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Table of Contents
Year : 2020  |  Volume : 69  |  Issue : 2  |  Page : 339-344

Evidence of nutritional abnormalities in chronic obstructive pulmonary disease

1 Department of Chest Medicine, Faculty of Medicine, Helwan University, Cairo, Egypt
2 Department of Chest Medicine, Faculty of Medicine, Fayoum University, Fayoum, Egypt

Date of Submission28-Aug-2019
Date of Decision08-Oct-2019
Date of Acceptance14-Oct-2019
Date of Web Publication14-May-2020

Correspondence Address:
MD Fatmaalzahraa S Abdalrazik
Department of Chest Medicine, Faculty of Medicie, Helwan University, Ain Helwan, Helwan, Cairo
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ejcdt.ejcdt_177_19

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Rationale Chronic obstructive pulmonary disease (COPD) is one of the major causes of global morbidity and mortality, with increased economic and social burden. One of the most evident systemic effects of COPD is nutritional abnormalities and muscle bulk reduction, leading to muscle dysfunction and wasting, with or without muscle atrophy.
Aims This work aims to detect the prevalence of nutritional abnormalities in correlation to smoking status and COPD severity.
Design This was a case–control study.
Patients and methods The present study included 300 candidates functionally diagnosed of having COPD according GOLD 2017. All patients were subjected to history taking, clinical examination, BMI and free fat mass index (FFMI) assessment, spirometry before and after bronchodilator testing, and questionnaires, such as COPD Assessment Test, Clinical COPD Questionnaire, and Hospital Anxiety and Depression Scale.
Results The study included 300 patients with COPD who are current smokers. Overall, 98% of them were males, and all were older than 40 years. Patients were classified into three groups: mild, moderate, and severe. The study found a statistically significant negative correlation between FFMI and COPD severity, whereas nonsignificant correlation with BMI. A strong statistically significant negative correlation was found between BMI and FFMI with smoking status. A positive correlation was seen between modified Medical Research Council scale with BMI and FFMI, but this was of nonstatistical significance. Correlation of BMI and FFMI with COPD Assessment Test score, Clinical COPD Questionnaire three domains (functional, symptoms, and mental), and Hospital Anxiety and Depression Scale (depression and anxiety) was found to have a strong positive significant correlation.
Conclusion Nutritional abnormalities related to COPD and smoking should be considered while managing patients with COPD.

Keywords: body mass index, chronic obstructive pulmonary disease, free fat mass index

How to cite this article:
Elhadidi SK, Elessawy AF, Elhefny RA, Abdalrazik FS. Evidence of nutritional abnormalities in chronic obstructive pulmonary disease. Egypt J Chest Dis Tuberc 2020;69:339-44

How to cite this URL:
Elhadidi SK, Elessawy AF, Elhefny RA, Abdalrazik FS. Evidence of nutritional abnormalities in chronic obstructive pulmonary disease. Egypt J Chest Dis Tuberc [serial online] 2020 [cited 2020 Aug 4];69:339-44. Available from: http://www.ejcdt.eg.net/text.asp?2020/69/2/339/284325

  Introduction Top

Chronic obstructive pulmonary disease (COPD) is a common, preventable, and treatable disease, characterized by the irreversible airflow limitation secondary to alveolar and/or airway changes [1].

COPD is considered to be a major cause of mortality and morbidity worldwide. This causes increased social and economic burden [1]. In addition to adding high health care expenses, COPD is considered a burden regarding impaired quality of life and disability [2].

Few studies have been done to assess COPD burden in developing countries [3], and the prevalence of COPD morbidity indices is underestimated, as it is not correctly measured [4].

One of the most evident systemic effects of COPD is nutritional abnormalities and muscle bulk reduction, leading to muscle dysfunction and wasting, with or without muscle atrophy. Nutritional abnormalities in COPD are divided into three types [5]: semistarvation [low BMI with normal or above-normal free fat mass index (FFMI)], muscle atrophy (normal or above-normal BMI with low FFMI), and cachexia (low BMI with low FFMI).

Infrequently, patients with COPD may have obesity owing to physical inactivity and stationary lifestyle, or it may occur in patients receiving systemic steroids [6].

Assessments of BMI and FFMI are reliable ways to measure body impedance [7].

In this study, we used BMI and FFMI as indicators to COPD burden and also assess their association with other COPD morbidities.

  Patients and methods Top

Study design

This is a case–control study that was conducted in chest department, Fayoum University hospitals and Helwan University hospitals, through November 2017–April 2019. Ethics approval was obtained from the Ethical Committee of the Faculty of Medicine, Fayoum University, Egypt, June 2017. Consent was obtained from all the patients.

The study design was approved by the Scientific Ethics Committee of Faculty of Medicine, Fayoum University, Egypt, on June 2017.

Study population

The study included 300 patients, with 100 cases in each severity group (mild, moderate, and severe) of COPD, diagnosed according to GOLD guidelines 2017 [8]. Very severe group was not included owing to deficiency of cases, and the already found cases were incapable of fulfilling the questionnaires. All patients were selected from Helwan University Hospital outpatients departments according to the following inclusion and exclusion criteria.

Inclusion criteria

  1. Patients diagnosed as COPD according to GOLD guidelines 2017.
  2. 40 years of age or older.

Exclusion criteria

  1. Terminal illnesses, for example, malignancies, chronic kidney disease, and chronic liver disease.
  2. Diagnosed with old or current psychiatric condition.
  3. Exacerbation during the study.

Analytical method

All candidates were subjected to the following:
  1. Full history taking and full clinical assessment.
  2. BMI and FFMI.
  3. Dyspnea score according to modified Medical Research Council scale (mMRC).
  4. Questionnaires.

Chronic obstructive pulmonary disease assessment test

All patients completed this questionnaire in Arabic language. COPD Assessment Test (CAT) is designed to assess the effect of COPD on a candidate’s life, and how this effect changes with time. CAT is simple and gives clinicians the data that helps them to give their patients’ better management of their condition [9].

Clinical chronic obstructive pulmonary disease questionnaire

This patient questionnaire included a validated Swedish version of the Clinical COPD Questionnaire (CCQ) in Arabic language. The CCQ consists of ten questions distributed in three domains: symptoms, mental state, and functional state. Observed symptoms are dyspnea, cough, and phlegm; mental state includes questions about feeling depressed and concerns about breathing; and functional state describes limitations in different activities of daily life owing to the lung disease. The questions apply to the previous week and use a seven-point scale from 0 to 6 [10].

Hospital Anxiety and Depression Scale

The patients answered the Hospital Anxiety and Depression Scale (HADS) questionnaire translated to Arabic Language. HADS is a questionnaire composed of statements relevant to either generalized anxiety or depression, the latter being largely composed of reflections of the state of anhedonia [11].
  1. Spirometry before and after bronchodilator testing.

Dynamic spirometry was performed using MIR Spirobank II Spirometer (MIR Medical International Research, Roma, Italy). The test was done before and after nebulization of 5 mg of salbutamol sulfate with 2 ml saline 0.9% for 3 min All cases with values of post-forced expiratory volume in 1 s (FEV1) less than 80% of the expected value and post-FEV1/forced vital capacity less than 0.7 without significant improvement postbronchodilator inhalation were included in our study.

Statistical analysis

Microsoft excel 2013 was used for data entry. Data analysis was done by using the statistical package statistical package for the social sciences, version 25. All statistical calculations were carried out using the computer program SPSS (SPSS Inc., Chicago, Illinois, USA) release 15 for Microsoft Windows (2006). Data were summarized using mean, SD, median, minimum, and maximum in quantitative data and using frequency (count) and relative frequency (percentage) for categorical data. Comparison among the three groups regarding dyspnea scale was done using the nonparametric test, Kruskal–Wallis H test, and differences between groups together were done by Mann–Whitney U test (categorical variables). Comparison among the three groups regarding other numerical variables was done by one-way analysis of variance test (Tukey HSD). Pearson correlation test was used to estimate correlation between numerical variables. A P value less than 0.05 was considered statistically significant.

  Results Top

This research included 300 candidates clinically and functionally diagnosed as having COPD. Of the 300 cases, 294 were males, and all were above 40 years old. The study population’s mean age was 57.69 years. The mean BMI was 27.06, and mean FFMI was 18.86. All the patients were current smokers, and their mean smoking index (SI) was 66.39 pack/year ([Table 1]).
Table 1 Descriptive statistics for the whole study population

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The study cases were classified into mild moderate and severe according to GOLD 2017 classification. We did not enroll any cases with very severe COPD in the current study. The mean age in the mild group was 54.37, BMI was 2.63, mean FFMI was 19.48, and mean SI was 23.11. In moderate group, the mean age was 57.46, mean BMI was 27.12, mean FFMI was 19.00, and mean SI was 61.19. In the severe group, mean age was 61.30, mean BMI was 26.51, mean FFMI was 18.16, and mean SI was 114.68. The correlation of these variables to COPD severity was found to be statistically significant (P>0.0001; [Table 2]).
Table 2 Descriptive statistics for each chronic obstructive pulmonary disease severity group

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All study population underwent the CCQ, CAT, and HADS.

In the current study, we correlated BMI and FFMI with the three COPD stages, SI, mMRC grades, CAT score, the three domains of CCQ score, and HADS.

In our study, we found that the correlation between BMI and COPD stages was found to be statistically nonsignificant (P>0.4); however, when FFMI was correlated to COPD stages, the results were found to be statistically significant ([Table 3]).
Table 3 Correlation of BMI and free fat mass index to stages of chronic obstructive pulmonary disease

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FFMI is lower in more severe COPD groups; in mild group, FFMI was 19.42, in moderate group, FFMI was 19.01, and in severe group, FFMI was 18.16 ([Figure 1]).
Figure 1 Correlation of FFMI to stages of COPD. COPD, chronic obstructive pulmonary disease; FFMI, free fat mass index.

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When SI was correlated to BMI and FFMI, we found a strong negative statistically significant correlation ([Table 4]). The higher the SI the lower BMI and FFMI.
Table 4 Correlation between BMI and free fat mass index to smoking index

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In this study, when grades of dyspnea according to mMRC score were correlated to BMI and FFMI, using Kruskal–Wallis test and the correlation, no statistical significance was found ([Table 5]).
Table 5 Correlation of BMI and free fat mass index to modified Medical Research Council scale grades

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In this research, when we correlated BMI and FFMI to CAT score, CCQ three domains (functional, symptoms, and mental), and HADS (depression and anxiety), we found a strong significant correlation ([Table 6]).
Table 6 Correlation of BMI and free fat mass index to COPD Assessment Test, Clinical COPD Questionnaire three domains, and Hospital Anxiety and Depression Scale

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These data are in agreement with a study done by Luo and colleagues, which enrolled 235 patients with stable COPD, to evaluate the nutritional status in patients diagnosed with COPD. These researchers stated that 48.5% of the candidates were malnourished, and malnourishment was more significant in severe COPD groups. They also found that FFMI was significantly lower in in patients with very severe COPD stage (P<0.001) [12].

A research done by Zhou and colleagues enrolled 1818 Chinese candidates in a 4-year study, including 759 controls. The candidates were subjected to questionnaire interviews, spirometry, and history taking. They found that candidates with lower BMI showed a higher incidence of COPD, when compared with candidates with normal BMI. Obese and low BMI candidates showed lower FEV1. Moreover, through the 4 years, they found that non-COPD candidates who had low baseline BMI were more at risk to convert to patients with COPD [13].

Another study was conducted by Cazzola and colleagues to assess the combination between asthma, COPD, and BMI. The study included Italian candidates visiting general practitioners, and they are variably smokers, nonsmokers, or exsmokers. The study concluded that higher BMI is related to presence of COPD or asthma, not depending on candidates smoking status. The study also showed that there was a correlation between low BMI and COPD of statistical significance, but only in men [14].

The study by Karadag and colleagues enrolled 52 male patients with COPD with a mean age of 60 years . The candidates were subjected to spirometry and serum tumor necrosis factor alpha (TNF‐α) levels assessment. They found that there was a negative correlation with statistical significance between BMI and SI (P=0.004) but not with post-FEV1, arterial blood oxygen, or TNF‐α values. Current smokers had lower values of BMI than ex‐smokers (P=0.041), but TNF levels were the same [15].

Muller and colleagues conducted a study to assess the nutritional status of patients with COPD when compared with non-COPD healthy candidates. They enrolled candidates between 50 and 70 years old, measured body cell mass, and assessed relation between extracellular mass and body cell mass using bioelectrical impedance analysis. They concluded that BMI was less than 18.5% in 10.4% of patients with COPD, whereas all non-COPD candidates had BMI more than 19%. Overall, 31.7% of patients with COPD were overweight versus 54.2% in non-COPD candidates, whereas 17.1% of patients with COPD in comparison with 21.7% of non-COPD candidates were obese. Although lower BMI in patients with COPD had no statistical significance, the decreased muscle mass measurements were of statistical significance in patients with COPD when compared with non-COPD patients [16].

A study done by Ischaki and colleagues included 100 COPD cases. The candidates were classified into the five groups and underwent estimation of BMI, FFMI, spirometry, 6-min walk test, dyspnea score using the MRC scale, and chronic respiratory disease questionnaire (the emotional part). The study found that FFMI is significantly associated with higher mMRC scale and higher scores of emotional disturbances in chronic respiratory disease questionnaire; however, the results were not the same with BMI [17]. So, they concluded that FFMI is of more value with respect to COPD severity when compared with BMI.Another study was done by Janssen and colleagues to assess the correlation of mental health status and nutritional status in patients with COPD. The enrolled 701 patients were diagnosed to have COPD who were admitted for pulmonary rehabilitation. Candidates were subjected to the HADS, disease-specific health status, spirometry, SI, and modified medical research council scale to assess dyspnea score. The researchers found that patients who had BMI less than 21% were at higher risk of having depression and experienced dyspnea more than others [18].

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

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  [Figure 1]

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]


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