Nutritional status is related to fat-free mass, exercise capacity and inspiratory strength in severe chronic obstructive pulmonary disease patients

The Obesity Paradox in Chronic Heart Disease and Chronic Obstructive Pulmonary Disease

Obesity in recent years has become an epidemic. A high body mass index (BMI) is one of today's most crucial population health indicators. BMI does not directly quantify body fat but correlates well with easier body fat measurements. Like smoking, obesity impacts multiple organ systems and is a major modifiable risk factor for countless diseases. Despite this, reports have emerged that obesity positively impacts the prognosis of patients with chronic illnesses such as chronic heart failure (CHF) and chronic obstructive pulmonary disease (COPD), a phenomenon known as the Obesity Paradox. This article attempts to explain and summarize this phenomenon.

As it stands, two theories explain this paradox. The muscle mass hypothesis states that obese patients are better adapted to tide through acute exacerbations due to increased reserve because of greater muscle mass. The other theory focuses on brown adipose tissue and its anti-inflammatory effects on the body.

We performed a literature review on research articles published in English from 1983 to the present in the following databases - PubMed, Elsevier, and Google Scholar. The following search strings and Medical Subject Headings (MeSH) terms were used: "Obesity," "Heart Failure," "COPD," and "Cardio-Respiratory Fitness." In this review, we looked at the obesity paradox in Heart Failure and COPD. We summarized the current literature on the Obesity Paradox and reviewed its relationship with Cardio-Respiratory Fitness.

Physical Activity, Exercise Capacity, and Body Composition in U.S. Veterans with Chronic Obstructive Pulmonary Disease (COPD)

RATIONALE

Differences in body composition may contribute to variability in exercise capacity (EC) and physical activity (PA) in chronic obstructive pulmonary disease (COPD). Most studies have employed bioimpedance-based surrogates of muscle (lean) mass; relatively few studies have included consideration of fat mass and limited studies have been performed using dual X-ray absorptiometry (DXA)-assessed body composition.

OBJECTIVE

To determine whether DXA-assessed muscle (lean) and fat mass exhibit differential correlations with EC and PA in COPD Methods: US Veterans with COPD (defined as FEV1/FVC<0.7 or emphysema on clinical chest computed tomography) had DXA-assessed body composition, EC (6-minute walk distance; 6MWD), objective PA (average daily step counts), and self-reported PA measured at enrollment. Associations between EC, PA, and body composition were examined using Spearman correlations and multivariable models adjusted a priori for age, sex, race, and lung function.

RESULTS

Subjects (n=98) were predominantly white (88%), obese (mean BMI 30.2±6.2), and male, (94%) with a mean age (±SD) of 69.9±7.9 years and moderate airflow obstruction (mean FEV1% 68±20). Modest inverse correlations between EC and PA with fat mass were observed (Spearman's rho range [-0.20]-[-0.34]) while measures of muscle (lean) mass were not significantly associated with EC or PA. The appendicular skeletal muscle (ASM)-to-weight ratio, which considers both muscle (lean) and fat mass, was consistently associated with EC (8.4 [95%CI=2.9-13.8] meter increase on 6MWD per 1% increase in ASM-to-weight ratio), objective PA (194.8 [95%CI=15.2-374.4] steps per day per 1% increase in ASM-to-weight ratio), and self-reported PA in multivariable-adjusted models.

CONCLUSION

DXA-assessed body composition measures which include consideration of both lean and fat mass are associated with cross-sectional EC and PA in COPD populations. Clinical trial registered at ClinicalTrials.gov (NCT02099799).

The Association between Fat-Free Mass and Exercise Test Outcomes in People with Chronic Obstructive Pulmonary Disease: A Systematic Review

People with chronic obstructive pulmonary disease (COPD) tend to have abnormally low levels of fat-free mass (FFM), which includes skeletal muscle mass as a central component. The purpose of this systematic review was to synthesise available evidence on the association between FFM and exercise test outcomes in COPD. MEDLINE, Cochrane Library, EMBASE, Web of Science, and Scopus were searched. Studies that evaluated exercise-related outcomes in relation to measures of FFM in COPD were included. Eighty-three studies, containing 18,770 (39% female) COPD participants, were included. Considerable heterogeneity was identified in the ways that FFM and exercise test outcomes were assessed; however, higher levels of FFM were generally associated with greater peak exercise capacity. This association was stronger for some exercise test outcomes (e.g. peak rate of oxygen consumption during incremental cycle exercise testing) than others (e.g. six-minute walking distance). This review identified heterogeneity in the methods used for measuring FFM and exercise capacity. There was, in general, a positive association between FFM and exercise capacity in COPD. There was also an identified lack of studies investigating associations between FFM and temporal physiological and perceptual responses to exercise. This review highlights the significance of FFM as a determinant of exercise capacity in COPD.

Dietary Behaviour and Nutrition in Patients with COPD Treated with Long-Term Oxygen Therapy

BACKGROUND

It is the first study in Poland and one of the first in the world to assess the nutrition of patients with chronic obstructive pulmonary disease (COPD) treated with long-term oxygen therapy (LTOT).

METHODS

The study group consisted of 110 COPD patients treated with LTOT. Anthropometric measurements and spirometry were performed. The diet of patients was assessed using a 3-day nutrition diary.

RESULTS

When assessing the degree of airflow obstruction (FEV1% N) depending on the BMI in patients treated with LTOT, a statistically significant correlation was demonstrated between the BMI and the value of the FEV% N parameter (p = 0.0093). Patients with COPD with a BMI >30 had statistically significantly higher values of FEV1% N than patients with a BMI in the range of 20-24.9 (p = 0.0278). Intake of calcium, vitamins A, C, D, E and folates was lower than the recommended daily intake in more than 95% of COPD patients.

CONCLUSIONS

The diet of COPD patients treated with long-term oxygen therapy was improperly balanced, with deficiencies of important nutrients. Airflow obstruction in the respiratory tract was significantly smaller in obese patients, and greater in patients with diagnosed malnutrition.

Exercise capacity and its relationship with body composition and nutrition status in patients with interstitial lung disease

BACKGROUND

Patients with interstitial lung disease (ILD) are known to have diminished exercise ability. This study aimed to explore the relationship between nutrition status and body composition parameters with exercise capacity in ILD patients. A second aim focused on assessing the appropriateness of surrogate markers of nutrition status in ILD patients.

METHODS

Disease severity was determined by the percentage of predicted forced vital capacity. Exercise capacity was determined using 6-minute walk distance. Nutrition status was assessed using the subjective global assessment (SGA), standardized phase angle (SPhA), and impedance ratio z-score (z-IR). Bioelectrical impedance analysis estimated body composition parameters.

RESULTS

45 of 79 participants (57%) were malnourished according to the SGA. FFM index z-score (z-FFMI) (r = 0.42, P = .02) and SGA (r = 0.49, P < .01) were significant predictors of exercise capacity independent of disease severity. Age (odds ratio [OR] = 1.1; 95% CI, 1.01-1.25; P = .04), low body mass index (OR = 0.73; 95% CI, 0.57-0.92; P = .01), z-FFMI (OR = 0.34; 95% CI, 0.17-0.68; P < .01), and body fat mass index z-score (OR = 0.39; 95% CI, 0.17-0.91; P = .03) were significantly associated with severe malnutrition. There was no significant difference in SPhA across SGA groups; however, a higher z-IR (poorer cell health) significantly increased the odds of severe malnutrition (OR = 2.75; 95% CI, 1.27-6.03; P = .02).

CONCLUSION

In ILD patients, malnutrition and loss of FFM negatively impact the ability to perform activities of daily living.

Association of Body Mass Index with Risk of Chronic Obstructive Pulmonary Disease: A Systematic Review and Meta-Analysis

The association between body mass index (BMI) and chronic obstructive pulmonary disease (COPD) remains controversial. Therefore, a meta-analysis was conducted to further evaluate the relationship. A comprehensive literature search was performed in PubMed, Web of Science, EMBASE, China National Knowledge Infrastructure (CNKI), and Wanfang databases to identify eligible articles until July 15, 2020. Random effect model (REM) was used to compute the pooled results with 95% confidence intervals (CIs). We conducted meta-regression and subgroup analysis to explore potential sources of heterogeneity. Publication bias was evaluated by funnel plots and Egger's test. Thirty articles with 1,578,449 participants were included in the meta-analysis. The pooled OR of COPD was 1.96 (95% CI: 1.78-2.17) for the underweight group, 0.80 (95% CI: 0.73-0.87) for overweight group, and 0.86 (95% CI: 0.73-1.02) for obesity group. After further excluding 5 studies of high between-study heterogeneity in sensitivity analysis, the pooled OR of COPD was 0.77 (95% CI: 0.68-0.86) for the obesity group. This meta-analysis indicated that BMI was associated with COPD. Specifically, underweight might increase the risk of COPD; overweight and obesity might reduce the risk of COPD.

Using machine learning to investigate the relationship between domains of functioning and functional mobility in older adults

Previous studies have shown that functional mobility, along with other physical functions, decreases with advanced age. However, it is still unclear which domains of functioning (body structures, body functions, and activities) are most closely related to functional mobility. This study used machine learning classification to predict the rankings of Timed Up and Go tests based on the results of four assessments (soft lean mass, FEV1/FVC, knee extension torque, and one-leg standing time). We tested whether assessment results for each level could predict functional mobility assessments in older adults. Using support vector machines for machine learning classification, we verified that the four assessments of each level could classify functional mobility. Knee extension torque (from the body function domain) was the most closely related assessment. Naturally, the classification accuracy rate increased with a larger number of assessments as explanatory variables. However, knee extension torque remained the highest of all assessments. This extended to all combinations (of 2-3 assessments) that included knee extension torque. This suggests that resistance training may help protect individuals suffering from age-related declines in functional mobility.

Management of the COPD Patient with Comorbidities: An Experts Recommendation Document

Background

Chronic obstructive pulmonary disease (COPD) is associated with multiple comorbidities, which impact negatively on patients and are often underdiagnosed, thus lacking a proper management due to the absence of clear guidelines.

Purpose

To elaborate expert recommendations aimed to help healthcare professionals to provide the right care for treating COPD patients with comorbidities.

Methods

A modified RAND-UCLA appropriateness method consisting of nominal groups to draw up consensus recommendations (6 Spanish experts) and 2-Delphi rounds to validate them (23 Spanish experts) was performed.

Results

A panel of Spanish internal medicine experts reached consensus on 73 recommendations and 81 conclusions on the clinical consequences of the presence of comorbidities. In general, the experts reached consensus on the issues raised with regard to cardiovascular comorbidity and metabolic disorders. Consensus was reached on the use of selective serotonin reuptake inhibitors in cases of depression and the usefulness of referring patients with anxiety to respiratory rehabilitation programmes. The results also showed consensus on the usefulness of investigating the quality of sleep, the treatment of pain with opioids and the evaluation of osteoporosis by lateral chest radiography.

Conclusion

This study provides conclusions and recommendations that are intended to improve the management of the complexity of patients with COPD and important comorbidities, usually excluded from clinical trials.

Identification of relevant variables and construction of a multidimensional index for predicting mortality in COPD patients

Background and objective

The Body mass index, airflow Obstruction, Dyspnea, and Exercise (BODE) index is a well-known metric for chronic obstructive pulmonary disease (COPD), but it is inadequate for predicting mortality. This study proposed a new index that combines inspiratory muscle training with the BODE index and verified its ability to predict mortality in patients with COPD.

Methods

Cox regression identified predictors of mortality, which were then included in the new index. The receiver operating characteristic (ROC) curve verified the ability of the new index to predict mortality. The Kaplan-Meier curves compared the survival rates of patients with different scores on the new index.

Results

Among the 326 patients, 48 died during follow-up (1–59 months). Cox regression showed that the fat-free mass index (FFMI), forced expiratory volume in one second/the predicted value (FEV₁%), modified Medical Research Council (mMRC) score, six-minute–walk test (6MWT) distance, and maximal inspiratory pressure were predictors of mortality (P<0.05); these variables were included in the FODEP index. The AUC of the FODEP index (0.860, 95% CI: 95% CI: 0.817–0.896) was greater than that of the BODE index (0.778, 95% CI: 0.729–0.822). The Kaplan-Meier curves suggested that as the FODEP score increased, so did the risk of morality in patients with COPD. The cumulative survival in the group with the highest FODEP-value was significantly lower than that in the other groups (P<0.01).

Conclusion

The FODEP index was more effective than the BODE index at predicting the risk of mortality in patients with COPD.

Improvement in body composition following a supervised exercise-training program of adult patients with cystic fibrosis

OBJECTIVES

Maintenance of optimal nutritional status is a crucial issue for cystic fibrosis (CF) patients. Here, we evaluate the effects of an 8-week exercise training (ET) program on body composition in CF patients.

METHODS

This prospective pilot observational study was conducted in adult CF subjects in stable condition following their annual check-up. The ET program consisted of three sessions per week and included aerobic training (≥30min), muscle strengthening, circuit training, and relaxation. Exercise tolerance (6-minute walk test, 6MWT), pulmonary function, quadriceps isometric strength, and body composition (bioelectrical impedance analysis of fat-free mass [FFM], fat mass, and body cell mass) were analyzed before and immediately after the ET program. A control group of CF patients who preferred not to participate in the ET program received the same evaluations.

RESULTS

A total of 43 CF patients were enrolled and offered the ET program; 28 accepted (aged 28±5 years, forced expiratory volume in 1s [FEV₁] 48.8±19% predicted) and 15 declined the ET program but agreed to be part of the control group (matched for age and CF severity: 30.8±9 years, FEV₁ 51.8±16.5%). Pulmonary function was unchanged at the end of the ET program, but significant improvements were observed in 6MWT distance (from 520±96m to 562±105m, P<0.001) and muscle strength (331±141N to 379±168N, P<0.001). Although mean body mass index did not change, the ET group showed significantly increased FFM (43.85±8kg to 44.5±9.2kg, P=0.03) and a trend towards increased body cell mass (21.4±6 to 22.1±6.6kg, P=0.06). All other parameters were unchanged by ET. There were no significant correlations between the increase in FFM and the improvements in either 6MWT distance or muscle strength. The CF control group exhibited no significant changes in any parameters between evaluations.

CONCLUSIONS

ET significantly improved FFM, but not body mass index, in CF patients. The results illustrate the superiority of bioimpedancemetry for assessing changes in body composition and reveal the importance of ET for improving not only exercise tolerance but also nutritional status in these patients.

Inspiratory muscle strength, diaphragmatic mobility, and body composition in chronic obstructive pulmonary disease

BACKGROUND AND PURPOSE

Chronic obstructive pulmonary disease (COPD) is a systemic inflammatory disease that can cause repercussions on respiratory muscles and body composition. The aim of the current study was to evaluate inspiratory muscle strength, diaphragmatic mobility, and body composition in COPD subjects and to correlate these variables.

METHODS

This was a cross-sectional study performed with 21 COPD patients. Inspiratory muscle strength (manovacuometry), pulmonary function test (forced vital capacity [FVC], forced expiratory volume in 1 s [FEV₁ ], and FEV₁ /FVC ratio), diaphragmatic mobility (ultrasonography), and body composition (bioelectrical impedance analysis) were examined.

RESULTS

COPD individuals in Stages II (28.9%), III (52%), and IV (19%) according to Global Initiative for Chronic Obstructive Disease were recruited, 61.9% of which were men. Inspiratory muscle weakness was found in 47.6% of subjects, who presented a lower fat-free mass percentage (p = 0.017) and smaller fat-free mass index (p = 0.001) and greater fat mass percentage (p = 0.029) and less diaphragmatic mobility (p = 0.007) compared with the nonrespiratory weakness group. Maximal inspiratory pressure exhibited a moderately positive relationship to the fat-free mass index (r = 0.767, p < 0.001) and a weak positive relationship to diaphragmatic mobility (r = 0.496, p = 0.022).

CONCLUSION

Our study showed a high prevalence of inspiratory muscle weakness based on the severity of airway obstruction and on the presence of muscular depletion. The evaluation of body composition detected important changes. It also demonstrated that not only muscular weakness was present in these patients but also this had repercussions on the mobility of the diaphragm muscle.

Effects of Hochuekkito combined with pulmonary rehabilitation in patients with chronic obstructive pulmonary disease

Chronic obstructive pulmonary disease (COPD) has significant systemic effects, such as weight loss, which affects exercise capacity, health-related quality of life (HRQOL) and survival. The traditional herbal medicine, Hochuekkito (TJ-41), improves the nutritional status and decreases systemic inflammation in patients with COPD. However, to date, the additive effect of TJ-41 on pulmonary rehabilitation (PR) in patients with COPD has not been researched comprehensively. The purpose of the present study was to investigate the efficacy and safety of adding TJ-41 to PR for patients with COPD. Thirty-three malnourished patients with COPD were randomly assigned to receive low-intensity exercise with (TJ-41 group) or without (control group) TJ-41 treatment for 12 weeks. The primary outcome was the change in the 6-min walk distance (6MWD). Secondary outcomes included changes in the body composition, peripheral muscle strength, modified Medical Research Council dyspnea score, visual analog scale (VAS) score for dyspnea, VAS score for fatigue and COPD assessment test (CAT) score. After the 12-week treatment, body weight and percent ideal body weight were significantly increased in the TJ-41 group (P<0.05), but not in the control group. After the 12-week treatment, the modified Medical Research Council dyspnea score, VAS score for dyspnea, VAS score for fatigue and total CAT score decreased significantly in the TJ-41 group (all P<0.05), but not in the control group. There were no significant differences in the 6MWD and peripheral muscle strength between baseline and after 12 weeks of treatment in either group. No adverse effects were noted with the use of TJ-41. It was concluded that the addition of TJ-41 to PR may benefit malnourished patients with COPD with respect to dyspnea and HRQOL.

Malnutrition according to ESPEN consensus predicts hospitalizations and long-term mortality in rehabilitation patients with stable chronic obstructive pulmonary disease

BACKGROUND

Nutritional disorders are frequent in patients with chronic pulmonary obstructive disease (COPD) and have negative health impacts. This study aimed to explore the value of the European Society of Clinical Nutrition and Metabolism (ESPEN) definition of malnutrition (and/or its individual components) to predict hospitalizations and mortality at 2 years, and to determine the prevalence of malnutrition in COPD patients referred to pulmonary rehabilitation.

METHODS

The study was a prospective analysis of 118 patients with COPD free of exacerbations and/or hospital admissions in the previous two months. Main outcome variables were mortality, hospital admissions, and length of stay at 2-year follow-up; main covariates were malnutrition assessment according to the ESPEN definition and its components: unintentional weight loss, body mass index, and fat-free mass index (FFMI). Body composition was assessed by bioimpedance analysis. Kaplan-Meier survival curves and linear regression analyses were performed, adjusting for age and airflow obstruction as potential confounders.

RESULTS

The observed prevalence of malnutrition was 24.6%. Malnutrition was associated with increased mortality risk (HR = 3.9 [95% CI: 1.4-10.62]). FFMI was independently associated with increased mortality (HR = 17.0 [95% CI: 2.24-129.8]), which persisted after adjustment for age and lung function (adjusted HR = 13.0 [95% CI: 1.67-101.7]). Low age-related body mass index was associated with increased risk of hospital admissions.

CONCLUSIONS

Malnutrition according to ESPEN criteria, highly prevalent in patients with stable COPD referred to pulmonary rehabilitation, was associated with 4 times greater mortality risk after 2 years. Low FFMI was associated with a 17-fold increase in mortality risk, suggesting independent predictive value.

Testosterone a key factor in gender related metabolic syndrome

Metabolic syndrome (MetS) is highly correlated with cardiovascular diseases. Although an excess of body fat is a determinant factor for MetS development, a reduced level of testosterone plays a fundamental role in its regulation. Low testosterone level is highly related to insulin resistance, visceral obesity and MetS. We have searched in Pubmed clinical trial with the password: testosterone and insulin resistance, and testosterone and MetS. We found 19 studies on the correlation between testosterone level with insulin resistance and 18 on the effect of testosterone therapy on MetS. A high correlation between low testosterone and insulin resistance has been found in men, but not in women. Testosterone administration in hypogonadal men improved MetS and reduced the mortality risk. Androgen and oestrogen receptors are expressed in adipocytes, muscle and liver tissue, and their activation is necessary to improve metabolic control. Normalization of testosterone level should be the primary treatment in men, along with caloric restriction and physical exercise. These findings come mainly from correlative data, and there remains a need for randomized trials to strengthen this evidence. This review will consider the effects of testosterone on the regulation and development of MetS in men and women.

Fat-free mass depletion in patients with COPD in Brazil: development of a new cutoff point and its relation with mortality and extrapulmonary manifestations

BACKGROUND/OBJECTIVES

None of the cutoff points for fat-free mass index (FFMI) were tested for the Brazilian population, and it is unknown whether the available ones are able to discriminate extrapulmonary disease manifestations. This cross-sectional study aims to develop and validate a cutoff point for FFM depletion based on Brazilian patients with chronic obstructive pulmonary disease (COPD) and to verify its association and of previously published cutoffs with extrapulmonary manifestations.

SUBJECTS/METHODS

A new cutoff point was obtained from the best FFMI value for discrimination of preserved exercise capacity in a sample of patients (n=57). The discriminative capacity was assessed in another sample (n=96). The new cutoff point and other previously published ones were tested to discriminate low exercise capacity, physical inactivity, sedentary lifestyle and low quality of life. A receiver operation characteristics curve with area under the curve (AUC) value was plotted and each cutoff points' discriminative capacity was calculated. Cox regression and Kaplan-Meier method assessed the association between the cutoff points and mortality.

RESULTS

The new cutoff points for FFMI were 14.65 kg/m² for women (AUC=0.744; sensitivity (Se)=0.88; specificity (Sp)=0.60) and 20.35 kg/m² for men (AUC=0.565; Se=0.36; Sp=0.81). The new cutoffs were the best to discriminate poor exercise capacity assessed by walked distance in % predicted and quality of life. Only the new cutoff point was associated with mortality (HR=2.123; 95% CI: 1.03-4.33, P=0.039, log rank P=0.035).

CONCLUSIONS

Only the new cutoff point was associated with all-cause mortality, and it had the highest discriminating capacity for exercise capacity and quality of life in Brazilian patients with COPD.

Nutritional status and its relationship with different dimensions of functional status in patients with chronic obstructive pulmonary disease

ABSTRACT Objective: To investigate whether there is a relationship between nutritional status and limitations in activities of daily living in patients with chronic obstructive pulmonary disease. Methods: A cross sectional study was conducted from July to December 2011 in Santa Catarina. Seventeen chronic obstructive pulmonary disease patients [age (years) = 67±8; forced expiratory volume in one second (% of the predicted value) = 38.6±16.1; body mass index (kg/m2) = 24.7±5.4] underwent the assessments: pulmonary function (spirometry); functional status (London Chest Activity of Daily Living scale, physical activities in daily life, and Glittre ADL-Test; nutritional status (anthropometry and dual-energy X-Ray absorptiometry). Results: The total score of the London Chest Activity of Daily Living scale correlated with fat-free mass (r=-0.50; p=0.04) and lean mass (r=-0.50; p=0.04). The lying time in physical activities in daily life correlated with bone mineral content (r=-0.50; p=0.04). Nutricional status was not correlated with time spent on Glittre ADL-test. Conclusion: Variables that reflect muscle mass depletion are related to variables of self-reported limitation in activities of daily living. Bone mineral content is correlated with time patients spend lying, reflecting the impact of inactive postures on the nutritional status of these patients.

Overweight and obesity in Slovak high school students and body composition indicators: a non-randomized cross-sectional study

BACKGROUND

Physical development can be considered as an indicator of the overall health status of the youth population. Currently, it appears that the increasing trend of the prevalence of obesity among children and youths has stopped in a number of countries worldwide. Studies point to the fact that adolescence is a critical period for the development of obesity. Body mass index (BMI) seems to be an orientation parameter in the assessment of prevalence of obesity which is not sufficient for more accurate identification of at risk individuals. The purpose of this study was to evaluate association between BMI percentile zones as health-risk for being overweight and obese and body composition indicators in high-school students from the Prešov (Slovakia) region.

METHODS

A non-randomized cross-sectional study in high school students from the Prešov (Slovakia) region was conducted. The research sample consisted of 1014 participants (boys n = 466, girls n = 549). Body composition was measured using direct segmental multi-frequency bioelectrical impedance analysis (DSM-BIA). To examine the association between obesity and selected body composition indicators, Kruskal-Wallis ANOVA and Eta(2) were used. The relationship between selected body composition indicators and percentile BMI zones was determined using the Kendall tau correlation.

RESULTS

In groups with different BMI percentile zones (normal weight, overweight, obese), ANOVA showed significant differences for girls and boys (p ˂.05) with high effect size (η(2) ˂.26) in body weight, body fat mass index, body fat percentage, fat free mass index, fat-free mass percentage, visceral fat area, waist-to-hip ratio, waist circumference, protein mass and mineral mass. The highest degree of correlation among boys was between BMI values indicating overweight and obesity and fat free mass index and waist circumference, respectively (τ = .71, τ = .70, respectively). In girls, the highest correlation was found between classification of BMI percentile zones and waist circumference (t = .78).

CONCLUSION

The characteristics of body composition are very useful determinants of health and nutrition status. Our data revealed a direct association between BMI value and chosen body composition indicators. The most accurate indicator of overweight and obesity in our study appears to be waist circumference for both male and female population.

Brazilian studies on pulmonary function in COPD patients: what are the gaps?

BACKGROUND

COPD is a major cause of death and morbidity worldwide, and is characterized by persistent airflow obstruction. The evaluation of obstruction is critically dependent on sensitive methods for lung-function testing. A wide body of knowledge has been accumulated in recent years showing that these methods have been significantly refined and seems promising for detection of early disease.

OBJECTIVES

This review focuses on research on pulmonary function analysis in COPD performed in Brazil during this century.

MATERIALS AND METHODS

The literature was searched using a systematic search strategy limited to English language studies that were carried out in Brazil from the year 2000 onward, with study objectives that included a focus on lung function.

RESULTS

After we applied our inclusion and exclusion criteria, 94 articles addressed our stated objectives. Among the new methods reviewed are the forced-oscillation technique and the nitrogen-washout test, which may provide information on small-airway abnormalities. Studies investigating the respiratory muscles and thoracoabdominal motion are also discussed, as well as studies on automatic clinical decision-support systems and complexity measurements. We also examined important gaps in the present knowledge and suggested future directions for the cited research fields.

CONCLUSION

There is clear evidence that improvements in lung-function methods allowed us to obtain new pathophysiological information, contributing to improvement in our understanding of COPD. In addition, they may also assist in the diagnosis and prevention of COPD. Further investigations using prospective and longitudinal design may be of interest to elucidate the use of these new methods in the diagnosis and prevention of COPD.

Results of a Multimodal Program During Hospitalization in Obese COPD Exacerbated Patients

The objective of this study was to analyze the results of a multimodal therapeutic program during hospitalization in obese AECOPD patients. This was a randomized, single-blind clinical trial conducted at two university hospitals in Granada, Spain. Forty-nine patients hospitalized due to AECOPD were randomly allocated to a control group (CG), in which patients received standard care, or to an intervention group (IG), in which patients were included in a multimodal therapeutic program, added to the standard care. The main outcome measures were pulmonary, physical (strength and exercise capacity) and perceived (dyspnea, quality of life and psychological distress) variables. Within-group significant improvements (p < 0.05) were found in physical and perceived variables in the IG after the treatment. In the CG, a significant decrease was found in lower limb strength and a significant improvement in dyspnea and in three subscales of the EuroQol-5D questionnaire. The between-groups analysis showed significant differences after the treatment on lower limb strength and exercise capacity values (p < 0.05), in three of the EuroQol-5D subscales, and in the total score and the depression subscale of the Hospital Anxiety and Depression Scale. A multimodal therapeutic program has a beneficial effect on physical functioning and perceived variables in hospitalized obese patients with AECOPD.

The inspiratory capacity/total lung capacity ratio as a predictor of survival in an emphysematous phenotype of chronic obstructive pulmonary disease

BACKGROUND

Forced expiratory volume in 1 second (FEV1) grades severity of COPD and predicts survival. We hypothesize that the inspiratory capacity/total lung capacity (IC/TLC) ratio, a sensitive measure of static lung hyperinflation, may have a significant association with survival in an emphysematous phenotype of COPD.

OBJECTIVES

To access the association between IC/TLC and survival in an emphysematous phenotype of COPD.

METHODS

We performed a retrospective analysis of a large pulmonary function (PF) database with 39,050 entries, from April 1978 to October 2009. Emphysematous COPD was defined as reduced FEV1/forced vital capacity (FVC), increased TLC, and reduced diffusing capacity of the lungs for carbon monoxide (DLCO; beyond 95% confidence intervals [CIs]). We evaluated the association between survival in emphysematous COPD patients and the IC/TLC ratio evaluated both as dichotomous (≤25% vs >25%) and continuous predictors. Five hundred and ninety-six patients had reported death dates.

RESULTS

Univariate analysis revealed that IC/TLC ≤25% was a significant predictor of death (hazard ratio [HR]: 2.39, P<0.0001). Median survivals were respectively 4.3 (95% CI: 3.8-4.9) and 11.9 years (95% CI: 10.3-13.2). Multivariable analysis revealed age (HR: 1.19, 95% CI: 1.14-1.24), female sex (HR: 0.69, 95% CI: 0.60-0.83), and IC/TLC ≤25% (HR: 1.69, 95% CI: 1.34-2.13) were related to the risk of death. Univariate analysis showed that continuous IC/TLC was associated with death, with an HR of 1.66 (95% CI: 1.52-1.81) for a 10% decrease in IC/TLC.

CONCLUSION

Adjusting for age and sex, IC/TLC ≤25% is related to increased risk of death, and IC/TLC as a continuum, is a significant predictor of mortality in emphysematous COPD patients.

What is the effect of peripheral muscle fatigue, pulmonary function, and body composition on functional exercise capacity in acromegalic patients?

[Purpose] The six-minute walk test (6MWT) is increasingly being used as an important tool for analyzing functional capacity in patients with multisystem disorders. The aim of this study was to evaluate the effect of body composition, peripheral muscle function, and pulmonary function on the six-minute walk distance (6MWD) in acromegalic patients. [Subjects and Methods] Thirty-two patients with active acromegaly, with a mean age of 48.6 ± 12.1 years, underwent an evaluation of body composition using electrical bioimpedance, isometric dynamometry with surface electromyography, tests of pulmonary function, and the 6MWT. [Results] The mean ± SD values for the 6MWD, fat-free mass (FFM), and maximal expiratory pressure (MEP) were 65.5 ± 11.7% predicted, 55.1 ± 10.6 kg, and 55.2 ± 16.8% predicted, respectively. There was a significant correlation between the 6MWD and the following parameters: the angle of the linear regression line obtained using the values of the median frequency electromyography signal over time during the fatigability test for the vastus medialis muscle (MDF, r=0.65), FFM (r=0.62), MEP (r=0.60), height⁽²⁾/resistance index (r=0.52), resistance (r=−0.50), and forced expiratory volume in 1 second (r=0.50). Multivariate analysis showed that MDF, FFM, and MEP were independent predictors of the 6MWD (R²=0.52). [Conclusion] The fatigability of the peripheral muscles, FFM, and MEP are the primary determinants of the 6MWD in acromegalics.

Effects of dynamic hyperinflation on exercise capacity and quality of life in stable COPD patients

BACKGROUND AND AIMS

Dynamic hyperinflation (DH) is an important pathophysiological characteristic of chronic obstructive pulmonary disease (COPD). There is increasing evidence that DH has negative effects on exercise performance and quality of life. The objective of this study was to explore effects of DH on exercise capacity and quality of life in stable COPD patients.

METHODS

Fifty-eight COPD patients and 20 matched healthy individuals underwent pulmonary function test, 6-min walk test and symptom-limited cardiopulmonary exercise test (CPET). End-expiratory lung volume/total lung capacity ratio (EELVmax/TLC) at peak exercise of CPET was evaluated, and EELVmax/TLC ≥ 75% was defined as 'severe dynamic hyperinflation (SDH)'.

RESULTS

Of the 58 patients studied, 29 (50.0%) presented with SDH (SDH+ group, EELVmax/TLC 79.60 ± 3.60%), having worse maximal exercise capacity reflected by lower peakload, maximal oxygen uptake (VO2 max), maximal carbon dioxide output (VCO2 max) and maximal minute ventilation (VEmax) than did those without SDH (SDH- group, EELVmax/TLC 67.44 ± 6.53%). The EELVmax/TLC ratio at peak exercise had no association with variables of pulmonary function and 6-min walk distance (6MWD), but correlated inversely with peakload, VO2 max, VCO2 max and VEmax (r = -0.300~-0.351, P < 0.05). Although no significant differences were observed, patients with EELVmax/TLC ≥ 75% tended to have higher COPD assessment test score (15.07 ± 6.55 vs 13.28 ± 6.59, P = 0.303).

CONCLUSIONS

DH develops variably during exercise and has a greater impact on maximal exercise capacity than 6MWD, even in those with the same extent of pulmonary function impairment at rest.

Influence of diet and obesity on COPD development and outcomes

The global increase in the prevalence and incidence of obesity has called serious attention to this issue as a major public health concern. Obesity is associated with many chronic diseases, including cardiovascular disease and diabetes, and recently the role of overweight and obesity in lung disease has received new interest. Independently of obesity, diet also plays a role as a risk factor for many chronic diseases, and evidence is accumulating to support a role for diet in the prevention and management of several lung diseases. Chronic obstructive lung disease is the third-leading cause of death globally, and both obesity and diet appear to play roles in its pathophysiology. Obesity has been associated with decreased lung-function measures in population-based studies, with increased prevalence of several lung diseases and with compromised pulmonary function. In contrast, obesity has a protective effect against mortality in severe chronic obstructive pulmonary disease (COPD). Nutrient intake and dietary patterns have also been associated with lung-function measures and the development and progression of COPD. Taken together, this suggests that a focus on obesity and diet should be part of public health campaigns to reduce the burden of lung disease, and could have important implications for clinicians in the management of their patients. Future research should also focus on elucidating these relationships in diverse populations and age-groups, and on understanding the complex interaction between behavior, environment, and genetics in the development and progression of COPD. The goal of this article is to review current evidence regarding the role that obesity and diet play in the development of COPD, and in COPD-related outcomes.

Ultrasonographic assessment of the diaphragm in chronic obstructive pulmonary disease patients: relationships with pulmonary function and the influence of body composition - a pilot study

BACKGROUND

Skeletal muscle weakness with loss of fat-free mass (FFM) is one of the main systemic effects of chronic obstructive pulmonary disease (COPD). The diaphragm is also involved, leading to disadvantageous conditions and poor contractile capacities.

OBJECTIVES

We measured the thickness of the diaphragm (TD) by ultrasonography to evaluate the relationships between echographic measurements, parameters of respiratory function and body composition data.

METHODS

Thirty-two patients (23 males) underwent (1) pulmonary function tests, (2) echographic assessment of TD in the zone of apposition at various lung volumes, i.e. TD at residual volume (TDRV), TD at functional residual capacity (TDFRC) and TD at total lung capacity (TDTLC), and (3) bioelectrical body impedance analysis. The BMI and the BODE (BMI-Obstruction-Dyspnea-Exercise) index values were reported.

RESULTS

TDRV, TDFRC and TDTLC measured 3.3, 3.6 and 6 mm, respectively, with good intraobserver reproducibility (0.97, 0.97 and 0.96, respectively). All the TDs were found to be related to FFM, with the relationship being greater for TDFRC (r(2) = 0.39 and p = 0.0002). With regard to lung volumes, inspiratory capacity (IC) was found to be closely related to TDTLC (r(2) = 0.42 and p = 0.0001). The difference between TDTLC and TDRV, as a thickening value (TDTLCRV), was closely related to FVC (r(2) = 0.34 and p = 0.0004) and to air-trapping indices (RV/TLC, FRC/TLC and IC/TLC): the degree of lung hyperinflation was greater and the TDTLCRV was less. Finally, we found a progressive reduction of both thicknesses and thickenings as the severity of IC/TLC increased, with a significant p value for the trend in both analyses (p = 0.02).

CONCLUSIONS

Ultrasonographic assessment of the diaphragm could be a useful tool for studying disease progression in COPD patients, in terms of lung hyperinflation and the loss of FFM. © 2014 S. Karger AG, Basel.

Acute exacerbation of chronic obstructive pulmonary disease: cardiovascular links

Chronic obstructive pulmonary disease (COPD) is a chronic, progressive lung disease resulting from exposure to cigarette smoke, noxious gases, particulate matter, and air pollutants. COPD is exacerbated by acute inflammatory insults such as lung infections (viral and bacterial) and air pollutants which further accelerate the steady decline in lung function. The chronic inflammatory process in the lung contributes to the extrapulmonary manifestations of COPD which are predominantly cardiovascular in nature. Here we review the significant burden of cardiovascular disease in COPD and discuss the clinical and pathological links between acute exacerbations of COPD and cardiovascular disease.

Body composition in patients with chronic obstructive pulmonary disease

OBJECTIVES

Body composition assessment in chronic obstructive pulmonary disease (COPD) is important, as weight loss and muscular wasting are responsible for low exercise capacity in these patients, and low body mass index (BMI) and fat free mass index (FFMI) are important prognostic factors. Our study aims were: (a) to describe body composition in COPD patients referred to a pulmonary rehabilitation center in Bucharest; (b) to examine the relationships between body composition and disease severity (bronchial obstruction, exercise capacity, quality of life); (c) to test if segmental wasting of lower limbs muscle mass (measured by segmental body composition analysis) correlates with decreased exercise capacity.

MATERIAL AND METHODS

We studied 36 consecutive COPD patients referred to our clinic for pulmonary rehabilitation. Patients performed pulmonary function tests, six minutes walking test (6MWT), and health status was evaluated with COPD Assessment Test (CAT). Body composition measurements were performed by direct segmental multi-frequency bioelectrical impedance analysis (BIA).

OUTCOMES

This study offers the first data on body composition of Romanian COPD patientsThe prevalence of nutritional depletion (defined by low BMI and/or low FFMI) among our COPD patients was 22.2%. Mean FFMI was significantly lower in normal or underweight patients versus overweight or obese patients. Patients with low FFMI had lower exercise capacity at the 6MWT and higher CAT scores than patients with normal FFMI.Depending on the BMI and FFMI values the patients were divided in four categories: normal, semistarvation, sarcopenia and cachexia. The group of patients with sarcopenia (low FFMI and normal BMI) had the lowest mean MIP (Maximal Inspiratory Pressure), the lowest mean 6MWD (six minutes walking distance) and the higher CAT mean scores among all groups. Exercise capacity was significantly lower in muscular depleted patients (with low skeletal muscle mass index - SSMI). MIP correlated significantly with FFMI and SMMI. No correlations were found between parameters of body composition and FEV1 or CAT. Segmental body composition assessment revealed that unbalanced upper/lower skeletal muscle mass is associated with a lower exercise capacity as measured by 6WMT.

CONCLUSIONS

This study offers the first data on body composition of Romanian COPD patients. The prevalence of nutritional depletion is similar to that found in other European studies. No significant correlations were found between FFMI and severity of the disease (bronchial obstruction, distance walked, CAT score). FFMI and SSMI correlated significantly with MIP. Sarcopenic patients had the lowest mean 6MWD, the lowest mean MIP and the highest CAT mean scores. SMMI significantly correlated with 6MWD. Segmental body composition assessment of revealed that "unbalanced" patients had lower results at 6MWT. These results show that body composition evaluation is useful for the assessment of COPD patients referred to pulmonary rehabilitation and should be routinely performed.

The impact of obesity on risk factors and prevalence and prognosis of coronary heart disease-the obesity paradox

Obesity is associated with a host of cardiovascular risk factors and its prevalence is rising rapidly. Despite strong evidence that obesity predisposes to the development and progression of coronary heart disease (CHD), numerous studies have shown an inverse relationship between various measures of obesity (most commonly body mass index) and outcomes in established CHD. In this article we review the evidence surrounding the ≪obesity paradox≫ in the secondary care of CHD patients and the CHD presentations where a paradox has been found. Finally we discuss the impact of cardiorespiratory fitness and a number of mechanisms which may offer potential explanations for this puzzling phenomenon.

Evaluation of articles on pulmonology published in Brazilian journals other than the Brazilian Journal of Pulmonology

In Brazil, research on pulmonology has become increasingly more visible in recent years. In addition to the Brazilian Journal of Pulmonology, other journals have contributed to that by publishing relevant articles in this area. The objective of this article was to briefly report the most relevant studies on pulmonology that were published in other important Brazilian journals between 2009 and 2010. Altogether, there were 56 articles related to the various subareas that compose the field of respiratory diseases.

The effect of acute magnesium loading on the maximal exercise performance of stable chronic obstructive pulmonary disease patients

OBJECTIVE

The potential influence of magnesium on exercise performance is a subject of increasing interest. Magnesium has been shown to have bronchodilatatory properties in asthma and chronic obstructive pulmonary disease patients. The aim of this study was to investigate the effects of acute magnesium IV loading on the aerobic exercise performance of stable chronic obstructive pulmonary disease patients.

METHODS

Twenty male chronic obstructive pulmonary disease patients (66.2 + 8.3 years old, FEV1: 49.3+19.8%) received an IV infusion of 2 g of either magnesium sulfate or saline on two randomly assigned occasions approximately two days apart. Spirometry was performed both before and 45 minutes after the infusions. A symptom-limited incremental maximal cardiopulmonary test was performed on a cycle ergometer at approximately 100 minutes after the end of the infusion.

RESULTS

Magnesium infusion was associated with significant reductions in the functional residual capacity (-0.41 l) and residual volume (-0.47 l), the mean arterial blood pressure (-5.6 mmHg) and the cardiac double product (734.8 mmHg.bpm) at rest. Magnesium treatment led to significant increases in the maximal load reached (+8 w) and the respiratory exchange ratio (0.06) at peak exercise. The subgroup of patients who showed increases in the work load equal to or greater than 5 w also exhibited significantly greater improvements in inspiratory capacity (0.29 l).

CONCLUSIONS

The acute IV loading of magnesium promotes a reduction in static lung hyperinflation and improves the exercise performance in stable chronic obstructive pulmonary disease patients. Improvements in respiratory mechanics appear to be responsible for the latter finding.

Neuromuscular electrical stimulation improves exercise tolerance in chronic obstructive pulmonary disease patients with better preserved fat-free mass

BACKGROUND

High-frequency neuromuscular electrical stimulation increases exercise tolerance in patients with advanced chronic obstructive pulmonary disease (COPD patients). However, it is conceivable that its benefits are more prominent in patients with better-preserved peripheral muscle function and structure.

OBJECTIVE

To investigate the effects of high-frequency neuromuscular electrical stimulation in COPD patients with better-preserved peripheral muscle function.

DESIGN

Prospective and cross-over study.

METHODS

Thirty COPD patients were randomly assigned to either home-based, high-frequency neuromuscular electrical stimulation or sham stimulation for six weeks. The training intensity was adjusted according to each subject's tolerance. Fat-free mass, isometric strength, six-minute walking distance and time to exercise intolerance (Tlim) were assessed.

RESULTS

Thirteen (46.4%) patients responded to high-frequency neuromuscular electrical stimulation; that is, they had a post/pre Δ Tlim >10% after stimulation (unimproved after sham stimulation). Responders had a higher baseline fat-free mass and six-minute walking distance than their seventeen (53.6%) non-responding counterparts. Responders trained at higher stimulation intensities; their mean amplitude of stimulation during training was significantly related to their fat-free mass (r = 0.65; p<0.01). Logistic regression revealed that fat-free mass was the single independent predictor of Tlim improvement (odds ratio [95% CI] = 1.15 [1.04-1.26]; p<0.05).

CONCLUSIONS

We conclude that high-frequency neuromuscular electrical stimulation improved the exercise capacity of COPD patients with better-preserved fat-free mass because they tolerated higher training stimulus levels. These data suggest that early training with high-frequency neuromuscular electrical stimulation before tissue wasting begins might enhance exercise tolerance in patients with less advanced COPD.

Effects of preoperative inspiratory muscle training in obese women undergoing open bariatric surgery: respiratory muscle strength, lung volumes, and diaphragmatic excursion

OBJECTIVE

To determine whether preoperative inspiratory muscle training is able to attenuate the impact of surgical trauma on the respiratory muscle strength, in the lung volumes, and diaphragmatic excursion in obese women undergoing open bariatric surgery.

DESIGN

Randomized controlled trial.

SETTING

Meridional Hospital, Cariacica/ES, Brazil.

SUBJECTS

Thirty-two obese women undergoing elective open bariatric surgery were randomly assigned to receive preoperative inspiratory muscle training (inspiratory muscle training group) or usual care (control group).

MAIN MEASURES

Respiratory muscle strength (maximal static respiratory pressure--maximal inspiratory pressure and maximal expiratory pressure), lung volumes, and diaphragmatic excursion.

RESULTS

After training, there was a significant increase only in the maximal inspiratory pressure in the inspiratory muscle training group. The maximal expiratory pressure, the lung volumes and the diaphragmatic excursion did not show any significant change with training. In the postoperative period there was a significant decrease in maximal inspiratory pressure in both the groups. However, there was a decrease of 28% in the inspiratory muscle training group, whereas it was 47% in the control group. The decrease in maximal expiratory pressure and in lung volumes in the postoperative period was similar between the groups. There was a significant reduction in the measures of diaphragmatic excursion in both the groups.

CONCLUSION

The preoperative inspiratory muscle training increased the inspiratory muscle strength (maximal inspiratory pressure) and attenuated the negative postoperative effects of open bariatric surgery in obese women for this variable, though not influencing the lung volumes and the diaphragmatic excursion.