Body weight and mortality in COPD: focus on the obesity paradox

Abstract

Abstract

The positive association between overweight, obesity, and cardiovascular and all-cause mortality is well established, even though this relation is typically U shaped with an increased risk also in low-weight subjects. However, being overweight or obese has been associated with a better prognosis in subjects suffering from chronic diseases, id est the “obesity paradox”. In both community-dwelling and hospitalized patients with COPD, several studies have reported a significant protective effect of obesity on all-cause mortality, indicating that also in obstructive pulmonary diseases, an obesity paradox may be present. Interestingly, the “paradox” is more evident for subjects with severe bronchial obstruction (i.e., a lower FEV1), while in mild–moderate conditions, the weight-related mortality shows a behavior similar to that observed in the general population. Several factors may confound the relation between COPD, obesity and mortality. The lower FEV1 found in obese people may be linked to a restrictive defect rather than to an obstructive one. Due to the modified chest wall mechanical properties—related to increased fat mass—obese COPD patients may present, respect to their lean counterpart, a lower lung hyperinflation which is associated with higher mortality. The traditional classification of COPD attributes to obese “blue bloaters” a low-grade emphysema in opposition to lean “pink puffers”; the fact that emphysema extent is related to mortality may bias the relationship between weight and survival. It is also to underline that the majority of the studies, consider BMI rather than body composition (a better predictor of mortality) when studying the intriguing relation between weight, COPD, and mortality. Reverse bias has also to be taken into account, hypothesizing that an unintentional weight loss may be the deleterious factor related to mortality, rather than considering obesity a protective one. Further prospective studies are needed to shed light on the complexity of this emerging issue.

Level of evidence

Level V: Narrative Review.

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Reprinted with permission of the American Thoracic Society. Copyright © 2017 American Thoracic Society [42]

References

  1. 1.

    NCD Risk Factor Collaboration (NCD-Risk) (2016). Trends in adult body-mass index in 200 countries from 1975 to2014: a pooled analysis of 1698 population-based measurement studies with 19.2 million participants. The Lancet 387:1377–1396. doi:10.1016/S0140-6736(16)30054-X

    Article  Google Scholar 

  2. 2.

    Lavie CJ, Milani RV, Ventura HO (2009) Obesity and cardiovascular disease: risk factor, paradox and impact of weight loss. J Am Coll Cardiol 53:1925–1932. doi:10.1016/j.jacc.2008.12.068

    Article  PubMed  Google Scholar 

  3. 3.

    Yang L, Drake BF, Coldits GA (2016) Obesity and Other Cancers. J Clin Oncol 34:4231–4237. doi:10.1200/JCO.2016.68.4837

    Article  PubMed  Google Scholar 

  4. 4.

    Zammit C, Liddicoat H, Moonsie I, Makker H (2010) Obesity and respiratory diseases. Int J Gen Med 3:335–343. doi:10.2147/IJGM.S11926

    Article  PubMed  PubMed Central  Google Scholar 

  5. 5.

    Lavie CJ, De Schutter A, Parto P, Jahangir E, Kokkinos P, Ortega FB, Arena R, Milani RV (2016) Obesity and prevalence of cardiovascular diseases and prognosis—the obesity paradox updated. Prog Cardiovasc Dis 58:537–547. doi:10.1016/j.pcad.2016.01.008

    Article  PubMed  Google Scholar 

  6. 6.

    Chittal P, Babu AS, Lavie CJ (2015) Obesity Paradox: does fat alter outcomes in chronic obstructive Pulmonary Disease? COPD 12:14–18. doi:10.3109/15412555.2014.915934

    Article  PubMed  Google Scholar 

  7. 7.

    Gruberg L, Weissman NJ, Waksman R, Fuchs S, Deible R, Pinnow EE, Ahmed LM, Kent KM, Pichard AD, Suddath WO, Satler LF, Lindsay J Jr (2002) The impact of obesity on the short-term and long-term outcomes after percutaneous coronary intervention: the obesity paradox? J Am Coll Cardiol 39(4):578–584. doi:10.1016/S0735-1097(01)01802-2

    Article  PubMed  Google Scholar 

  8. 8.

    Hanson C, Rutten EP, Wouters EFM, Rennard S (2014) Influence of diet and obesity on COPD development and outcomes. IntJ Chron Obstruct Pulmon Dis 9:723–733. doi:10.2147/COPD.S5011

    Article  Google Scholar 

  9. 9.

    Guo Y, Zhang T, Wang Z, Yu F, Xu Q, Guo W, Wu C, He J (2016) Body mass index and mortality in chronic obstructive pulmonary disease. Medicine (Baltimore) 95(28):e4225. doi:10.1097/MD.0000000000004225

    Article  Google Scholar 

  10. 10.

    Luo Y, Zhou L, Li Y, Guo S, Ki X, Zheng J, Zhu Z, Chen Y, Huang Y, Chen R, Chen X (2016) Fat-free mass index for evaluating the nutritional status and disease severity in COPD. Respir Care 61(5):680–688. doi:10.4187/respcare.04358

    Article  PubMed  Google Scholar 

  11. 11.

    Vozoris NT, O’Donnell DE (2012) Prevalence, risk factors, activity limitation and health care utilization of an obese, population-based sample with chronic obstructive pulmonary disease. Can Respir J 19(3):e18–e24

    Article  Google Scholar 

  12. 12.

    Eisner MD, Blanc PD, Sidney S et al (2007) Body composition and functional limitation in COPD. Respir Res 8:7. doi:10.1186/1465-9921-8-7

    Article  PubMed  PubMed Central  Google Scholar 

  13. 13.

    Montes de Oca M, Tálamo C, Perez-Padilla R et al (2008) Chronic obstructive pulmonary disease and body mass index in five Latin America cities: the PLATINO study. Respir Med 102(5):642–650. doi:10.1016/j.rmed.2007.12.025

    Article  PubMed  Google Scholar 

  14. 14.

    Gan WQ, Man SF, Senthilselvan A, Sin DD (2004) Association between chronic obstructive pulmonary disease and systemic inflammation: a systematic review and a meta-analysis. Thorax 59(7):574–580. doi:10.1136/thx.2003.019588

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  15. 15.

    Vernooy JH, Kucukaycan M, Jacobs JA et al (2002) Local and systemic inflammation in patients with chronic obstructive pulmonary disease: soluble tumor necrosis factor receptors are increased in sputum. Am J Respir Crit Care Med 166(9):1218–1224. doi:10.1164/rccm.2202023

    Article  PubMed  Google Scholar 

  16. 16.

    Fratta Pasini AM, Ferrari M, Stranieri C, Vallerio P, Mozzini C, Garbin U, Zambon G, Cominacini L (2016) Nrf2 expression is increased in peripheral blood mononuclear cells derived from mild–moderate ex-smoker COPD patients with persistent oxidative stress. Int J Chron Obstruct Pulmon Dis 11:1733–1743. doi:10.2147/COPD.S102218

    Article  PubMed  PubMed Central  Google Scholar 

  17. 17.

    Agusti A, Edwards LD, Rennard SI et al (2012) Persistent systemic inflammation is associated with poor clinical outcomes in COPD: a novel phenotype. PLoS One 7(5):e37483. doi:10.1371/journal.pone.0037483

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  18. 18.

    Mancuso P (2010) Obesity and lung inflammation. J Appl Physiol 108:722‑8. doi:10.1152/japplphysiol.00781.2009

    Article  Google Scholar 

  19. 19.

    Breyer MK, Spruit MA, Celis AP et al (2009) Highly elevated C-reactive protein levels in obese patients with COPD: a fat chance? Clin Nutr 28(6):642–647. doi:10.1016/j.clnu.2009.05.005

    CAS  Article  PubMed  Google Scholar 

  20. 20.

    Rutten EP, Breyer MK, Spruit MA et al (2010) Abdominal fat mass contributes to the systemic inflammation in chronic obstructive pulmonary disease. Clin Nutr 29(6):756–760 oi. 10.1016/j.clnu.2010.04.007

    Article  PubMed  Google Scholar 

  21. 21.

    van den Borst B, Gosker HR, Wesseling G et al (2011) Low-grade adipose tissue inflammation in patients with mild-to-moderate chronic obstructive pulmonary disease. Am J Clin Nutr 94(6):1504–1512. doi:10.3945/ajcn.111.023911

    CAS  Article  PubMed  Google Scholar 

  22. 22.

    International Diabetes Federation. Metabolic syndrome. The IDF consensus worldwide definition of the metabolic syndrome. http://www.idf.org. Accessed March 2017

  23. 23.

    Cebron Lipovec N, Beijers RJ, van den Borst B, Doehner W, Lainscak M, Schols AM (2016) The prevalence of metabolic syndrome in chronic obstructive pulmonary disease: a systematic review. COPD 13:399–406. doi:10.3109/15412555.2016.1140732

  24. 24.

    Clini E, Crisafulli E, Radaeli A, Malerba M (2013) COPD and the metabolic syndrome: an intriguing association. Intern Emerg Med 8:283–289. doi:10.1007/s11739-011-0700-x

    Article  PubMed  Google Scholar 

  25. 25.

    Mirrakhimov AE (2012) Chronic obstructive pulmonary disease and glucose metabolism: a bitter sweet symphony. Cardiovasc Diabetol 11:132. doi:10.1186/1475-2840-11-132

    Article  PubMed  PubMed Central  Google Scholar 

  26. 26.

    McClean KM, Kee F, Young IS, Elborn JS (2008) Obesity and the lung: 1. Epidemiology. Thorax 63(7):649–654. doi:10.1136/thx.2007.086801

    CAS  Article  PubMed  Google Scholar 

  27. 27.

    Salome CM, King GG, Berend N (2010) Physiology of obesity and effects on lung function. J Appl Physiol 108:206–211. doi:10.1152/japplphysiol.00694.2009

    Article  PubMed  Google Scholar 

  28. 28.

    Chen Y, Rennie D, Cormier YF, Dosman JA (2007) Waist circumference is associated with pulmonary function in normal-weight, overweight, and obese subjects. Am J Clin Nutr 85:35–39

    CAS  Article  Google Scholar 

  29. 29.

    Jones RL, Nzekwu MM (2006) The effects of body mass index on lung volumes. Chest 130:827–833. doi:10.1378/chest.130.3.827

    Article  PubMed  Google Scholar 

  30. 30.

    Watson RA, Pride NB, Thomas EL et al (2010) Reduction of total lung capacity in obese men: comparison of total intrathoracic and gas volumes. J Appl Physiol 108:1605–1612. doi:10.1152/japplphysiol.01267.2009

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  31. 31.

    Sin DD, Jones Rl, Man SF (2002) Obesity is a risk factor for dyspnea but not for airflow obstruction. Arch Intern Med 162:1477–1481. doi:10.1001/archinte.162.13.1477

    Article  PubMed  Google Scholar 

  32. 32.

    Zerah F, Harf A, Perlemuter L, Lorino H, Lorino AM, Atlan G (1993) Effects of obesity on respiratory resistance. Chest 103:1470–1476. doi:10.1378/chest.103.5.1470

    CAS  Article  PubMed  Google Scholar 

  33. 33.

    Sharp JT, Henry JP, Swaeny SK, Meadows WR, Pietras RJ (1964) Effects of mass loading the respiratory system in man. J Appl Physiol 19:959–966

    CAS  Article  Google Scholar 

  34. 34.

    Yap JC, Watson RA, Gilbey S, Pride NB (1995) Effects of posture on respiratory mechanics in obesity. J Appl Physiol 79:1199–1205

    CAS  Article  Google Scholar 

  35. 35.

    Rubinstein I, Zamel N, DuBarry L, Hoostein V (1990) Airflow limitation in morbidly obese, nonsmoking men. Ann Intern Med 112:828–832. doi:10.7326/0003-4819-112-11-828

    CAS  Article  PubMed  Google Scholar 

  36. 36.

    Biring MS, Lewis MI, Liu JT, Mohsenifar Z (1999) Pulmonary physiologic changes of morbid obesity. Am J Med Sci 318:293–297. 10.1016/S0002-9629(15)40641-X

    CAS  Article  PubMed  Google Scholar 

  37. 37.

    Jee SH, Sull JW, Park J et al (2006) Body-mass index and mortality in Korean men and women. N Engl J Med 355(8):779–787. doi:10.1056/NEJMoa054017

    CAS  Article  PubMed  Google Scholar 

  38. 38.

    Hallin R, Gudmundsson G, Suppli Ulrik C et al (2007) Nutritional status and long-term mortality in hospitalised patients with chronic obstructive pulmonary disease (COPD). Respir Med 101(9):1954–1960. doi:10.1016/j.rmed.2007.04.009

    Article  PubMed  Google Scholar 

  39. 39.

    McGhan R, Radcliff T, Fish R, Sutherland ER, Welsh C, Make B (2007) Predictors of rehospitalization and death after a severe exacerbation of COPD. Chest 132(6):1748–1755. doi:10.1378/chest.06-3018

    Article  PubMed  Google Scholar 

  40. 40.

    Lainscak M, von Haehling S, Doehner W et al (2011) Body mass index and prognosis in patients hospitalized with acute exacerbation of chronic obstructive pulmonary disease. J Cachexia Sarcopenia Muscle 2(2):81–86. doi:10.1007/s13539-011-0023-9

    Article  PubMed  PubMed Central  Google Scholar 

  41. 41.

    Wilson DO, Rogers RM, Wright EC, Anthonisen NR (1989) Body weight in chronic pulmonary disease—the National Institute of Health Intermittent positive-pressure breathing trial. Am Rev Respir Dis 139:1435–1438. doi:10.1164/ajrccm/139.6.1435

    CAS  Article  PubMed  Google Scholar 

  42. 42.

    Landbo C, Prescott E, Lange P, Vestbo J, Almdal TP (1999) Prognostic value of nutritional status in chronic obstructive pulmonary disease. Am J Respir Crit Care Med 160(6):1856–1861. doi:10.1164/ajrccm.160.6.9902115

    CAS  Article  PubMed  Google Scholar 

  43. 43.

    Cao C, Wang R, Wang J, Bunjhoo H, Xu Y, Xiong W (2012) Body mass index and mortality in chronic obstructive pulmonary disease: a meta-analysis. PLoS One 7(8):e43892. doi:10.1371/journal.pone.0043892

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  44. 44.

    Zapatero A, Barba R, Ruiz J et al (2013). Malnutrition and obesity: influence in mortality and readmissions in chronic obstructive pulmonary disease patients. J Hum Nutr Diet 26 Suppl 1:16–22 doi:10.1111/jhn.12088

  45. 45.

    Prescott E, Almdal T, Mikkelsen KL, Tofteng CL, Vestbo J, Lange P (2002) Prognostic value of weight change in chronic obstructive pulmonary disease: results from the Copenhagen City Heart Study. Eur Respir J 20(3):539–544. doi:10.1183/09031936.02.00532002

    CAS  Article  PubMed  Google Scholar 

  46. 46.

    Divo MJ, Cabrera C, Casanova C, Marin JM, Pinto-Plata VM, de-Torres JP, Zulueta J, Zagaceta J, Sanchez-Salcedo P, Berto J, Cote C, Celli BR (2014) Comorbidity distribution, clinical expression and survival in COPD patients with different body mass index. Chronic Obstr Pulm Dis 1(2):229–238 8. doi:10.15326/jcopdf.1.2.2014.0117

    Article  PubMed  PubMed Central  Google Scholar 

  47. 47.

    Yamauchi Y, Hasegawa W, Yasunaga H, Sunohara M, Jo T, Takami K, Matsui H, Fushimi K, Nagase T (2014) Paradoxical association between body mass index and in-hospital mortality in elderly patients with chronic obstructive pulmonary disease in Japan. Int J Chron Obstruct Pulmon Dis 9:1337–1346. doi:10.2147/COPD.S75175

    Article  PubMed  PubMed Central  Google Scholar 

  48. 48.

    Schols AM, Slangen J, Volovics L, Wouters EFM (1998) Weight loss is a reversible factor in the prognosis of chronic obstructive pulmonary disease. Am J Respir Crit Care Med 157:1791–1797. doi.10.1164/ajrccm.157.6.970517

    CAS  Article  PubMed  Google Scholar 

  49. 49.

    Chailleux E, Laaban JP, Veale D (2003) Prognostic value of nutritional depletion in patients with COPD treated by long-term oxygen therapy: data from the ANTADIR observatory. Chest 123(5):1460–1466. doi.10.1378/chest.123.5.1460

    Article  PubMed  Google Scholar 

  50. 50.

    Ringbaek TJ, Viskum K, Lange P (2004) BMI and oral glucocorticoids as predictors of prognosis in COPD patients on long-term oxygen therapy. Chron Respir Dis 1:71–78. doi:10.1191/1479972304cdOlloa

    CAS  Article  PubMed  Google Scholar 

  51. 51.

    Ringbaek T, Seersholm N, Viskum K (2005) Standardised mortality rates in females and males with COPD and asthma. Eur Respir J 25:891–895. doi:10.1183/09031936.05.00099204

    CAS  Article  PubMed  Google Scholar 

  52. 52.

    Marti S, Munoz X, Rios J, Morell F, Ferrer J (2006) Body weight and comorbidity predict mortality in COPD patients treated with oxygen therapy. Eur Resp J 27:689–696. doi:10.1097/SMJ.0b013e3181d394b4

    CAS  Article  Google Scholar 

  53. 53.

    Schembri S, Anderson W, Morant S, Winter J, Thompson P, Pettitt D, MacDonald TM, Winter JH (2009) A predictive model of hospitalization and death from chronic obstructive pulmonary disease. Respir Med 103:1461–1467. doi:10.1016/j.rmed.2009.04.021

    Article  PubMed  Google Scholar 

  54. 54.

    Jordan JG Jr, Mann JR (2010) Obesity and mortality in persons with obstructive lung disease using data from the NHANES III. South Med J 103:323–330. doi:10.1097/SMJ.0b013e3181d394b4

    Article  PubMed  Google Scholar 

  55. 55.

    Collins PF, Stratton RJ, Kurukulaaratchy R, Elia M (2010) The “obesity paradox” in chronic obstructive pulmonary disease. Thorax 65(Suppl 4):A73-A74. doi:10.1136/thx.2010.150953.14

    Article  Google Scholar 

  56. 56.

    Lazarus R, Sparrow D, Weiss ST (1997) Effects of obesity and fat distribution on ventilatory function: the normative aging study. Chest 111(4):891–898 doi:10.1378/chest.111.4.891

    CAS  Article  Google Scholar 

  57. 57.

    Ora J, Laveneziana P, Ofir D, Deesomchok A, Webb KA, O’Donnell DE (2009) Combined effects of obesity and chronic obstructive pulmonary disease on dyspnea and exercise tolerance. Am J Respir Crit Care Med 180(10):964–971. doi:10.1164/rccm.200904-0503OC

    Article  PubMed  Google Scholar 

  58. 58.

    Guenette JA, Jensen D, O’Donnell DE (2010) Respiratory function and the obesity paradox. Curr Opin Clin Nutr Metab Care 13:618–624. doi:10.1097/MCO.0b013e32833e3453

    Article  PubMed  Google Scholar 

  59. 59.

    McAuley PA, Beavers KM (2014) Contribution of cardiorespiratory fitness to the Obesity Paradox. Prog Cardiovasc dis: 56:434–440. doi:10.1016/j.pcad.2013.09.006

    Article  Google Scholar 

  60. 60.

    Kurosaki H, Ishii T, Motohashi N, Motegi T, Yamada K, Kudoh S, Jones RCM, Kida K (2009) Extent of emphysema on HRCT affects loss of fat-free mass and fat mass in COPD. Intern Med 48:41–48. doi:10.2169/internalmedicine.48.1102

    Article  PubMed  Google Scholar 

  61. 61.

    Oey IF, Bal S, Spyt TJ, Morgan MDL, Waller DA (2004) The increase in body mass index observed after lung volume reduction may act as surrogate marker of improved health status. Respir Med 98:247–253

    Article  Google Scholar 

  62. 62.

    Zulueta JJ, Wisnivesky JP, Henschke CI, Yip R, Farooqi AO, McCauley DI, Chen M, Libby DM, Smit JP, Pasmantier MW, Yankelevitz DV (2012) Emphysema scores predict death from COPD and lung cancer. 141(5):1216–1223 doi:10.1378/chest.11-0101

  63. 63.

    Oelsner EC, Carr JJ, Enright PL, Hoffman EA, Folsom AR, Kawut SM, Kronmal RA, Lederer DJ, Lima JAC, Lovasi GS, Smith BM, Shea S, Graham Barr R (2016) Per cent emphysema is associated with respiratory and lung cancer mortality in the general population: a cohort study. Thorax 71:624–632. doi:10.1136/thoraxjnl-2015-207822

    Article  PubMed  PubMed Central  Google Scholar 

  64. 64.

    Schols AMWJ, Broekhuizen R, Weiling-Scheepers CA, Wouters EF (2005) Body composition and mortality in chronic obstructive pulmonary disease. Am J Clin Nutr 82:53–59

    CAS  Article  Google Scholar 

  65. 65.

    Marquis K, Debigare R, Lacasse Y et al (2002) Midthigh muscle cross sectional area is a better predictor of mortality than body mass index in patients with chronic obstructive pulmonary disease. Am J Respir Crit Care Med 166:809–813. doi:10.1164/rccm.2107031

    Article  PubMed  Google Scholar 

  66. 66.

    Snijder MB, van Dam RM, Visser M, Seidell JC (2006) What aspects of body fat are particularly hazardous and how do we measure them? Int J Epidemiol 35(1):83–92. doi:10.1093/ije/dyi253

    CAS  Article  PubMed  Google Scholar 

  67. 67.

    Cerhan JR, Moore SC, Jacobs EJ, Kitahara CM, Rosenberg PS, Adami HO et al (2014) A pooled analysis of waist circumference and mortality in 650,000 adults. Mayo Clin Proc 89(3):335–345. doi:10.1016/j.mayocp.2013.11.011

    Article  PubMed  PubMed Central  Google Scholar 

  68. 68.

    Stokes A, Preston SH (2015) Smoking and reverse causation create an obesity paradox in cardiovascular disease. Obesity 23:2485–2490. doi:10.1002/oby.21239

    Article  PubMed  Google Scholar 

  69. 69.

    Lavie CJ, Ventura HO, Milani RV (2008) The “obesity paradox”—is smoking/lung disease the explanation? Chest 134:896–898. doi:10.1378/chest.08-1673

    Article  PubMed  Google Scholar 

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Spelta, F., Fratta Pasini, A.M., Cazzoletti, L. et al. Body weight and mortality in COPD: focus on the obesity paradox. Eat Weight Disord 23, 15–22 (2018). https://doi.org/10.1007/s40519-017-0456-z

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Keywords

  • Overweight
  • Obesity
  • Visceral obesity
  • Obesity paradox
  • Pulmonary function
  • COPD