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Original Article

Association body mass index and spirometric lung function

in chronic obstructive pulmonary disease (COPD) patients
attending RIMS Hospital, Manipur
Awungshi Jannie Shimray, Wangkheimayum Kanan, Wangkheimayum Asoka Singh1, Ashem Nandarani Devi,
Kanmi Ningshen, Ranjita Laishram
Departments of Physiology and 1Respiratory Medicine, Regional Institute of Medical Sciences, Imphal, Manipur, India

Abstract
Background: Weight loss is highly prevalent in chronic obstructive pulmonary disease (COPD) patients and studies
have consistently shown significantly greater mortality rates in underweight and normal-weight COPD patients with
than in overweight and obese COPD patients.Objective: To study association between mass index (BMI) and severity
of COPD as assessed by spirometric lung function tests.Materials and Methods: 50 patients with COPD (25 women and
25 men), ages ranging from 40 to 65 years attending OPD and ward of Department of Respiratory Medicine, RIMS were
included in the study. This preliminary study was conducted in the Department of Physiology, RIMS. Lung function was
measured with Computerized Spirometer Helios 701 (Recorders and Medicare System, Chandigarh). Body mass index
was calculated and related to recently developed reference values. Statistical analysis was performed using SPSS version
16.0 Independent t-tests and Pearson’s correlation coefficient was used.Results: Mean body weight values were 59.66 ±
13.10 kg and 42.54 ± 2 kg, and BMI values were 21.75 ± 3.33 and 19.10 ± 1.0788 in males and females, respectively.33.3% of
the patients had malnutrition and their flow parameters were found to be lower as compared to well-nourished subjects.
FVC, FEV1 and FEV1% predicted were all positively correlated to low BMI.Conclusions: Low BMI is prevalent in COPD
patients. Inclusion of BMI in assessment of COPD severity in addition to measurement of FEV1 is supported.
Key Words: Body mass index, chronic obstructive pulmonary disease (COPD), lung function

INTRODUCTION and the indicator used to determine the nutritional

Chronic obstructive pulmonary disease (COPD)
is a preventable and treatable disease with some
significant extra pulmonary effects that may contribute
to the severity in individual patients. Its pulmonary
component is characterized by airflow limitation that
is not fully reversible. The airflow obstruction is usually
both progressive and associated with an abnormal
inflammatory response of the lungs to noxious particles
and gas.[1] It is a major cause of chronic morbidity and
mortality throughout the world and is currently the fourth
leading cause of death.[2] Patients with COPD often
lose weight and, depending on the population studied
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DOI: 10.4103/0972-4958.148498
status, between 19 and 60% of patients are classified as
malnourished.[3] The clinical deterioration associated
with weight loss leads to deterioration in the quality of
life in many patients with COPD.[4]The pathogenesis of
body wasting in subjects withchronic diseases like COPD
is unclear. However, increases in the work of breathing
and respiratory muscle activity increase resting energy
expenditure by as much as 50 to 100% above normal. In
normal subjects in whom basal energy requirements are
similarly increased by heavy physical labor, caloric intake
is increased appropriately to meet metabolic demands
and body weight is preserved. Accordingly, the root of
the problem in undernourished patients with COPD may
be “relative anorexia,” so that increases in basal caloric
requirements are not accompanied by adequate caloric
intake. Undernourished patients with COPD have higher
blood levels of the cachexia factor tumor necrosis factor-α
(TNF-α) than well-nourished COPD subjects.[5]
Survival studies in selected groups of patients with
chronic obstructive pulmonary obstruction (COPD)
and in population based studies have consistently

Address for correspondence: Dr. Awungshi Jannie Shimray, Department of Physiology, Regional Institute of Medical Sciences, Imphal, Manipur, India.
E-mail: shimray.jannie@gmail.com

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Shimray, et al.: Association between body mass index and spirometric lung function in COPD
shown higher COPD-related mortality rates in
underweight and normal-weight patients than in
overweight and even obese patients.[6-8]Undernutrition,
is extremely common in patients with COPD,
occurring in about 25% of stable outpatients and
about 40% of hospitalized patients.[5]Undernutrition is
an independent risk factor for mortality.[5]For a given
level of lung function, undernourished patients with
COPD have a greater 5-year mortality than normally
nourished subjects.[5]
Contemporarily, the diagnosis and classification of
chronic obstructive pulmonary disease (COPD) is based
onspirometric assessment only.[9] Weight loss is a poor
prognosticfactor and interestingly it is independent of
other traditional indices such as the volume of air exhaled
in the first second of a forced spirometric manoeuvre
(FEV1) or the arterial partial pressure of oxygen.[8]
Therefore, weight loss identifies the systemic domain of
COPD that needs to be taken into consideration in their
clinical management.[10]In this context, Celli, et al. have
recently proposeda composite index (BODE index) that
includes body weight (assessed by BMI), the degree of
airflow obstruction (assessed by the FEV1 value expressed
as percentage of the reference value), and the level of
dyspnoea experienced by the patient and their exercise
capacity that predicts survival much more accurately than
FEV1 alone.[11]
Therefore, this study was conducted to investigate the
co-existence of low BMI and airflow obstruction, and if
so, whether it is associated with the grade of severity in a
population of COPD patients.
MATERIALS AND METHODS
A cross sectional study constituting 50 COPD patients
between the age range of 40-65 years who attended
Respiratory Medicine OPD (Out Patient Department)
and Respiratory Medicine Ward of Regional Institute
of Medical Sciences (RIMS), Imphal were included in
the study. Institutional Ethics Committee approved the
research study and patients gave their informed consent
to participate in the study.
Patients with associated cardiac problems, renal failure,
diabetes mellitus, hypertension, pulmonary fibrosis,
neuromuscular diseases and ascites were excluded. Lung
function was measured with Computerized Spirometer
Helios 701 (Recorders and Medicare System, Chandigarh)
in the Department of Physiology, RIMS.
The study variables which include Forced Vital Capacity
(FVC), Forced Expiratory Volume in one second (FEV1),
FEV1% predicted and FEV1/FVC were recorded by
spirometry. Severity of COPD was graded according to
GOLD classification.[12]
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Demographic history such as age, sex and so on was
recorded. The occupational and smoking history (past
and present) was also recorded. Subjects were classified
according to smoking status as 1, Current smokers who
have smoked regularly with 1 month prior to examination
and 2, Ex-smokers who have stopped more than 1 month
prior to examination. Pack years were calculated from the
average number of cigarettes smoked per day in a year,
one pack year being smoking of 20 cigarettes per day for
1 year.
CALCULATING PACK YEARS OF SMOKING
20 cigarettes = 1 packet pack years of smoking =
(Number of cigarettes smoked per day × no of years of
smoking)/20 for example, a smoker of 10 cigarettes a day
who has smoked for 15 years would have smoked: (10 ×
15)/20 = 7.5 pack years.
Quantification of pack-years smoked is important
in clinical care, where degree of tobacco exposure is
correlated to risk of disease.[13]Pack years of smoking being
a key predictive factor in the development of COPD is
well supported by numerous studies.[14]
All the patients were assessed for height, body
weight (BW), Body mass index (BMI) and BW and
height were measured with indoor clothing without
shoes. Measurements were compared with standard
recommended by World Health Organization.[15] BMI
was calculated by the formulae given as weight (kg)
divided by height in metre2 (m). BMI was categorized
as underweight (<18.5 kg/m2), normal weight
(18.5-24.9 kg/m2), overweight (25.0-29.9 kg/m2), and
obese ( ≥30.0 kg/m2). Statistical analysis was performed
using SPSS version 16.0. Independent t-test was used to
compare values during the study. Pearson’s correlation
coefficient was applied to the correlation of nutritional
status and lung function. P-value of less than 0.05 was
considered to be significant.
RESULTS
Demographic description of total group is shown in
Table 1. Fifty patients (mean age 57.19 ± 11.01; Male/
Female = 25/25) were evaluated. All patients were
smokers. Smoking history of the subject showed 14.58%
to be former smoker and 85.2% current smoker.
Table 2 presents the descriptive statistics of nutritional
variables in both the sexes. Mean body weight for males
was 59.67 ± 13.10 kg and females were 42.54 ± 2.89 kg.
Lung function test according to the gender is shown in
Table 3. Spirometry of the subjects revealed low FEV1%
predicted values, which are 69.04 ± 25.06 and 59.32 ±
28.11 in males and females, respectively. This shows that
all the subjects were moderately deteriorated.
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Shimray, et al.: Association between body mass index and spirometric lung function in COPD

Table 1: Demographic profile of patients

Total Male Female
Age in years (Mean ± SD) 57.19±11.01 57±10.70 59.33±6.60
Male/Female ratio 25/25
Smoking history N (%) Current smokers 41 (85.2) 21 20
Ex-smokers 7(14.58) 4 5
Pack year (Mean ± SD) 27.70±12.24 29.91±17.56 24.80±20

Out of 50 patients of the study population, N = 27 had Table 2: Nutritional profile among males
BMI ≥18.5 while N = 23 had BMI <18.5 as shown in and females (N = 50)
Table 4a. The table also shows that patients with normal Anthropometry Males Females
BMI have better lung functions and higher flow rates and (Mean ± S.D) (Mean ± S.D)
these findings are statistically significant for FVC, FEV1
Weight (kg) 59.66±13.10 42.54±2.88
and FEV1% predicted. Height (cm) 164.95±7.20 149.20±5.06
So, to determine if there was a relationship between BMI (kg/m2) 21.75±3.33 19.10±1.07
poor nutrition and airway obstruction in the subjects
studied, the flow rates were correlated with BMI, as
Table 3: Lung function tests among males
shown in Table 4b. TheFVC, FEV1 and FEV1% predicted
and females (N = 50)
are strongly correlated with BMI with high statistical
significance (r = 0.600, P = 0.000; r = 0.517, P = 0.000; Lung function Males (N = 25) Females (N = 25)
r = 0.433, P = 0.002, respectively). No statistically parameters
significant correlation was found between body weight FVC (L) 1.85±0.78 1.20±0.55
and FEV1/FVC% (r = 0.033, P = 0.826). FVC (%pred) 60.29±21.29 53.19±23.12
FEV1 (L) 1.61±0.74 1.05±0.68
Table 5 shows the comparison of spirometric parameters
FEV1 (%pred) 69.04±25.06 59.32±28.11
between ex-smokers and present smokers. There is no FEV1/FVC 0.98±0.22 1.37±2.85
significant difference between the two groups. EV1/FVC (% pred) 72.59±3.32 60±45.22

DISCUSSION
COPD is defined functionally by a decrease in
maximal expiratory flow from the lung. The influence
of the BMI on different epidemiologic and functional
aspects of COPD has become an area of increasing
research during the last decade. Several studies have
documented a clear association between low BMI
with poor prognosis and mortality in patients with
established COPD.[7,9,16-18]
In the present study we have taken 50 diagnosed
cases of COPD and recorded flow rates by spirometry.
We found that out of the total number ofsubjects
(n = 50) 33.3% were malnourished (BMI<18.5) and the
rest of the subjects were well-nourished(BMI ≥18.8).
The malnourished subjects had mean FEV1 and FEV1%
predicted values of 0.89 ± 0.62 and 50.71 ± 26.02,
respectively, which was lower as compared to 1.55 ± 0.74
and 70.91 ± 24.9 as found in well-nourished patients.
FEV1/FVC was also found to be lower in malnourished
subjects. This finding suggests that subjects with low
BMI have more severe lung disease based on FVC,
FEV1and FEV1% predicted values.
Table 4b shows correlation values of expiratory flow
rates with BMI. FVC, FEV1 and FEV1 % predicted are
strongly correlated with BMI with P-value <0.005. This
finding implies that expiratory flow rates increase with
increase in BMI, and BMI reflects the nutritional status
of the patients. However correlation between FEV1/FVC
and BMI is not statistically significant. It is not known
whether poor lung function is a cause of poor nutritional
status or if poor nutritional status precipitates a decline
in lung function results. Malnutrition may be deleterious
in COPD patients due to decreased respiratory muscle
mass and muscle strength; poor wound healing; decreased
cell immunity and decreased ventilatory response to
hypoxia.[18] This will increase the predisposition to
respiratory failure. It is therefore important to be aware of
this problem and respond quickly by providing nutritional
support to the malnourished subjects with COPD.
Refeeding malnourished COPD patients has been
shown to improve both immune function and muscle
function.[19] Substantial number of COPD patients are
underweight.[3]Schols, et al. investigated factors affecting
survival in patients with COPD.[20] They found that
body weight has an independent effect on survival in
COPD which could not be explained by lung function.
Because BMI has been shown to correlate with mortality
in COPD patients,[19] Low BMI should be considered a
great risk of mortality. Our study also reports low values

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Table 4a: Flow parameters according to malnutrition status

Flow parameters BMI
≥18.5 (21.69 ± 2.64) N = 27 <18.5 (17.90 ± 0.40) N =23 P-value
FVC (L) 1.76±0.75 1.05±0.46 0.001
FVC (% pred) 71.3±10.46 60.11±25.8 0.002
FEV1 (L) 1.55±0.74 0.89±0.62 0.005
FEV1 (% pred) 70.91±24.9 50.71±26.02 0.014
FEV1/FVC 1.37±2.46 0.81±0.26 0.392
FEV1/FVC (% pred) 72.58±28.43 59±20.2 0.026

Table 4b: Flow parameters and BMI correlation considered while interpreting the results of the study.
Flow parameters BMI
The present study is limited by relatively smaller number
of patients. For further investigations larger sample size
r (Pearson) P-value and a prospective study in various populations would
FVC (L) 0.600 0.000 yield more significant results.
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How to cite this article: Shimray AJ, Kanan W, Singh WA,
Devi AN, Ningshen K, Laishram R. Association body mass index
and spirometric lung function in chronic obstructive pulmonary
disease (COPD) patients attending RIMS Hospital, Manipur. J Med
Soc 2014;28:157-61.
Source of Support: Nil, Conflict of Interest: None.
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