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 Table of Contents  
ORIGINAL ARTICLE
Year : 2014  |  Volume : 28  |  Issue : 3  |  Page : 157-161

Association body mass index and spirometric lung function in chronic obstructive pulmonary disease (COPD) patients attending RIMS Hospital, Manipur


1 Department of Physiology, Regional Institute of Medical Sciences, Imphal, Manipur, India
2 Department of Respiratory Medicine, Regional Institute of Medical Sciences, Imphal, Manipur, India

Date of Web Publication5-Jan-2015

Correspondence Address:
Awungshi Jannie Shimray
Department of Physiology, Regional Institute of Medical Sciences, Imphal, Manipur
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0972-4958.148498

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  Abstract 

Background: Weight loss is highly prevalent in chronic obstructive pulmonary disease (COPD) patients and studies have consistently shown significantly greater mortality rates in underweight and normal-weight COPD patients with than in overweight and obese COPD patients. Objective: To study association between mass index (BMI) and severity of COPD as assessed by spirometric lung function tests. Materials and Methods: 50 patients with COPD (25 women and 25 men), ages ranging from 40 to 65 years attending OPD and ward of Department of Respiratory Medicine, RIMS were included in the study. This preliminary study was conducted in the Department of Physiology, RIMS. Lung function was measured with Computerized Spirometer Helios 701 (Recorders and Medicare System, Chandigarh). Body mass index was calculated and related to recently developed reference values. Statistical analysis was performed using SPSS version 16.0 Independent t-tests and Pearson's correlation coefficient was used. Results: Mean body weight values were 59.66 ΁ 13.10 kg and 42.54 ΁ 2 kg, and BMI values were 21.75 ΁ 3.33 and 19.10 ΁ 1.0788 in males and females, respectively.33.3% of the patients had malnutrition and their flow parameters were found to be lower as compared to well-nourished subjects. FVC, FEV 1 and FEV 1 % predicted were all positively correlated to low BMI. Conclusions: Low BMI is prevalent in COPD patients. Inclusion of BMI in assessment of COPD severity in addition to measurement of FEV 1 is supported.

Keywords: Body mass index, chronic obstructive pulmonary disease (COPD), lung function


How to cite this article:
Shimray AJ, Kanan W, Singh WA, Devi AN, Ningshen K, Laishram R. Association body mass index and spirometric lung function in chronic obstructive pulmonary disease (COPD) patients attending RIMS Hospital, Manipur. J Med Soc 2014;28:157-61

How to cite this URL:
Shimray AJ, Kanan W, Singh WA, Devi AN, Ningshen K, Laishram R. Association body mass index and spirometric lung function in chronic obstructive pulmonary disease (COPD) patients attending RIMS Hospital, Manipur. J Med Soc [serial online] 2014 [cited 2020 Oct 22];28:157-61. Available from: https://www.jmedsoc.org/text.asp?2014/28/3/157/148498


  Introduction Top


Chronic obstructive pulmonary disease (COPD) is a preventable and treatable disease with some significant extra pulmonary effects that may contribute to the severity in individual patients. Its pulmonary component is characterized by airflow limitation that is not fully reversible. The airflow obstruction is usually both progressive and associated with an abnormal inflammatory response of the lungs to noxious particles and gas. [1] It is a major cause of chronic morbidity and mortality throughout the world and is currently the fourth leading cause of death. [2] Patients with COPD often lose weight and, depending on the population studied and the indicator used to determine the nutritional status, between 19 and 60% of patients are classified as malnourished. [3] The clinical deterioration associated with weight loss leads to deterioration in the quality of life in many patients with COPD. [4] The pathogenesis of body wasting in subjects withchronic diseases like COPD is unclear. However, increases in the work of breathing and respiratory muscle activity increase resting energy expenditure by as much as 50 to 100% above normal. In normal subjects in whom basal energy requirements are similarly increased by heavy physical labor, caloric intake is increased appropriately to meet metabolic demands and body weight is preserved. Accordingly, the root of the problem in undernourished patients with COPD may be "relative anorexia," so that increases in basal caloric requirements are not accompanied by adequate caloric intake. Undernourished patients with COPD have higher blood levels of the cachexia factor tumor necrosis factor-α (TNF-α) than well-nourished COPD subjects. [5]

Survival studies in selected groups of patients with chronic obstructive pulmonary obstruction (COPD) and in population based studies have consistently shown higher COPD-related mortality rates in underweight and normal-weight patients than in overweight and even obese patients. [6],[7],[8] Undernutrition, is extremely common in patients with COPD, occurring in about 25% of stable outpatients and about 40% of hospitalized patients. [5] Undernutrition is an independent risk factor for mortality. [5] For a given level of lung function, undernourished patients with COPD have a greater 5-year mortality than normally nourished subjects. [5]

Contemporarily, the diagnosis and classification of chronic obstructive pulmonary disease (COPD) is based onspirometric assessment only. [9] Weight loss is a poor prognosticfactor and interestingly it is independent of other traditional indices such as the volume of air exhaled in the first second of a forced spirometric manoeuvre (FEV 1 ) or the arterial partial pressure of oxygen. [8] Therefore, weight loss identifies the systemic domain of COPD that needs to be taken into consideration in their clinical management. [10] In this context, Celli, et al. have recently proposeda composite index (BODE index) that includes body weight (assessed by BMI), the degree of airflow obstruction (assessed by the FEV 1 value expressed as percentage of the reference value), and the level of dyspnoea experienced by the patient and their exercise capacity that predicts survival much more accurately than FEV 1 alone. [11]

Therefore, this study was conducted to investigate the co-existence of low BMI and airflow obstruction, and if so, whether it is associated with the grade of severity in a population of COPD patients.


  Materials and Methods Top


A cross sectional study constituting 50 COPD patients between the age range of 40-65 years who attended Respiratory Medicine OPD (Out Patient Department) and Respiratory Medicine Ward of Regional Institute of Medical Sciences (RIMS), Imphal were included in the study. Institutional Ethics Committee approved the research study and patients gave their informed consent to participate in the study.

Patients with associated cardiac problems, renal failure, diabetes mellitus, hypertension, pulmonary fibrosis, neuromuscular diseases and ascites were excluded. Lung function was measured with Computerized Spirometer Helios 701 (Recorders and Medicare System, Chandigarh) in the Department of Physiology, RIMS.

The study variables which include Forced Vital Capacity (FVC), Forced Expiratory Volume in one second (FEV 1 ), FEV 1 % predicted and FEV 1 /FVC were recorded by spirometry. Severity of COPD was graded according to GOLD classification. [12]

Demographic history such as age, sex and so on was recorded. The occupational and smoking history (past and present) was also recorded. Subjects were classified according to smoking status as 1, Current smokers who have smoked regularly with 1 month prior to examination and 2, Ex-smokers who have stopped more than 1 month prior to examination. Pack years were calculated from the average number of cigarettes smoked per day in a year, one pack year being smoking of 20 cigarettes per day for 1 year.


  Calculating Pack Years of Smoking Top


20 cigarettes = 1 packet pack years of smoking = (Number of cigarettes smoked per day × no of years of smoking)/20 for example, a smoker of 10 cigarettes a day who has smoked for 15 years would have smoked: (10 × 15)/20 = 7.5 pack years.

Quantification of pack-years smoked is important in clinical care, where degree of tobacco exposure is correlated to risk of disease. [13] Pack years of smoking being a key predictive factor in the development of COPD is well supported by numerous studies. [14]

All the patients were assessed for height, body weight (BW), Body mass index (BMI) and BW and height were measured with indoor clothing without shoes. Measurements were compared with standard recommended by World Health Organization. [15] BMI was calculated by the formulae given as weight (kg) divided by height in metre 2 (m). BMI was categorized as underweight (<18.5 kg/m 2 ), normal weight (18.5-24.9 kg/m 2 ), overweight (25.0-29.9 kg/m 2 ), and obese ( ≥30.0 kg/m 2 ). Statistical analysis was performed using SPSS version 16.0. Independent t-test was used to compare values during the study. Pearson's correlation coefficient was applied to the correlation of nutritional status and lung function. P-value of less than 0.05 was considered to be significant.


  Results Top


Demographic description of total group is shown in [Table 1]. Fifty patients (mean age 57.19 ± 11.01; Male/Female = 25/25) were evaluated. All patients were smokers. Smoking history of the subject showed 14.58% to be former smoker and 85.2% current smoker.
Table 1: Demographic profile of patients


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[Table 2] presents the descriptive statistics of nutritional variables in both the sexes. Mean body weight for males was 59.67 ± 13.10 kg and females were 42.54 ± 2.89 kg.
Table 2: Nutritional profile among males and females (N = 50)


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Lung function test according to the gender is shown in [Table 3]. Spirometry of the subjects revealed low FEV 1 % predicted values, which are 69.04 ± 25.06 and 59.32 ± 28.11 in males and females, respectively. This shows that all the subjects were moderately deteriorated.

Out of 50 patients of the study population, N = 27 had BMI ≥18.5 while N = 23 had BMI <18.5 as shown in [Table 4]a. The table also shows that patients with normal BMI have better lung functions and higher flow rates and these findings are statistically significant for FVC, FEV 1 and FEV 1 % predicted.
Table 3: Lung function tests among males and females (N = 50)


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Table 4

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So, to determine if there was a relationship between poor nutrition and airway obstruction in the subjects studied, the flow rates were correlated with BMI, as shown in [Table 4]b. TheFVC, FEV 1 and FEV 1 % predicted are strongly correlated with BMI with high statistical significance (r = 0.600, P = 0.000; r = 0.517, P = 0.000; r = 0.433, P = 0.002, respectively). No statistically significant correlation was found between body weight and FEV 1 /FVC% (r = 0.033, P = 0.826).{Table 4}

[Table 5] shows the comparison of spirometric parameters between ex-smokers and present smokers. There is no significant difference between the two groups.
Table 5: Comparison of smokers and ex-smokers


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  Discussion Top


COPD is defined functionally by a decrease in maximal expiratory flow from the lung. The influence of the BMI on different epidemiologic and functional aspects of COPD has become an area of increasing research during the last decade. Several studies have documented a clear association between low BMI with poor prognosis and mortality in patients with established COPD. [7],[9],[16],[17],[18]

In the present study we have taken 50 diagnosed cases of COPD and recorded flow rates by spirometry. We found that out of the total number ofsubjects (n = 50) 33.3% were malnourished (BMI<18.5) and the rest of the subjects were well-nourished(BMI ≥18.8). The malnourished subjects had mean FEV 1 and FEV 1 % predicted values of 0.89 ΁\\\177; 0.62 and 50.71 ± 26.02, respectively, which was lower as compared to 1.55 ± 0.74 and 70.91 ± 24.9 as found in well-nourished patients. FEV 1 /FVC was also found to be lower in malnourished subjects. This finding suggests that subjects with low BMI have more severe lung disease based on FVC, FEV 1 and FEV 1 % predicted values.

[Table 4]b shows correlation values of expiratory flow rates with BMI. FVC, FEV 1 and FEV 1 % predicted are strongly correlated with BMI with P-value <0.005. This finding implies that expiratory flow rates increase with increase in BMI, and BMI reflects the nutritional status of the patients. However correlation between FEV 1 /FVC and BMI is not statistically significant. It is not known whether poor lung function is a cause of poor nutritional status or if poor nutritional status precipitates a decline in lung function results. Malnutrition may be deleterious in COPD patients due to decreased respiratory muscle mass and muscle strength; poor wound healing; decreased cell immunity and decreased ventilatory response to hypoxia. [18] This will increase the predisposition to respiratory failure. It is therefore important to be aware of this problem and respond quickly by providing nutritional support to the malnourished subjects with COPD. Refeeding malnourished COPD patients has been shown to improve both immune function and muscle function. [19] Substantial number of COPD patients are underweight. [3] Schols, et al. investigated factors affecting survival in patients with COPD. [20] They found that body weight has an independent effect on survival in COPD which could not be explained by lung function. Because BMI has been shown to correlate with mortality in COPD patients, [19] Low BMI should be considered a great risk of mortality. Our study also reports low values of flow rates in female subjects as compared to males with mean values of all flow parameters lower in females except FEV 1 /FVC.

In the present study patients who had low BMI were seen to have poorer lung function. Fletcher, et al. suggest that the enhanced rate of decline in FEV 1 is related to smoking pattern, but the results in this study support the notion that nutritional depletion may also influence the decline in lung function. [21] High prevalence of malnutritionamong hospitalized COPD patients with acute exacerbationis also related to their lung function and duration of hospital stay. [22]


  Conclusion Top


In the present study we can conclude that BMI is positively correlated to lung function in COPD and low BMI is prevalent in COPD patients. Nutritional intervention by inclusion of supplements in overall management of COPD may improve prognosis of the disease. Inclusion of BMI in assessment of COPD severity in addition to measurement of FEV 1 is supported. There are limitations of this study, several issues must be considered while interpreting the results of the study. The present study is limited by relatively smaller number of patients. For further investigations larger sample size and a prospective study in various populations would yield more significant results.

 
  References Top

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Pauwels RA, Buist AS, Calverley PM, Jenkins CR, Hurd SS;GOLDScientific Committee. Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease. NHLBI/WHO Global Initiative for Chronic Obstructive Lung Disease (GOLD) Workshop summary. Am J RespirCrit Care Med 2001;163:1256-76.  Back to cited text no. 1
    
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World Health Report. Geneva:World Health Organisation;2000.  Back to cited text no. 2
    
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Hunter AM, Carey MA, Larsh HW. The nutritional status of patients with chronic obstructive pulmonary disease. Am Rev Respir Dis 1981;124:376-81.  Back to cited text no. 3
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Wilson DO, Rogers RM, Wright EC, Anthonisen NR. Body weight in chronic obstructive pulmonary disease. The National Institutes of Health Intermittent Positive-Pressure Breathing Trial. Am Rev Respir Dis1989;139:1435-8.  Back to cited text no. 4
    
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Kelsen SG, Marchetti N. Pump failure:The pathogenesisof hypercapnic lung failure in patients with lung and chest wall disease. In:Fishman AP, Elias JA, Fishman JA, Grippi MA, Senior RM, Pack AI, editors. Fishman's Pulmonary Diseases and Disorders. 4 th ed. Vol. 2. USA: McGraw Hill; 2007. p. 2605.  Back to cited text no. 5
    
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Gray-Donald K, Gibbons L, Shapiro SH, Macklem PT, Martin JG. Nutritional status and mortality in chronic obstructive pulmonary disease. Am J RespirCrit Care Med 1996;153:961-6.  Back to cited text no. 7
    
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Schols AM, Slangen J, Volovics L, Wouters EF. Weight loss is a reversible factor in the prognosis of chronic obstructive pulmonary disease. Am J RespirCrit Care Med 1998;157:1791-7.  Back to cited text no. 8
    
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Hoogendoorn M, Feenstra TL, Schermer TR, Hesselink AE, Rutten-van MolkenMP. Severity distribution of chronic obstructive pulmonary disease (COPD) inDutch general practice. Respir Med 2006;100:83-6.  Back to cited text no. 9
    
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Augusti A. Systemic manifestations. In: Barnes PJ, Drazen JM, Rennard SI, Thomson NC, editors. Asthma and COPD: Basic Mechanisms and Clinical Management.2 nd ed. USA: Elsevier; 2009. p. 569.  Back to cited text no. 10
    
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Celli BR, Cote CG, Marin JM, Casanova C, Montes de Oca M, Mendez RA, et al. The body-mass index, airflow obstruction, dyspnea, and exercise capacity index in chronic obtructive pulmonary disease. N Engl J Med 2004;350:1005-12.  Back to cited text no. 11
    
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Anon. Diagnosing Obstructive Airways Disease. Bandolier;2000. p. 78-2.  Back to cited text no. 14
    
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World Health Organisation. Global Database on Body Mass Index. Available from: http://www.who.int/bmi/index.[Last accessed on 2006.  Back to cited text no. 15
    
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Vestbo J, Prescott E, Almdal T, Dahl M, Nordestgaard BG, Andersen T, et al. Body mass, fat-free body mass, and prognosis in patients with chronic obstructive pulmonary disease from a random population sample: Findings from the Copenhagen City Heart Study. Am J RespirCrit Care Med 2006;173:79-83.  Back to cited text no. 16
    
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Chailleux E, Laaban JP, Veale D. Prognostic value of nutritional depletion in patients with COPD treated by long-term oxygen therapy: Data from the ANTADIR observatory. Chest 2003;123:1460-6.  Back to cited text no. 17
    
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Gray-Donald K, Gibbons L, Shapiro SH, Martin JG. Effect of nutritional status on exercise performance in patients with chronic obstructive pulmonary disease. Am Rev Repir Dis1989;140:1544-8.  Back to cited text no. 18
    
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Rogers RM, Donahoe M, Costantino J. Physiologic effects of oral supplemental feeding in malnourished patients with chronic obstructive pulmonary disease.A randomized control study. Am Rev Respir Dis 1992;146:1511-7.  Back to cited text no. 19
    
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Schols AM, Fredrix EW, Soeters PB, Westerterp KR, Wouters EF. Resting energy expenditure in patients with chronic obstructive pulmonary disease. Am J ClinNutr 1991;54:983-7.  Back to cited text no. 20
    
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Gupta B, Kant S, Mishra R, Verma S. Nutritional status of chronic obstructive pulmonary disease patients admitted in hospital with acute exacerbation. J Clin Med Res2010;2:68-74.  Back to cited text no. 22
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]


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