Iranian J Publ Health, Vol. 38, No.3, 2009, pp.39-45 Iranian J Publ Health, Vol. 38, No.3, 2009, pp.39-45
Original Article
Assessment of Nutritional Status in Chronic Obstructive Pulmonary Disease Patients *
L Yazdanpanah 1, F Shidfar 1, JA Moosavi 2, H Heidarnazhad 3, H Haghani 4
1
Dept. of Nutrition, School of Public Health, Iran Univ. of Medical Sciences, Tehran, Iran Dept. of Pulmonology, Rasul-e-Akram Hospital, Iran University of Medical Sciences, Tehran, Iran 3 Chronic Respiratory Disease Research Center, NRITLD, Masih Daneshvari Hospital, Shahid Beheshti University (MC) 4 Dept.of Biostatistics, Iran University of Medical Sciences, Tehran, Iran
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2
(Received 19 Feb 2009; accepted 30 Jul 2009)
Abstract Background: Chronic obstructive pulmonary disease (COPD) is considered a major public health problem in the world. Weight loss, muscle and fat mass depletion are common nutritional problems in COPD patients and are determinant factors in pulmonary function, health status, disability and mortality. In the present study, we assessed nutritional status in COPD patients. Methods: This cross-sectional study was performed in the Rasul-e-Akram Hospital, Tehran, Iran on 63 COPD patients with mean age (SD) of 67.6 (9.4) years. All subjects were diagnosed by a pulmonary specialist and based on a spirometry test. They were divided into three groups (2, 3, 4 stages of disease). Anthropometric and biochemical indices, body composition analyses by bioelectric impedance, spirometry test and determination of disease severity were performed for all subjects. All analyses were performed using the SPSS 14. All data presented as means (± sd). Results: Reduction of body mass index (BMI), Mid-Arm Muscle Circumference (MAMC) and Fat-Free Mass (FFM) were observed alongside an increase in disease severity but it was not significant. Significant reduction of Fat Mass (FM) (P= 0.007), Fat Mass Index (FMI) (P= 0.03) and biochemical indices like Albumin (P= 0.000) and Total Protein (P= 0.04) were associated with an increase in disease stages. Conclusion: It is suggested that in addition to BMI, other nutritional status indices like MAMC, FFM and FM should be used for early diagnosis of malnutrition before weight loss occurs.
Keywords: Chronic obstructive pulmonary disease, Mid-arm muscle circumference, Fat-free mass, Fat mass index, Bioelectric impedance
Introduction Chronic obstructive pulmonary disease (COPD) is a major public health concern and characterized by progressive airflow limitation that is not completely reversible (1-5). The increasing prevalence of disease morbidity and mortality is a significant and alarming public health problem in the world and will be the third cause of death and the fifth cause of disability by 2020 worldwide (5). COPD is a very costly disease and poses a major economic burden on individuals and society (2). Smoking is the most important cause of COPD (3). The use of biomass fuel, such as wood for cooking and heating, increases the risk of COPD by three to four times, and may be an important contributor to COPD prevalence, especially in de-
veloping countries and rural areas (4, 6). Air pollution, occupational smoke or dust and genetic factors are other causes of COPD (7). COPD is often associated with significant nutritional abnormalities, the so-called systemic effects of COPD. The alterations like weight loss, depletion of fat free mass and to a lesser extent loss of fat mass are common in COPD patients. Weight loss can be seen in 15-50% of patients with mild to severe COPD (8, 9). Low body weight, body mass index and depletion of fat free mass are independent risk factors for mortality in COPD patients (10). Muscle wasting that is reflected by reduction of fat free mass is observed in 20-40% of the patients (11). Assessment of body composition has shown that loss
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L Yazdanpanah et al: Assessment of Nutritional…
of muscle mass can be the main cause of weight loss in these patients (12, 13). Muscle wasting may also occur in normal weight stable subjects. These abnormalities are associated with peripheral muscle weakness, decrease in muscle mass, impaired functional and exercise capacity, increase in the length of hospital stay, make the symptoms of the disease and the quality of life worse (14). The causes of weight loss, depletion of fat free mass and fat mass are unclear; although increased metabolic rate and decreased caloric intake(10), tissue hypoxia (9), systemic inflammation like cytokines, interleukins and tumor necrosis factor (TNF)- (11, 15), oxidative stress(9), drugs(16) and sedentary life (9,17), are likely to be relevant pathogenic factors. The high prevalence of weight loss, muscle and fat mass wasting in COPD patients suggests that effective nutritional screening must be implemented to detect and treat nutritional problems, to minimize COPD-related medical care costs, to improve the patients’ health and to ameliorate their quality of life. The aim of this study, which has been performed for the first time in Iran, was to assess nutritional status in COPD patients, therefore anthropometric and biochemical indices, analysis of body composition were assessed for all COPD patients who participated in this study.
Materials and Methods This cross-sectional study was performed in the Rasul-e-Akram Hospital in Tehran on 63 COPD patients with mean age (SD) of 67.6 (9.4) yr. All subjects had COPD which was diagnosed by a pulmonary specialist and on the basis of a spirometry test, then according to the Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines, COPD severity for all subjects was determined and they were divided into three groups (2, 3, 4 stages of disease). At the time of the study all COPD patients were no more exacerbated and were in stable condition. Exclusion criteria were liver, heart or kidney failure, cancer, endocrine abnormalities and fever, presence of other pulmonary disease in addition to COPD. 40
Spirometry and determination of COPD severity The spirometry test is a simple and is the most common of the Pulmonary Function Tests, and it measures lung function using a device called a spirometer. All subjects underwent the test with a nurse who was specially trained to perform spirometry. Patients were instructed not to use bronchodilator on the day of pulmonary function assessment. All patients were studied in a sitting position. Data from the highest amount of flowvolume curve Forced Vital Capacity (FVC) and Forced Expiratory Volume in 1 Second (FEV1) were used for calculations. FEV1 was expressed as FEV1% predicted, based on gender, height and age, using the reference of the American Thoracic Society, and then severity of disease in accordance to GOLD guidelines was determined as follows: Stage1: FEV1/FVC
