Prevalence and characteristics of nutritional depletion were established by body composition measurements in 255 COPD patients in stable clinical condition admitted to a pulmonary rehabilitation center. Depletion of body weight, fat-free mass (using bioelectrical resistance measurements), and muscle mass [from creatinine height index (CHI) and midarm muscle circumference] was most pronounced (40 to 50%) in patients suffering from chronic hypoxemia and in normoxemic patients with severe airflow obstruction (FEV1 < 35%) but also occurred in +/- 25% of patients with moderate airflow obstruction. Classification of the patients in four groups by body weight and fat-free mass revealed that depletion of fat-free mass may occur in normal-weight COPD patients (Group 3). These patients also exhibit a decreased CHI (61 +/- 21%, mean +/- SD) and suffer from physical impairment (12-min walking distance, WD, 532 +/- 152 m) to an even greater degree than underweight patients with relative preservation of fat-free mass (Group 2) (CHI = 73 +/- 16%; WD = 744 +/- 233 m). No systematic differences were established between the four groups in serum protein concentrations or medication use. We conclude that fat-free mass is a better indicator of body mass depletion than body weight. Classification of COPD patients by body weight and fat-free mass may have consequences for planning and interpretation of intervention strategies, particularly in Group 2 and 3 patients.

Nutritional depletion commonly occurs in patients with COPD, causing muscle wasting and impaired physiologic function. Two hundred seventeen patients with COPD participated in a placebo-controlled, randomized trial investigating the physiologic effects of nutritional intervention alone (N) for 8 wk or combined with the anabolic steroid nandrolone decanoate (N + A). Nandrolone decanoate or placebo (P) was injected intramuscularly (women, 25 mg; men, 50 mg) in a double-blind fashion on Days 1, 15, 29, and 43. Nutritional intervention consisted of a daily high caloric supplement (420 kcal; 200 ml). Also, all patients participated in an exercise program. In the depleted patients, both treatment regimens induced a similar significant body weight gain (2.6 kg) but different body compositional changes. Particularly in the last 4 wk of treatment, weight gain in the N group was predominantly due to an expansion of fat mass (p < 0.03 versus P and N + A), whereas the relative changes in fat-free mass (FFM) and other measures of muscle mass were more favorable in the N + A group (p < 0.03 versus P). Maximal inspiratory mouth pressure improved within both treatment groups in the first 4 wk of treatment, but after 8 wk only N + A was significantly different from P (p < 0.03). Nutritional supplementation in combination with a short course of anabolic steroids may enhance the gain in FFM and respiratory muscle function in depleted patients with COPD without causing adverse side effects.

The relationship between tissue depletion and decreased exercise performance has been well established in patients with COPD. In this study we investigated the influence of the pattern of tissue depletion on health related quality of life (HRQL) and their mutual relationship with exercise capacity and dyspnoea. Patients with low body weight and/or low fat-free mass (FFM; using bioelectrical impedance) were categorized in three groups according to type of tissue depletion: loss of both FFM and fat mass (FM), and loss of FFM or FM only. Handgrip strength (HGS) was used as a functional outcome measure of tissue depletion. Exercise performance was assessed by 12 min walking distance (12MWD) and dyspnoea by visual analogue scale (VAS). HRQL was measured with the St George's Respiratory Questionnaire (SGRQ) and the Medical Psychological Questionnaire for Lung diseases (MPQL). Patients with depletion of FFM irrespective of body weight showed greater impairment in 12MWD, HGS, the 'activity' and 'impact' scores of the SGRQ and the domain 'invalidity' of the MPQL, in comparison with depleted patients with relative preservation of FFM. Exercise performance and dyspnoea were also significantly related to these subscores of HRQL. In addition, dyspnoea related significantly to the domain 'symptoms' of the SGRQ. Tissue depletion pattern remained significantly related to SGRQ-scores and the domain 'invalidity' of the MPQL when dyspnoea and walking distance were added to the model as a covariates. Tissue depletion is an important determinant of HRQL independent of exercise capacity and dyspnoea.

Background -The consequences of chronic obstructive pulmonary disease (COPD) on daily life, encapsulated by the term "health-related quality of life" (HRQL), are important in determining appropriate home care. There is a need to understand the relative contribution of respiratory impairment, physical disability, coping, age, and socioeconomic variables on HRQL. Methods -Patients with COPD were recruited on admission to a pulmonary rehabilitation centre. Respiratory impairment was assessed by lung function tests and physical disability was evaluated by a 12 minute walking test. HRQL was assessed by means of the St George's Respiratory Questionnaire (SGRQ) measuring "symptoms", "activity", and "impact". Because the SGRQ does not include a measure of "well being", this was taken from the medical psychological questionnaire for lung diseases. The COPD coping questionnaire and a questionnaire covering basic socioeconomic variables were also used. Results -One hundred and twenty six patients of mean (SD) age 65 (9) years and mean (SD) forced expiratory volume in one second (FEVy) 39 (9)% predicted were included. The scores on the SGRQ indicated severe impairment. Correlations were found between lung function parameters, 12 minute walking test, and the HRQL "activity" and "impact" components. Coping strategies were correlated with the "activity", "impact", and "well being" components. No correlations were found between age, socioeconomic variables, and HRQL. FEV1, 12 minute walking test, and the coping strategies "avoidance" and "emotional reaction" were the best predictors of HRQL. Conclusion -In patients with COPD methods of improving physical performance and teaching adequate coping strategies should be considered in order to improve HRQL.

aaAmong the overall pattern of functional impairment in patients with chronic obstructive pulmonary disease (COPD), limitation of peak exercise capacity is an essential feature, which can be accurately determined by incremental cycle ergometry [1]. The impaired exercise capacity in COPD patients has long been ascribed to an impaired ventilatory capacity due to disturbed pulmonary mechanics, respiratory muscle dysfunctioning, impaired gas exchange and cardiovascular dysfunctioning. Recent publications have drawn attention to peripheral muscle weakness and an altered muscle energy metabolism as contributing factors to impaired exercise capacity [2,3]. Muscle strength and metabolism are closely related to body composition [4]. It could be hypothesized that the association between peripheral muscle weakness and alterations in muscle metabolism with exercise impairment is partly related to depletion of muscle mass.Muscle mass is the largest constituent of the body cell mass (BCM), the energy-exchanging part of the body. The BCM and the extracellular fluids and solids of the body represent the fat-free mass (FFM). Direct measurement of muscle mass, for instance by magnetic resonance imaging, requires expensive, sophisticated instrumentation, that is not readily accessible [5]. Dilution methods are the next most accurate methods in the hierarchy of body composition methods [5] that can be applied to estimate muscle mass, by the assessment of FFM. The additional value of measurement of FFM instead of body weight in the functional characterization of patients with COPD was demonstrated in an earlier study which showed that FFM correlated stronger with the 12 min walking distance than body weight [6]. In addition, in this previous study it was found that normal weight patients with a selective loss of FFM expressed a lower walking distance than underweight patients with a relative preservation of FFM [6].In a recent study it was shown, however, that measurement of FFM may mask the loss of BCM in some COPD patients [7]. From this study it was hypothesized that subtle changes in the BCM can be estimated by the extracellular water (ECW)/intracellular water (ICW) ratio, and it was found that an increased ECW/ICW ratio may occur particularly in patients with severe FFM depletion [7]. Peak exercise response in relation to tissue depletion in patients with chronic obstructive pulmonary disease. E.M. Baarends, A.M.W.J. Schols, R. Mostert, E.F.M. Wouters. ERS Journals Ltd 1997.ABSTRACT: In several studies a correlation between body weight and peak exercise capacity has been found in patients with chronic obstructive pulmonary disease (COPD). In the present study a thorough analysis of the relationship between body composition and peak exercise performance was executed in 62 patients with clinically stable COPD. This was based on the hypothesis that particularly muscle mass, as the largest constituent of both fat-free mass (FFM) and body cell mass, is related to exercise capacity.Body composition was assessed using deuterium and b...