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Overweight and Obesity Are Risk Factors for COPD Misdiagnosis and OvertreatmentHigh BMI and COPD FREE TO VIEW

Frits M. E. Franssen, MD, PhD
Author and Funding Information

From the CIRO+, Center of Expertise for Chronic Organ Failure, Horn, The Netherlands.

CORRESPONDENCE TO: Frits M. E. Franssen, MD, PhD, Department of Research and Education, CIRO+, Center of Expertise for Chronic Organ Failure, Hornerheide 1, 6085 NM Horn, The Netherlands; e-mail: fritsfranssen@ciro-horn.nl


FINANCIAL/NONFINANCIAL DISCLOSURES: The author has reported to CHEST that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details.


Chest. 2014;146(6):1426-1428. doi:10.1378/chest.14-1308
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Overweight and obesity are major public health problems around the world. Despite global efforts and actions for their prevention and control, the prevalence of these conditions is rising and expected to increase even further in the next decades. Data from the Global Burden of Disease Study 2013 indicated that the number of adults with a BMI ≥ 25 kg/m2 increased from 857 million in 1980 to 2.1 billion in 2013,1 corresponding with 37% of adult men and 38% of adult women. In 2010, high BMI was ranked sixth in the risk factors for global burden of disease, accounting for almost 3.5 million deaths per year.2

The contribution of high BMI to the development of various chronic diseases, including cardiovascular disease, diabetes, osteoarthritis, and several types of malignancies, is well established. In addition, overweight and obesity have a direct effect on respiratory health. Numerous studies have shown a significant dose-dependent relationship between BMI and the incidence of asthma.3 Also, overweight and obesity are important determinants of response to asthma treatment.4 In addition, obesity is the major risk factor for OSA; > 50% of those with OSA are obese.5 Finally, a link between obesity and COPD is increasingly recognized. Although high BMI is generally not regarded as a risk factor for development of COPD, the effects of obesity on outcomes in COPD are increasingly understood. Independent of the severity of chronic airflow limitation, the degree of static lung hyperinflation, indicated by functional residual capacity and residual volume, is decreased in overweight and obese patients with COPD compared with underweight and normal-weight patients.6 Although improved static and dynamic ventilatory mechanics probably result in comparable nonweightbearing exercise limitation in obese and normal-weight patients,7 obese patients with COPD experience a more pronounced limitation during weightbearing activities.8 In patients with mild to moderate COPD, overweight and obesity are associated with increased mortality risk, and in patients with severe disease, an obesity paradox is apparent.9

Although obese subjects with respiratory disease are more symptomatic than normal-weight patients,10 the presence of respiratory symptoms in overweight and obese subjects is not necessarily related to the existence of airways disease. Increasing BMI is associated with enhanced dyspnea on exertion, bronchodilator use, and risk of self-reported respiratory disease in the general population.11 Also, in an exercise laboratory setting it was shown that breathing discomfort is significantly higher at any given submaximal cycle work rate in obese subjects in comparison with healthy age- and sex-matched normal-weight subjects.12 Paradoxically, however, the adjusted risk of objectively identified chronic airflow limitation is lower in people with overweight and obese BMIs than in those with low or normal BMIs.11,13 In middle-aged people without a clinical diagnosis of COPD, obesity was associated with respiratory symptoms, poor health status, and reduced exercise tolerance,13 whereas the presence of airflow limitation was not. Thus, previous data suggested that mechanisms other than airflow obstruction may be responsible for dyspnea genesis in overweight and obesity and that respiratory diseases might be overdiagnosed in the overweight and obese population. This contrasts with data from the general population, where obstructive lung disease commonly remains underdiagnosed and undertreated.14

In this issue of CHEST (see page 1513), Collins and colleagues15 further explore the association between high BMI and COPD management. In a large cohort of male US veterans with a clinical diagnosis of COPD, the authors investigated both the association between BMI and misdiagnosis of COPD as well as the consequences of spirometry results for respiratory pharmacotherapy in different BMI categories. After adjustment for possible confounders, the proportion of subjects with objectified airflow limitation decreased with each BMI category. Although airflow limitation on spirometry was confirmed in approximately 64% of subjects with a clinical diagnosis of COPD, this percentage fell by 10% in overweight and by > 20% in obese subjects with a previous COPD diagnosis. Despite these large percentages of clinical misdiagnosis, overweight and obese subjects were more likely to be treated with inhaled medications. Although 44% of normal-weight subjects without airflow limitation used any inhaled medication, these percentages were 50% and 57% in overweight and obese subjects, respectively.

Probably the most interesting finding in this study is what the investigators observed 9 to 12 months after spirometry showed the absence of airflow limitation. Misdiagnosed overweight and obese subjects were significantly less likely to experience deescalation of therapy or continue not receiving therapy than were misdiagnosed normal-weight subjects. Indeed, > 40% of overweight and obese subjects without spirometric evidence for airflow limitation still were on inhaled medications after almost 1 year and, thus, inappropriately treated. So, in addition to misdiagnosis, overweight and obese subjects are at increased risk for overtreatment with respiratory medications. Not only is this ineffective, potentially harmful, and unnecessarily expensive, it also leaves a large proportion of the population with respiratory symptoms neglected. By treating respiratory symptoms with inhaled medications in the absence of airways disease, health-care professionals are currently missing the opportunity to establish alternative diagnoses and correctly manage respiratory symptoms in overweight and obese people. Importantly, this does not only apply to those professionals dealing with respiratory disease; in subjects with suspected heart failure and preserved left ventricular systolic function, obesity is a common cause of misdiagnosis.16

In the face of the global trend of overweight and obesity, knowledge among health-care professionals about the respiratory consequences of high BMI in both healthy and diseased populations should be increased. First, health-care professions should be aware that high BMI affects respiratory symptoms and function per se.17 Second, they should be trained in diagnosing respiratory disease in populations with increased BMI. Finally, treatments should be adjusted accordingly, and alternative causes of respiratory symptoms should be recognized and managed. For now, based on the results of the study by Collins and colleagues,15 misdiagnosis and overtreatment of COPD should be added to the long list of risk factors associated with overweight and obesity.

References

Ng M, Fleming T, Robinson M, et al. Global, regional, and national prevalence of overweight and obesity in children and adults during 1980-2013: a systematic analysis for the Global Burden of Disease Study 2013. Lancet. 2014;384(9945):766-781. [CrossRef] [PubMed]
 
Lim SS, Vos T, Flaxman AD, et al. A comparative risk assessment of burden of disease and injury attributable to 67 risk factors and risk factor clusters in 21 regions, 1990-2010: a systematic analysis for the Global Burden of Disease Study 2010. Lancet. 2012;380(9859):2224-2260. [CrossRef] [PubMed]
 
Beuther DA, Sutherland ER. Overweight, obesity, and incident asthma: a meta-analysis of prospective epidemiologic studies. Am J Respir Crit Care Med. 2007;175(7):661-666. [CrossRef] [PubMed]
 
Peters-Golden M, Swern A, Bird SS, Hustad CM, Grant E, Edelman JM. Influence of body mass index on the response to asthma controller agents. Eur Respir J. 2006;27(3):495-503. [CrossRef] [PubMed]
 
Crummy F, Piper AJ, Naughton MT. Obesity and the lung: 2. Obesity and sleep-disordered breathing. Thorax. 2008;63(8):738-746. [CrossRef] [PubMed]
 
O’Donnell DE, Deesomchok A, Lam YM, et al. Effects of BMI on static lung volumes in patients with airway obstruction. Chest. 2011;140(2):461-468. [CrossRef] [PubMed]
 
Ora J, Laveneziana P, Ofir D, Deesomchok A, Webb KA, O’Donnell DE. Combined effects of obesity and chronic obstructive pulmonary disease on dyspnea and exercise tolerance. Am J Respir Crit Care Med. 2009;180(10):964-971. [CrossRef] [PubMed]
 
Bautista J, Ehsan M, Normandin E, Zuwallack R, Lahiri B. Physiologic responses during the six minute walk test in obese and non-obese COPD patients. Respir Med. 2011;105(8):1189-1194. [CrossRef] [PubMed]
 
Landbo C, Prescott E, Lange P, Vestbo J, Almdal TP. Prognostic value of nutritional status in chronic obstructive pulmonary disease. Am J Respir Crit Care Med. 1999;160(6):1856-1861. [CrossRef] [PubMed]
 
Cecere LM, Littman AJ, Slatore CG, et al. Obesity and COPD: associated symptoms, health-related quality of life, and medication use. COPD. 2011;8(4):275-284. [CrossRef] [PubMed]
 
Sin DD, Jones RL, Man SF. Obesity is a risk factor for dyspnea but not for airflow obstruction. Arch Intern Med. 2002;162(13):1477-1481. [CrossRef] [PubMed]
 
Ofir D, Laveneziana P, Webb KA, O’Donnell DE. Ventilatory and perceptual responses to cycle exercise in obese women. J Appl Physiol (1985). 2007;102(6):2217-2226. [CrossRef] [PubMed]
 
Zutler M, Singer JP, Omachi TA, et al. Relationship of obesity with respiratory symptoms and decreased functional capacity in adults without established COPD. Prim Care Respir J. 2012;21(2):194-201. [CrossRef] [PubMed]
 
Vanfleteren LE, Franssen FM, Wesseling G, Wouters EF. The prevalence of chronic obstructive pulmonary disease in Maastricht, the Netherlands. Respir Med. 2012;106(6):871-874. [CrossRef] [PubMed]
 
Collins BF, Ramenofsky D, Au DH, Ma J, Uman JE, Feemster LC. The association of weight with the detection of airflow obstruction and inhaled treatment among patients with a clinical diagnosis of COPD. Chest. 2014;146(6):1513-1520.
 
Caruana L, Petrie MC, Davie AP, McMurray JJ. Do patients with suspected heart failure and preserved left ventricular systolic function suffer from “diastolic heart failure” or from misdiagnosis? A prospective descriptive study. BMJ. 2000;321(7255):215-218. [CrossRef] [PubMed]
 
Salome CM, King GG, Berend N. Physiology of obesity and effects on lung function. J Appl Physiol (1985). 2010;108(1):206-211. [CrossRef] [PubMed]
 

Figures

Tables

References

Ng M, Fleming T, Robinson M, et al. Global, regional, and national prevalence of overweight and obesity in children and adults during 1980-2013: a systematic analysis for the Global Burden of Disease Study 2013. Lancet. 2014;384(9945):766-781. [CrossRef] [PubMed]
 
Lim SS, Vos T, Flaxman AD, et al. A comparative risk assessment of burden of disease and injury attributable to 67 risk factors and risk factor clusters in 21 regions, 1990-2010: a systematic analysis for the Global Burden of Disease Study 2010. Lancet. 2012;380(9859):2224-2260. [CrossRef] [PubMed]
 
Beuther DA, Sutherland ER. Overweight, obesity, and incident asthma: a meta-analysis of prospective epidemiologic studies. Am J Respir Crit Care Med. 2007;175(7):661-666. [CrossRef] [PubMed]
 
Peters-Golden M, Swern A, Bird SS, Hustad CM, Grant E, Edelman JM. Influence of body mass index on the response to asthma controller agents. Eur Respir J. 2006;27(3):495-503. [CrossRef] [PubMed]
 
Crummy F, Piper AJ, Naughton MT. Obesity and the lung: 2. Obesity and sleep-disordered breathing. Thorax. 2008;63(8):738-746. [CrossRef] [PubMed]
 
O’Donnell DE, Deesomchok A, Lam YM, et al. Effects of BMI on static lung volumes in patients with airway obstruction. Chest. 2011;140(2):461-468. [CrossRef] [PubMed]
 
Ora J, Laveneziana P, Ofir D, Deesomchok A, Webb KA, O’Donnell DE. Combined effects of obesity and chronic obstructive pulmonary disease on dyspnea and exercise tolerance. Am J Respir Crit Care Med. 2009;180(10):964-971. [CrossRef] [PubMed]
 
Bautista J, Ehsan M, Normandin E, Zuwallack R, Lahiri B. Physiologic responses during the six minute walk test in obese and non-obese COPD patients. Respir Med. 2011;105(8):1189-1194. [CrossRef] [PubMed]
 
Landbo C, Prescott E, Lange P, Vestbo J, Almdal TP. Prognostic value of nutritional status in chronic obstructive pulmonary disease. Am J Respir Crit Care Med. 1999;160(6):1856-1861. [CrossRef] [PubMed]
 
Cecere LM, Littman AJ, Slatore CG, et al. Obesity and COPD: associated symptoms, health-related quality of life, and medication use. COPD. 2011;8(4):275-284. [CrossRef] [PubMed]
 
Sin DD, Jones RL, Man SF. Obesity is a risk factor for dyspnea but not for airflow obstruction. Arch Intern Med. 2002;162(13):1477-1481. [CrossRef] [PubMed]
 
Ofir D, Laveneziana P, Webb KA, O’Donnell DE. Ventilatory and perceptual responses to cycle exercise in obese women. J Appl Physiol (1985). 2007;102(6):2217-2226. [CrossRef] [PubMed]
 
Zutler M, Singer JP, Omachi TA, et al. Relationship of obesity with respiratory symptoms and decreased functional capacity in adults without established COPD. Prim Care Respir J. 2012;21(2):194-201. [CrossRef] [PubMed]
 
Vanfleteren LE, Franssen FM, Wesseling G, Wouters EF. The prevalence of chronic obstructive pulmonary disease in Maastricht, the Netherlands. Respir Med. 2012;106(6):871-874. [CrossRef] [PubMed]
 
Collins BF, Ramenofsky D, Au DH, Ma J, Uman JE, Feemster LC. The association of weight with the detection of airflow obstruction and inhaled treatment among patients with a clinical diagnosis of COPD. Chest. 2014;146(6):1513-1520.
 
Caruana L, Petrie MC, Davie AP, McMurray JJ. Do patients with suspected heart failure and preserved left ventricular systolic function suffer from “diastolic heart failure” or from misdiagnosis? A prospective descriptive study. BMJ. 2000;321(7255):215-218. [CrossRef] [PubMed]
 
Salome CM, King GG, Berend N. Physiology of obesity and effects on lung function. J Appl Physiol (1985). 2010;108(1):206-211. [CrossRef] [PubMed]
 
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