Mr. S is a 59-year old man diagnosed with stage 1 COPD who has experienced weight loss from 68kg to 59kg. He was referred to a dietitian for a diet consultation to address his poor appetite and malnutrition. The dietitian assessed his nutrition status and designed a 2,200 calorie diet plan focusing on small, frequent meals high in calories, protein, and antioxidants to support his lung function and delay COPD progression.

1. Medical Nutritional Therapy
(MNT) AHD 3233
Question 6: Chronic Obstructive Pulmonary Disease
-Saifullah Osman
-Al- Abdullah Jaffar
-Muhamad Arif Abdullah
-Muhammad Kamil Mashor
-Muhammad Luqman Hakim Romali

2. Question
Mr S is a 59 years old man. He was diagnosed with stage 1 Chronic Obstructive
Pulmonary Disease (emphysema) 5 years ago. Previous medical history showed
that he suffered bronchitis and upper respiratory infections especially during cold
weather. He was a smoker for 46 years and quit smoking about 1 year ago. Current
diagnosis is acute exacerbation of COPD 2º to bacterial pneumonia. He was unable
to do anything by himself, even taking a bath or getting dressed makes him short
of breath.
He responded well to treatment for the emphysema, however COPD has
progressed. He was discharged home O2 therapy and bronchodilators, and
referred to an outpatient pulmonary rehabilitation program
He was referred to dietitian for diet consultation, as patient has poor appetite, and
experienced weight loss, 6 month ago he was 68 kg and now is 59kg and his
height is 167 cm. He avoids milk as he believed that milk will increase the mucus
production

3. Nutrition Status Assessment
Anthropometry data
Weight : 59kg
Height : 1.67m
Body Mass Index : 59
(1.67 x 1.67)
: 21.15 kg/m
BMI of the patient is normal range.

4. Nutrition Status Assessment
Bio-chemical Data
Patient value Normal value Indication
White Blood Cell 15 x 103 mm3 4.3 - 10 x 103 mm3 Inflammatory
(high) response
Hemoglobin 11.5 g/dl 12.0 – 16.0 g/dl -
Total protein 59 g/L 67 – 88 g/L Muscle wasting
(low)
Albumin 29 g/L 35 – 50 g/L Muscle wasting
(low)

5. Problem Etiology Symptoms (PES) Statements

6. Objectives and Principles
Objectives:
1) Screen early and correct any malnutrition. Because there less oxygen
available for adenosine triphosphate (ATP) formation, the patient will
less active and there are less blood flow to GI tract and muscle.
Malnutrition will increase the like hood of infection.
2) Delay progression of COPD, by improving pulmonary function
3) Prevent respiratory infection or reparatory acidosis from decrease CO2
elimination. Decrease excess CO2 production
4) Ensure adequate flavor of foods because appetite is often minimized

7. Objectives and Principles
Principles:
1) The diet should 40-55% carbohydrate, 30-45% fat and 15-20% protein.
2) A soft diet (not tough or stringy foods) recommended.
3) Avoid gas forming foods to avoid excess formation CO2.
4) Enrich the diet with antioxidant to support lung function.
5) Use small frequent feeding at frequent intervals to lessen the fatigue
6) Ensure high fluid intake
7) Limit salt intake, too much sodium will cause water retention that may
interfere with breathing.

8. Objectives and Principles
Patient Education:
1) Explain the patient to conserve energy while preparing meals at home. Choose
food that easily prepared.
2) Explain how to concentrate protein and calories in small feedings.
3) Encourage rest periods before and after meals
4) Encourage slow eating.
5) Improve physical conditioning with planned exercises , especially strength
exercise.

9. Nutrition Intervention
Energy requirement:
1) Quick Method
Due to patient BMI is normal, so we use the current body weight (59kg) and can
consider having sedentary lifestyle as the statement stated unable to do anything by
himself.
= 59 kg x 30 kcal/kg
= 1770 kcal
= 1770

10. Nutrition Intervention
2) Harris- Benedict Equation
Male:
Basal Energy Expenditure (BEE) = 66.47 + (13.75 x Weight) + (5 x Height) – (6.76 x Age)
= 66.47 + (13.75 x 59) + (5 x 167) – (6.76 x 59)
= 1315 kcal
Total Energy Intake = BEE x Injury Factor (1.5) x Activity Factor (1.3)
= 1315 x 1.5 x 1.3
=2564 kcal

11. Nutrition Intervention
Average Energy Requirement:
= Quick method + Harris- Benedict
2
=1770 + 2564
2
= 2167 kcal
≈ 2200 kcal

12. Nutrition Distribution Table
Distribution Macronutrients
Carbohydrate Protein Fat
General 40 % 17 % 43 %
Enteral 300 kcal = 10% 177.86 kcal = 5.93 % 586.8 kcal = 19.6 %
Feeding
Percentage (%) 1 can RTH = 235ml 1 day x 3 can = 705 ml
235 ml x 1.5 kcal = 352.5 kcal 705 ml x 1.5 kcal = 1057.5 kcal
Total CHO = 25.0 g Total CHO/day = 75.0 g
Total Protein = 14.8 g Total Protein/day= 44.4 g
Total Fat = 22.1 g Total Fat/ day = 66.3 g
Normal Diet 40 % - 10 % = 30 % 17% - 5.93 % = 11.07% 43% - 19.6% = 23.4 %
Percentage (%) =30 x 2200 kcal =11.07 x 2200 kcal = 23.4 X 2200 kcal
100 100 100
=660 kcal =243.5 kcal = 514.8 kcal
=660 =243.5 = 514.8
4 4 9
= 165 g =60.87 – (14+8) = 57.2 – (3.5+10+3+8)
=165 7 5
15 =5.5 ex = 6.5 ex
=11 Ex

13. Nutrition Distribution Table
Exchange distribution table:

14. Menu Planning
Enteral Feeding:
Pulmocare EN products:
Information PULMOCARE® is a high-calorie, low-carbohydrate liquid
formula, designed to help reduce carbon dioxide production,
thereby minimizing CO2 retention.
Nutrient density (Cal/mL) : 1.5
Protein (% Cal) : 16.7
Carbohydrate (% Cal) : 28.1
Fat (% Cal) : 55.2
Feeding time:
1 tin (235ml) - Mid-morning
- Mid- afternoon
- Supper

15. Menu Planning
Breakfast:
½ cup oat + ½ desert spoon raisin + 1/3 tsp sugar + ½ glass Full Cream Milk
(blended)
1 glass of plain water
Mid-morning:
1 medium size potato mashed + pepper + salt]
1 scrambled egg (gred c) + 1 tsp heap mayonese + minced onions and garlics + 1
tsp oil
1 glass Pulmocare + ½ berangan banana + 1 tsp sugar (blended)
1 glass of plain water
Lunch:
1 slice of whitebread (peeled outer skin) + 1 tsp peanut butter
1.5 cube chicken soup + salt +pepper + 1/3 thin sliced of carrots + bunga lawang
+ cinnamon + 1 tsp oil
1 glass of plain water

16. Menu Planning
Mid-afternoon:
1 slice watermelon
1 glass Pulmocare + 6 pieces strawberry + 1/3 tsp sugar (blended)
A glass of plain water
Dinner:
2 slices whitebread (peel outer skin) + 1 tsp heap mayonese
2 desertspoons sardine + 1/3 minced chillie, kasturi ½ lime (the juice and
content only) + salt + 1 tsp oil
½ slice of cheese
A glass of plain water
Supper:
1/2 cup rice porridege
1 cube fish soup + salt + onions + garlic + bunga lawang + cinnamon + ½
potato in the soup + few celery + onions leaves
1 glass pulmocare + ½ of a slice of watermelon
A glass of plain water