LLL Session - Nutritional support in respiratory diseases

Transcription

1 ESPEN Congress Leipzig 2013 LLL Session - Nutritional support in respiratory diseases Issues related to obesity in COPD F. Franssen (NL)

2 Issues related to obesity in COPD Frits M.E. Franssen, MD, PhD CIRO+, center of expertise for chronic organ failure The Netherlands

3 Conflict of interest disclosure Consultancies, research grants and speaker support: Almirall AstraZeneca GlaxoSmithKline Novartis Takeda

4 Issues related to obesity in COPD: agenda 1) Epidemiology 2) Impact of obesity on clinical outcomes in COPD 3) Role of fat mass in the pathophysiology of COPD

5 Globesity Obesity (BMI > 30 kg m -2 ) is a preventable complex multifactorial chronic condition that develops from an interaction of genotype and the environment The worldwide prevalence of obesity has doubled since 1980, resulting in an estimated number of 500 million obese adults around the world in 2008 Obesity is a major cause of worldwide morbidity and mortality WHO, Global Database on BMI, 2013

6 Prevalence of obesity in COPD The prevalence of obesity in COPD varies across studies, probably as a result of differences in general and COPD specific risk factors for obesity 1 Vozoris et al., Can Respir J 2012; 2 Montes De Oca et al., Respir Med 2008; 3 Steuten et al., Prim Care Respir J 2006; 4 Eisner et al., Respir Res 2007

7 Prevalence of obesity in the Burden of Obstructive Lung Disease (BOLD) initiative (n=13.774) COPD: 18% obese Normal: 23% obese Vanfleteren et al., in preparation

8 Prevalence of obesity in the Burden of Obstructive Lung Disease (BOLD) initiative (n=13.774) NS: Never smokers CS: Current smokers * * Both in normal subjects as well as COPD, lower prevalence of obesity was observed in smokers. COPD subjects were less frequently obese Vanfleteren et al., in preparation

9 Lung function in obesity Obesity Decreased lung compliance Decreased FRC and ERV, preserved TLC and VC Lean Impact on symptoms, lung function and exercise performance in COPD? Obese Franssen et al., Thorax 2008 Gifford et al., Chest 2010

10 Combined effects of obesity and COPD: lung function at rest O Donnell et al., Chest 2011

11 COPD and obesity: symptoms and health status Dyspnea Health status Cecere et al., COPD 2011

12 Dyspnea (Borg scale) Exercise capacity in normal weight and obese COPD patients Obese Normal weight FEV 1 49% FEV 1 49% Ventilation (Liters/min) Obese COPD patients do not experience greater exercise limitation and dyspnea than normal weight patients during peak cycle ergometry. Ora et al., Am J Respir Crit Care Med 2009

13 Operating lung volumes during cycling exercise in normal weight and obese COPD Ora et al., Am J Respir Crit Care Med 2009

14 Walking capacity in normal weight and obese COPD In contrast to cycle ergometry, six minute walking distance is shorter in obese COPD patients compared with non-obese patients. FEV 1 58% FEV 1 52% BMI 26 kg m -2 BMI 37 kg m -2 However, walk-work and physiologic responses to walking were comparable in both groups Bautista et al., Respir Med 2011

15 Obesity and osteoporosis in COPD Overweight and obese COPD patients have a decreased risk of osteoporosis Increased mechanical loading and secretion of bone active hormones (leptin, insulin) may contribute Graat-Verboom et al., Bone 2012

16 Comorbidity clusters in COPD: metabolic cluster Vanfleteren et al., Am J Respir Crit Care Med 2013

17 Combined effects of obesity and COPD: prognosis Schols et al., Am J Respir Crit Care Med 1998

18 All-cause mortality COPD related mortality Combined effects of obesity and COPD: obesity paradox Landbo et al., Am J Respir Crit Care Med 1999

19 Pathophysiology of comorbidities in COPD: hypothesis Fabbri et al., Eur Respir J 2008

20 Persistent systemic inflammation in COPD 30% of patients do not have systemic inflammation, whereas only 16% have persistent systemic inflammation Age, high BMI, current smoking, poor health status and airflow limitation were independent risk factors for persistent systemic inflammation Role of fat mass in pathophysiology? Agusti et al., PloS One 2012

21 Adipocyte dysfunction, systemic inflammation and cardiovascular risk Van Gaal et al., Nature 2006

22 Fat mass contributes to systemic inflammation in COPD Breyer et al., Clin Nutr 2009

23 Obesity and COPD: unanswered questions??? Koehler et al., Int J Cardiol 2007? Franssen et al., Thorax 2008

24 Adipose tissue inflammation in patients with COPD Higher CRP in COPD patients, but: * Comparable adipocyte size * Comparable gene expression * Comparable ATM infiltration * Comparable systemic adipokines van den Borst et al., Am J Clin Nutr 2011

25 Excessive visceral fat accumulation in COPD Age, sex and BMI matched Visceral fat Subcutaneous fat van den Borst et al., Am J Respir Crit Care Med 2013

26 Common link between inflammatory activity of visceral fat and the abdominal aorta in COPD Max: 0.5 SUV Mean: 0.4 SUV Diameter: 10.0 mm Max: 0.3 SUV Mean: 0.2 SUV Diameter: 10.0 mm Max: 1.6 SUV Mean: 1.3 SUV Diameter: 16.7 mm Inflammatory activity of visceral fat and abdominal aorta, measured by 18FDG-PET-scanning, was increased in COPD compared to non-copd, while subcutaneous fat inflammation was comparable Vanfleteren et al., submitted

27 WHY? Management of obesity in COPD HOW? CV risk factors? VLCD? Comorbidities? Activity? Symptoms? Behavior? Performance? Surgery? Mortality? Drugs?

28 Multidimensional treatment of adult obesity Pharmacotherapy Dietary therapy Surgery Behavioral modification (including smoking cessation) Physical activity Role for pulmonary rehabilitation!? Expert Panel on the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults, National Institute of Health, 1998

29 The impact of obesity on response to pulmonary rehabilitation in COPD Obesity and overweight do not influence the magnitude of improvement after pulmonary rehabilitation Sava et al., BMC Pulm Med 2010

30 Issues related to obesity in COPD: summary 1) The number of COPD patients with obesity is expected to increase, in line with the obesity pandemic 2) For accurate clinical assessment and disease management it is essential to understand the effects of excessive fat mass in patients in which COPD and obesity collide 3) Contrary to expectations, obesity is not necessarily associated with worse patient-related outcomes in COPD 4) The role of adipose tissue dysfunction in COPD pathophysiology and increased cardiovascular risk is a hot research topic. 5) The effects of weight loss and the optimal BMI for obese patients with COPD are currently unkwown. fritsfranssen@ciro-horn.nl