Both underweight and unintentional weight loss are common problems for people with chronic obstructive pulmonary disease (COPD). Patients with COPD who are underweight may experience associated nutrition-related problems as their condition greatly increases energy requirements. The work required for breathing in COPD may be 10 to 20 times that of a person with normal lung function. Energy expenditure is elevated as the body works harder to breathe, combats chronic infection, and experiences altered metabolism. Energy expenditure is also affected by participation in pulmonary rehabilitation exercise programs, which can lead to increased fatigue at meal time, further decrease intake, and increase weight loss. Risk for COPD-related death doubles with weight loss, and BMI of <20 kg/m2 may be seen in up to 30 percent of individuals with COPD. Energy needs are even higher during COPD exacerbation. The most accurate way to determine caloric needs in these patients is through the use of indirect calorimetry. [gallery ids="225676,225677,225678,225680,225679,225681,225682,225683,225684,"] Feeding goals for COPD focus on achieving maximum nutrition with minimal effort and fatigue. Nutrition practitioners should encourage patients to eat slowly, biting and chewing methodically, and breathing deeply while they eat. Placing utensils down between bites can help appropriately pace food intake. Encourage patients to select foods that are easy to chew and prepare, and opt for five or six small meals per day. Encourage them to drink liquids between meals or at the end of meals to conserve valuable space in the stomach for food. Also encourage them to sit upright while eating and avoid lying down immediately after meals in order to reduce pressure on the lungs. While the calorie needs are significantly higher in the COPD population, the distribution of macronutrients does not differ much from that of healthy people. Specific vitamin and mineral considerations involve vitamin C and sodium. As with smokers, COPD patients who Nutrition Intervention Strategies for COPD Liberalize diet to encourage oral intake within the parameters of medical priorities. Provide small, frequent, mini-meals and snacks to help compensate for shortness of breath and reduced oxygen supply to GI tract. Choose foods that are easy to chew, swallow, and digest. Utilize easy to prepare whole grains, fruits, and vegetables to achieve fiber intake goals. Include nutrient-dense nutrition supplements or shakes between meals to meet calorie goals. Supplement diet with vitamin-mineral supplements. Exercise appropriate sitting posture and practice sequencing of breathing to increase ease of swallowing and eating. Discourage elimination of milk from the diet; milk is unrelated to mucus production despite common beliefs otherwise smoke have increased vitamin C needs of 35 mg per day above the healthy, non-smoking population, meaning that male adult smokers need 125 mg vitamin C per day and female adult smokers need 105 mg vitamin C total per day (IM, 2000). For patients with cor pulmonale and fluid retention, consider limiting both sodium and fluid. If on diuretic therapy, the COPD patient should increase dietary potassium intake. Individuals with COPD are advised to undergo bone mineral density screening, as they are at increased risk for developing osteoporosis (AND, 2015a). By far, the greatest challenge in nutrition care for COPD, especially in underweight people, is consuming adequate calories. Table 3.2 contains a list of helpful nutrition intervention strategies for people with COPD to maximize their calorie intake.