified six core reasons given by the study participants for why they continue to smoke even though they have advanced lung disease. The six reasons were as follows:

Too late to stop now – health already compromised, can’t change it, why stop now
Finding motivation – can’t muster the willpower to try again
Guilt about continued smoking – led to depression which led to lack of desire to change
Bargaining/contemplation – need to deal w/another life issue before quitting
Need to stop – past failure at attempts to quit led to giving up trying again
Reduced quality of life – smoking provided structure/social outlet – don’t want to lose

In all of these responses (and the candid snippets of comments from study participants included in the study), there is strong sense of loss of hope. There is also a strong current of a belief that no action a smoking COPD patient can take will help them feel better. (Wilson JS, et al. ‘It’s not worth stopping now’: why do smokers with chronic obstructive pulmonary disease continue to smoke? A qualitative study. J Clin Nurs. 2010 Aug 24. [Epub ahead of print])

Comments like:

“The way I have suffered with my chest for the last two years, I say to myself is it worth it stopping now? It’s the only enjoyment I’ve got.”

“I cough and cough and I know rightly if I wasn’t smoking I would be able come up the stairs a bit better and feel a bit better. I know that for a fact like.”

“Emptiness in the house, nobody cares about me (pause) I don’t see anybody hardly… (I’m) just lonely.”

I don’t think smokers (COPD patients included) should believe there is no hope of feeling better – whether they quit now or later. Yes, smoking cessation is difficult decision to make and a harder decision to see through. The physical habit of smoking and the addiction to nicotine are very powerful inhibitors. But there are steps you can take to feel better - even if you continue to smoke.

To be clear, I am not advocating the concept that one should continue to smoke. Quite the opposite – quitting smoking is so powerfully beneficial to your health (at any stage of lung disease) that it is always the best first option you can consider.

However, I am increasingly concerned that medical professionals are so focused on smoking cessation that they do not discuss with patients other steps a cigarette smoker can take in conjunction with smoking cessation or in lieu of smoking cessation (in the event one is not ready to quit but is ready to take steps to improve their health).

It is remarkable when I read in studies and articles (and hear at conferences and symposiums) physicians make comments along the lines of, “I am reluctant to share this information with patients who smoke because they will interpret my sharing this information as me granting permission for them to continue smoking.”

While I can understand the basic sentiment behind the comment, I think it is misguided. Knowing that smoking cessation success rates are very low in general, knowing that these rates are even lower for COPD patients, knowing that in the U.S. alone there are over 40 million currently smoking adults, doesn’t it make sense to provide smokers every available option to help improve their health – whether it involves smoking cessation or not?

Imagine if doctors said to obese patients - I want you to lose weight and so I want you to change your diet. But, I’m not going to tell you to exercise until you’ve lost the weight because I don’t want you to think you don’t need to change your diet. Weight loss programs are all about combining dietary changes with exercise to improve metabolism, burn calories and increase overall physical activity. Why not the same kind of approach for smokers?

From a societal standpoint, the main goal of medical professionals and public policy makers is to lower the societal burden of smoking (meaning reduce the health care costs associated with smoking). So shouldn’t we as a society provide smokers with every option available to improve their health (including smoking cessation) in pursuit of this goal?

Statistics from bodies like the American Lung Association and U.S. Surgeon General’s office tell us that approximately 70% of current smoking adults express a desire to quit each year. Of this 70%, only 40% actually try, and of this amount only about 15% are successful in quitting for 12 months or more if you take the most aggressive/optimistic range of success rates. That means that out of approximately 43 million current smoking adults, only about 2 million adults successfully quit for 12 months or more each year.

So what does society/medicine do for the 41 million people who can’t or won’t stop smoking in a given year? Other than barrage them with new laws that restrict smoking in public, passive smoking cessation discussions in doctor’s offices, and public service announcements that also push the smoking cessation message, the honest answer is…nearly nothing outside of prescribing rescue inhalers for shortness of breath (that is until lung disease is so advanced that more intensive medical intervention is required).

But did you know, for example, there have been a number of studies conducted that demonstrate health benefits for smokers from exercise and improving nutrition/dietary intake? We’ve written articles in the past that shed more light on recent studies in these areas (links to a sampling of these articles provided below):

Exercise articles:

http://breathebetterblog.blogspot.com/2010/02/exercise-as-medicine-for-smokers_16.html

http://breathebetterblog.blogspot.com/2010/04/cardiorespiratory-fitness-reduces-lung.html
http://breathebetterblog.blogspot.com/2009/11/pulmonary-rehabilitation-as-precursor.html
http://breathebetterblog.blogspot.com/2010/04/new-study-demonstrates-pulmonary-rehab.html

Nutrition articles:

http://breathebetterblog.blogspot.com/2010/08/black-currant-shown-to-reduce-airway.html
http://breathebetterblog.blogspot.com/2010/07/n-acetyl-cysteine-reduces-airway.html
http://breathebetterblog.blogspot.com/2010/06/chinese-herb-dramatically-reduces.html
http://breathebetterblog.blogspot.com/2010/05/vitamin-c-supplementation-possible.html

Now I recognize that many smokers (especially COPD patients who smoke) find it hard to do any form of physical activity because they become breathless quickly. But guess what? Lack of physical activity actually makes breathlessness worse…greater physical activity reduces breathlessness! Exercise also lowers lung cancer risk (even if you continue to smoke) and has been shown in recent studies to improve success rates for smoking cessation.

No one expects a person who suffers from chronic breathlessness to leap up and run a marathon. One has to start slow, build a base level of conditioning, and slowly over time increase the intensity and duration of exercise. That is the core belief set behind the treatment option pulmonary rehabilitation and our Breathe Better for Life guide/CD, www.breathebetterforlife.com.

On the nutrition side, smoking seriously depletes protective nutrients in the body known as antioxidants. So much so, in my humble opinion, it is impossible for a pack-a-day-or-more smoker to consume enough antioxidant rich food to offset the effects of smoking. But, improving dietary intake and supplementing with vitamins and other dietary supplements that have good antioxidant content have been shown to reduce lung inflammation – the core cause of breathlessness in COPD patients according to the vast majority of practitioners and researchers.

Imagine then if you, as a current smoker who has not been successful in quitting, decided to start a modest exercise program and add antioxidant rich foods and/or dietary supplements to your daily routine (in consultation with your physician). Imagine then that the proactive acts each day of trying to do something healthy (while continuing to smoke) helped you feel better physically, helped you gain confidence in your ability to improve your quality of life, helped you get out and meet new people, and helped you accomplish more basic activities of normal every-day life like shopping, walking up stairs and preparing meals without pronounced breathlessness.

If you were able to do that for 8-12 weeks, wouldn’t you think that because of all of these positive changes you would be in a better frame of mind and better physical condition to attempt smoking cessation, therefore increasingly the likelihood of your success?

I think so, and from a COPD patient perspective I think it is a helluva lot better option than believing that nothing will help you feel better. From a physician standpoint, I think it’s a helluva lot better option than simply writing a prescription for a bronchodilator, providing a brochure about smoking cessation, and then waiting for the inevitable hospital admission call to come.

Misdiagnosis of COPD and the prescribing of inhaled therapies

2010-09-04T09:57:00.000-04:00

A troubling study was recently published in the International Journal of Chronic Obstructive Pulmonary Disease which highlighted that only 14% of the study subjects over the age of 40 could be confirmed with a diagnosis of COPD based on the criteria of the Global Initiative for Chronic Obstructive Lung Disease (GOLD).

The problem: 51% of the study subjects over 40 were diagnosed with COPD by the primary care physicians participating in the study and were prescribed some combination of bronchodilators or corticosteroids. That’s a pretty alarming difference and means a significant percentage of the study subjects may have received prescription medication that may not be appropriate for their reported respiratory symptoms.

The study, conducted in Spain, involved approximately 9,500 patients who had visited one of approximately 1,400 primary care physicians in Spain between May and November of 2008 complaining of respiratory symptoms and who were prescribed an inhaled therapy as a result of the visit. The research team conducting the study gathered the medical records related to the visits from each of the physicians and then looked at both the quantitative diagnostic test results reported by the doctors and the qualitative survey responses provided by the patients. (Izquierdo JL, et al. Misdiagnosis of patients receiving inhaled therapies in primary care. International Journal of Chronic Obstructive Pulmonary Disease. 2010:5 241–249)

The study team then compared the combination of the quantitative and qualitative test results with the internationally accepted criteria for establishing a diagnosis of COPD (the GOLD guidelines mentioned above) and the internationally accepted criteria for determining an asthma diagnosis (GINA – Global Initiative for Asthma). Overall, the primary care physicians diagnosed 43% of the total study population with COPD, 43% with asthma, and the remaining 14% with disease of unknown origin. When the researchers further parsed the data to look specifically at the study population over 40 years of age, they determined that the primary care physicians had diagnosed COPD in 51% of the over-40 group.

However, when the researchers applied the GOLD criteria to the over-40 study population, they found that only 14% had met all of the criteria necessary to confirm a diagnosis of COPD, not 51%! The paper’s authors noted, “These data suggest that there could be a significant percentage of patients with an incorrect or unclear diagnosis.”

In other words, many of the people diagnosed with COPD in this study might actually be suffering from a different respiratory condition (asthma, for example). It means that bronchodilators and steroids commonly prescribed for relieving temporary airway obstruction in COPD patients may not be appropriate for a large percentage of the people diagnosed with COPD in this study. As a result of the misdiagnosis, it is possible that the prescribed inhaled therapies may be masking the real respiratory condition, or may be preventing the patient from receiving an inhaled therapy that is more effective for the undiagnosed condition.

So what were the primary care physicians basing their diagnoses on? The study authors seem to indicate that the diagnoses were largely made based on the subjective judgment of the physicians involved - not based on the GOLD or GINA guidelines.

For example, in this study, of the 100% of patients prescribed an inhaled therapy as a result of a respiratory disease diagnosis determined by the participating primary care physicians, only about 50% received spirometry as part of their office visit.

Spirometry is a standard diagnostic test to determine the degree of airflow obstruction. A poor spirometry test result is not conclusive alone for diagnosing COPD but is widely considered a significant leading indicator and is one of the criteria elements of the GOLD guidelines. Spirometry is typically only administered if a physician suspects COPD based on other symptoms (there is a sizeable group of physicians opposed to providing blanket spirometry to all people who report respiratory symptoms – they view it as wasteful - so it is typically limited to those patients where COPD is suspected).

According to the research paper, of the 50% who took the spirometry test, approximately 45% of them received a functional confirmation of COPD – meaning that only 23% of the total study population had a spirometry test that indicated COPD – 100% x 50% x 45%).

So presuming the primary care physicians were accurate in their subjective judgments of other symptoms in deciding spirometry was appropriate for only 50% of the total study population, the maximum percentage of the total study population that should have received a COPD diagnosis was 23%. Yet, as state above, the primary care physicians diagnosed and treated 43% of the total study population for COPD.

Now, we suspect that some of you reading this article might conclude this must be a problem only in Spain but sadly this issue exists worldwide. We’ve written several previous articles about the misdiagnosis of COPD that you can find by visiting the archives of our blog site, www.breathebetterblog.blogspot.com, or if you are one of our e-letter subscribers, by visiting the website for your particular e-letter.

The studies we’ve highlighted in the past have dealt with under-diagnosis of COPD where this study seems to also reveal problems with over-diagnosis. Either way, there are some real problems confronting the medical profession and its ability to accurately diagnose COPD. The research team in this study seems to agree, “In conclusion, the majority of patients in our study who were receiving inhaled therapy in primary care did not have an accurate diagnosis according to current international guidelines for COPD or asthma…More initiatives for improving diagnosis accuracy in respiratory diseases must be implemented in primary care, and focusing on use of spirometry. Improving the differential diagnosis in primary care will improve the management of these common respiratory diseases and ultimately improve the health care of affected patients.”

Nordic Walking as exercise for COPD patients

2010-08-31T12:15:00.000-04:00

Many people who suffer from chronic shortness of breath tend to live sedentary lives – sitting or laying down for significant blocks of time each day. Over time, this behavior pattern leads to reduced cardiovascular fitness, degraded muscle function, bone mass loss, and has been shown in previous studies to increase the likelihood of exacerbation events (shortness of breath attacks significant enough to require an emergency room visit and/or hospitalization).

Therefore, for COPD patients and people who live with persistent breathlessness, respiratory care professionals highly recommend starting and maintaining a daily physical activity program that involves activities that require more walking and standing than sitting or laying.

To kick start this higher level of physical activity in moderate to severe COPD patients, pulmonologists can prescribe pulmonary rehabilitation. This treatment option has been shown in many studies to improve exercise capacity, reduce shortness of breath, reduce hospitalizations and improve overall patient quality of life.

However, 99% of COPD patients in the U.S. cannot gain entry to a pulmonary rehab program given the limited number of available outpatient programs and the restrictive reimbursement rules that govern admission (similar issues exist in many countries around the globe).

Further, for the lucky few who do gain entry, pulmonary rehab programs typically only last 8-12 weeks and the benefits gained during rehab only persistent long-term if the exercise, breathing technique and nutrition recommendations continue to be practiced post-rehab. Unfortunately, many COPD patients who successfully complete a pulmonary rehab program do not continue the practices and principles gained during rehab and therefore lose the conditioning benefits within one year.

As our readers know, we are strong advocates for pulmonary rehabilitation and believe COPD patients should demand their pulmonologist refer them to a program in their local area. We also believe that it is feasible for many COPD patients to start and maintain an at-home rehab-style program on their own if they can’t gain entry to a program in their area or if they have already completed a program and are on their own at this point. We created the Breathe Better for Life program based on the principles of pulmonary rehabilitation for this very purpose. To learn more, visit www.breathebetterforlife.com.

That said, given the overall low level of daily physical activity among COPD patients in general, pulmonology researchers continue to search for additional ideas beyond pulmonary rehabilitation that will help COPD patients achieve and maintain a higher level of daily physical activity for the long-term. To that end, a new Austrian research study published this month online ahead of print in the journal Respiratory Research examined a new and interesting option – Nordic Walking.

In particular, the researchers desired to know whether a 12 week Nordic Walking program would provide lasting conditioning benefits and increase daily activity levels of the COPD patients participating in the study. (Breyer MK, et al. Nordic Walking improves daily physical activities in COPD: a randomized controlled trial. Respiratory Research. 2010, 11:112 doi: 10.1186/1465-9921-11-112. epub ahead of print)

What is Nordic Walking, you ask? Simply put, it is an exercise technique that involves walking outdoors utilizing poles that look a lot like ski poles but have been modified to provide shock absorption and slip resistance. According to the research team, the specialized walking poles increase walking speed and muscle use.

In the study, the research team selected 60 COPD patients and divided them into two groups of 30 - a Control group who received “usual care” (meaning they received no exercise intervention), and a Walking group who participated in a 12 week Nordic Walking program. The Nordic Walking program involved walking outdoors at a brisk pace with the specialized poles for 1 hour, 3 days a week over the 12 week period.

The study subjects’ level of daily activity, movement intensity, exercise capacity and perceived breathlessness among other measures were all established at the outset of the study. Then at the end of the 12 week training period for the Walking group, these measures were taken again for both the Control group and the Walking group to determine the effectiveness of the training program itself. To determine whether there were lasting benefits from the Nordic Walking program, the researchers again measured the COPD patients on these same measures at 3 months and 6 months after the training program ended.

The study results showed significant improvements in the Nordic Walking group with regard to movement intensity, daily activity level, exercise capacity and perceived breathlessness. These improvements were evident at the end of the 12 week training program and were largely still present at the 3 month and 6 month post-training evaluation checkpoints.

For example, the Walking group’s mean time spent each day either walking or standing at the end of the 12 week training program increased by over 50% compared to readings taken at the beginning of the study, and the higher level of daily activity was still around 50% higher than baseline when measured again 6 months after the training program completed. The research team noted one likely reason for the maintained higher level of daily activity of the Walking group at 6 months post-training program was that 63% of the Walking group continued their Nordic Walking program on their own after the official training program ended.

In contrast to these results, the Control group saw the mean time they spent walking or standing drop by about 10% from their readings at the beginning of the study to their readings at the end of the study. Overall, the Walking group was approximately 70% more active each day than the Control group at the 6-month post-training program evaluation checkpoint.

By way of further example, at the end of the 3-month training period the Nordic Walking group members were able to walk 17% further in the 6-minute walk test (the main diagnostic tool used by the researchers to measure exercise capacity) compared to their baseline results at the outset of the study. At 6 months after the training program ended, the Nordic Walking group’s mean 6-minute walk distance was still 13% higher than it had been at baseline. By comparison, the Control group members’ 6-minute walk distance declined 3% at the 9 month evaluation checkpoint (6 months after the Walking group completed its 12 week training program) compared to their mean baseline results.

The paper’s authors concluded, “Nordic Walking has proven to be a simple, safe, and effective physical training modality for patients with COPD. Indeed, this is the first study demonstrating that Nordic Walking is feasible in patients with COPD and can improve COPD patients’ daily physical activity levels. In addition to the positive short-term effects of Nordic Walking on the physical exercise performance and daily symptoms of COPD patients, Nordic Walking created a long term effect on the training results even after an un-coached observation period of six months.”

So, Nordic Walking may be an interesting method for improving daily activity among COPD patients. It certainly seems like the combination of outdoor walking and the use of the specialized walking poles might at a minimum spice up a basic walking program and thereby make it a more interesting form of exercise to continue for a longer period of time.

New study shows dietary counseling improves COPD patient body weight and physical performance

2010-08-26T08:55:00.000-04:00

Earlier this month we reported the results of a study that showed combining nutritional supplementation with low intensity exercise training improved physical performance among malnourished/underweight COPD patients. In that study, the researchers theorized that the combination of an anabolic stimulus (exercise) with high-energy content nutritional supplementation sparked improvements in physical performance more than nutritional supplementation alone has shown in previous studies. Click here to read the article.

Now, a new Swedish study published online ahead of print reports that dietary counseling offered as part of a pulmonary rehab program improved physical performance and increased positive changes in body weight among underweight COPD patients. What’s striking about the results is that none of the COPD patients received nutritional supplementation or participated in an exercise program as part of the study. (Farooqi N, et al. Changes in body weight and physical performance after receiving dietary advice in patients with chronic obstructive pulmonary disease (COPD), 1-year follow-up. Archives of Gerontology and Geriatrics. 2010, doi: 10.1016/j.archger.2010.06.005)

While the results of these two studies seem to contradict each other on the surface, we believe they depict complementary results. Certainly, there are many studies on exercise training for COPD patients that clearly show improved physical performance with no nutrition counseling or supplementation involved. On the nutrition front, the research team in the Archives of Gerontology and Geriatrics study acknowledged that the results of the COPD patients in their study would likely have experienced even greater improvements if nutritional supplementation had been provided.

But it is interesting to note that the study subjects’ body weight and physical performance did improve at 3-months and 12-months after the initial dietary counseling based on that counseling alone. The research team speculated that the reason for the successful outcome of their study may be rooted in the longer follow-up period (12 months). By way of explanation, the article authors said, “This study differs from most of the previous nutritional studies in COPD patients, in that the nutritional intervention consisted of dietary advice alone rather than of oral nutritional supplements and that the follow-up time was longer. To achieve substantial changes in physiological functions by nutritional intervention, a longer follow-up period might be beneficial.”

In other words, past studies might have shown greater improvements in COPD patient performance and body weight due to nutritional intervention if the previous research teams had followed up with patients on their progress over a longer period of time. Most studies tend to look at performance improvement at 3-months or 6-months after interventions (exercise or nutrition). Part of the reason for shorter duration studies is to discern whether the examined interventions offer immediate, statistically significant improvements. Additionally, it is expensive to conduct longer-term studies and patient participation over longer time periods tends to wane (which skews and/or dilutes research results).

In this particular research project, 41 COPD patients were recruited after being referred to a pulmonary rehabilitation program at a Swedish hospital (20 women, 21 men). The study subjects received a nutritional assessment from a trained dietician and then were provided counseling on specific foods/portions to improve their diet. Over the course of the study, 7 patients dropped out.

The dietician analyzed each patient’s current total energy (calorie) intake as compared to the total energy intake necessary to achieve ideal body weight (IBW). The dietician did this by asking each COPD patient to recall what and how much they ate within the previous 24-hour period. The dietician then calculated each patient’s corresponding consumed calories based on their self-reported dietary intake.

At the outset of the study, the results of this analysis showed the mean energy intake of the COPD patients was 76% of the amount required for ideal body weight (meaning the patients on average were not consuming enough calories each day to reach their ideal body weight – and indeed the mean average body weight of the study subjects was 95% of their ideal body weight at the beginning of the study).

The dietician’s recommended diet plan (foods/portions) was intended to boost energy intake and bring the study subjects closer to their ideal body weight over time. For the underweight patients in the study (the significant majority of the study subjects), the recommendations including eating breakfast, lunch, dinner and 3-4 snacks each day. Foods rich in protein and calories were recommended (including meat, poultry, fish, egg, dairy products) and advice on complementing their diet with nutrient-fortified foods was provided. Then, the patients were sent on their way to follow their recommended diet plans.

The researchers had the patients return at 3 months and at 12 months after their initial dietician consultation for follow-up consultations. For those follow-up visits, each patient was provided a 3-day food log to record their dietary intake for the 3 days leading up to each follow-up visit. Again, the dietician examined the energy (calorie) content of the food logs and calculated the patients’ intakes in relation to the energy required to achieve ideal body weight.

The 3-month results showed that energy intake by the participating COPD patients rose to 90% of the energy required to achieve ideal body weight (an 18% improvement over the baseline measurement). At 12-months, this calculation climbed slightly higher to 91% (20% over the baseline measurement). As a result of the higher caloric intake over the 12-month period, the COPD patients in the study saw their mean body weight rise to 97% of ideal body weight.

The researchers also evaluated handgrip strength and the distance walked by the study subjects in 12 minutes as measures of physical performance. They took baseline readings for both measures at the outset of the study and again tested the COPD patients at 3 months and 12 months thereafter.

While both measures did improve, the most impressive result from these physical performance measures was that mean distance walked in 12 minutes rose by 18% over the baseline measure at 3-months and by 16% at 12-months. That’s pretty remarkable given that no exercise component was included in either the rehab program or as part of the follow-up regimen for the study participants.

The researchers suggested that the higher caloric intake resulting from the dietician’s recommendations boosted energy levels and strengthened muscles in the study participants which in turn allowed the COPD patients who completed the study to perform physical activity at a higher level.

So, if you are underweight and suffer from chronic shortness of breath, you might consider asking your physician to at refer you to a local dietician. After doing an initial nutritional assessment of your current diet, the dietician can/should develop a food/portion plan for you designed to boost your caloric intake (taking into account other health factors particular to your own circumstance).

In our opinion, if you do this and combine it with an exercise program you will experience gains in physical strength, endurance, and body weight. If past research is any indication, you should also benefit in terms of reduced shortness of breath and improved sense of well being.

The best resource for an exercise program geared for COPD patients is pulmonary rehabilitation. Ask your doctor for a referral to a program in your area. They are notoriously difficult to get into but you risk nothing by asking. If you can’t gain entry to a rehab program, and you need guidance for an exercise program geared specifically for people with COPD or chronic shortness of breath, we suggest you consider purchasing our Breathe Better for Life guide/CD, www.breathebetterforlife.com. Our guide recommendations are based on guidelines published by the American Thoracic Society, European Respiratory Society and the American College of Sports Medicine. If you decide to follow our recommendations, please consult with your physician first to ensure our recommendations are appropriate for your particular situation.

Alternatively, ask your doctor to recommend an exercise or walking program or consult a fitness instructor at a local health club/community center who is certified to construct exercise programs for people with chronic health conditions.

Black currant shown to reduce airway inflammation

2010-08-23T22:07:00.000-04:00

In July 2010, a group of New Zealand researchers reported that the berry fruit black currant showed promise in reducing airway inflammation in a human cell study. In particular, one of the chemical compounds present in black currant, proanthocyanidins, was shown to suppress certain proteins in the epithelial cells (the cells that make up the lining of lung tissue) that are responsible for triggering inflammation in response to the presence of allergens in the lungs. (Hurst SM, et al. Blackcurrant proanthocyandins augment IFN-gamma-induced suppression of IL-4 stimulated CCL26 secretion in alveolar epithelial cells. Mol Nutr Food Res. 2010 Jul,54 Suppl 2:S159-170)

The study focused primarily on the black currant’s effectiveness in reducing over-production of white blood cells that lead to inflammation and ultimately trigger asthma attacks, but given that the researchers speculated that black currant may help alleviate airway inflammation in general we thought the study was worthy of your attention.

As the research team explained, “The search for suitable foods as a natural alternative or as a complement to traditional therapies for the prevention and/or alleviation of inflammatory related diseases has become the focus of recent research. In particular, berry fruit consumption has been shown to alleviate lung inflammation in animal models. In this study we provide supportive evidence that blackcurrant-derived polyphenolic compounds, in particular proanthocyanidins, have the potential to modulate cellular events leading to the suppression of IL-4 and IL-13-stimulated CCL26 secretion, a primary eosinophilic chemokine that facilitates chronic lung inflammation in asthma patients.”

In the study, the researchers isolated human epithelial cells in culture. In one set of cell samples, they exposed the cells to black currant prior to introducing cell proteins known as cytokines (specifically, interleukin-4 otherwise known as IL-4, and interleukin-13, or IL-13) that signal secretion of certain white blood cells known as eosinophils (specifically CCL26) that in turn trigger lung inflammation. In effect, the researchers were trying to simulate the cell’s response to the presence of an allergen.

You see, when bacterial or fungal material is inhaled into the lungs, the cells of the lung lining detect their presence and begin secreting the proteins called cytokines that are responsible for signaling the body to produce white blood cells to attack and kill the invading bacteria or fungi.

In asthmatics, there is a miscommunication in the body between these proteins and the white blood cells which results in the production of way-too-many white blood cells. This in turn inflames the lung tissue (in effect hardening the cells due to the overload of the white blood cells crowding around). The hardening of the cells causes the cells themselves to enlarge and results in airways that constrict or narrow. This makes it extremely difficult to breathe. Scientists are not certain of the root cause that drives this miscommunication in asthmatics but suspect that the epithelial cells in asthmatics are damaged/altered by a yet-unknown source.

There is a similar mechanism in COPD patients that involves essentially the same process but typically different cytokines and different white blood cells. In the case of COPD, scientists believe the main reason for the miscommunication between the epithelial proteins and white blood cells is damage/alteration of epithelial cell structure caused by long-term exposure to cigarette smoke and other harmful airborne pollutants.

So, getting back to the study, the research team compared the black currant/cytokine exposed samples to cell samples that were exposed to cytokines alone. Then, the researchers counted the number of white blood cells (CCL26) generated in each set of cell samples. They determined that the black currant/cytokine exposed cell samples had notably fewer counts of the white blood cells compared to the cells exposed only to cytokines.

While the researchers speculated on a few reasons why black currant (and other berry fruits) may help reduce airway inflammation, there is no scientific consensus as to the precise mechanism. The article authors’ speculations included the possibility that the antioxidant properties of berry fruits such as black currant may cause certain fruit chemical compounds to bind to the cytokines thereby reducing the number of cytokines available to signal white blood cell production.

If you are interested in trying black currant, it is available in produce stores as raw fruit or juice. There are also a wide variety of black currant oil nutritional supplements available on the market. This particular study made no recommendations regarding consumption levels or dosage levels so we don’t have a dosage recommendation to offer but we did find the following dosage information on healthline.com, “As a dietary supplement, black currant is available in 500 milligram and 1,000 milligram capsules that typically contain black currant seed oil, vegetable glycerine, and gelatin. Black currant is likely safe when used at a maximum dose of 1,000 milligrams (500-1,000 milligrams are often used per day). Black currant juice is also commercially available and has been taken in doses up to 1.5 liters per day, when mixed with apple juice. Maximum doses of black currant seed oil used in clinical trials range from 4.5-6 grams per day up to eight weeks, although there is no proven effective dose, and safety has not been established. Black currant anthocyanins have been taken in doses of 7.7-50 milligrams for up to two months. Based on some herbal textbooks, there is a lack of reported toxicity concerns with black currant consumed as food or ingested in 500 milligram tablets three times a day.”
As we have counseled before regarding other nutritional supplements, please consult your physician prior to consuming black currant to ensure there are no counter-indications related to other medications you take or other aspects of your particular situation.

Long-term effectiveness of smoking cessation approaches among COPD patients

2010-08-12T14:11:00.000-04:00

A new study published in the August edition of the journal Thorax reviews the success rates of different smoking cessation approaches among COPD patients. In doing so, the results of the study seem to indicate that quitting smoking is more challenging for COPD patients than the general population of smokers. In fact, in the two most aggressive approaches evaluated, COPD patients were 27-40% less likely to achieve continuous 12-month smoking abstinence than the general smoking population. The article authors further noted a previous study which showed that COPD patients who are successful in quitting smoking are 30% more likely to relapse than the general smoking population.

Overall, the average continuous 12-month smoking cessation success rates for COPD patients in the nine studies reviewed by the article authors were very low – ranging from 1.4% abstinence among those who received no medical intervention to 12.3% abstinence for COPD patients who received the most aggressive approach (intensive counseling plus pharmacotherapy). (Hoogendoom M, et al. Long-term effectiveness and cost-effectiveness of smoking cessation interventions in patients with COPD. Thorax. 2010 Aug; 65(8):711-718)

In their study, the Dutch research team examined the results of nine previous COPD patient smoking cessation studies conducted over the past 25 years in which continuous smoking abstinence was biochemically verified after 12 months (versus self-reporting by patients). The purpose of their study was to determine the potential patient benefits and health care cost savings among the Netherlands smoking population for each of the smoking cessation options explored.

To be clear, the studies they examined were not exclusively Dutch population studies (meaning the results are not applicable only to smokers in the Netherlands). The researchers took the average results of the nine studies and extrapolated their implications across 50% of the Dutch COPD smoking population (the percentage of the Netherlands COPD smoking population that annually expresses a willingness to quit smoking).

The smoking cessation approaches evaluated were as follows:

1. Usual care – no smoking cessation counseling or pharmacotherapy (control group)
2. Minimal counseling – less than 90 minutes in total and no pharmacotherapy
3. Intensive counseling – 90 minutes or more of counseling and no pharmacotherapy
4. Intensive counseling plus pharmacotherapy – more than 90 minutes of smoking cessation counseling plus any type of pharmacotherapy (meaning they did not distinguish between types of pharmacotherapy).

The results showed that COPD patients who followed usual care had a 1.4% success rate in achieving continuous 12-month smoking abstinence. Those who pursued minimal counseling reached 2.6% while the intensive counseling group reported 6.0% success. The COPD patients who chose the combination of intensive counseling and pharmacotherapy reported the highest average 12-month continuous abstinence at 12.3%. By comparison, general smoking population studies have shown 10% success among those opting for intensive counseling and 17% abstinence among those who received both intensive counseling and pharmacotherapy.

The article authors did not speculate on reasons why COPD patients have lower success rates than smokers who have not yet developed COPD. One would think those who are suffering the greatest adverse health effects of long-term smoking would be more motivated to quit than those who are not yet exhibiting symptoms of lung disease. But regardless of the reasons, the results appear to highlight that long-term smoking cessation is a particularly tough proposition for COPD patients.

The article’s reported results reinforce our belief that respiratory care professionals should provide COPD patients greater access to pulmonary rehabilitation programs regardless of their smoking status. For those who are unaware, in the U.S. (and likely in many other countries around the globe) a very high percentage of pulmonary rehabilitation programs do not admit COPD patients who are active smokers unless they first successfully complete a smoking cessation program (meaning those unwilling to commit to quit are either denied entry or simply decide not to pursue entry).

Given that COPD patients find it harder to quit smoking (and to stay abstinent long-term) than the general smoking population, isn’t it misguided to deny those patients who can’t quit smoking a highly effective therapy for improving physical conditioning, reducing shortness of breath, improving patient quality of life, reducing COPD exacerbations, reducing COPD related hospital admissions and health costs? It’s not like smokers don’t benefit from pulmonary rehab – a number of other studies have demonstrated this fact.

We think it is misguided and it is one of the reasons we created the Breathe Better for Life guidebook and companion CD-ROM…to provide smokers and COPD patients with the knowledge and tools to begin a pulmonary rehab style exercise and nutrition program at home or at a local fitness center in the event they are unable or unwilling to gain entry to a rehab program in their area. To learn more about the Breathe Better for Life, please visit our web site at www.breathebetterforlife.com.

Low intensity exercise and nutritional supplementation effective for malnourished COPD patients

2010-08-08T16:13:00.000-04:00

A significant percentage of people with COPD are underweight and considered malnourished. For many of these COPD patients, the main reason for the malnutrition stems from a higher than normal metabolism due to the need for their bodies to work harder to generate each breath (even at rest) compared to people with healthy lung function. Additionally, the act of eating food is more demanding and less satisfying for many people with COPD due to difficulty in swallowing, persistent coughing, chronic sputum secretion, and general shortness of breath.

As a result, many underweight COPD patients have suppressed appetites and eat less food than their bodies’ need to meet the heightened energy requirements to simply keep breathing. By eating less food, underweight/malnourished COPD patients also have less energy and therefore are more sedentary. Being sedentary leads in turn to a condition known as muscle wasting where the combination of low nutrient intake and lack of exercise/movement causes the body’s muscles to become weak and dysfunctional.

In past COPD nutrition studies, researchers have sought to test different ways of delivering calorie rich foods and nutritional supplements to help patients add weight, build lean muscle, boost energy, and increase exercise capacity. The results of these studies have been mixed.

A new study published in June 2010 in the journal Respiratory Medicine took a fresh look at this problem and proposed a new solution – combine nutritional supplementation with a low intensity pulmonary rehabilitation exercise program. The study team speculated that nutritional supplementation alone is not sufficient to produce desired conditioning benefits because the body also needs an anabolic stimulus (exercise) to build muscle mass and improve physiologic function.

In the study, a group of Japanese researchers enrolled 32 moderate to severe COPD patients. The patients were divided into two groups. The control group of 15 patients did not receive nutritional supplementation and did not participate in an outpatient pulmonary rehab program. The nutrition/exercise group consisted of 17 patients who underwent a 12 week program of low intensity exercise and oral nutritional supplementation. This group also received other core elements of pulmonary rehabilitation such as breathing training and counseling/education on other aspects of COPD disease management.

The nutritional supplementation provided to the nutrition/exercise group consisted of two 200ml packages of a nutritional drink each day that contained 60% carbohydrates, 25% fat, and 15% protein. The nutrition drink provided an extra 400 calories per day, and included Omega-3 polyunsaturated fatty acids and vitamins (the study does not describe what specific vitamins were supplemented but does indicate that the vitamins incorporated in the drink were primarily antioxidants).

The daily nutrition/exercise group exercise training consisted of 15 minutes of walking, strength training exercises for both upper and lower body, calisthenics and respiratory muscle stretching. The intensity level targeted for these exercises was 40-50% of maximum oxygen consumption (a measure of peak oxygen usage for each patient, established at the outset of the program). At this level, the exercise was considered low intensity.

One interesting note is the nutrition/exercise group only trained in the outpatient pulmonary rehab center one day every two weeks of the 12 week study. The rest of their training was supposed to take place unsupervised at home – which is putting a lot of faith in the exercise compliance of the nutrition/exercise group.

The researchers found that the nutrition/exercise group experienced significant increases from the beginning of the program to the end of the program (as compared to the control group) in quadriceps muscle force, walking endurance, body weight, weight bearing capability, and self-reported health status. For example, the nutrition/exercise group’s mean quadriceps muscle force rose 21% over the course the 12 week program while the control group’s quadriceps force declined by 3%. The nutrition/exercise group’s mean performance on the 6 minute walk test (a measure of walking endurance) improved 6% while the control group declined by 11%. The mean ability to bear weight rose by 15% for the nutrition/exercise group but remained flat for the control group.

Separately, the researchers also measured whether the combination of nutritional supplementation and low intensity exercise reduced airway inflammation in the nutrition/exercise group of COPD patients. The study results demonstrated that the combination of exercise and nutrition supplementation did in fact reduce counts of proteins known as “cytokines” that are general indicators of the presence of tissue inflammation.

In response to inflammation, cytokines are released by cells in the lining of the lungs and signal the body to react to suppress the inflammation. A high cytokine count is indicative of significant inflammation and vice versa. Over the 12 week program, the nutrition/exercise group saw mean cytokine counts for the three types of cytokines evaluated (interleukin-6, interleukin-8, and Tumor Necrosis Factor-alpha) drop 10%, 45% and 22% respectively. By contrast, the control group cytokine counts for these types rose 44%, 58% and 24% respectively. These are significant differences and clearly demonstrate the effectiveness of the nutrition/exercise intervention.

The research team concluded, “our data suggest a potential role for the combination of nutritional support and low-intensity exercise, and that this combination may improve the outcomes of exercise tolerance and health-related QOL (quality of life) in patients with malnourished COPD. Thus a combination of nutritional support and low-intensity exercise may provide a new therapeutic approach for pulmonary cachexia (muscle wasting).”

Pursed-lips breathing technique improves inspiratory capacity in COPD patients

2010-08-05T08:00:00.000-04:00

An abstract of new study published online ahead of print in the journal Respiration highlights the benefits of a breathing technique known as pursed-lips breathing (often referred to as PLB by respiratory care professionals). Specifically, the researchers reported that inspiratory capacity (the maximum of volume of air inhaled by the lungs from a fully expired state) increased significantly in the 35 severe COPD patients tested during the study. (Visser FJ, et al. Pursed-Lips Breathing Improves Inspiratory Capacity in Chronic Obstructive Pulmonary Disease. Respiration. 2010 July 17 [Epub ahead of print])

Pursed-lips breathing is a highly effective breathing technique taught by respiratory therapists and other pulmonology professionals in pulmonary rehabilitation programs to help COPD reduce the sensation of breathlessness before, during or after exercise or other strenuous activities. Despite its effectiveness, it is remarkable to me how many COPD patients have never used it or heard of it.

PLB has been shown in previous studies to help moderate to severe COPD patients improve pulmonary gas exchange, reduce hyperinflation of the lungs, improve physical function and reduce oxygen desaturation in the lungs. In one recent study, 32 COPD patients who used pursed-lip breathing immediately before walking boosted the time they were about to walk before fatiguing by 16%. (Faager G, et al. Influence of spontaneous pursed lips breathing on walking endurance and oxygen saturation in patients with moderate to severe chronic obstructive pulmonary disease. Clin Rehabil. 2008 Aug;22(8):675-83)

Pursed-lips breathing works like this - first, with your mouth closed you breathe in through your nose for 2-3 seconds. Then, you purse your lips (like you are blowing out candles on a birthday cake or blowing bubbles through the small opening of a bubble wand) and blow air out through your pursed-lips for about twice as long as you inhaled through your nose (approximately 4-6 seconds).

This technique works because narrowing the opening of your mouth when you exhale creates back pressure. Back pressure helps you blow out more used air from your lungs. And that’s the core of the issue when you feel short of breath. While it feels like you can’t breathe in fresh air, the real issue is that you have too much used air trapped in your lungs. Until you can get the used air out, it doesn’t matter how hard you try to breathe in. Your lungs don’t have the capacity to accept a large volume of fresh air when you have used air dominating your airway passages. PLB helps clear out the used air more quickly so that more fresh air (and hence, more oxygen) can be taken in by your lungs. In turn, PLB helps reduce shortness of breath related to walking, climbing stairs, exercising, and other vigorous activities. This is likely the mechanism that increased inspiratory capacity in the COPD patients in the Respiration study mentioned above. By clearing out more old/used air using PLB, the lungs are in a better position to absorb a greater maximum volume of fresh air when inhaling.

A simple example to demonstrate how PLB works – face the palm of one of your hands a couple of inches from the opening of your mouth and exhale for 3 seconds without pursing your lips. Now, exhale again on the palm of your hand using the pursed-lips breathing technique for 3 seconds. If you’ve executed PLB correctly, you should have noticed a significant difference in the force of air hitting your hand when using PLB versus exhaling normally from your mouth.

Though I don’t have COPD nor have I ever smoked cigarettes, I use the pursed-lips breathing technique frequently when I climb long flights of stairs and when I’m feeling short of breath when running or working out in the gym. I have to say I’ve been very impressed at two effects of PLB when I use it. First, I definitely believe it helps me reduce shortness of breath in a relatively short time frame. Second, and more surprising to me, is the sensation I get when using PLB that I am in greater control of my breathing rhythm during vigorous activity which to me has a calming/relaxing effect.

For a printable sheet demonstrating the pursed-lips breathing technique taken from our Breathe Better for Life CD-ROM, click here. For more information about our Breathe Better for Life guidebook and CD-ROM, visit www.breathebetterforlife.com.

Wood smoke exposure, COPD and chronic bronchitis

2010-08-02T15:10:00.000-04:00

Outside of the United States a number of research studies have looked at the connection between wood smoke, COPD and chronic bronchitis. While cigarette smoke exposure remains the number one cause of developing COPD worldwide, wood smoke exposure has been identified as a major contributing factor in many countries that utilize wood as a room heating and cooking heat source.

A new study published this month online ahead of print in the American Journal of Respiratory and Critical Care Medicine examines the connection between wood smoke and COPD/chronic bronchitis diagnosis in the United States. In the study, the research team found a significant correlation between wood smoke exposure and COPD/chronic bronchitis diagnosis among current smokers (and further noted higher odds among people of Hispanic origin and men of all origin). (Sood A, et al. Wood Smoke Exposure and Gene Promoter Methylation are Associated with Increased Risk for COPD in Smokers.Am J Respir Crit Care Med. 2010 Jul 1. [Epub ahead of print])

As the study authors explained, “In developed countries, people are exposed to wood smoke in a variety of ways, including smoke from residential heating, cooking stoves, campfires, forest fires, and prescribed fires. Wood burning is an important contributor to particle and gaseous material in ambient air, and in some locations accounts for up to 80% of the airborne particle concentrations during the winter...Wood burning not only increases indoor but also outdoor ‘neighborhood’ pollution; thereby exposing many non-users to wood smoke components… Wood smoke is a complex mixture of numerous volatile and particulate substances constituted by different organic and inorganic compounds known to be toxic or irritating to the respiratory system. Its composition varies with the wood type and the conditions of combustion. More than 200 chemical and compound groups have been identified, most of which are in the inhalable size range…Exposure to wood smoke in developed countries tends to be at sustained low-levels unlike exposure to cigarette smoke that is short-term but intense with a single cigarette…

Our study contrasts with most studies conducted outside the United States that have focused on non-smokers. Our population of relatively older smokers may be particularly susceptible to the adverse respiratory effects of wood smoke exposure, compared to the general population. This conclusion is supported by the observed additive effect between current cigarette smoke and wood smoke exposures on COPD phenotypes. Furthermore, these epidemiological findings are substantiated by our laboratory findings in which pulmonary inflammation and pathological changes were enhanced in mice concurrently exposed to wood smoke and cigarette smoke compared to cigarette smoke alone”.

In the study, researchers examined the medical records of the Lovelace Smoker Cohort. A Cohort is a group of people who have agreed to participate in an ongoing study, typically conducted over a generation. In such studies, subjects submit to periodic medical tests and examinations over time and also answer periodic surveys regarding a variety of health information. The Lovelace Smoker Cohort follows approximately 2,000 New Mexico residents who identified themselves as ever-smokers (study participants enrolled between 2001 and 2007).

The research team sampled approximately 1,800 relevant subjects from the cohort and reviewed surveys completed this sampling to identify those who self-reported exposure to wood smoke (approximately 500 people). Then the researchers examined spirometry results and sputum samples taken periodically for both the group exposed to wood smoke/cigarette smoke and those who were only exposed to cigarette smoke.

They discovered that those who were exposed to wood smoke and reported themselves as current cigarette smokers had a 116% higher odds ratio of being diagnosed with COPD than study subjects who were current smokers but were not exposed to wood smoke. Additionally, those exposed to wood/cigarette smoke had a 46% higher odds ratio of being diagnosed with chronic bronchitis.

Further, the study results revealed that the odds ratio of developing COPD among former smokers exposed to wood smoke was 36% higher than current cigarette smokers not exposed to wood smoke. This result implies that wood smoke is potentially more harmful than cigarette smoke in the odds of developing COPD. However, in contrast of this result, former smokers exposed to wood smoke had a 46% lower odds ratio of developing chronic bronchitis as compared to current smokers exposed to cigarette smoke only. So, there does not appear to be a correlation between wood smoke exposure and chronic bronchitis among former smokers.

Overall, the study seems to indicate that current smokers who regularly utilize wood as a cooking, heating, or brush removal fire source dramatically increase their odds of developing COPD and/or chronic bronchitis. If you are both a current smoker and are exposed to wood smoke frequently, these results suggest you can significantly reduce your odds of developing COPD and chronic bronchitis by halting your exposure to wood smoke. That is not to say that doing so will prevent you from being diagnosed with COPD and/or chronic bronchitis, especially if you are a current smoker. But any positive step you can take to avoid regular exposure to pollutants/irritants (such as wood smoke) that contribute to persistent airway inflammation and sputum production is surely a step in the right direction.

Pulmonary rehab effective in reducing overall COPD health care utilization

2010-07-30T13:33:00.000-04:00

A revealing study published this month in the Kuwaiti journal Medical Principles and Practice showed significant health care utilization reductions for COPD patients who completed a pulmonary rehabilitation program.

The study was conducted in Saudi Arabia at the ONLY pulmonary rehabilitation clinic in the country. The results of the study echo similar results of studies conducted in other countries around the world – pulmonary rehabilitation consistently reduces subsequent emergency room visits, hospital stays, and length of hospital stays. Additionally, this study also demonstrated significant reductions in the use of antibiotics, steroids, and short-acting bronchodilator inhalers about the COPD patients who completed a pulmonary rehab program – a novel finding as depicted by the study author. (Al Moamary MS. Health care utilization among chronic obstructive pulmonary disease patients and effect of pulmonary rehabilitation. Med Princ Pract. 2010, 19(5):373-378, Epub 2010 Jul 14)

In this study, the research team looked retrospectively at the medical records of 50 COPD patients who were admitted to the King Abdulaziz Medical City Pulmonary Rehabilitation Center between 2004 and 2008. All of these patients had been initially admitted to the hospital for an acute exacerbation (a shortness of breath/coughing attack severe enough to require hospitalization) shortly immediately preceding enrollment into the rehab program. Of the 50 patients, 27 completed the pulmonary rehabilitation program (hereafter referred to as the compliant group) and 23 did not (noncompliant group).

The researchers sought to evaluate the differences between the compliant group and non-compliant group over the following 12 month period in terms of subsequent hospital visits/stays and prescription medication usage compared to the 12 months leading up to their entry into the pulmonary rehab program. The results were dramatically different between the two groups.

For example, the compliant group saw a 51% decrease in subsequent outpatient clinic visits, 60% decrease in emergency department visits, and a 72% drop in the length of hospital stays compared to their pre-pulmonary rehab experiences. By comparison, the non-compliant group visited outpatient clinics 14% more after bailing out of the pulmonary rehab program, visited emergency departments 14% more and experienced a mean increase in average hospital length of stay of 90%!

You could not paint a more convincing picture of the divergent experiences of COPD patients who pursue and complete pulmonary rehab programs versus those who don’t. These results are not novel – as mentioned above, previous studies around the globe have shown similar results (some more dramatic, others less dramatic – but the majority showing statistically significant differences in subsequent health care utilization). It makes you really scratch your head when you realize that even in the U.S. only 1-2% of COPD patients are ever admitted to a pulmonary rehab program. If there is a serious interest in reducing overall health care costs related to COPD (for both providers and patients), pulmonary rehab should become a standard treatment option for ALL COPD patients.

Separately, regarding subsequent usage of antibiotics, steroids, and short-acting bronchodilators, the Saudi Arabian study showed significant drops in reliance on these pharmacological agents in the compliant group compared to the non-compliant group.

Among the compliant group, short-acting bronchodilator use dropped 51%, antibiotic courses fell 53% and cumulative steroid dosage decreased by 31% compared to usage levels prior to entering and completing pulmonary rehabilitation. By comparison, the non-compliant group saw their usage of these three pharmacological options rise by 5%, 31% and 38% respectively. These are all significant differences and further reinforce the value of pulmonary rehabilitation.

As an aside, the researchers also reported that the compliant group saw their walking endurance rise 121 meters in the 6 minute walk test (a 54 meter rise is considered statistically significant by most researchers). Again, a clear indication of the power of pulmonary rehab.

The rehab program followed during the study was described the research team as follows, “1-hour session, 2–3 times per week over 8–12 weeks for a total of 18–24 sessions in an outpatient setting. The patients were discharged from the PR program at 8 weeks provided that they had completed 18 sessions or that they would complete 18 sessions within 8–12 weeks. The program consisted of exercises combining track or treadmill walking, upright cycling, stair stepping and arm ergometer. Direct small group education sessions were conducted by the PR physiotherapist. Both the exercise and education programs were carried out as previously described. The program provided exercise therapy consisting of combination treadmill or track walking, upright cycling, stair stepping and arm ergometer. The intensity of the exercises was individualized based on the patient’s tolerance, physiological parameters and PR physiotherapist judgment. Aerobic exercises comprised upper extremity, lower extremity, flexibility and strength. The educational component included modules covering obstructive and restrictive lung diseases, breath retraining, pulmonary hygiene, dietary modification, risk factor modification, pulmonary medications and equipment, stress management/relaxation, smoking cessation advice, exercise benefits, musculoskeletal injury prevention and overall pulmonary disease intervention.”

As regular readers of our e-letters and blog are well aware, we are strong proponents of pulmonary rehabilitation for COPD patients (and anyone else who suffers from chronic shortness of breath). If you can gain entry to a program in your area, we highly endorse participating in the program. If you can’t gain entry, there are still many aspects of pulmonary rehab you can practice at home or in a fitness center. We created our Breathe Better for Life guide and CD-ROM to assist COPD patients and others who suffer from persistent breathlessness with the resources to start such an at-home or fitness center based program (in consultation with your personal physician of course). Our program is based on guidelines established by the American Thoracic Society, European Respiratory Society, and the American College of Sports Medicine and has been reviewed and edited by prominent respiratory care professionals. To order Breathe Better for Life, visit www.breathebetterforlife.com.

COPD and walking abnormalities

2010-07-26T19:32:00.001-04:00

Muscular dysfunction is a common symptom of COPD patients and is most often related to lack of physical activity. People who suffer from chronic shortness of breath tend to limit physical activity in order to avoid dyspnea events (shortness of breath episodes). The downside of limiting physical activity for an extended period of time is that as a person becomes more sedentary, the body loses its cardiovascular and muscular conditioning. This in turn results in persistent fatigue, greater dyspnea events and creates a vicious cycle of physical de-conditioning. One way this de-conditioning is evidenced is through walking gait abnormalities such as limping and shuffling as muscle fibers change/weaken from lack of use.

A new study published this month online ahead of print examined the association between walking abnormalities and COPD and determined there is a direct correlation between the presence of walking abnormalities and severity of COPD. (Yentes J, et al. Walking abnormalities are associated with COPD: An investigation of the NHANES III dataset. Respiratory Medicine. 2010 Jul 6. Epub ahead of print)

According to the study authors, while other research studies have examined the connection between COPD severity/physical activity level related to respiratory function, muscle strength, and cardiovascular conditioning, this is the first study to examine the association between COPD severity and walking gait abnormalities. As the researchers explained, “There is evidence that lack of physical activity contributes to peripheral muscle abnormalities and dysfunction.

Disuse of the muscular system can result in muscular atrophy, decreased muscle strength, increased muscle fatigability, reduced oxidative capacity, and capillary loss…These muscular impairments may also lead to abnormal walking patterns; however this has not previously been tested in COPD.”

In their study, the researchers sampled medical records of approximately 8,400 U.S. adults from the NHANES III database. The NHANES III database contains the medical records of over 31,000 U.S. adults who agreed to be examined and surveyed between 1988 and 1994 and is sampled in a wide range of medical research.

The 8,400 patient records were selected based on criteria established by the research team, including age, walking status, and respiratory function measures. Once selected, the research team then examined the statistical relationship between COPD severity and walking gait abnormalities (defined in the study as either a chronic limp or shuffle). They determined that severe COPD patients had almost 2 times the odds of a walking gait abnormality compared to those with mild or moderate COPD (there was not a statistically significant difference between mild and moderate COPD patients).

They researchers concluded, “The novel finding is that COPD is related to walking abnormalities. When using a comprehensive classification scheme for COPD status, a significant association between severe COPD status and walking abnormalities was observed. From clinical point of view, reduced physical activity in daily life and impaired muscle strength are the most likely causes. This was confirmed as demonstrated by decreased physical activity being significantly associated will all levels of COPD severity. These results strengthen the novel findings by demonstrating the importance of physical activity and the effect of inactivity on walking abnormalities.”

We wholeheartedly agree with this last statement. Research study after research study has shown that physical activity/exercise in COPD patients actually reduces fatigue and shortness of breath events in addition to building cardiovascular function, stronger muscle fibers, and higher quality of life. These are the primary goals behind the treatment option known as pulmonary rehabilitation and are the basis of our exercise recommendations in the Breathe Better for Life guidebook, www.breathebetterforlife.com.

While the study authors do not suggest that COPD patients who have walking gait abnormalities may see the abnormalities diminished or eliminated by engaging in regular physical activity/exercise, they do suggest that there is likely a correlation between inactivity and the development of walking abnormalities.

Whether regular physical activity/exercise can reverse a walking gait abnormality or not, the other benefits gained by COPD patients from regular physical activity/exercise are unambiguous. As the study authors offered, “…studies have demonstrated positive effects of exercise training on COPD patients. These positive effects include increased muscular size, strength, power, endurance, mitochondrial capacity, and restoration of protein levels.”

29% of people with persistent cough undetected for COPD in new study

2010-07-21T12:40:00.001-04:00

One of the greatest challenges facing pulmonology professionals worldwide is under-diagnosis of COPD. In fact, many researchers estimate that the number of worldwide undiagnosed COPD cases are equivalent to diagnosed COPD cases - meaning for every one person with a COPD diagnosis there is one additional person who has COPD but is unaware they have the condition. That’s astounding when you consider that in the U.S. alone, there are over 13 million people who’ve already been diagnosed with COPD. There are a variety of reasons why the under-diagnosis dilemma exists.

First, many people who have COPD-like symptoms (e.g. recurrent bouts of persistent cough, heavy sputum, breathlessness) don’t go to see their doctor unless and until they have an exacerbation event (a term meaning a shortness of breath attack severe enough to require an emergency room visit and/or hospital stay). For example, we wrote about a UK study in April 2010 that showed 34% of people admitted for a first-time exacerbation event to UK hospitals participating in the study were previously undiagnosed for COPD. Of these people, 57% already had severe COPD before they were diagnosed. To read more about that study, click here.

Second, many people who do seek out a doctor’s evaluation tend to first visit their general practitioner. Many general practitioners address the COPD-like symptoms with a combination of antibiotics (to reduce sputum and persistent cough), bronchodilator inhalers (to temporarily open up airways and relieve acute breathlessness), and smoking cessation counseling. These are all reasonable treatment solutions to address the patient’s immediate symptoms but often times this is where the general practitioner stops. They do not often administer spirometry tests (one of the few diagnostic tests available to identify whether COPD is indicated) and do not often refer patients to pulmonologists for lung function testing.

By way of illustration, this month a Dutch team of researchers reported their findings of a 3 year study looking at undetected cases of COPD among 353 Dutch citizens who visited 73 general practitioners between 2006 and 2009 complaining of persistent cough. They found that 29% of the study participants (39% of men and 21% of women) over the age of 50 who visited their GP for persistent cough lasting 14 days or more had undetected COPD. In addition, 7% of men and women evaluated during the study were found to have undetected asthma. (Broekhuizen B, et al. Undetected chronic obstructive pulmonary disease and asthma in people over 50 years with persistent cough. British Journal of General Practice. 2010; 60:489-494)

Further, in a Canadian study we wrote about in our above mentioned April 2010 article, nearly 67% of people visiting their GP reporting one or more respiratory symptoms were unaware they had COPD and were not diagnosed by the GP during his/her evaluation.

Third, when people do receive spirometry (whether from a pulmonologist or a GP), the results of the tests are often either interpreted incorrectly or do not indicate the presence of COPD (even though other respiratory symptoms indicate COPD). In March 2010, we reported the findings of a Swedish study that showed that nearly 70% of patients in their study had initial spirometry tests that did not confirm a diagnosis of COPD. To read more about this study, click here.

This combination of factors means that tens of millions of people worldwide do not receive access to the full range of treatment options for COPD early in the development of their condition. As a result, when COPD is finally diagnosed, most “previously undiagnosed” patients are already considered moderate to severe (in the Canadian study mentioned above, 21% of the people who were finally diagnosed with COPD after their GP did not detect COPD actually were later confirmed with severe COPD).

As we’ve counseled before – if you suspect that shortness of breath, persistent cough or an increase in sputum secretion is increasingly affecting your ability to participate in everyday activities you owe it to yourself to see your doctor ASAP. Yes, you’ll probably have to undergo some tests and you will likely hear an earful about stopping smoking, exercising more and/or changing your dietary habits (all excellent recommendations for making an immediate impact on your shortness of breath). You’ll also likely receive a prescription for a prescription inhaler such as Spiriva, Advair or Combivent and you may be prescribed antibiotics.

When you visit your doctor, ask for a referral to a local pulmonologist and in turn ask the pulmonologist to order a spirometry test. You are far more apt to get a correct diagnosis by seeking an evaluation from a qualified pulmonologist trained to administer and interpret spirometry results than through any other means. In the end , you have a far better chance of limiting the ravaging effects of severe lung disease by seeking treatment sooner rather than later – even if some of the prescribed solutions mean altering your long practiced habits.

If you are unfamiliar with the treatment options available for COPD, we have detailed the full range of treatment options in our Breathe Better for Life guide and companion CD-ROM. We developed the guide and CD to provide people who suffer from chronic shortness of breath with self-management strategies for reducing shortness of breath, improving physical conditioning, and improving overall quality of life (whether you have COPD already or you are a current/former smoker and you'd simply like to breathe & feel better). However, our guide and CD describe the full range of COPD treatment options including pictorial demonstrations. To purchase the guide and CD, visit www.breathebetterforlife.com.

Depression, smoking and exercise

2010-07-18T12:39:00.001-04:00

In April 2010, the U.S. National Center for Health Statistics (NCHS) published a report detailing their findings about the association between depression and smoking. The report showed that 43% of Americans who report being depressed are current smokers. The report further demonstrated that depression was most severe in the heaviest of smokers. (Pratt LA, Brody, DJ. Depression and Smoking in the U.S. Household Population Aged 20 and Over, 2005-2008. NCHS Data Brief. 2010 April; (34)1-8).

Overall, depression among adults over the age of 20 is only reported by 7% of the total U.S. adult population, but that still represents over 15 million people. By comparison, the total number of confirmed COPD cases in the U.S. is around 13 million people so depression is clearly a significant societal issue.

The NCHS-reported 43% depression rate among current smokers implies that approximately 6.5 million of the 15 million people in our country suffering from depression are current smokers. Since there are approximately 43 million current smokers in the U.S., the 6.5 million smokers reporting depression represent about 15% of total current U.S. adult smokers.

Among the other significant findings reported by NCHS is the fact that 51% of smokers who light up their first cigarette of the day within 5 minutes of waking up report depression. By contrast, only 23% of smokers who waited over 30 minutes before consuming their first cigarette of the day reported depression. In addition, those who smoked the most (2 packs a day or more) reported the most severe depressive symptoms.

The report authors speculate that current smokers’ depression is largely related to frustration about the inability to quit smoking. We agree with that speculation and would further add concern/frustration among smokers about other elements of their health status (poor diet, breathlessness, and other conditions such as hypertension, heart disease and diabetes).

Is there a way out for smokers who are clinically depressed?

Most doctors will focus first and foremost on recommending smoking cessation. However, as most smokers who’ve attempted to quit in the past (successfully or unsuccessfully) can attest – it is excruciatingly difficult to do. A slew of research continues to search for aids to help improve smoking cessation success but thus far the “successful” results are modest at best. Though smoking cessation statistics vary by source quoted, it is safe to say that of the 43 million current smokers in our country, approximately 70% report a desire to quit each year, 35-40% actually try in a given year, and about 5-15% of the people who try are successful in abstaining for more than 1 year.

A common treatment option for depressive symptoms among smokers is to prescribe anti-depressant drugs such as Chantix. While these drugs taken alone, or combined with nicotine replacement can boost cessation success rates, they also have scary potential side effects.

But if you’re in a situation where you either have tried to stop smoking and can’t, or you are just not ready to try quitting, what do you do?

We think it is worth considering exercise. Now, you may chuckle at this suggestion but there have been a number of studies showing exercise’s benefits for smokers in the following ways:

- Slowing the progression of lung disease (click here to read more)
- Improving physical conditioning, reducing shortness of breath, and Improving sense of well being/quality of life (click here to read more)
- Enhancing smoking cessation success rates (click here to read more)
- Reducing the incidence of lung cancer (click here to read more)

In addition, there is evidence that exercise among people who exhibit depressive symptoms does modestly improve sense of well being though this review of depression/exercise studies does not specifically evaluate depression among smokers. (Mead GE, et al. Exercise for depression. Cochrane Database Syst Rev. 2009 Jul 8;(3):CD004366)

We’re not saying exercise will cure depression but we think it may help. Specifically, we are saying that if your depression stems from frustration that you can’t seem to quit smoking and you’re not ready to try again right now, there is a viable option to consider beyond prescription anti-depressants (exercise). Further, we are saying that there is evidence that improving your physical conditioning prior to smoking cessation or in conjunction with smoking cessation can boost success rates (ala the links to other articles we’ve written on these topics).

It also makes intuitive sense to us – if you’re in a position where you feel you are not in control of your health (i.e. you want to quit smoking but can’t seem to do it), taking any positive steps to improve your health improves your sense of well being. Improving your sense of well being sounds like relieving depression to us, and if exercise can improve your physical conditioning and sense of well being, it’s quite possible that it will be easier for you to consider stopping smoking.

If you want to begin an exercise program, where do you start? Well, the most likely concern about beginning an exercise program if you are a current smoker is the high likelihood you will experience an uncomfortable degree of breathlessness. That’s where the principles of pulmonary rehabilitation come into play. Exercise programs in pulmonary rehab are specifically designed to help people who suffer from chronic shortness of breath start out at a manageable level and then increase the intensity and duration of exercise over time in an effort to lessen the likelihood and severity of shortness of breath attacks (known as dyspnea). For most smokers though, gaining entry to a pulmonary rehab program without completing a smoking cessation program first is almost unheard of. There is a strong bias against offering current smokers entry even though physicians agree smokers can significantly benefit from this valuable treatment option (a chicken and egg problem of modern pulmonary medicine).

That is one of the reasons why we developed the Breathe Better for Life guidebook and companion CD-ROM. We scoured the research, visited pulmonary rehab centers, and consulted leading respiratory care professionals to construct an at-home or fitness center based exercise program for people who suffer from chronic shortness of breath (whether you quit smoking first or not). To learn more about purchasing Breathe Better for Life, visit www.breathebetterforlife.com.

Whether you consider our exercise program in consultation with your physician, or begin one recommended by your physician, it is highly worth your time to give exercise a shot. There is so much health benefit upside for current smokers from an active, ongoing exercise program and in our opinion, it may make a significant difference about how you feel about yourself, your prospects, and ultimately your ability to stop smoking.

N-acetyl-cysteine reduces airway inflammation caused by cigarette smoke

2010-07-14T12:08:00.000-04:00

A new study published in the Chinese Medical Journal demonstrated the effectiveness of the powerful antioxidant, N-acetyl-cysteine (commonly referred to as NAC), in reducing airway inflammation in rats exposed to cigarette smoke.

Buyers of our Breathe Better for Life guidebook and readers of our e-letters and blog know we are a strong proponent of NAC for its effectiveness in boosting exercise tolerance among COPD patients undergoing pulmonary rehabilitation (click here to read more) and its previously studied ability to reduce COPD exacerbations.

To begin, NAC is an amino acid that stimulates the body’s production of glutathione. According to the Chinese Medical Journal study authors, “glutathione (GSH) appears to be an important antioxidant in the lungs and is present in high concentrations in epithelial lining fluid [the epithelium is the smooth coating/lining of the bronchioles in the lungs]”. Glutathione is not particularly absorbed well by the body in nutritional supplement form and so researchers tend to utilize NAC since it stimulates the body’s own production of GSH. That said GSH is absorbed well by the body in foods such as asparagus, avocado, cabbage, broccoli, brussels sprouts, walnuts, dill seeds, caraway seeds, and some cooked fish.

Previous studies have shown that cigarette smoke exposure reduces GSH levels in epithelial tissue and damages the epithelial lining. A number of researchers have speculated that these two events are related but no one to date has definitively proved the connection.

In this study, the research team focused on a particular type of cell that is highly present in the epithelial lining called a Clara cell. These cells secrete a protein known as CC16 that is believed to be a protective agent against inflammation and infection. According to the study authors, previous studies have shown that in COPD patients and smokers that Clara cell and CC16 levels are decreased compared to healthy epithelial tissue.

So the researchers set out to determine whether laboratory rats exposed to cigarette smoke experienced a drop in Clara cells and CC16 protein and a corresponding increase in airway inflammation. Further, the researchers wanted to know whether oral supplementation of NAC would increase the number of Clara cells and CC16 protein and, by virtue of these increases, reduce airway inflammation. (Liao J, et al. Effects of N-acetyl-cysteine on Clara cells in rats with cigarette smoke exposure. Chin Med J 2010; 123(4):412-417)

The 18 laboratory rats in the study were divided into three groups. Group 1 (the Control Group) received no cigarette smoke exposure and no NAC supplementation. Group 2 (Cigarette Group) received exposure to cigarette smoke from 10 cigarettes 3 times a day for 30 minutes over the course of 1 week but no supplemental NAC. Group 3 (NAC Group) was exposed to an equal dose of cigarette smoke as Group 2 but also received 80mg of NAC per kilogram of body weight each day they were exposed to cigarette smoke.

Even though the study lasted only one week, the rats in the Cigarette Group had a 33% lower count of Clara cells and a 50% lower count of CC16 protein molecules in respiratory epithelial lining tissue compared to the Control Group. According to the research team, the Cigarette Group also had a 164% higher count of observed small airways in lung tissue samples examined under microscope compared to the Control Group (their measure of airway inflammation).

While the NAC Group also had lower counts of Clara cells and CC16 protein compared to the Control Group, the gaps in counts were significantly lower than the Cigarette Group. Clara cells in the NAC Group were 22% lower than the Control Group (as opposed to 33% lower for the Cigarette Group). CC16 protein counts were 33% lower (compared to 50% lower in the Cigarette Group), and the number of small airways observed under microscope for the NAC group was only 24% higher than the Control Group (versus 164% higher in the Cigarette Group).

So it appears that while NAC was not successful in this study in completely offsetting the impact of cigarette exposure it did significantly lessen the impact of cigarette smoke on Clara cell count, CC16 protein count, and on the number of small airways present in observed in the rat lung tissue samples.

This study utilized 80mg/kg of laboratory rat body weight but there is no guidance offered by the researchers for what an appropriate human dosage level would be to achieve similar results. Previous human studies on NAC for COPD patients have examined daily dosage levels of 300mg, 600mg, and 1200mg though there is no consensus/standard recommendation regarding human dosage levels for reducing airway inflammation. The recent study regarding NAC’s effectiveness in improving exercise tolerance we mentioned above utilized a daily dosage of 1200mg. Among our other nutritional supplement recommendations for people who suffer from chronic shortness of breath, our Breathe Better for Life guidebook recommends 300-600mg of NAC once or twice daily based on the previously published research studies we’ve reviewed.

NAC is widely available as a nutritional supplement online and in retail stores in 300mg and 600mg dosage levels for $10-$30 for a 30 day supply depending on dosage level chosen. Please consult your physician if you intend to try NAC to ensure it is an appropriate nutrient for your particular situation (i.e. there is a known counter-indication for people who take nitroglycerin and your physician may be aware of others).

Four foods associated with lower risk of developing COPD

2010-07-03T08:48:00.001-04:00

Of the research studies published over the past two years regarding foods that are associated with reduced risk of developing COPD, there are four foods in particular that have been studied multiple times with similar results over a number of years. Most likely the list will not surprise you as all four food items are commonly viewed as good additions to the average person’s daily diet. However, these foods have been specifically recently studied in relationship to COPD risk:

1. Dietary fiber – an April 2010 study published in the Journal of Epidemiology showed that U.S. men and women whose diet contained higher fiber content from fruits, vegetables, and particularly cereal fiber had notably lower new COPD diagnoses compared to those with low dietary fiber intake. (Varraso R, et al. Prospective study of dietary fiber and risk of chronic obstructive pulmonary disease among US women and men. Am J Epidemiol. 2010 Apr 1; 71(7):776-84. Epub 2010 Feb 19)

2. Soy (isoflavones such as tofu and bean sprouts) – a January 2010 Japanese study examining dietary differences between study participants with COPD and participants with healthy lung function showed that low soy consumption was significantly correlated with COPD diagnosis and degree of breathlessness (meaning those participants who consumed the least soy were more likely to be diagnosed with COPD and experience notably worse breathlessness). (Hirayama F, et al. Dietary intake of isoflavones and polyunsaturated fatty acids associated with lung function, breathlessness and the prevalence of chronic obstructive pulmonary disease: Possible protective effect of traditional Japanese diet. Mol Nutr Food Res. 2010 Jan 28. [Epub ahead of print])

3. Fish (Omega-3 and Omega-6 fatty acids) – the same January 2010 Japanese study also examined participants’ intake of fish, a main staple of the Japanese diet. Much like the results for soy, the researchers found, “High intakes of PUFA (polyunsaturated fatty acids) and omega-6 fatty acids (derived from foods excluding oils and fats as seasonings) also appeared to reduce the risks of COPD and breathlessness symptoms”.

4. Vegetables with high Vitamin A content (carrots, sweet potatoes, broccoli, peas, spinach) – a separate Japanese study published online in June 2009 examined the dietary consumption of fruits and vegetables among COPD participants and otherwise healthy adults in the study and discovered that people who consumed the highest levels of vegetables had the lowest risk of developing COPD. Further, the most pronounced benefit was provided by consuming vegetables high in Vitamin A (those who consumed the highest amounts of Vitamin A had a 52% lower risk of developing COPD versus those with the lowest levels of Vitamin A). Interestingly, there did not appear to be a strong correlation between fruit consumption and reduced COPD risk (Hirayama F, et al. Do vegetables and fruits reduce the risk of chronic obstructive pulmonary disease? A case-control study in Japan. Prev Med. 2009 Aug-Sep; 49(2-3):184-9. Epub 2009 Jun 23)

New study shows 56% lower lung cancer risk among those with high levels of Vitamin B6

2010-06-28T10:35:00.001-04:00

Vitamin deficiencies are highly common among current smokers, former smokers and COPD patients. The primary mechanism depressing levels of essential vitamins is exposure to cigarette smoke and the inflammation it causes throughout the human body.

Researchers continue to examine a range of vitamins and other naturally occurring food based nutrients (primarily antioxidants) to judge the impact of deficiencies in COPD patient and smoker outcomes. While very few studies have pointed to optimum dosages for most of these nutrients, researchers continue to look at these nutrients as potential solutions to help moderate the effects of cigarette smoke, airway inflammation and lung disease.

We’ve recently written about 2 such ingredients (folate and Vitamin E). Click here for our posting on folate and click here for our posting on Vitamin E.

Now you can add Vitamin B6 to the list. The Journal of the American Medical Association just published the results of a retrospective study to evaluate the connection between B Vitamin deficiency and lung cancer. They discovered that study participants with the highest levels of B6 in their blood serum had a 56% lower risk of developing lung cancer compared with those with the lowest level of B6 (Johansson, M, et al. Serum B Vitamin Levels and Risk of Lung Cancer. JAMA. 2010; 303 (23):2377-2385).

In explaining their results, the study’s authors indicated their belief that B Vitamin deficiencies increase the possibility of gene damage and mutation which in turn elevates cancer risk.

In the study itself, the research team accessed the medical records of nearly 400,000 people who had agreed to participate in a large, long-term study population known as the European Prospective Investigation into Cancer and Nutrition (EPIC). In particular the study group sought to determine if there were any statistically significant correlations between blood levels of 4 particular B Vitamins (B2, B6, folate, and B12) and lung cancer risk.

As mentioned above, the researchers discovered that of the four B Vitamins, there was a notable reduction in lung cancer incidence among participants who had higher levels of Vitamin B6 in their past blood work across all study participants (meaning both smokers and non-smokers). They also discovered a similar but lesser correlation with folate that appeared only among current smokers and former smokers.

For a detailed description about Vitamin B6, including food sources high in Vitamin B6 content, we recommend visiting the National Institutes of Health’s Office of Dietary Supplements web site by clicking here.

For a more detailed description of the JAMA study and its results, please click here.

Chinese herb dramatically reduces inflammation caused by cigarette smoke

2010-06-26T15:15:00.000-04:00

A new study published online ahead of print in the journal Pharmacology and Pulmonology Therapeutics demonstrates the effectiveness of the Chinese herb known as scutellaria root in reducing airway inflammation caused by cigarette smoke exposure.

Scutellaria root, also known as Chinese Skull Cap, contains an extract called baicalin. According to the study’s authors, baicalin has been shown to possess anti-inflammatory, anti-bacterial and anti-viral properties in a number of other studies. However, the study authors note that baicalin has never been previously evaluated in relation to its impact on inflammation caused by cigarette smoke among COPD patients. (Lixuan Z, et al, Baicalin attenuates inflammation by inhibiting NF-kB activation in cigarette smoke induced inflammatory models, Pulmonary Pharmacology & Therapeutics 2010, doi:10.1016/j.pupt.2010.05.004)

Therefore, the research team set out to evaluate baicalin’s ability to reduce airway inflammation caused by exposure to cigarette smoke. The study was based on a “rat model” which simply means the researchers used laboratory rats instead of human subjects (this is a common practice for many dietary supplement studies because it is easier to control external variables in laboratory animals in comparison human subjects and such a study is less expensive to undertake). So while the results of the study are promising, more research will be required (preferably using live human subjects) before a wide cross section of pulmonology professionals will support the conclusions. Nevertheless, the results of the study are worth your attention in our opinion.

To begin, the study authors describe the impact of cigarette smoke on the lungs as follows: “Smoking is one of the main causes of COPD. CS (cigarette smoke) directly damages airway epithelium (lining of lung tissue) and activates macrophages and lymphocytes (white blood cells) to generate pre-inflammatory cytokines TNF-a, IL-6 and IL-8 (cytokines are proteins that signal the production of other white blood cells). It then activates neutrophils (white blood cells) leading to chronic bronchial inflammation and emphysema.” In other words, cigarette smoke triggers production of cytokines and neutrophils and the higher the level of cytokines and neutrophils, the higher the level of airway inflammation.

So in the study, the authors sought to evaluate the impact of varying dosages of baicalin on these immune response components (white blood cells and proteins that signal their production), and in turn determine baicalin’s impact on lung tissue inflammation.

The research team used 36 rats in the study and divided them into a control group which was not exposed to cigarette smoke and five other groups that were exposed to cigarette smoke over the 5 week study period (one group exposed to cigarette smoke with no treatment, another group given a prescription drug known to reduce inflammation called DMX or dexamethasone, a group given 20 milligrams of baicalin per 1 kilogram of body weight, a group given 40mg/1kg of baicalin, and the final group provided 80mg/1kg of baicalin).

After the 5 week period the rats were euthanized and their tissues were evaluated for the presence of inflammation and the specific immune response components mentioned above. They discovered that in every component measured, baicalin markedly reduced the precursors of inflammation and by extension the inflammation itself.

As the authors explained, “Our COPD rat models showed characteristic pathological changes of chronic bronchitis in the trachea and bronchi and the alveolar type of emphysema. These pathological changes in rats are consistent with human chronic bronchitis and obstructive pulmonary disease. Percentage of neutrophils of CS group was significantly higher than Control group. It indicated that CS exposure can induce a significant increase of neutrophil percentage. In addition, the difference of neutrophil percentage is the largest in the differential leukocyte counting items. Thus the COPD inflammation is mainly caused by neutrophil inflammation. According to Table 1, 20 mg, 40 mg and 80 mg dosage baicalin reduced total leukocyte count by 33%, 47% and 54% respectively. It revealed that baicalin has substantial anti-inflammatory effect on rats with COPD.”
There are no human dosage level recommendations available today for smokers and COPD patients but hopefully other researchers will follow up this research with human studies that provide better direction.

In the interim, there are some Chinese Skullcap dietary supplements available online and in health food retail stores. The most common dosage range we’ve seen advertised is between 100-200mg daily dosage. Be sure to look at the supplement facts box to ensure the formula contains the extract baicalin. Also be aware that just because a supplement facts box says there is 200mg of scutellaria root it does not mean that it has 200mg of the active ingredient baicalin. This is a common trick among supplement marketers to make it appear they have more of a particular herbal ingredient than is really present in the formula. Look for formulas which indicate the concentration of baicalin (such a label would say something like 200mg of scutellaria root, baicalin 20% concentration - meaning that there is actually only 40mg of baicalin in the formula). At least you will know the manufacturers of such products are being open and honest about what is in their product if they describe the baicalin concentration in the supplement facts box. Also, as always, please make sure you consult with your physician before taking any dietary supplement to ensure that there are no counter indications with your current medications or particular situation.

How Seasonality Impacts Pulmonary Rehabilitation Outcomes in COPD patients

2010-06-24T11:44:00.000-04:00

Last week, a group of UK based researchers reported the results of a study that found notable differences in COPD patient physical activity achieved during pulmonary rehabilitation depending on what season of the year patients started their rehab. (Sewell L, et al. Seasonal Variations Affect Physical Activity and Pulmonary Rehabilitation Outcomes. J Cardiopulm Rehabil Prev. 2010 Jun 14. [Epub ahead of print])

The study findings shed light on a number of interesting differences in COPD patient conditioning and performance based on when patients start rehab (spring, summer, autumn or winter). The most noteworthy finding according to the study authors was that COPD patients who began a pulmonary rehab program during the winter months achieved the largest boost in subsequent physical activity – a 130% increase in mean “physical activity” compared to baseline measures taken prior to the rehab program (the term “physical activity” in this study means how much COPD patients move around doing normal every day activities outside of the pulmonary rehabilitation program – sometimes referred to as “activities of daily living” by respiratory care professionals).

The pulmonary rehab program followed during the study lasted 7 weeks and involved 95 patients. COPD patients visited an outpatient rehab facility 2 times each week for 2 hours. In each session, patients participated in 1 hour of aerobic and strength training exercise and 1 hour of educational counseling on topics ranging from nutrition to breathing techniques to proper use of medications among other topics. Patients were also asked to exercise at home on a daily basis by walking and practicing some of the strength training exercises. Patients kept a log of their unsupervised at-home exercise and provided their data to the research team.

The fact that COPD patients who began rehab during the winter months saw the largest increase in physical activity did not surprise the researchers given that in geographic areas that experience cold winters (such as the UK), the incidences of COPD exacerbations that require hospitalization jump significantly. The reigning belief is that when COPD patients are exposed to cold, inhospitable outdoor/indoor temperatures they become far more sedentary. The more sedentary a COPD patient is, the lower their level of physical conditioning.

By way of example, patients in the study who began rehab in the summer months averaged almost 9,000 activity units on the device used to measure physical activity (a uniaxial accelerometer – sort of a souped-up pedometer), while patients who began in the winter months averaged just over 3,000 activity units. That’s obviously a huge difference and drives home the researchers point.

What seemed to surprise the researchers is how little the rehab program lifted the summer group’s physical activity (2% increase) in comparison to the winter group (130% increase – which translated to over 7,000 activity units for the winter group by the end of the study – still below the summer group but much closer).

Does this mean that pulmonary rehab is not effective for those who commence a program in the summer months? Absolutely not. It just means that COPD patients who begin a rehab program during milder/warmer/dryer weather are more active at the outset of a rehab program compared to those who begin in the winter months and therefore don’t achieve as dramatic gains in their activity levels outside of rehab.

In support of this contention it is worthwhile to look at the improvement in exercise performance of the four seasonal groups reported in this study. To assess exercise performance, the researchers used a test known as the Incremental Shuttle Walk Test (ISWT). In an ISWT patients are asked to walk as fast as they reasonably can for as long as they reasonably can before fatigue requires them to stop. The researchers asked patients to perform 2 ISWT tests, one at the outset of the program (baseline) and one at the end of the study.

Not surprisingly, the winter group had the lowest mean baseline ISWT at 146 meters walked before fatigue required them to stop, while the summer group had the highest mean baseline ISWT at 225 meters. Both groups (in fact, all four groups) saw their end-of-study ISWT mean distance walked rise between 79-83 meters. This translated into a 54% improvement in exercise performance for the winter group and a 37% improvement in the summer group with the spring and autumn groups’ improvement falling between these two extremes.

While the researchers concluded there was not a statistically significant difference in the absolute increase in distance walked among the four seasonal groups, it seems clear to us that all four groups experienced statistically significant improvements in overall exercise performance regardless of seasonality.

So while seasonality does play a role in COPD patient physical conditioning at the outset of a pulmonary rehab program, and as a result can influence the degree of improvement experienced in rehab, all COPD patients can experience significant conditioning benefits by participating in such a program regardless of season.

Study shows potential risk of heart attack and stroke after COPD exacerbation

2010-06-17T09:43:00.000-04:00

A recently published study indicated that approximately 1-2% of COPD patients following hospitalizations for an exacerbation (a shortness of breath attack severe enough to require hospitalization often triggered by a respiratory infection). For heart attacks, the risk was most pronounced within 1-5 days after an exacerbation, while the stroke risk was most pronounced 1-49 days after an exacerbation. (Donaldson GC, et al. Increased Risk of Myocardial Infarction and Stroke Following Exacerbation of COPD. Chest. 2010; 137(5):1091-1097)

The 1-2% range seems a very small number to us but the UK based researchers declared that even at these levels the results of their study are clinically significant because these risk levels are double those reported in stable COPD patients.

The study team suggested the reason for these increased risk levels for heart attack and stroke was that systemic inflammation associated with a COPD exacerbation event lingers beyond the event itself. Systemic inflammation is best described as persistent inflamed tissues in the lungs (and other parts of the body) that over long periods of time causes obstruction in the airways that make it difficult to breathe fully and makes it tougher for the body to fight off respiratory infections by depressing immune function.

Our only quibble with the study is the author’s conclusion that, “Knowledge of these risks would inform rational drug prescribing for prevention of cardiovascular disease, not only at exacerbation but also in stable COPD.”

What about smoking cessation? Pulmonary rehabilitation? Boosting antioxidant consumption (through diet and/or nutritional supplementation)? These three treatment strategies have been shown to reduce symptoms associated with airway inflammation (most notably reduced shortness of breath) and are not drug dependent. Further, smoking cessation and pulmonary rehab have been shown to reduce the number and intensity of subsequent exacerbation events among COPD patients. We think is in COPD patients’ best interests to discuss these other treatments options with their physicians in addition to exploring their recommendations for pharmaceutical support. We have previously written a number of blog articles about the power of pulmonary rehabilitation and a range of antioxidant supplements that show promise for those who suffer from chronic shortness of breath. Check out our blog archive for more information on these treatment options.

General healthy eating tips for COPD patients and smokers

2010-06-14T12:18:00.000-04:00

Poor dietary intake of important nutrients is common among COPD patients and smokers. Most pulmonology professionals believe that improving dietary intake can contribute to a reduction in shortness of breath symptoms and in slowing the progression of lung disease.

However, there is no current standard recommended diet offered by physicians for smokers and people with COPD. This is because there are two widely divergent ways poor diet is evidenced in COPD patients and smokers (underweight/overweight) that necessitate different recommendations. Further complicating matters to provide general dietary advice is the wide range of medications used by COPD patients. Some of these medications prevent absorption of key nutrients or otherwise deplete key nutrients in the body.

Most COPD patients/smokers are underweight and in many cases are considered malnourished. Diet recommendations for this audience typically focus on increasing consumption of calorie dense foods to add weight and improve access to vital base nutrients. According to a recent article, (Shepherd A. The nutritional management of COPD: an overview. British Journal of Nursing. 2010; 19(9): 559-562), respiratory care professionals believe the main causes driving underweight/malnourished COPD patients include:

Difficulty chewing because of chronic shortness of breath
Chronic mouth breathing which alters the taste of food
Excess mucus production depressing appetite
Coughing spasms which can lead to retching and vomiting
Depression
Lack of motivation/effort to prepare meals
Side effects of medication

On the other end of the spectrum, there is a segment of COPD patients who are obese but, according to the same British Journal of Nursing article, researchers have far less understanding of what drives the connection between COPD and obesity. The diet recommendations for this audience tend to focus on reduction of overall caloric intake and substitution of high fat/high carbohydrate foods with foods that provide a greater proportion of protein compared to fat/carbohydrates.

However, whether underweight or overweight, there are some valuable healthy eating tips for those who suffer from chronic shortness of breath offered in the British Journal of Nursing article that we’ve categorized into two different groupings:

Before eating:

Rest prior to meals if possible
Avoid consuming fluids prior to meals to avoid bloating
Choose foods that are easy to prepare to conserve energy for eating
Choose foods are soft and easy to chew
For foods that are not naturally soft/easy to chew - cut or blend food into smaller, softer pieces
Avoid foods that cause gas and bloating, which can cause abdominal/diaphragm discomfort

While eating:

Maintain an upright position during/after meals to assist in digestion & reduce abdominal pressure
Eat meals when energy levels are at their highest
Eat several small meals/snacks throughout the day instead of a couple large meals
Eat slowly and avoid swallowing air
Limit salt intake as this can cause fluid retention, making breathing more difficult
Limit caffeinated beverages and sugary foods as both contribute to inflammation & anxiety
Drink fluids at the end of the meal

Separately, there is a significant and growing body of evidence that people with COPD and smokers have dramatically reduced levels of antioxidants in their bodies. The significant depletion of antioxidants is believed to be mostly related to the pro-oxidative effects of cigarette smoke. Further, a number of studies have shown that the majority of COPD patients and smokers do not consume foods rich in antioxidant content (colorful fruits and vegetables are the typical sources of antioxidants in a traditional diet). The combination of pro-oxidative stress created by cigarette smoke and poor intake of anti-oxidative nutrients is believed to be a significant contributing factor to the degree of systemic inflammation present in COPD patients and smokers. In turn, systemic inflammation is believed to be a major cause of airway obstruction and the inability to breathe fully.

While researchers suggest that boosting antioxidant intake through diet and nutritional supplementation can raise blood levels of antioxidants there is not yet a standard recommendation regarding which foods/supplements to consume, and in what quantities/dosages to consume them. However, it is hard to imagine that a COPD patient or current smoker could consume enough antioxidant rich food to offset the effects of cigarette smoke/lung disease. Therefore, we recommend that COPD patients and smokers consider taking a high potency multi-nutrient in addition to consuming more antioxidant rich foods. It is worth at least discussing a high-potency multi-nutrient with your doctor. No individual ingredient in any supplement is a silver-bullet to prevent or cure lung disease, but a broad range of ingredients that have antioxidant properties may prove helpful in restoring your body’s natural antioxidant defenses.

Early use of antibiotics after COPD exacerbation improves patient outcomes

2010-06-12T10:30:00.000-04:00

In late May, a group of Massachusetts based researchers published the results of a study examining the effectiveness of early antibiotic therapy for COPD patients hospitalized with an acute exacerbation. The researchers concluded that those patients who began receiving antibiotics within 2 days of admission to the hospital experienced significantly fewer inpatient complications and subsequent hospital readmission. (Rothberg M, et al. Antibiotic Therapy and Treatment Failure in Patients Hospitalized for Acute Exacerbations of Chronic Obstructive Pulmonary Disease. JAMA. 2010; 303(20): 2035-2042)

An acute exacerbation is generally defined as a significant shortness of breath attack, often brought on by a respiratory infection and/or excess production of sputum. While it might seem commonsense to treat all COPD patients who are hospitalized due to an acute exacerbation with antibiotics, they are not consistently prescribed. According to the research team, current treatment guidelines only call for prescribing antibiotics when COPD patients are producing an increased amount of sputum. This study’s results challenge this guideline. In fact, the research team recommends providing early antibiotics to all COPD patients who are admitted to hospitals with an acute exacerbation.

In the study, the research team reviewed hospital admission records of over 80,000 COPD patients admitted over 400 U.S. hospitals between 2006 and 2007 and looked for differences in patient outcomes between those who received early antibiotics and those who did not.

While a large majority (79%) of the patients received at least 2 days of antibiotics during their hospital stay, there were notable differences in the outcomes of patients who began receiving antibiotics within the first 2 days of their stay versus those who began antibiotics later in their hospital stay. Those who received the antibiotics early in their hospital stay were less likely to be placed on mechanical ventilation, had lower inpatient mortality, and had fewer readmissions for subsequent exacerbations within the first 30 days after discharge.

The results, published in the Journal of the American Medical Association, were widely reported in media outlets around the globe. For a good synopsis of the study’s findings and some pull quotes from the research team leader, Dr. Michael Rothberg, click here.

Is ground walking better than cycling for COPD patients in pulmonary rehab programs?

2010-06-10T14:59:00.000-04:00

A new research study published in the Journal of Physiotherapy revealed that COPD patients who “ground walked” (i.e. walking on the ground, not a treadmill) as part of a pulmonary rehabilitation exercise program reported significantly higher walking endurance capacity than COPD patients who cycled.

In many pulmonary rehab programs, stationary cycles are used for aerobic exercise due to space constraints (not many facilities have large indoor walking areas) and due to concerns about patient falls (many moderate to severe COPD patients have difficulty keeping their balance due to poor leg strength). In addition, a number of programs use treadmills as a substitute for indoor ground walking. A debate has gone back and forth over time as to which method is optimal. While this study does not resolve that debate, it does show that indoor ground walking should be considered as an additional form of aerobic exercise in pulmonary rehab programs.

The Australian research team that led the study divided 32 COPD patients into two groups. One group performed indoor ground walks 30-45 minutes 3 days a week for 8 weeks. The other group participated in indoor stationary cycle training for the same 30-45 minutes, 3 days a week during the 8 week study. The researchers evaluated exercise performance differences between the two groups on a variety of measures at the outset of the study (otherwise known as baseline measurements) and the end of the study. (Leung RW, et al. Ground walk training improves functional exercise capacity more than cycle training in people with chronic obstructive pulmonary disease (COPD): a randomised trial. J Physiother. 2010; 56(2):105-12).

The results of the study showed no significant differences between improvements in physical conditioning between the ground-walk group and the cycle group on most of the evaluated measures (including improving peak walking capacity, peak and endurance cycle capacity and quality of life).

However, in an endurance capacity test known as the endurance shuttle walk test (ESWT) the ground-walk group’s improvement between the baseline ESWT and the end of study ESWT was notably better than the cycle group’s improvement. In fact, the ground-walk group improvement exceeded the cycle group improvement by 279 seconds (or approximately 4.5 minutes).

The endurance shuttle walk test has two different components. First, patients are asked to walk a defined distance as fast as they reasonably can and a baseline measure of their speed/pace is recorded. This component of the test is known as an Incremental Shuttle Walk Test (ISWT). Then, in the second component of the ESWT, a patient is asked to walk at 75% to 95% of the maximum speed/pace exhibited in the ISWT for as long as they can before they need to stop and rest. During the ESWT, the patients are prompted to keep pace in the 75%-95% range by researchers.

Based on this outcome the research team concluded, “This study provides evidence for ground walking as a mode of exercise training in pulmonary rehabilitation programs.”

Getting ahead of the curve - pulmonary rehab for mild COPD patients

2010-06-09T13:28:00.000-04:00

In late April 2010, the journal Nursing Times published a study review article that posed the question, “Do people with mild COPD benefit from early pulmonary rehabilitation programs?”

The study, conducted at a U.K. based outpatient medical services center known as a PCT (Primary Care Trust), involved a 3 week pre-pulmonary rehab program for 8 mild COPD patients. During the program, patients met twice a week for two hours to receive educational counseling from the researchers regarding exercise, breathlessness, relaxation techniques, smoking cessation, proper use of inhalers and nutrition among other topics. (Gulrajani R. Do people with mild COPD benefit from early pulmonary rehabilitation programmes? Nursing Times. 2010:106: 17, Epub ahead of print)

At the end of the program 50% of the patients in the study reported less dyspnea (shortness of breath episodes) and said they had more control over their condition. 25% of the study participants reported feeling less fatigued. 100% of the patients in the study felt the program was beneficial and would recommend it to other mild COPD patients.

While scientific researchers will likely discount the results of the study given its small size, construction, and duration, the article explores a critical question for both practitioners and patients – is there value in providing access to some of the core information provided in pulmonary rehabilitation programs for people who have yet to develop severe lung disease?

To fully appreciate this question, it is important to understand that today pulmonary rehabilitation is typically only offered to moderate to severe COPD patients in the U.K. (same is true in the U.S.), meaning mild COPD patients cannot gain access to such a program. Pulmonary rehabilitation is a treatment program which combines observed/managed aerobic and strength training exercise with counseling on nutrition, breathing techniques, airway clearing techniques, and proper use of medications among other topics. It has been proven time and time again as effective in improving COPD patient physical conditioning, reducing shortness of breath, reducing hospital admissions and improving overall patient quality of life.

According to the article author, people in the U.K. who visit a PCT complaining of chronic shortness of breath typically receive a spirometry test (to determine lung function quality). If mild COPD is suspected, a patient receives counseling on smoking cessation (if they smoke). They may also be prescribed rescue inhalers (which temporarily open airways during shortness of breath attacks) and provided instruction on the proper use of the inhalers. These counseling sessions typically last only 15 minutes and therefore a minimum of valuable information beyond these topics is communicated and, as mentioned above, pulmonary rehab is not offered. The same basic patient treatment scenario also occurs in U.S. medical practices.

To the researchers, this truncated practitioner/patient interaction leaves a lot to be desired especially when the practitioners know that pulmonary rehab has such a strong track record in improving symptoms and quality of life – even for those with mild COPD. So the researchers decided to investigate a novel approach to “try to prevent deteriorating lung function rather than wait until patients had moderate to severe disease and (then) could attend PRP (pulmonary rehabilitation program).”

Knowing it would not fly with their health care system administrators to simply offer a full scale pulmonary rehab program for mild COPD patients (pulmonary rehab services are only reimbursed for moderate to severe COPD patients), the U.K. based researchers sought to offer a mini-education program based on the core elements of pulmonary rehabilitation.

Intuition would suggest that offering a full scale pulmonary rehab as a treatment option earlier in the development of COPD might help slow or halt the progression of lung disease and reduce hospital admissions related to COPD exacerbation events. And indeed, there have been previously published studies that demonstrate efficacy of pulmonary rehab for those with mild COPD as well as more severe cases. However, despite the evidence that pulmonary rehab is helpful to people with mild COPD, it remains a treatment option largely only available to those with more advanced lung disease. And this reality is frustrating for the on the ground physicians, therapists and nurses who work in pulmonary rehab settings who believe they could make a bigger difference if they were given the opportunity to work with less severe COPD patients. This study attempts to fill the frustrating void with a mini-pre-rehab program and its results seem to demonstrate value in their approach (understanding that more rigorous follow on research is warranted).

This state of affairs is the primary reason we created the Breathe Better for Life guide and companion CD. We desired to expand awareness of pulmonary rehab and provide people who would otherwise have no access to its proven efficacy the opportunity to undertake a rehab-style program based on the principles of this powerful treatment option (in consultation with their doctor). For those interested in learning more about the guide and CD, visit http://www.breathebetterforlife.com./

We would encourage those who suffer from chronic shortness of breath to engage your physician (primary care or pulmonologist) about pulmonary rehab and whether it is appropriate to your situation. If the only weapons in your arsenal to manage your lung disease are rescue inhalers, antibiotics prescriptions, and/or supplemental oxygen, you are dramatically selling yourself short. These treatments do relieve short-term symptoms, but none of them improve physical conditioning, reduce shortness of breath on an ongoing basis, or improve long-term sense of quality of life like pulmonary rehabilitation.

Quadriceps resistance training after a COPD exacerbation improves muscular function

2010-06-01T11:09:00.000-04:00

We have written often about the power of pulmonary rehabilitation in improving COPD patient physical conditioning, shortness of breath and quality of life. In most pulmonary rehabilitation studies, aerobic exercise (i.e. walking, cycling) is the primary exercise mode studied (although many studies also combine strength training with aerobic exercise).

So it was interesting to read a new study published in the journal Respiratory and Critical Care Medicine which showed 8 days of moderate strength training of the quadriceps muscles after an acute COPD exacerbation (doctor-speak for a shortness of breath attack significant enough to require hospital admission) improved muscular function and distance walked – even one month after discharge. (Troosters T, et al. Resistance Training Prevents Deterioration in Quadriceps Muscle Function During Acute Exacerbations of Chronic Obstructive Pulmonary Disease. Respiratory and Critical Care Medicine. May 2010: 181; 1072-1077)

Unlike pulmonary rehabilitation, which (when prescribed) is typically administered post-hospital discharge, this study sought to evaluate the effects of strength training during the 8-day exacerbation-related hospital stay of 36 COPD patients who completed the study. The research team divided the 36 patients into two groups. One group (17 patients) received quadriceps muscle strength training during their hospital stay while the other group (19 patients) received no training.

The group that trained the quadriceps muscles (the large set of muscles on the top of the leg between the hip and knee) performed 3 sets of 8 repetitions each day of their 8-day hospital stay on a knee extension weight machine (a machine which isolates the quadriceps muscles for strengthening). For this particular exercise, a person sits on the back supported seat of the machine, placing their feet behind a padded arm connected to the weights. The patient then raises their feet upward pressing their lower shins against the weighted arm of the machine until their toes reach approximately knee height. Then the patient lowers their feet and the weighted arm almost all the way back down before repeating this movement. The repetitions during the study were performed at an average of 70% of each patient’s 1-rep maximum force. Basically this means that at the outset of the study each patient was tested to see how much weight they could comfortably lift one time on the machine and then the researchers conducted the exercise sessions at approximately 70% of that weight.

Among other measures, the research team evaluated maximum quadriceps force and distance walked in 6 minutes for both the quadriceps training group and the control group which received no training. These measurements were taken at the beginning the study, at the end of the 8-day hospitalization, and again 30 days after discharge.

The results showed that the quadriceps training group produced an average 10% increase in quadriceps muscle force and distance walked in 6 minutes at the end of the 8 day hospitalization and more remarkably maintained both measures of improvement 30 days after discharge. By contrast, the control group saw their quadriceps muscle force and distance walked in 6 minutes decline slightly at discharge and decline slightly further 30 days after discharge.

For the quadriceps group, the research team viewed the degree of increase in quadriceps force as significant but did not view the improvement in distance walked as significant (typically in pulmonary rehab studies, an improvement of 50 meters walked in 6 minutes is considered clinically significant – the trained group in this study increased by only 38 meters).

Still, that’s pretty amazing improvement considering these COPD patients did not go through a formal 6-8 week pulmonary rehab program where they would have participated in both aerobic and strength training exercises for about an hour a day, 3 days a week over 6-8 weeks. They simply performed 3 sets of 8 reps of 1 exercise – knee extensions – each day of their 8 day hospitalization (which likely took less than 15 minutes to complete each day). This low level of activity over a very short period of time nearly achieved a clinically significant improvement in walking distance.

The research team theorized that encouraging physical activity as soon as feasible after a hospitalization for a breathing attack would help COPD patients recover from the exacerbation more quickly. In testing this hypothesis, they further believed that moderate strength training of a large, lower extremity muscle group like the quadriceps would place less intense breathing burden on a hospitalized COPD patient versus attempting aerobic exercise. Their results seem to bear out both suppositions as muscle strength improved and there were no adverse events reported by the group who underwent the exercise program.

Interestingly, the study team seemed a little surprised that the quadriceps force and 6 minute walk distance were maintained 30 days after discharge given the low dose/duration of the strength training regimen. They speculated that the quadriceps group patients may have become more active in basic daily activities post-discharge given that their quadriceps muscles had strengthened (i.e. the quadriceps muscles are the dominant muscles used when walking). It is another example of the power of even simple exercise to improve the fortunes of COPD patients.

Level of daily folic acid intake inversely related to breathlessness

2010-05-28T11:32:00.001-04:00

A recent Japanese study examined the relationship of folic acid intake and degree of breathlessness and functional capacity among COPD patients and concluded that the lower a COPD patient’s daily folic acid intake, the more prevalent the symptoms of breathlessness. (Hirayama F, et al. Folate intake associated with lung function, breathlessness and the prevalence of chronic obstructive pulmonary disease. Asia Pac J Clin Nutr. 2010; 19(1):103-9)

So what is folic acid? According to the National Institutes of Health Office of Dietary Supplements folic acid (also known as folate) is defined as, “a water-solubleB vitamin that occurs naturally in food. Folic acid is the synthetic form of folate that is found in supplements and added to fortified foods…Folate helps produce and maintain new cells . This is especially important during periods of r apid cell division and growth such as infancy and pregnancy. Folate is needed to make DNA and RNA, the building blocks of cells. It also helps prevent changes to DNA that may lead to cancer. Both adults and children need folate to make normal red blood cells and prevent anemia. Folate is also essential for the metabolism of homocysteine, and helps maintain normal levels of this amino acid …Leafy green vegetables (like spinach and turnip greens), fruits (like citrus fruits and juices), and dried beans and peas are all natural sources of folate.”

On average, the Japanese COPD patients in the study consumed 231 micrograms of folic acid each day. By comparison, the National Institutes of Health recommends 400 micrograms daily for adults over the age of 19. Ironically, even the control subjects of the study (a random selection of Japanese adults without COPD) only consumed 261 mcg on average each day.

What is most interesting about the study is that even with the modest spread between the folic acid intake of the control subjects and COPD patients (30 microgram difference in daily consumption), the researchers found statistically significant variances in symptoms of breathlessness. Among COPD patients alone, the researchers found that the COPD patients with the highest levels of folic acid intake reported the least amount of breathlessness symptoms and vice versa. The researchers conclude that COPD patients would be well served by supplementing their dietary sources of folic acid.

In our opinion, current and former smokers would be well advised to also boost their folic acid intake. Depressed levels of folic acid and other key B-Vitamins in smokers have been reported in other studies. Low folic acid levels have been shown in these studies to be a causal element of developing a condition known as hyperhomocysteinaemia – a condition where the body produces too much of a chemical called homocysteine. Too much homocysteine in the blood has been linked to blot clots, heart attacks and stroke.

In the US, nearly all multivitamins contain at least 400 micrograms of folic acid given that this level has been deemed by the Institute of Medicine of the National Academy of Sciences as the recommended daily allowance (now referred to as dietary reference intake). In addition, many leafy green vegetables and even fortified cereals contain notable levels of folic acid. For more information about folic acid, its benefits, and food source content, click here to visit the National Institutes of Health’s Office of Dietary Supplements web site.