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Yao S, Zeng L, Wang F, Chen K. Obesity Paradox in Lung Diseases: What Explains It? Obes Facts 2023; 16:411-426. [PMID: 37463570 PMCID: PMC10601679 DOI: 10.1159/000531792] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2023] [Accepted: 06/28/2023] [Indexed: 07/20/2023] Open
Abstract
BACKGROUND Obesity is a globally increasing health problem that impacts multiple organ systems and a potentially modifiable risk factor for many diseases. Obesity has a significant impact on lung function and is strongly linked to the pathophysiology that contributes to lung diseases. On the other hand, reports have emerged that obesity is associated with a better prognosis than for normal weight individuals in some lung diseases, including pneumonia, acute lung injury/acute respiratory distress syndrome, chronic obstructive pulmonary disease, and lung cancer. The lesser mortality and better prognosis in patients with obesity is known as obesity paradox. While obesity paradox is both recognized and disputed in epidemiological studies, recent research has suggested possible mechanisms. SUMMARY In this review, we attempted to explain and summarize these factors and mechanisms, including immune response, pulmonary fibrosis, lung function, microbiota, fat and muscle reserves, which are significantly altered by obesity and may contribute to the obesity paradox in lung diseases. We also discuss contrary literature that attributes the "obesity paradox" to confounding. KEY MESSAGES The review will illustrate the possible role of obesity in the prognosis or course of lung diseases, leading to a better understanding of the obesity paradox and provide hints for further basic and clinical research in lung diseases.
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Affiliation(s)
- Surui Yao
- School of Public Health, Chengdu Medical College, Chengdu, PR China
| | - Lei Zeng
- School of Public Health, Chengdu Medical College, Chengdu, PR China
| | - Fengyuan Wang
- College of Animal and Veterinary Sciences, Southwest Minzu University, Chengdu, PR China
| | - Kejie Chen
- School of Public Health, Chengdu Medical College, Chengdu, PR China
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2
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Buttery SC, Zysman M, Vikjord SAA, Hopkinson NS, Jenkins C, Vanfleteren LEGW. Contemporary perspectives in COPD: Patient burden, the role of gender and trajectories of multimorbidity. Respirology 2021; 26:419-441. [PMID: 33751727 DOI: 10.1111/resp.14032] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2021] [Accepted: 02/21/2021] [Indexed: 12/13/2022]
Abstract
An individual's experience of COPD is determined by many factors in addition to the pathological features of chronic bronchitis and emphysema and the symptoms that derive directly from them. Multimorbidity is the norm rather than the exception, so most people with COPD are living with a range of other medical problems which can decrease overall quality of life. COPD is caused by the inhalation of noxious particles or gases, in particular tobacco smoke, but also by early life disadvantage impairing lung development and by occupations where inhaled exposures are common (e.g. industrial, farming and cleaning work). Wealthy people are therefore relatively protected from developing COPD and people who do develop the condition may have reduced resources to cope. COPD is also no longer a condition that predominantly affects men. The prevalence of COPD among women has equalled that of men since 2008 in many high-income countries, due to increased exposure to tobacco, and in low-income countries due to biomass fuels. COPD is one of the leading causes of death in women in the USA, and death rates attributed to COPD in women in some countries are predicted to overtake those of men in the next decade. Many factors contribute to this phenomenon, but in addition to socioeconomic and occupational factors, there is increasing evidence of a higher susceptibility of females to smoking and pollutants. Quality of life is also more significantly impaired in women. Although most medications (bronchodilators and inhaled corticosteroids) used to treat COPD demonstrate similar trends for exacerbation prevention and lung function improvement in men and women, this is an understudied area and clinical trials frequently have a preponderance of males. A better understanding of gender-based predictors of efficacy of all therapeutic interventions is crucial for comprehensive patient care. There is an urgent need to recognize the increasing burden of COPD in women and to facilitate global improvements in disease prevention and management in this specific population. Many individuals with COPD follow a trajectory of both lung function decline and also multimorbidity. Unfavourable lung function trajectories throughout life have implications for later development of other chronic diseases. An enhanced understanding of the temporal associations underlying the development of coexisting diseases is a crucial first step in unravelling potential common disease pathways. Lessons can be learned from exploring disease trajectories of other NCD as well as multimorbidity development. Further research will be essential to explain how early life risk factors commonly influence trajectories of COPD and other diseases, how different diseases develop in relation to each other in a temporal way and how this ultimately leads to different multimorbidity patterns in COPD. This review integrates new knowledge and ideas pertaining to three broad themes (i) the overall burden of disease in COPD, (ii) an unappreciated high burden in women and (iii) the contrast of COPD trajectories and different multimorbidity patterns with trajectories of other NCD. The underlying pathology of COPD is largely irreversible, but many factors noted in the review are potentially amenable to intervention. Health and social care systems need to ensure that effective treatment is accessible to all people with the condition. Preventive strategies and treatments that alter the course of disease are crucial, particularly for patients with COPD as one of many problems.
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Affiliation(s)
- Sara C Buttery
- National Heart and Lung Institute, Imperial College London, London, UK
| | - Maéva Zysman
- Centre de Recherche cardio-thoracique de Bordeaux, Univ-Bordeaux, Pessac, France.,Service des Maladies Respiratoires, CHU Bordeaux, Pessac, France
| | - Sigrid A A Vikjord
- Department of Medicine and Rehabilitation, Levanger Hospital, Nord-Trøndelag Hospital Trust, Levanger, Norway.,HUNT Research Centre, Department of Public Health and Nursing, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology (NTNU), Levanger, Norway
| | | | - Christine Jenkins
- Respiratory Group, The George Institute for Global Health, Sydney, NSW, Australia
| | - Lowie E G W Vanfleteren
- COPD Center, Department of Respiratory Medicine and Allergology, Sahlgrenska University Hospital, Gothenburg, Sweden.,Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
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3
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Kim J, Kim B, Bak SH, Oh YM, Kim WJ. A comparative study of chest CT findings regarding the effects of regional dust exposure on patients with COPD living in urban areas and rural areas near cement plants. Respir Res 2021; 22:43. [PMID: 33549113 PMCID: PMC7866433 DOI: 10.1186/s12931-021-01649-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2020] [Accepted: 02/01/2021] [Indexed: 12/02/2022] Open
Abstract
Background The clinical and radiological presentation of chronic obstructive pulmonary disease (COPD) is heterogenous depending on the characterized sources of inflammation. This study aimed to evaluate COPD phenotypes associated with specific dust exposure. Methods This study was designed to compare the characteristics, clinical outcomes and radiological findings between two prospective COPD cohorts representing two distinguishing regions in the Republic of Korea; COPD in Dusty Area (CODA) and the Korean Obstructive Lung Disease (KOLD) cohort. A total of 733 participants (n = 186 for CODA, and n = 547 for KOLD) were included finally. A multivariate analysis to compare lung function and computed tomography (CT) measurements of both cohort studies after adjusting for age, sex, education, body mass index, smoking status, and pack-year, Charlson comorbidity index, and frequency of exacerbation were performed by entering the level of FEV1(%), biomass exposure and COPD medication into the model in stepwise. Results The mean wall area (MWA, %) became significantly lower in COPD patients in KOLD from urban and metropolitan area than those in CODA cohort from cement dust area (mean ± standard deviation [SD]; 70.2 ± 1.21% in CODA vs. 66.8 ± 0.88% in KOLD, p = 0.028) after including FEV1 in the model. COPD subjects in KOLD cohort had higher CT-emphysema index (EI, 6.07 ± 3.06 in CODA vs. 20.0 ± 2.21 in KOLD, p < 0.001, respectively). The difference in the EI (%) was consistently significant even after further adjustment of FEV1 (6.12 ± 2.88% in CODA vs. 17.3 ± 2.10% in KOLD, p = 0.002, respectively). However, there was no difference in the ratio of mean lung density (MLD) between the two cohorts (p = 0.077). Additional adjustment for biomass parameters and medication for COPD did not alter the statistical significance after entering into the analysis with COPD medication. Conclusions Higher MWA and lower EI were observed in COPD patients from the region with dust exposure. These results suggest that the imaging phenotype of COPD is influenced by specific environmental exposure.
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Affiliation(s)
- Junghyun Kim
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, National Medical Center, Seoul, Republic of Korea
| | - Bom Kim
- Department of Internal Medicine and Environmental Health Center, Kangwon National University, Chuncheon, Republic of Korea
| | - So Hyeon Bak
- Deparment of Radiology, School of Medicine, Kangwon National University, Chuncheon, Republic of Korea
| | - Yeon-Mok Oh
- Department of Pulmonary and Critical Care Medicine and Clinical Research Center for Chronic Obstructive Airway Diseases, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Woo Jin Kim
- Department of Internal Medicine and Environmental Health Center, Kangwon National University, Chuncheon, Republic of Korea.
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4
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Rodrigues GC, Rocha NN, Maia LDA, Melo I, Simões AC, Antunes MA, Bloise FF, Woyames J, da Silva WS, Capelozzi VL, Abela GP, Ball L, Pelosi P, Rocco PRM, Silva PL. Impact of experimental obesity on diaphragm structure, function, and bioenergetics. J Appl Physiol (1985) 2020; 129:1062-1074. [PMID: 32909923 DOI: 10.1152/japplphysiol.00262.2020] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
Obesity is associated with bioenergetic dysfunction of peripheral muscles; however, little is known regarding the impact of obesity on the diaphragm. We hypothesized that obesity would be associated with diaphragm dysfunction attributable to mitochondrial oxygen consumption and structural and ultrastructural changes. Wistar rat litters were culled to 3 pups to induce early postnatal overfeeding and consequent obesity. Control animals were obtained from unculled litters. From postnatal day 150, diaphragm ultrasound, computed tomography, high-resolution respirometry, immunohistochemical, biomolecular, and ultrastructural histological analyses were performed. The diaphragms of obese animals, compared with those of controls, presented changes in morphology as increased thickening fraction, diaphragm excursion, and diaphragm dome height, as well as increased mitochondrial respiratory capacity coupled to ATP synthesis and maximal respiratory capacity. Fatty acid synthase gene expression was also higher in obese animals, suggesting a source of energy for the respiratory chain. Myosin heavy chain-IIA was increased, indicating shift from glycolytic toward oxidative muscle fiber profile. Diaphragm tissue also exhibited ultrastructural changes, such as compact, round, and swollen mitochondria with fainter cristae and more lysosomal bodies. Dynamin-1 expression in the diaphragm was reduced in obese rats, suggesting decreased mitochondrial fission. Furthermore, gene expressions of peroxisome γ proliferator-activated receptor coactivator-1α and superoxide dismutase-2 were lower in obese animals than in controls, which may indicate a predisposition to oxidative injury. In conclusion, in the obesity model used herein, muscle fiber phenotype was altered in a manner likely associated with increased mitochondrial respiratory capability, suggesting respiratory adaptation to increased metabolic demand.NEW & NOTEWORTHY Obesity has been associated with peripheral muscle dysfunction; however, little is known about its impact on the diaphragm. In the current study, we found high oxygen consumption in diaphragm tissue and changes in muscle fiber phenotypes toward a more oxidative profile in experimental obesity.
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Affiliation(s)
- Gisele C Rodrigues
- Laboratory of Pulmonary Investigation, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Nazareth N Rocha
- Laboratory of Pulmonary Investigation, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil.,Fluminense Federal University, Niteroi, Brazil
| | - Ligia de A Maia
- Laboratory of Pulmonary Investigation, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Isabella Melo
- Laboratory of Pulmonary Investigation, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Ana Carolina Simões
- Laboratory of Pulmonary Investigation, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Mariana A Antunes
- Laboratory of Pulmonary Investigation, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Flavia F Bloise
- Laboratory of Translational Endocrinology, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Juliana Woyames
- Laboratory of Molecular Endocrinology, Institute of Biophysics Carlos Chagas Filho, Rio de Janeiro, Brazil
| | - Wagner S da Silva
- Laboratory of Metabolic Adaptations, Institute of Medical Biochemistry Leopoldo de Meis, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Vera L Capelozzi
- Laboratory of Pulmonary Genomics, Department of Pathology, University of São Paulo, São Paulo, Brazil
| | - Glenn Paul Abela
- Anesthesiology and Intensive Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neurosciences, Genoa, Italy
| | - Lorenzo Ball
- Anesthesiology and Intensive Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neurosciences, Genoa, Italy.,Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy
| | - Paolo Pelosi
- Anesthesiology and Intensive Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neurosciences, Genoa, Italy.,Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy
| | - Patricia R M Rocco
- Laboratory of Pulmonary Investigation, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Pedro L Silva
- Laboratory of Pulmonary Investigation, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
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Betancourt JA, Stigler Granados P, Pacheco GJ, Shanmugam R, Kruse CS, Fulton LV. Obesity and Morbidity Risk in the U.S. Veteran. Healthcare (Basel) 2020; 8:healthcare8030191. [PMID: 32610637 PMCID: PMC7551346 DOI: 10.3390/healthcare8030191] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Revised: 06/16/2020] [Accepted: 06/25/2020] [Indexed: 12/26/2022] Open
Abstract
The obesity epidemic in the United States has been well documented and serves as the basis for a number of health interventions across the nation. However, those who have served in the U.S. military (Veteran population) suffer from obesity in higher numbers and have an overall disproportionate poorer health status when compared to the health of the older non-Veteran population in the U.S. which may further compound their overall health risk. This study examined both the commonalities and the differences in obesity rates and the associated co-morbidities among the U.S. Veteran population, utilizing data from the 2018 Behavioral Risk Factor Surveillance System (BRFSS). These data are considered by the Centers for Disease Control and Prevention (CDC) to be the nation’s best source for health-related survey data, and the 2018 version includes 437,467 observations. Study findings show not only a significantly higher risk of obesity in the U.S. Veteran population, but also a significantly higher level (higher odds ratio) of the associated co-morbidities when compared to non-Veterans, including coronary heart disease (CHD) or angina (odds ratio (OR) = 2.63); stroke (OR = 1.86); skin cancer (OR = 2.18); other cancers (OR = 1.73); chronic obstructive pulmonary disease (COPD) (OR = 1.52), emphysema, or chronic bronchitis; arthritis (OR = 1.52), rheumatoid arthritis, gout, lupus, or fibromyalgia; depressive disorders (OR = 0.84), and diabetes (OR = 1.61) at the 0.95 confidence interval level.
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6
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Wu TD, Ejike CO, Wise RA, McCormack MC, Brigham EP. Investigation of the Obesity Paradox in Chronic Obstructive Pulmonary Disease, According to Smoking Status, in the United States. Am J Epidemiol 2019; 188:1977-1983. [PMID: 31504124 DOI: 10.1093/aje/kwz185] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2019] [Revised: 08/05/2019] [Accepted: 08/13/2019] [Indexed: 11/14/2022] Open
Abstract
An obesity paradox in chronic obstructive pulmonary disease (COPD), whereby overweight/obese individuals have improved survival, has been well-described. These studies have generally included smokers. It is unknown whether the paradox exists in individuals with COPD arising from factors other than smoking. Nonsmoking COPD is understudied yet represents some 25%-45% of the disease worldwide. To determine whether the obesity paradox differs between ever- and never-smokers with COPD, 1,723 adult participants with this condition were examined from 2 iterations of the National Health and Nutrition Examination Survey (1988-1994, 2007-2010), with mortality outcomes followed through December 2011. Using Cox proportional hazards models, adjusted for sociodemographic factors, lung function, and survey cycle, ever/never-smoking was found to modify the association between body mass index and hazard of death. Compared with normal-weight participants, overweight/obese participants had lower hazard of death among ever-smokers (for overweight, adjusted hazard ratio (aHR) = 0.56, 95% confidence interval (CI): 0.43, 0.74; for obesity, aHR = 0.66, 95% CI: 0.48, 0.92), but never-smokers did not (overweight, aHR = 1.41, 95% CI: 0.66, 3.03; obesity, aHR = 1.29, 95% CI: 0.48, 3.48). An obesity paradox appeared to be absent among never-smokers with COPD. This, to our knowledge, novel finding might be explained by pathophysiological differences between smoking-related and nonsmoking COPD or by smoking-associated methodological biases.
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7
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Vestal BE, Carlson NE, Estépar RSJ, Fingerlin T, Ghosh D, Kechris K, Lynch D. Using a spatial point process framework to characterize lung computed tomography scans. SPATIAL STATISTICS 2019; 29:243-267. [PMID: 31750077 PMCID: PMC6867806 DOI: 10.1016/j.spasta.2018.12.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
Pulmonary emphysema is a destructive disease of the lungs that is currently diagnosed via visual assessment of lung Computed Tomography (CT) scans by a radiologist. Visual assessment can have poor inter-rater reliability, is time consuming, and requires access to trained assessors. Quantitative methods that reliably summarize the biologically relevant characteristics of an image are needed to improve the way lung diseases are characterized. The goal of this work was to show how spatial point process models can be used to create a set of radiologically derived quantitative lung biomarkers of emphysema. We formalized a general framework for applying spatial point processes to lung CT scans, and developed a Shot Noise Cox Process to quantify how radiologically based emphysematous tissue clusters into larger structures. Bayesian estimation of model parameters was done using spatial Birth-Death MCMC (BD-MCMC). In simulations, we showed the BD-MCMC estimation algorithm is able to accurately recover model parameters. In an application to real lung CT scans from the COPDGene cohort, we showed variability in the clustering characteristics of emphysematous tissue across disease subtypes that were based on visual assessments of the CT scans.
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Affiliation(s)
- Brian E. Vestal
- Center for Genes, Environment and Health, National Jewish Health, 1400 Jackson St, Denver, CO 80206, USA
- Department of Biostatistics and Informatics, University of Colorado Denver, Anschutz Medical Campus, Aurora, CO, USA
| | - Nichole E. Carlson
- Department of Biostatistics and Informatics, University of Colorado Denver, Anschutz Medical Campus, Aurora, CO, USA
| | - Raúl San José Estépar
- Applied Chest Imaging Laboratory (ACIL), Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Tasha Fingerlin
- Center for Genes, Environment and Health, National Jewish Health, 1400 Jackson St, Denver, CO 80206, USA
| | - Debashis Ghosh
- Department of Biostatistics and Informatics, University of Colorado Denver, Anschutz Medical Campus, Aurora, CO, USA
| | - Katerina Kechris
- Department of Biostatistics and Informatics, University of Colorado Denver, Anschutz Medical Campus, Aurora, CO, USA
| | - David Lynch
- Department of Radiology, National Jewish Health, Denver, CO, USA
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8
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Rutting S, Papanicolaou M, Xenaki D, Wood LG, Mullin AM, Hansbro PM, Oliver BG. Dietary ω-6 polyunsaturated fatty acid arachidonic acid increases inflammation, but inhibits ECM protein expression in COPD. Respir Res 2018; 19:211. [PMID: 30390648 PMCID: PMC6215599 DOI: 10.1186/s12931-018-0919-4] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2018] [Accepted: 10/21/2018] [Indexed: 02/06/2023] Open
Abstract
Background The obesity paradox in COPD describes protective effects of obesity on lung pathology and inflammation. However, the underlying relationships between obesity, diet and disease outcomes in COPD are not fully understood. In this study we measured the response to dietary fatty acids upon markers of inflammation and remodelling in human lung cells from people with and without COPD. Methods Pulmonary fibroblasts were challenged with ω-3 polyunsaturated fatty acids (PUFAs), ω-6 PUFAs, saturated fatty acids (SFAs) or the obesity-associated cytokine TNFα. After 48–72 h release of the pro-inflammatory cytokines interleukin (IL)-6 and CXCL8 was measured using ELISA and mRNA expression and deposition of the extracellular matrix (ECM) proteins fibronectin, type I collagen, tenascin and perlecan were measured using qPCR or ECM ELISA, respectively. Results Challenge with the ω-6 PUFA arachidonic acid (AA), but not ω-3 PUFAs or SFAs, resulted in increased IL-6 and CXCL8 release from fibroblasts, however IL-6 and CXCL8 release was reduced in COPD (n = 19) compared to non-COPD (n = 36). AA-induced cytokine release was partially mediated by downstream mediators of cyclooxygenase (COX)-2 in both COPD and non-COPD. In comparison, TNFα-induced IL-6 and CXCL8 release was similar in COPD and non-COPD, indicating a specific interaction of AA in COPD. In patients with or without COPD, regression analysis revealed no relationship between BMI and cytokine release. In addition, AA, but not SFAs or ω-3 PUFAs reduced the basal deposition of fibronectin, type I collagen, tenascin and perlecan into the ECM in COPD fibroblasts. In non-COPD fibroblasts, AA-challenge decreased basal deposition of type I collagen and perlecan, but not fibronectin and tenascin. Conclusions This study shows that AA has disease-specific effects on inflammation and ECM protein deposition. The impaired response to AA in COPD might in part explain why obesity appears to have less detrimental effects in COPD, compared to other lung diseases. Electronic supplementary material The online version of this article (10.1186/s12931-018-0919-4) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Sandra Rutting
- Respiratory Cellular and Molecular Biology, Woolcock Institute of Medical Research, The University of Sydney, Sydney, Australia.,Priority Research Centre for Healthy Lungs, Hunter Medical Research Institute and The University of Newcastle, Newcastle, NSW, Australia
| | - Michael Papanicolaou
- Respiratory Cellular and Molecular Biology, Woolcock Institute of Medical Research, The University of Sydney, Sydney, Australia.,School of Life Sciences, University of Technology Sydney, Sydney, Australia
| | - Dia Xenaki
- Respiratory Cellular and Molecular Biology, Woolcock Institute of Medical Research, The University of Sydney, Sydney, Australia
| | - Lisa G Wood
- Priority Research Centre for Healthy Lungs, Hunter Medical Research Institute and The University of Newcastle, Newcastle, NSW, Australia
| | - Alexander M Mullin
- Respiratory Cellular and Molecular Biology, Woolcock Institute of Medical Research, The University of Sydney, Sydney, Australia
| | - Philip M Hansbro
- Priority Research Centre for Healthy Lungs, Hunter Medical Research Institute and The University of Newcastle, Newcastle, NSW, Australia
| | - Brian G Oliver
- Respiratory Cellular and Molecular Biology, Woolcock Institute of Medical Research, The University of Sydney, Sydney, Australia. .,School of Life Sciences, University of Technology Sydney, Sydney, Australia.
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9
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What do polymorphisms tell us about the mechanisms of COPD? Clin Sci (Lond) 2017; 131:2847-2863. [PMID: 29203722 DOI: 10.1042/cs20160718] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2017] [Revised: 10/22/2017] [Accepted: 11/01/2017] [Indexed: 12/11/2022]
Abstract
COPD (chronic obstructive pulmonary disease) is characterized by irreversible lung airflow obstruction. Cigarette smoke is the major risk factor for COPD development. However, only a minority number of smokers develop COPD, and there are substantial variations in lung function among smokers, suggesting that genetic determinants in COPD susceptibility. During the past decade, genome-wide association studies and exome sequencing have been instrumental to identify the genetic determinants of complex traits, including COPD. Focused studies have revealed mechanisms by which genetic variants contribute to COPD and have led to novel insights in COPD pathogenesis. Through functional investigations of causal variants in COPD, from the proteinase-antiproteinase theory to emerging roles of developmental pathways (such as Hedgehog and Wnt pathways) in COPD, we have greatly expanded our understanding on this complex pulmonary disease. In this review, we critically review functional investigations on roles of genetic polymorphisms in COPD, and discuss future challenges and opportunities in discovering novel mechanisms of functional variants.
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10
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Kim C, Ko Y, Kim SH, Yoo HJ, Lee JS, Rhee CK, Lee JH, Lee JH, Kim TH, Lim SY, Yoo KH, Seo JB, Oh YM, Lee SD, Park YB. Urinary desmosine is associated with emphysema severity and frequent exacerbation in patients with COPD. Respirology 2017; 23:176-181. [PMID: 28905464 DOI: 10.1111/resp.13170] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2017] [Revised: 06/28/2017] [Accepted: 06/28/2017] [Indexed: 11/29/2022]
Abstract
BACKGROUND AND OBJECTIVE Matrix degradation is a key feature of chronic obstructive pulmonary disease (COPD). Desmosine and isodesmosine (desmosines) are excreted in urine following matrix degradation. The main purpose of this study was to investigate the association between computed tomography (CT) emphysema indices and urinary desmosines in patients with COPD. METHODS A total of 152 subjects were selected from the Korean Obstructive Lung Disease cohort. Their urine samples were assayed for desmosines using liquid chromatography-tandem mass spectrometry (LC-MS/MS) methods. The cohort was divided into emphysema-dominant (n = 80) and non-emphysema dominant- (n = 72) groups according to the CT emphysema index. RESULTS The level of urinary desmosines was significantly higher in the emphysema-dominant group. Significant differences were also observed between the two groups for body mass index and lung function. Multivariate analysis indicated that a high level of urinary desmosines was a significant independent predictor of emphysema (relative risk: 2.6; 95% CI: 1.11-6.09; P = 0.028). The percentage of frequent exacerbators was significantly higher in the high urinary desmosine group in the first year of follow-up (P = 0.041). The mean number of exacerbations was higher in the high urinary desmosine group, although this difference was not statistically significant (P = 0.067). The changes in emphysema index did not differ between the two urinary desmosine groups over 3 years of follow-up. CONCLUSION This study indicates that the level of urinary desmosines measured by LC-MS/MS methods is associated with the CT emphysema index. Urinary desmosine can be a useful predictor in identifying frequent exacerbators.
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Affiliation(s)
- Changhwan Kim
- Department of Internal Medicine, Jeju National University Hospital, Jeju National University School of Medicine, Jeju, Republic of Korea.,Clinical Research Center for Chronic Obstructive Airway Diseases, Seoul, Republic of Korea
| | - Yousang Ko
- Clinical Research Center for Chronic Obstructive Airway Diseases, Seoul, Republic of Korea.,Department of Pulmonary and Critical Care Medicine, Hallym University Kangdong Sacred Heart Hospital, Seoul, Republic of Korea
| | - Su Hee Kim
- Department of Convergence Medicine, Institute for Life Sciences, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Hyun Ju Yoo
- Department of Convergence Medicine, Institute for Life Sciences, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Jae Seung Lee
- Clinical Research Center for Chronic Obstructive Airway Diseases, Seoul, Republic of Korea.,Department of Pulmonary and Critical Care Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Chin Kook Rhee
- Clinical Research Center for Chronic Obstructive Airway Diseases, Seoul, Republic of Korea.,Department of Internal Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Jin Hwa Lee
- Clinical Research Center for Chronic Obstructive Airway Diseases, Seoul, Republic of Korea.,Department of Internal Medicine, Ewha Womans University Mokdong Hospital, College of Medicine, Ewha Womans University, Seoul, Republic of Korea
| | - Ji-Hyun Lee
- Clinical Research Center for Chronic Obstructive Airway Diseases, Seoul, Republic of Korea.,Department of Internal Medicine, CHA Bundang Medical Center, CHA University, Seongnam, Republic of Korea
| | - Tae-Hyung Kim
- Clinical Research Center for Chronic Obstructive Airway Diseases, Seoul, Republic of Korea.,Division of Pulmonology, Department of Internal Medicine, Hanyang University Guri Hospital, Hanyang University College of Medicine, Guri, Republic of Korea
| | - Seong Yong Lim
- Clinical Research Center for Chronic Obstructive Airway Diseases, Seoul, Republic of Korea.,Division of Pulmonary and Critical Care Medicine, Department of Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Kwang Ha Yoo
- Clinical Research Center for Chronic Obstructive Airway Diseases, Seoul, Republic of Korea.,Department of Internal Medicine, Konkuk University School of Medicine, Seoul, Republic of Korea
| | - Joon Beom Seo
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Yeon-Mok Oh
- Clinical Research Center for Chronic Obstructive Airway Diseases, Seoul, Republic of Korea.,Department of Pulmonary and Critical Care Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Sang-Do Lee
- Clinical Research Center for Chronic Obstructive Airway Diseases, Seoul, Republic of Korea.,Department of Pulmonary and Critical Care Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Yong Bum Park
- Clinical Research Center for Chronic Obstructive Airway Diseases, Seoul, Republic of Korea.,Department of Pulmonary and Critical Care Medicine, Hallym University Kangdong Sacred Heart Hospital, Seoul, Republic of Korea
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Ji W, Lim MN, Bak SH, Hong SH, Han SS, Lee SJ, Kim WJ, Hong Y. Differences in chronic obstructive pulmonary disease phenotypes between non-smokers and smokers. CLINICAL RESPIRATORY JOURNAL 2016; 12:666-673. [PMID: 27805311 DOI: 10.1111/crj.12577] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/06/2016] [Revised: 10/05/2016] [Accepted: 10/25/2016] [Indexed: 11/29/2022]
Abstract
INTRODUCTION AND OBJECTIVES Although tobacco smoking is a major risk factor for chronic obstructive pulmonary disease (COPD), more than one-fourth of COPD patients are non-smokers. In this cross-sectional study, the differences in COPD phenotypes between non-smokers and smokers in male subjects were investigated and were focused on structural lung changes using a quantitative assessment of computed tomography (CT) images. METHODS They divided male participants with COPD, from a Korean cohort near a cement plant, into non-smokers and smokers by a cutoff of a 5 pack-year smoking history. Clinical characteristics, including age, body mass index (BMI), spirometry results, history of biomass smoke exposure, and CT measurements, were compared between the two groups. Emphysema index (EI) and mean wall area percentage (MWA %) were used to evaluate the structural lung changes on volumetric CT scans. RESULTS The non-smoker group (n = 49) had younger patients and had a greater BMI than the smoker group (n = 113) (P < .05). Spirometry results, including post-bronchodilator forced expiratory volume in 1 s, were comparable between the two groups. More smokers had emphysema than non-smokers (EI 10.0 vs. 6.5, P < .001), but after accounting the potential confounders in model analysis, the difference was borderline significance (P = .051). In the subgroup of biomass smoke-exposed subjects, MWA% was significantly greater in smokers than in non-smokers (MWA 69.1 vs. 65.3, P = .03), while EI was not statistically different (EI 7.1 vs. 10.4, P = .52). CONCLUSIONS Non-smoker males with COPD were younger and had a greater BMI than the smokers. Tobacco smoke exposure seemed to be associated with an emphysema-predominant phenotype, while biomass smoke exposure exhibited a significant interaction with tobacco smoking in an airway-predominant phenotype.
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Affiliation(s)
- Wonjun Ji
- Department of Pulmonary and Critical Care Medicine, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, Korea
| | - Myoung Nam Lim
- Department of Respiratory Center, Kangwon National University Hospital, 156, Baengyeong-ro, Chuncheon-si, Gangwon-do, Korea
| | - So Hyeon Bak
- Department of Radiology, Kangwon National University Hospital, 156, Baengyeong-ro, Chuncheon-si, Gangwon-do, Korea
| | - Seok-Ho Hong
- Department of Internal Medicine and Environmental Health Center, Kangwon National University Hospital, 156, Baengyeong-ro, Chuncheon-si, Gangwon-do, Korea
| | - Seon-Sook Han
- Department of Internal Medicine and Environmental Health Center, Kangwon National University Hospital, 156, Baengyeong-ro, Chuncheon-si, Gangwon-do, Korea
| | - Seung-Joon Lee
- Department of Internal Medicine and Environmental Health Center, Kangwon National University Hospital, 156, Baengyeong-ro, Chuncheon-si, Gangwon-do, Korea
| | - Woo Jin Kim
- Department of Internal Medicine and Environmental Health Center, Kangwon National University Hospital, 156, Baengyeong-ro, Chuncheon-si, Gangwon-do, Korea
| | - Yoonki Hong
- Department of Internal Medicine and Environmental Health Center, Kangwon National University Hospital, 156, Baengyeong-ro, Chuncheon-si, Gangwon-do, Korea
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Blasi F, Neri L, Centanni S, Falcone F, Di Maria G. Clinical Characterization and Treatment Patterns for the Frequent Exacerbator Phenotype in Chronic Obstructive Pulmonary Disease with Severe or Very Severe Airflow Limitation. COPD 2016; 14:15-22. [PMID: 27824270 DOI: 10.1080/15412555.2016.1232380] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Chronic obstructive pulmonary disease (COPD) patients experiencing several episodes of acute clinical derangement suffer from increased morbidity, mortality, and accelerated decline in lung function. Nevertheless, the relationship between co-morbidity profile and exacerbation rates in the frequent exacerbator phenotype is poorly characterized, and evidence-based management guidelines are lacking. We sought to evaluate the co-morbidity profile and treatment patterns of "frequent exacerbators" with severe or very severe airflow limitation. We conducted a cross-sectional, multicenter study in 50 Italian hospitals. Pulmonologists abstracted clinical information from medical charts of 743 COPD frequent exacerbators. We evaluated the exacerbation risk and center-related variations in diagnostic testing. One-third of patients (n = 210) underwent a bronchodilator response test, and 163 (22%) received a computerized tomography (CT) scan; 35 had a partial response to bronchodilators, while 119 had a diagnosis of emphysema; 584 (79%) lacked sufficient diagnostic testing for classification. Only 17% of patients did not have any coexistent disease. Cardiovascular conditions were the most frequent co-morbidities. A history of heart failure [odds ratio (OR): 1.89; 95% confidence interval (CI) 1.48-2.3] and affective disorders (OR: 1.66; 95% CI 1.24-2.1) was associated with the frequency of exacerbations. Center membership was strongly associated with exacerbation risk, independent of casemix (variance partition coefficient = 29.6%). Examining the regional variation in health outcomes and health care behavior may help identify the best practices, especially when evidence-based recommendations are lacking and uncertainties surround clinical decision-making.
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Affiliation(s)
- Francesco Blasi
- a Dipartimento di Fisiopatologia Medico-Chirurgica e dei Trapianti , University of Milan , Milan , Italy
| | - Luca Neri
- b Care Value Advanced Analytics , Fresenius Medical Care , Palazzo Pignano , Italy
| | - Stefano Centanni
- c Dipartimento di Scienze della Salute , University of Milan , Milan , Italy
| | - Franco Falcone
- d Unità Operativa di Malattie dell'Apparato Respiratorio, PneumoTisiatria , Presidio Ospedaliero Bellaria-Maggiore Azienda USL della Città di Bologna , Bologna , Italy
| | - Giuseppe Di Maria
- e Unità Operativa di Pneumologia , Azienda Ospedaliero-Universitaria Policlinico Vittorio Emanuele , Catania , Italy
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Hong Y, Ji W, An S, Han SS, Lee SJ, Kim WJ. Sex differences of COPD phenotypes in nonsmoking patients. Int J Chron Obstruct Pulmon Dis 2016; 11:1657-62. [PMID: 27524891 PMCID: PMC4965225 DOI: 10.2147/copd.s108343] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND There is growing evidence about sex-related phenotypes of COPD. However, the sex differences in COPD mainly result from smokers. This study evaluated the sex differences in nonsmoking patients with COPD, focusing on structural changes in the lungs in airway diseases and emphysema. METHODS Ninety-seven nonsmoking patients, defined as having <1 pack-year of lifetime cigarette smoking, diagnosed with COPD were selected from a Korean COPD cohort. Emphysema extent and mean wall area percentage (WA%) on computed tomography were compared between the male and female groups. RESULTS The 97 patients with COPD included 62 females and 35 males. Emphysema index was significantly lower (3.5±4.2 vs 6.2±5.7, P<0.01) and mean WA% on computed tomography was significantly higher (71.8%±5% vs 69.4%±5%, P<0.01) in females than in males, after adjusting for age, body mass index, history of biomass exposure, and postbronchodilator forced expiratory volume in 1 second (% of predicted). CONCLUSION WA% was higher and emphysema extent was lower in nonsmoking females with COPD than in nonsmoking males with COPD. These findings suggest that males may be predisposed to an emphysema phenotype and females may be predisposed to an airway phenotype of COPD.
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Affiliation(s)
- Yoonki Hong
- Department of Internal Medicine, Environmental Health Center, Kangwon National University Hospital, Chuncheon, South Korea
| | - Wonjun Ji
- Department of Pulmonary and Critical Care Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Soojeong An
- Department of Statistics, Kangwon National University, Chuncheon, South Korea
| | - Seon-Sook Han
- Department of Internal Medicine, Environmental Health Center, Kangwon National University Hospital, Chuncheon, South Korea
| | - Seung-Joon Lee
- Department of Internal Medicine, Environmental Health Center, Kangwon National University Hospital, Chuncheon, South Korea
| | - Woo Jin Kim
- Department of Internal Medicine, Environmental Health Center, Kangwon National University Hospital, Chuncheon, South Korea
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Lee HS, Lee CG, Kim DH, Song HS, Jung MS, Kim JY, Park CH, Ahn SC, Yu SD. Emphysema prevalence related air pollution caused by a cement plant. Ann Occup Environ Med 2016; 28:17. [PMID: 27057315 PMCID: PMC4823915 DOI: 10.1186/s40557-016-0101-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2015] [Accepted: 03/28/2016] [Indexed: 01/26/2023] Open
Abstract
Background To identify adverse pulmonary health effects due to air pollution derived from a cement plant in Korea. The emphysema prevalence in residents around a cement plant was compared to that in the group who live far away from the plant by chest films (PA and lateral view) and high-resolution computed tomography (HRCT) lung images. Methods From June to August in 2013 and from August to November in 2014, chest films and HRCT scan were conducted on residents over the age of 40 who lived around a cement plant. The residents were divided into two groups; a “more exposed group (MEG)” which consisted of 1,046 people who lived within a 1 km radius and a “less exposed group (LEG)” which consisted of 317 people who lived more than 5 km away from the same plant. We compared the emphysema prevalence and estimated the OR of this between the MEG and the LEG by using a chi-square and logistic regression on chest films and HRCT. Results The emphysema prevalence was 9.1 % in the LEG, 14.3 % in the MEG on chest films and 11.4 %, 17.8 % on the HRCT, respectively. The OR of the emphysema prevalence in MEG was 2.92 (95 % CI 1.77-4.83) on the chest films, 2.56 (95 % CI 1.64–3.99) on the HRCT after sex, age, body mass index (BMI), smoking history, residency period and firewood used history were adjusted. The OR in the less than 29 pack-years smoking history was 1.66 (95 % CI 0.92–3.06) and in the more than 30 pack-years was 3.05 (95 % CI 1.68–5.52) on the chest films, and was 1.68 (95 % CI 0.98–2.90), 2.93 (95 % CI 1.72–4.98) on the HRCT, respectively. Conclusion The emphysema prevalence seems to be affected by the level of exposure to air pollution derived from the cement plant as well as sex, age, BMI, and smoking history in this study. Moreover, the OR of the case of the more exposed to the air pollution was similar to that of the case in smoking.
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Affiliation(s)
- Hyun Seung Lee
- Department of Occupational & Environmental Medicine, School of Medicine, Chosun University, 558 Pilmun-daero, Dong-gu Gwangju, 61453 Korea
| | - Chul Gab Lee
- Department of Occupational & Environmental Medicine, School of Medicine, Chosun University, 558 Pilmun-daero, Dong-gu Gwangju, 61453 Korea
| | - Dong Hun Kim
- Department of Radioloy, School of Medicine, Chosun University, 558 Pilmun-daero, Dong-gu Gwangju, 61453 Korea
| | - Han Soo Song
- Department of Occupational & Environmental Medicine, School of Medicine, Chosun University, 558 Pilmun-daero, Dong-gu Gwangju, 61453 Korea
| | - Min Soo Jung
- Department of Occupational & Environmental Medicine, School of Medicine, Chosun University, 558 Pilmun-daero, Dong-gu Gwangju, 61453 Korea
| | - Jae Yoon Kim
- Department of Occupational & Environmental Medicine, School of Medicine, Chosun University, 558 Pilmun-daero, Dong-gu Gwangju, 61453 Korea
| | - Choong Hee Park
- National Institute of Environmental Research, 42 Hwangyong-ro, Seogu Incheon, 22689 Korea
| | - Seung Chul Ahn
- National Institute of Environmental Research, 42 Hwangyong-ro, Seogu Incheon, 22689 Korea
| | - Seung Do Yu
- National Institute of Environmental Research, 42 Hwangyong-ro, Seogu Incheon, 22689 Korea
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Wheaton AG, Pleasants RA, Croft JB, Ohar JA, Heidari K, Mannino DM, Liu Y, Strange C. Gender and asthma-chronic obstructive pulmonary disease overlap syndrome. J Asthma 2016; 53:720-31. [PMID: 27043854 DOI: 10.3109/02770903.2016.1154072] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
OBJECTIVE To assess relationships between obstructive lung diseases, respiratory symptoms, and comorbidities by gender. METHODS Data from 12 594 adult respondents to the 2012 South Carolina Behavioral Risk Factor Surveillance System telephone survey were used. Five categories of chronic obstructive airway disease (OAD) were defined: former asthma only, current asthma only, chronic obstructive pulmonary disease (COPD) only, asthma-COPD overlap syndrome (ACOS), and none. Associations of these categories with respiratory symptoms (frequent productive cough, shortness of breath, and impaired physical activities due to breathing problems), overall health, and comorbidities were assessed using multivariable logistic regression for men and women. RESULTS Overall, 16.2% of men and 18.7% of women reported a physician diagnosis of COPD and/or asthma. Former asthma only was higher among men than women (4.9% vs. 3.2%, t-test p = 0.008). Current asthma only was more prevalent among women than men (7.2% vs. 4.7%, p < 0.001), as was ACOS (4.0% vs. 2.2%, p < 0.001). Having COPD only did not differ between women (4.3%) and men (4.4%). Adults with ACOS were most likely to report the 3 respiratory symptoms. COPD only and ACOS were associated with higher likelihoods of poor health and most comorbidities for men and women. Current asthma only was also associated with these outcomes among women, but not among men. CONCLUSIONS In this large population-based sample, women were more likely than men to report ACOS and current asthma, but not COPD alone. Gender differences were evident between the OAD groups in sociodemographic characteristics, respiratory symptoms, and comorbidities, as well as overall health.
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Affiliation(s)
- Anne G Wheaton
- a Division of Population Health , National Center for Chronic Disease Prevention and Health Promotion , Centers for Disease Control and Prevention , Atlanta , GA , USA
| | - Roy A Pleasants
- b Division of Pulmonary, Allergy, and Critical Care Medicine , Duke University School of Medicine , Durham , NC , USA
| | - Janet B Croft
- a Division of Population Health , National Center for Chronic Disease Prevention and Health Promotion , Centers for Disease Control and Prevention , Atlanta , GA , USA
| | - Jill A Ohar
- c Section on Pulmonary, Critical Care, Allergy & Immunologic Disease , Wake Forest University School of Medicine , Winston Salem , NC , USA
| | - Khosrow Heidari
- d Chronic Disease Epidemiology Office , South Carolina Department of Health and Environmental Control , Columbia , SC , USA
| | - David M Mannino
- e Division of Pulmonary, Critical Care, and Sleep Medicine , Pulmonary Epidemiology Research Laboratory , University of Kentucky , Lexington , KY , USA
| | - Yong Liu
- a Division of Population Health , National Center for Chronic Disease Prevention and Health Promotion , Centers for Disease Control and Prevention , Atlanta , GA , USA
| | - Charlie Strange
- f Division of Pulmonary, Critical Care, Allergy and Sleep Medicine , Medical University of South Carolina , Charleston , SC , USA
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