Research

Body size and physical activity in relation to incidence of chronic obstructive pulmonary disease

Gundula Behrens, Charles E. Matthews, Steven C. Moore, Albert R. Hollenbeck and Michael F. Leitzmann
CMAJ September 02, 2014 186 (12) E457-E469; DOI: https://doi.org/10.1503/cmaj.140025

Abstract

Background: Limited evidence suggests that adiposity and lack of physical activity may increase the risk of chronic obstructive pulmonary disease (COPD). We investigated the relation of body size and physical activity with incidence of COPD.

Methods: We obtained data on anthropometric measurements and physical activity from 113 279 participants in the National Institutes of Health–AARP Diet and Health Study who reported no diagnosis of COPD at baseline (1995–1996). We estimated associations between these measurements and subsequent diagnosis of COPD between 1996 and 2006, with extensive adjustment for smoking and other potentially confounding variables.

Results: Participants reported 3648 new COPD diagnoses during follow-up. The incidence of COPD was higher in both severely obese (body mass index [BMI]D≥ 35) and underweight (BMID< 18.5) participants, but after adjustment for waist circumference, only underweight remained positively associated with COPD (relative risk [RR]D1.56, 95% confidence interval [CI]D1.15–2.11). Larger waist circumference (highest v. normal categories, adjusted RRD1.72, 95% CID1.37–2.16) and higher waist–hip ratio (highest v. normal categories, adjusted RRD1.46, 95% CID1.23–1.73) were also positively associated with COPD. In contrast, hip circumference (highest v. normal categories, adjusted RR 0.78, 95% CI 0.62–0.98) and physical activity (≥ 5 v. 0 times/wk, adjusted RRD0.71, 95% CID0.63–0.79) were inversely associated with COPD.

Interpretation: Obesity, in particular abdominal adiposity, was associated with an increased risk of COPD, and increased hip circumference and physical activity were associated with a decreased risk of COPD. These findings suggest that following guidelines for a healthy body weight, body shape and physical activity decrease the risk of COPD.

Chronic obstructive pulmonary disease (COPD) is a progressive, irreversible condition that severely affects quality of life1 and ability to work.2 Direct and indirect annual costs of COPD, including inpatient and outpatient care, medication and loss of productivity, sum to $50 billion in the United States3 and R39 billion (about US$50 billion) in Europe.4

Chronic obstructive pulmonary disease may be prevented by avoidance of tobacco smoke, occupational dust and other environmental air pollution.5 Body mass index (BMI) and physical activity are established correlates of disease progression among patients with COPD,6,7 but data relating body size or physical activity to incident COPD are sparse. The few studies available are based on small samples and show inverse relations of both BMI8,9 and physical activity10,11 to incidence of COPD. Data are lacking regarding waist or hip circumference in relation to COPD incidence. We therefore examined BMI, waist circumference, hip circumference, waist–hip ratio and physical activity in relation to incidence of COPD in a large cohort of women and men in the US.

Methods

Study cohort and follow-up

The National Institutes of Health (NIH)–AARP Diet and Health Study12 was originally designed to prospectively investigate dietary and lifestyle factors in relation to the development of cancer in a large US cohort of men and women aged 50 to 70 years at baseline in 1995–1996. Participants were recruited from among members of the AARP in 6 states (California, Florida, Pennsylvania, New Jersey, North Carolina and Louisiana) and 2 metropolitan areas (Atlanta, Georgia, and Detroit, Michigan). The NIH-AARP Diet and Health Study involved a large number of AARP members and cancer registries certified to have at least 90% completeness of case ascertainment. The study also included both rural and metropolitan areas, and geographic areas with large minority populations. The 3.5 million members who were invited to participate were sampled uniformly from the age distribution of 50 to 70 years. A total of 566 398 AARP members joined the study by returning a 16-page baseline questionnaire (available at http://dietandhealth.cancer.gov/resource) in 1995–1996, thereby expressing informed consent. Of those, 334 894 participants replied to a second questionnaire (available at http://dietandhealth.cancer.gov/resource) sent 6 months later to all respondents of the baseline questionnaire. A follow-up questionnaire (available at http://dietandhealth.cancer.gov/resource) was sent between 2004 and 2006 to all 475 297 nondeceased participants who had completed the baseline questionnaire and was completed by 318 449 participants.

Our analytic cohort comprised 113 279 participants who reported no history of COPD, cancer or heart disease at baseline, and who provided complete self-reported information on anthropometric measurements, physical activity, smoking and COPD incidence during follow-up. The distributions of age, sex and ethnicity of the analytic cohort are comparable to those of the overall cohort of the NIH-AARP Diet and Health Study (Appendix 1, available at www.cmaj.ca/lookup/suppl/doi:10.1503/cmaj.140025/-/DC1). However, because a history of COPD, cancer or heart disease is positively associated with adiposity, current smoking and low socioeconomic status, the analytic cohort had an anticipated slightly lower average BMI, a greater proportion of people who had never smoked and a great proportion of people who had completed postgraduate education than the overall cohort. Cohort follow-up, as estimated by the comprehensiveness of cancer and mortality ascertainment, is more than 93% complete.13,14

Ethics

The NIH-AARP Diet and Health Study was approved by the Special Studies Institutional Review Board of the US National Cancer Institute.

Assessment of anthropometric measurements and physical activity

Participants were instructed to measure their weight, height, and waist and hip circumferences. Anthropometric information from self-reported measurements is valid.15,16

We defined BMI categories according to the World Health Organization (WHO) classification,17 and waist circumference categories according to the classifications proposed by Lean and colleagues18 and the WHO.19 We used the second lowest categories of BMI, waist circumference, hip circumference and waist–hip ratio as reference groups. The physical activity variable was based on validated self-reports20 of frequency of vigorous physical activity at home or work, or for exercise.

Ascertainment of COPD cases

Participants indicated incidence of COPD between 1996 and 2006 using self-reported questionnaires. Self-reported COPD diagnoses are highly specific, although they tend to underascertain cases.21,22

Statistical analysis

We investigated BMI, waist and hip circumferences, waist–hip ratio and physical activity in relation to COPD incidence using relative risks (RRs) estimated as odds ratios and 95% confidence intervals (CIs) obtained from multivariable logistic regression, with additional adjustment for age, sex, marital status, education, ethnicity, alcohol intake, smoking status, smoking intensity, history of type 2 diabetes mellitus and height. Effect modification was assessed by likelihood-ratio tests. All p values correspond to 2-sided tests at the 5% significance level.

Results

Distribution of risk factors at baseline

Participants whose BMI, waist circumference, waist–hip ratio or physical activity levels fell within the recommended categories tended to have a higher level of education than those whose levels did not meet recommended guidelines. In addition, BMI was inversely associated with never having smoked and current smoking, whereas it was positively related to past smoking. In contrast, participants who met the recommendations for waist circumference were slightly more likely to currently smoke than those who did not meet the recommendations (Table 1).

View this table:
Table 1:

Age-standardized* baseline characteristics by body mass index, waist circumference, hip circumference, waist–hip ratio and vigorous physical activity (NIH-AARP Diet and Health Study, 1995–1996)

Multivariate analyses of anthropometric measurements and physical activity in relation to COPD

Overweight and class 1 obesity were unrelated to COPD (Table 2). However, class 2 to 3 obesity (RR 1.36, 95% CI 1.13–1.63) and underweight (RR 1.50, 95% CI 1.12–2.03) were positively associated with COPD. Additional adjustment for waist circumference attenuated COPD risk in the top BMI category and created inverse associations in the 2 intermediate BMI categories.

View this table:
Table 2:

Relative risk of chronic obstructive pulmonary disease in relation to body mass index, waist circumference, hip circumference, waist–hip ratio and physical activity (NIH-AARP Diet and Health Study, 1996–2006)

The highest waist circumference had a positive association with COPD both before (RR 1.47, 95% CI 1.23–1.75) and after (RR 1.55, 95% CI 1.25–1.92) adjustment for BMI (Table 2). The relation strengthened after additional adjustment for hip circumference (RR 1.72, 95% CI 1.37–2.16). In contrast, the group with the lowest waist circumference showed no association with COPD. The highest hip circumference had an inverse relation to COPD (RR 0.78, 95% CI 0.62–0.98). A positive association was observed between high waist–hip ratio and COPD (RR 1.46, 95% CI 1.23–1.73). A high level of physical activity was associated with a decreased risk of COPD (RR 0.71, 95% CI 0.63–0.79). These relations remained materially unchanged after exclusion of the first 5 years of follow-up (data not shown).

Multivariate analyses stratified by sex, ethnicity, education and smoking status

Sex did not modify the relations of BMI (pinteraction = 0.07), waist circumference (pinteraction = 0.6), waist–hip ratio (pinteraction = 0.5) or physical activity (pinteraction = 0.3) to COPD. In contrast, the relation of hip circumference to COPD was more pronounced among women than men. The RRs for increasing hip circumference categories in women were 1.76, 1.0 (ref.), 0.98, 0.92 and 0.67. The corresponding values in men were 1.07, 1.0 (ref.), 0.73, 0.77 and 0.80 (pinteraction = 0.008). The relations of BMI, body shape and physical activity to COPD did not vary by ethnicity or educational achievement (all pinteraction ≥ 0.1).

Smoking significantly modified the associations of BMI, waist circumference, hip circumference and waist–hip ratio (all pinteraction ≤ 0.01), but not physical activity (pinteraction = 0.7) with COPD (Table 3).

View this table:
Table 3:

Multivariate-adjusted* relative risk of chronic obstructive pulmonary disease in relation to body mass index, waist circumference, hip circumference, waist–hip ratio and physical activity, stratified by smoking status (NIH-AARP Diet and Health Study, 1996–2006)

Significant positive associations between BMI and COPD were seen among participants who had never smoked (ptrend < 0.001) and those who had smoked in the distant past (ptrend = 0.02), but not among participants who had smoked in the recent past (ptrend = 0.3) or those who currently smoked (ptrend = 0.4). Underweight was significantly associated with COPD only among participants who had never smoked. After additional adjustment for waist circumference, the risk estimates for high BMI in relation to COPD were decreased in all smoking strata, and BMI was inversely associated with COPD among those who had smoked in the recent past (ptrend < 0.001).

Waist circumference showed significant positive associations with COPD in all smoking strata. In contrast, the inverse relation of hip circumference to COPD was apparent only among those who had smoked in the recent past (ptrend = 0.001) and who currently smoked (ptrend = 0.02). Low hip circumference was positively associated with COPD among those who had smoked in the distant past. Waist–hip ratio was positively associated with COPD in all smoking groups. Physical activity was inversely related to COPD in all smoking strata, although the association was not significant among those who had never smoked (ptrend = 0.07), particularly after adjustment for waist circumference (ptrend = 0.3).

Multivariate analyses of the combination of BMI and waist circumference by smoking status

In the entire analytic cohort, the risk of COPD was increased among overweight or obese participants only if they had a large waist circumference (Table 4). That pattern was particularly evident among those who had never smoked and, to a certain degree, among those who had smoked in the distant past. The pattern was not apparent among participants who had smoked in the recent past or who currently smoked (pinteraction < 0.001).

View this table:
Table 4:

Multivariate-adjusted* relative risk of chronic obstructive pulmonary disease in relation to combinations of body mass index, waist circumference and physical activity in the entire analytic cohort and stratified by smoking status (NIH-AARP Diet and Health Study, 1996–2006)

We further stratified the joint analyses of BMI and waist circumference by level of physical activity (Table 4). Among those who had never smoked, the previously observed pattern of increased COPD risk among overweight and obese participants with a large waist circumference was seen both for those with high and low levels of physical activity. Smoking status affected the joint relations of BMI and waist circumference more strongly among those with a high level of physical activity (pinteraction = 0.004) than among those with a low level of physical activity (pinteraction = 0.06).

Interpretation

The primary findings from this large, prospective study of middle-aged to older women and men in the US are that total and abdominal obesity were associated with an increased risk of COPD. Participants with a large waist circumference (≥ 110 cm in women or ≥ 118 cm in men) had a 72% increased risk of COPD. A secondary finding is that underweight was related to a 56% increased risk of COPD. In contrast, increased hip circumference and physical activity were associated with a decrease in COPD risk by up to 29%.

Data have been lacking regarding the relations of waist circumference, hip circumference and waist–hip ratio to COPD incidence. One cohort study23 of visceral fat and respiratory function did not exclude patients with COPD at baseline, so the relation of visceral fat to COPD incidence could not be established. Another cohort study24 observed that a decline in respiratory function during follow-up was associated with a gain in visceral fat mass during follow-up but was not able to discern whether the gain in visceral fat mass was the cause or the consequence of the decline in respiratory function.

In addition, the large size of our prospective study provided substantial power to evaluate BMI and physical activity in relation to COPD risk, as well as to examine potential differential associations according to smoking status, a major determinant of COPD.5 Previous data on BMI and COPD incidence are limited to 2 small studies.8,9 One prospective study from China8 reported an increased risk of COPD among people with BMI values less than 18.5 (RR 2.88, 95% CI 1.06–7.85) compared with BMI values of 18.5 or greater. In contrast, when modelling BMI as a continuous variable, a significant positive association between BMI and COPD was observed in that study8 (RR [per 1-unit BMI increase] 1.14, 95% CI 1.02–1.26). One retrospective US study9 observed an increased risk of COPD among people with BMI values below 24.3 (RR 2.76, 95% CI 1.15–6.59) compared with BMI values of 26.6 or greater. Data regarding obese values of BMI in relation to COPD were not presented in those studies.8,9 Inverse associations between physical activity and risk of COPD have been previously reported from a Danish cohort10 and a Japanese case–control study.11

Chronic obstructive pulmonary disease is thought to be caused by toxic particles inhaled from tobacco smoke,25,26 air pollution27 or occupational dust,28 which damage the lung through oxidative stress, chronic local inflammation and disturbed tissue repair.5 Increased local,29 abdominal29 and overall fat depots30 increase local and systemic inflammation,31 thus potentially stimulating COPD-related processes in the lung.

We observed a stronger positive relation with abdominal body fat than with total body fat and COPD. In particular, overweight as measured by BMI emerged as a significant predictor of increased risk of COPD only among those with a large waist circumference. Visceral fat depots may play a greater role in the development of COPD than overall or subcutaneous fat depots because visceral fat depots produce more proinflammatory cytokines.32 One cross-sectional analysis involving people without COPD found that waist circumference and waist–hip ratio were inversely associated with lung function, whereas BMI was unrelated to lung function.33

In our study, increased waist circumference and waist–hip ratio were robust predictors of COPD in participants who had never smoked and who had ever smoked, the latter of whom are at increased COPD risk. By comparison, the relations of BMI to COPD were inconsistent across smoking strata, which may have been due to strong residual confounding by smoking.

Underweight BMI was positively associated with COPD both before and after adjustment for waist circumference. Because underweight BMI adjusted for waist circumference represents an indirect marker of low muscularity, particularly in the elderly,34 we suspect that low muscularity is positively associated with development of COPD. Similarly, if hip circumference adjusted for waist circumference represented an indirect marker of gluteal muscularity, our finding of an inverse association between hip circumference and COPD suggests that large gluteal muscularity protects against COPD.

Engaging in physical activity 5 or more times per week was associated with a 29% decreased risk of COPD. Relevant biologic mechanisms are speculative, but they include physical activity–induced reductions in oxidative stress35 and chronic inflammation,36 factors that promote COPD. In addition, physical activity improves processes of lung repair37 and reduces obesity.38 In our study, the inverse effect estimates for physical activity were strongest among those who currently smoked, and they became progressively less pronounced across strata of those who smoked in the recent past, distant past and never. Residual confounding by smoking is one possible explanation for this constellation of findings. Also, the inverse association between physical activity and COPD may have been susceptible to reverse causation because lung damage in COPD reduces exercise capacity.39

Limitations and strengths

Limitations of our study include potential measurement errors due to self-reported anthropometric and physical activity variables. However, validation studies of assessments of anthropometric variables and physical activity comparable to those used in our study indicate that our measurements are reasonably reliable and valid.15,16,20 Moreover, because the data regarding anthropometry and physical activity were collected before COPD diagnosis, any measurement errors would have weakened, not strengthened, the associations.

Another potential limitation of our study is the absence of spirometry data to confirm COPD. Self-reported COPD diagnoses have imperfect validity,21,22 but reporting is not affected by sex, age, BMI, socioeconomic status, smoking or comorbidities,40 which suggests that any potential misclassification of COPD status in our study would have biased results toward the null hypothesis.41 Also, our results for BMI and physical activity in relation to COPD are broadly consistent with previous data from studies that used spirometry-based definitions of COPD,8–11 which suggests that our findings are not merely an artifact of COPD misclassification at baseline or follow-up.

It is possible that our findings were affected by protopathic bias induced by excessive visceral fat42 or lack of physical activity7 increasing the rate of progression of subclinical COPD.

A further potential limitation is the predominantly white sample. However, we observed no effect variation by ethnicity.

Strengths of our study include the large sample size, which yielded precise risk estimates and allowed for extensive stratification by smoking status. Detailed anthropometric assessments allowed us to discern the independent and joint effects of abdominal and overall adiposity on COPD risk. Our prospective study design largely precluded recall and selection biases. Specific care was taken to adjust for a broad range of potential confounding variables. We reduced the potential for reverse causation by excluding participants with pre-existing chronic diseases at baseline and excluding the first 5 years of follow-up in a sensitivity analysis. Concern remains regarding reverse causation because the induction time for development of clinically relevant COPD exceeds our follow-up period.43

Conclusion

We found that obesity, in particular abdominal obesity, represents an important risk factor for incidence of COPD. We also noted that underweight was positively related to COPD, an association we suspect is at least partly attributable to the effects of low muscularity. By comparison, large hip circumference and increased physical activity levels were related to decreased COPD risk. Our findings suggest that next to smoking cessation and the prevention of smoking initiation, meeting guidelines for body weight, body shape and physical activity level may represent important individual and public health opportunities to decrease the risk of COPD. Physicians should encourage their patients to adhere to these guidelines as a means of preventing chronic diseases in general and possibly COPD in particular.

Acknowledgments

We are indebted to the participants in the National Institutes of Health–AARP Diet and Health Study for their outstanding cooperation.

Footnotes

  • Competing interests: None declared.

  • This article has been peer reviewed.

  • Contributors: Gundula Behrens and Michael Leitzmann wrote the article and have primary responsibility for the final content. All of the authors were involved in the conception and design of the study, in the analysis and interpretation of the data, and in the revision of the manuscript. Michael Leitzmann supervised the project. Albert Hollenbeck provided administrative, technical and material support. Gundula Behrens conducted the statistical analysis. All of the authors gave final approval of the manuscript submitted for publication.

  • Funding: This research was supported in part by the Intramural Research Program of the Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health.

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Canadian Medical Association Journal: 186 (12)
CMAJ
Vol. 186, Issue 12
2 Sep 2014

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Body size and physical activity in relation to incidence of chronic obstructive pulmonary disease
Gundula Behrens, Charles E. Matthews, Steven C. Moore, Albert R. Hollenbeck, Michael F. Leitzmann
CMAJ Sep 2014, 186 (12) E457-E469; DOI: 10.1503/cmaj.140025
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