## 3 Results and Discussion
### Grade of recommendation GPP, (88%) Consensus
#### 3.4.2 What Is the Role of Dietary Advice?  
**Recommendation 15**.: _GARIN recommends basic dietary advice as it is essential for COPD patients and the basis for proper lifestyle habits, especially in relation to diet._  
Grade of recommendation GPP, (100%) Consensus.  
Comment:  
Several clinical trials have studied the effect of dietary advice in COPD patients, showing an increase in caloric and protein intake, with an increase in weight and an improvement in SGA scores [70]. An increase in inspiratory strength and quality of life questionnaire scores has also been reported [73]. Several of these studies have also shown an improvement in clinical variables such as 6 MWD or grip strength [104] and a significant  
\begin{table}
\begin{tabular}{l l} \hline \hline \(\bullet\) & In stable patients, a varied, healthy and balanced diet, such as the Mediterranean dietary \\ \(\bullet\) & Do not decrease caloric intake to achieve less work of breathing because of the risk of \\  & malnutrition associated with a BMI below 21 kg/m\({}^{2}\). \\ \(\bullet\) & Eat fish 2-3 times a week. \\ \(\bullet\) & Split the intake into several meals (5–6 meals/day) in case of advanced COPD GOLD 3 or 4 \\  & and during exacerbations. \\ \(\bullet\) & Educate patients on healthy fat choices with a decrease in industrial saturated and trans fats. \\ \(\bullet\) & Eat a diet high in fruit and vegetables because of their high antioxidant and fiber content \\  & (five servings per day). \\ \(\bullet\) & Decrease intake of processed meats and carbonated beverages. \\ \hline \hline \end{tabular}
\end{table}
Table 5: The diet recommended by GARIN.  
reduction in the percentage of smokers, as well as better adherence to a Mediterranean diet and an increase in caloric intake with structured meal programs [105; 106].  
4.3 In Patients with COPD and Malnutrition, Is Nutritional Supplementation Associated with an Improvement in Morphofunctional Nutritional Parameters and Disease Progression?  
**Recommendation 16**.: _GARIN suggests the use of oral nutritional supplements (ONSs) in malhourished COPD patients to improve nutritional status and disease course (Table 6)._  
Grade of recommendation B, (96%) Strong consensus.  
_Comment--Weight and lean mass increase:_  
The scientific evidence in this area has evolved over time. While more recent authors have reported increases in weight and lean mass, as well as improvements in exercise tolerance, earlier studies did not support these findings.  
[PERSON]'s 2012 Cochrane Review [107] includes a meta-analysis of 17 RCTs with little evidence in favor of those patients receiving nutritional supplements in terms of improvement in weight, lean mass, respiratory muscle strength, and 6 MWD, particularly striking in malnourished patients [37].  
However, more recent studies show that the use of ONSs is associated with increased intake, improved anthropometric measures, and increased muscle strength [58; 67; 68; 69; 70; 71; 72; 73; 74; 75; 76; 77; 78; 79; 80; 81; 82; 83; 84; 85; 86; 87; 88; 89; 90; 91; 92].  
A significant improvement in anthropometric measures (fat-free mass, brachial circumference, tricipital fold), 6 MWD, ISWT, respiratory muscle strength (maximum inspiratory and expiratory pressure), and grip strength measured by dynamometry is described in the aforementioned studies [15; 67; 69; 92; 105; 107; 109; 110; 111; 112; 113; 114; 115].  
_Comment--Potency of effect in physical exercise:_  
Most studies, especially those focused on the assessment of fat-free mass, associate nutritional supplementation with regular physical exercise, so it is known that the association of the two enhances their effect [15; 92; 111; 112; 116; 117; 118; 119; 120; 121; 122; 123; 124; 125; 126; 127; 128; 129; 130; 131; 132;