Table of Contents  
ORIGINAL ARTICLE
Year : 2016  |  Volume : 9  |  Issue : 5  |  Page : 570-576  

Correlating nutritional status with severity of chronic obstructive pulmonary disease in adult females


1 Department of Pulmonary Medicine, Smt. Kashibai Navale Medical College and General Hospital, Pune, Maharashtra, India
2 Department of Community Medicine, Smt. Kashibai Navale Medical College and General Hospital, Pune, Maharashtra, India

Date of Web Publication13-Oct-2016

Correspondence Address:
Meenakshi Nikhil Bhakare
Department of Pulmonary Medicine, Smt. Kashibai Navale Medical College and General Hospital, Pune - 411  041, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0975-2870.192157

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  Abstract 

Context: Chronic obstructive pulmonary disease (COPD) is a leading cause of morbidity and mortality worldwide. Recent studies report increased the prevalence of COPD among adult females and nutrition is an important prognostic marker in COPD. Nutrition in Indian females is already a concern, further compromised by increasing the prevalence of COPD. Aims: A study correlation of six selected nutritional parameters: Body mass index, waist-hip ratio, waist-height ratio, serum albumin, hemoglobin, and Mini Nutritional Assessment (MNA) score with the severity of COPD (Global Initiative for Obstructive Lung Diseases [GOLD] categorization) in adult female patients. Settings and Design: A cross-sectional analytical study including all adult female patients diagnosed with COPD based on spirometry, attending pulmonary medicine outpatient department of a medical college between January and June 2014. Patients with pulmonary tuberculosis, acute exacerbations of COPD, and those unwilling to participate were excluded from the study. Subjects and Methods: A total of 100 patients were studied with a detailed history, physical examination, spirometry, anthropometric measurements, laboratory parameters of nutrition, and MNA questionnaire. Statistical Analysis Used: SPSS 14.01 version (IBM analytics) with Pearson's correlation coefficient and one-way analysis of variance (ANOVA) as tests of significance. Results: The study revealed that proportion of adult female COPD patients with GOLD categorization is 7% GOLD1, 40% GOLD 2, 42% GOLD 3, and 11% GOLD 4. Pearson's correlation coefficients calculated for the severity of COPD with six selected nutritional parameters showed statistically significant correlation with MNA score (correlation coefficient = −0.253, P< 0.01) and waist-height ratio. Mean MNA score in GOLD four patients (18.72) was significantly lower than that in GOLD 1 patients (22.14). MNA score decreases toward malnutrition as severity of COPD increases which is statistically significant (F = 2.353, df = 3, P< 0.05) using ANOVA. Similarly, waist-height ratio also decreased significantly with increasing severity of COPD (F = 2.582, df = 3, P< 0.05). Conclusions: The study concludes that malnutrition increases the severity of COPD. Further, it also concluded that MNA score and waist-height ratio correlate better with the severity of COPD than other nutritional parameters.

Keywords: Adult females, anthropological measurements, chronic obstructive pulmonary disease, Global Initiative for Obstructive Lung Diseases categorization, mini nutrition assessment score, nutritional parameters


How to cite this article:
Bhakare MN, Godbole GP, Khismatrao DS, Pophale HS, Magar PK, Kulkarni SS, Bhakare NH. Correlating nutritional status with severity of chronic obstructive pulmonary disease in adult females. Med J DY Patil Univ 2016;9:570-6

How to cite this URL:
Bhakare MN, Godbole GP, Khismatrao DS, Pophale HS, Magar PK, Kulkarni SS, Bhakare NH. Correlating nutritional status with severity of chronic obstructive pulmonary disease in adult females. Med J DY Patil Univ [serial online] 2016 [cited 2024 Mar 28];9:570-6. Available from: https://journals.lww.com/mjdy/pages/default.aspx/text.asp?2016/9/5/570/192157




  Introduction Top


Chronic obstructive pulmonary disease (COPD) is a leading cause of morbidity and mortality worldwide.[1] According to the WHO, COPD is to be expected to be the third most common cause of death in the year 2020.[1] Tobacco smoking is established as a major risk factor, but emerging evidence suggests that other risk factors are important, especially in developing countries.[2] Cigarette smoking is the main risk factor for COPD, but not all smokers develop COPD, an observation that suggests that other factors also are involved. Estimated 25–45% patients with COPD have never smoked; the burden of nonsmoking COPD is therefore much higher than the previously believed.[3] Many recent studies have reported increased the prevalence of COPD, especially among the women. COPD severity is categorized by Global Initiative for Obstructive Lung Diseases (GOLD) guidelines.[4] The studies indicate that people with low body mass index (BMI)[5] are at a higher risk of developing COPD. There are two important waist metrics which are complementary to BMI. They are waist to hip ratio 5 and waist to height ratio.[6] Waist metrics provide an indication of the extent of central fat distribution, and for this reason, they are a valuable complement to BMI. Low serum albumin level is one of the poor prognostic indicators in COPD patients.[7] Anemia is a poor prognostic factor for COPD patient.[8]

Thus, nutrition is an important prognostic marker in COPD. In India, female nutrition is itself subject of concern, which is further compromised by increasing the prevalence of COPD.

There are studies on BMI [5],[7] Mini Nutritional Assessment (MNA)[9],[10] serum albumin level [7] with disease severity of COPD. However, there were a very few studies which include female COPD patients and not a single nutritional study conducted exclusively only in female COPD patient. Furthermore, there is no study on other anthropometric measurements such as waist-hip ratio and waist-height ratio. Thus, in our study, we included anthropometric parameters such as BMI, waist-height ratio, waist-hip ratio, laboratory parameters such as serum albumin, hemoglobin, and questionnaire-based nutritional parameter MNA score with the severity of COPD that too focusing exclusively on female COPD patients.


  Subjects and Methods Top


A cross-sectional analytical study which included all adult female patients diagnosed with COPD based on spirometry, attending pulmonary medicine outpatient department (OPD) of Medical College between January and June 2014. Patients with pulmonary tuberculosis, acute exacerbations of COPD, and those unwilling to participate were excluded from the study. The sample size was decided by universal sampling. Hence, total no of COPD patients visiting OPD in the study period January to June 2014 included in the study. The Ethical Committee approval of College Ethical Committee was taken. A total of 100 patients were studied with detailed history, physical examination, spirometry, anthropometric measurements, laboratory parameters of nutrition, and MNA questionnaire.

Tools for data collection

Detailed history, clinical examination, and spirometry findings of the patient were recorded in a structured questionnaire. BMI, waist-hip ratio, and waist-height ratio were taken as anthropometric measurements and recorded. Serum albumin and hemoglobin were measured as laboratory parameters of nutrition. An MNA questionnaire consisting of screening and assessment score based on the patient recall is used in the form of questionnaire which gives malnutrition indicator score. The severity of COPD was classified as per the GOLD guidelines.

Anthropometric and nutritional parameters measurements

Body mass index[5]

Weight was measured after the removal of shoes while wearing light clothing. Height was measured without shoes in the standing position with the shoulders in relaxed position and arms hanging freely. BMI was calculated as weight (kg)/height in meter 2. It is then classified as <18.5 - underweight; 18.5–24.9 - normal; 25.0–29.9 - overweight; and more than 30.0 - obese.

Waist-hip ratio[5]

Waist circumference was measured using a measuring tape over the unclothed abdomen, with measurements made halfway between the lower border of the ribs and the highest point of iliac crest (at the umbilicus level) in the standing position in centimeters. Hip circumference was measured over light clothing at the widest point over the buttocks when viewed from the side in centimeters. Waist-hip ratio was obtained by dividing the waist circumference by hip circumference.

Waist-height ratio[6]

Waist-height ratio was obtained by dividing the waist circumference by height.

Serum albumin[7]

Blood sample checked in the Department of Biochemistry blood analyzer machine and measure in milligram per deciliter unit.

Hemoglobin[8]

Blood sample tested in the Department of Pathology by cell counter machine and measure in gram%.

Mini Nutritional Assessment questionnaire[9],[10]

The MNA [Annexure 1] consists of a three-step process: Screening, assessment, and the total score. Screening test contains six questions: Intake, weight loss, mobility, disease, neuropsychological problem. Assessment includes twelve questions about the health conditions and type of meals. The total score was then calculated by addition of screening and assessment score. The score was then further categorized as follows: Less than 17 points - malnourished, 17–23.5 points - at risk of malnutrition, 24–30 - normal.



Measuring severity of chronic obstructive pulmonary disease[4]

Classification of severity of airflow limitation in COPD (based on postbronchodilator forced expiratory volume [FEV] 1):

  1. GOLD 1: Mild - FEV1 >80% predicted
  2. GOLD 2: Moderate - 50% <FEV1 <80% predicted
  3. GOLD 3: Severe 30% <FEV1 <50% predicted
  4. GOLD 4: Very severe FEV1 <30% predicted.



  Results Top


A total of 100 adult females participated in the study with 54% above 60 years of age. [Graph 1] shows the age-wise distribution of study participants.



[Graph 2] shows the proportion of COPD patients as per the severity according to the GOLD categorization. The study reveals that almost 80% of patients visiting tertiary care hospital are in GOLD 2 and GOLD 3 category as per the severity of COPD.



[Table 1] shows the distribution of patients in the various nutritional parameters.
Table  1: Frequency distribution of patients according to various nutritional parameters

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Further, statistical analysis was performed to see the correlation of these selected nutritional parameters with the severity of COPD as per the GOLD categorization. [Table 2] shows the correlation coefficients calculated for various nutritional parameters with the severity of COPD. Statistically significant correlation was seen only with MNA score (value = −0.253, P < 0.05).
Table 2:  Correlation  coefficient  of  various  nutritional  parameters  with  severity of chronic obstructive pulmonary disease

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[Table 3] shows one-way analysis of variance (ANOVA), used to compare means of each of these nutritional parameters among patients with varied severity of disease as per the GOLD categorization. The mean MNA score in GOLD 1 is 22.14, GOLD 2 is 21.75, GOLD 3 is 20.49, and GOLD 4 is 18.73. Thus, mean MNA score in GOLD 4 patients (18.73) was significantly lower than that in GOLD 1 patients (22.14). MNA score decreases toward malnutrition as severity of COPD increases. This is statistically significant (F = 2.353, df = 3, P < 0.05). Similarly, the mean for waist-height ratio in GOLD 2 is 0.52, GOLD 3 is 0.49, and GOLD 4 is 0.47. This shows waist-height ratio also decreased significantly with increasing severity of COPD (F = 0.952, df = 3, P < 0.05).
Table  3: Comparison of means of nutritional parameters among patients with varied severity of chronic obstructive pulmonary disease

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However, other selected nutritional parameters of our study like waist-hip ratio, BMI, serum albumin, and serum hemoglobin does not have any significant correlation with severity of COPD.

Of the total sample size, 18% of the patients had comorbidities such as diabetes mellitus, hypertension, ischemic heart disease, and dyslipidemia. A multivariate analysis was performed to control for these confounding variable and it was observed that study results were not different after controlling for these confounding variables.


  Discussion Top


In routine clinical practice, the nutritional evaluation of COPD patients is seldom given sufficient attention. There is no ideal nutritional marker nor is there a gold standard for the diagnosis of malnutrition in COPD patients.

There were no studies done in India which correlate different nutritional parameters with disease severity of COPD in females b. In our study, we used seven different nutritional parameters which include nutritional questioner, anthropometric parameters, and laboratory parameters also. Hence, patient's nutrition is judged by all aspects in our study. Disease severity of COPD was done with GOLD standards.

A total of 100 adult females participated in the study with 54% above 60 years of age. The study reveals that almost 80% of patients visiting tertiary care hospital are in GOLD 2 and GOLD 3 category as per the severity of COPD.

In our study, 67 females were having normal BMI. Previously, there were many studies for correlating BMI [5],[7] with COPD, which shows decreasing BMI increases the severity of COPD. However, as in our study, more than 50% females were with normal BMI, and there is no correlation between BMI and COPD disease severity.

In our study, 77 females were having poor waist-height ratio which also correlates with increasing disease severity of COPD by one-way ANOVA analysis. The mean for waist-height ratio in GOLD 2 is 0.52, GOLD 3 is 0.49, and GOLD 4 is 0.47. This shows waist-height ratio also decreased significantly with increasing severity of COPD (F = 0.952, df = 3, P < 0.05). There was no single study for this correlation of waist-height ratio and disease severity in females.

According to waist-hip ratio, 51% of patient were overweight in our study, but with no correlation with disease severity of COPD. There have been no previous studies on this.

The previous studies showed that low level of serum albumin [7] correlates well with disease severity of COPD. However, in our study, there were 61% patients having normal serum albumin levels and no correlation with disease severity of COPD.

Ninety-five percent of our patients were having normal hemoglobin levels with no correlation with disease severity of COPD. There was study showing anemia [8] correlates with disease severity.

MNA score shows 61% of patients having a score of “at risk of malnutrition.” The mean MNA score in GOLD 1 is 22.14, GOLD 2 is 21.75, GOLD 3 is 20.49, and GOLD 4 is 18.73. Thus, mean MNA score in GOLD 4 patients (18.73) was significantly lower than that in GOLD 1 patients (22.14). MNA score decreases toward malnutrition as severity of COPD increases. This is statistically significant (F = 2.353, df = 3, P < 0.05). Furthermore, in the previous two studies MNA [9],[10] correlate in similar manner.

Gupta et al.[11] studied subjective global assessment (SGA) of nutritional status of COPD patients on admission at Lucknow in 2009. In which SGA scores correlated positively with pulmonary function parameters and negatively with anthropometric parameters. However, there was no correlation for biochemical parameters. Furthermore, in their study, out of 106 patients, only 14 were females. They use SGA score in their study which include patient history and physical examination. However, mini nutritional scale is the simple questioner. Anthropometric parameter used was only BMI.

Sun et al. studied MNA in patients with COPD and its correlation with BODE indexes in 139 geriatric outpatients.[11] They found that MNA scores are strongly correlated with the anthropometrical parameters and BODE indexes to allow screening of the nutritional status in patients with COPD. In this study, they use BODE index which is prognostic index of COPD. Waist-height ratio and waist-hip ratio were not considered in any study.

Our study concludes that malnutrition increases as severity of COPD increases. Further, we also concluded that MNA score and waist-height ratio correlate better with severity of COPD than other selected nutritional parameters.

MNA score is simple questionnaire which can be easily used in OPDs and clinics to assess the malnutrition in patients of COPD. This will help us to improve the overall quality of life of patients. Furthermore, waist-height ratio correlation with disease severity indicates the importance of skeletal muscle training (muscle strengthening and endurance training) in improving the quality of life of COPD patients. Waist-height ratio also gives an indication about central obesity; abdominal muscle strengthening will improve the quality of life in those patients.

This study is conducted in OPD of medical college with the inclusion of 100 female COPD patients which shows only iceberg of real COPD problem in India. Hence, there is a scope for further community-based studies to correlate the impact of nutritional parameters with disease severity of COPD and will help design and implement better rehabilitation programs.


  Conclusions Top


The study concludes that malnutrition increases the severity of COPD. Further, it also concluded that MNA score and waist-height ratio correlate better with the severity of COPD than other nutritional parameters.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
World Health Organization. Burden of COPD. Available from: http://www.who.int/respiratory/copd/burden/en/. [Last accessed on 2013 Jun 05].  Back to cited text no. 1
    
2.
Salvi SS, Barnes PJ. Chronic obstructive pulmonary disease in non-smokers. Lancet 2009;374:733-43.  Back to cited text no. 2
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Salvi S, Juvekar S, Londhe J, Brashier B, Madas S, Barnes PJ. Prevalence of COPD in a rural population in India. Eur Respir J 2011;2954.  Back to cited text no. 3
    
4.
Global Initiative for Chronic Obstructive Lung Disease (GOLD). Global Strategy for Diagnosis, Management, and Prevention of Chronic Obstructive Lung Disease; 2015. http://www.goldcopd.com. [Last accessed on 2016 Jun 20].  Back to cited text no. 4
    
5.
Huxley R, Mendis S, Zheleznyakov E, Reddy S, Chan J. Body mass index, waist circumference and waist: Hip ratio as predictors of cardiovascular risk – A review of the literature. Eur J Clin Nutr 2010;64:16-22.  Back to cited text no. 5
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Browning LM, Hsieh SD, Ashwell M. A systematic review of waist-to-height ratio as a screening tool for the prediction of cardiovascular disease and diabetes: 0·5 could be a suitable global boundary value. Nutr Res Rev 2010;23:247-69.  Back to cited text no. 6
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7.
Sharma MV, Anupama N, Harsha DS, Viswambhar, Bhat AC, Basavaraj S, et al. Low body mass index and low serum albumin level as risk factors for carbon dioxide retention during acute exacerbation of chronic obstructive pulmonary disease. Int J Innov Res Sci Eng Technol 2013;2/(8):3508-11.  Back to cited text no. 7
    
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Haja Mydin H, Murphy S, Clague H, Sridharan K, Taylor IK. Anemia and performance status as prognostic markers in acute hypercapnic respiratory failure due to chronic obstructive pulmonary disease. Int J Chron Obstruct Pulmon Dis 2013;8:151-7.  Back to cited text no. 8
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9.
Sun J, Zheng J, Guo S, Zhu Z, Chen X. Application of Mini Nutritional Assessment in patients with chronic obstructive pulmonary disease and its correlation with BODE indexes. Nan Fang Yi Ke Da Xue Xue Bao 2013;33:1217-20.  Back to cited text no. 9
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10.
Benedik B, Farkas J, Kosnik M, Kadivec S, Lainscak M. Mini nutritional assessment, body composition, and hospitalisations in patients with chronic obstructive pulmonary disease. Respir Med 2011;105 Suppl 1:S38-43.  Back to cited text no. 10
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11.
Gupta B, Kant S, Mishra R. Subjective global assessment of nutritional status of chronic obstructive pulmonary disease patients on admission. Int J Tuberc Lung Dis 2010;14:500-5.  Back to cited text no. 11
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    Tables

  [Table 1], [Table 2], [Table 3]


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