慢性阻塞性肺病病人GOLD分群與營養狀態的關係

Abstract

背景：營養不良是慢性阻塞性肺病(Chronic obstructive pulmonary disease；COPD)病人常見且嚴重的問題，出現體重下降及非脂肪質量減少(free-fat mass；FFM)情形。慢性阻塞性肺病全球創始組織(Global Initiative for Chronic Obstructive Lung Disease, GOLD)在2014年修改COPD的評估方法，將病人分為ABCD四群，以提供更有效的治療方式，但在COPD病人的疾病治療，營養不良常被忽略。 目的：探討COPD病人營養狀態的現況及GOLD分群與營養狀態的關係。 方法：研究設計採橫斷性研究方法，研究對象取自北台灣某醫學中心的COPD病人群，收案人數共有116個人。依照綜合性COPD評估方法，本研究運用COPD評估量表(COPD assessment test；CAT)來評估病人的症狀，並且以病人肺功能報告和急性發作次數來評估急性發作的風險，依此進而將病人分為ABCD四群。為了解COPD病人營養狀態，本研究使用簡易營養評估量表(Mini Nutritional Assessment；MNA)進行營養評估，以及運用體脂計(Tanita BC-565-WH,Japan)來測量身體組成。使用SPSS 20.0統計軟體進行個案資料分析，使用獨立t檢定與單因子變異分析進行不同分組的比較，以複迴歸分析來檢測哪些變項與營養狀態測量指標有關，p值<0.05表示在統計上有顯著意義者。 結果：研究個案以男性居多(96.6%)，平均年齡為70.6歲(SD=10.9)。若以身體質量指數(body mass index；BMI)做分組，低體重(BMI<20kg/m2)的COPD病人佔15.5%。高齡患者75歲以上的營養狀態差，尤其是BMI、FFM和非脂肪質量指數(fat-free mass index；FFMI)；無工作者的FFM和FFMI較差，因工作退休者大多為老年病患；共病症愈多不代表個案營養狀態愈差，與COPD病人合併代謝症候群有關；個案的急性發作次數愈多則MNA總分愈差。肺功能之FEV1/FVC%與FFM呈正相關(r=0.229,p=0.014)。GOLD分群中，A群佔32.8%，B群佔25.9%，C群佔17.2%與D群佔24.1%，C群與D群的病人中營養不良者與具有營養不良風險者近七成(MNA量表佔68.8%、MNA台灣修改一版(MNA-TⅠ)佔66.7%)。GOLD分群的嚴重度愈高，MNA總分愈低(p<0.001)。在複迴歸分析中，MNA總分與GOLD分群的COPD嚴重度具有相關性，當COPD病情愈嚴重，MNA總分愈減低。在其他的營養狀態測量指標(BMI、體脂肪率、FFM和FFMI)中， GOLD分群的COPD嚴重度並不是顯著的預測因子。 結論：本研究運用MNA量表及身體組成的測量來評估COPD病人營養狀態，發現那些病人可能具有營養不良危險性，需要提供營養支持及持續追蹤。GOLD分群與MNA總分具有顯著的相關性，建議GOLD分群中的CD群者宜進行營養評估及對高風險營養不良者飲食衛教，以改善病人的健康狀態及預後。

Background: Malnutrition is a common and serious problem among patients with chronic obstructive pulmonary disease (COPD), one which causes body weight loss and the depletion of free-fat mass (FFM). The Global Initiative for Chronic Obstructive Lung Disease (GOLD) strategy for the assessment of COPD was revised in 2014, and COPD patients are classified into groups A, B, C, and D. The GOLD ABCD groups help the treatment for COPD patients more efficient, but malnutrition was often neglected in the managements of patients with COPD. Aim: This study examined the nutritional status of patients with COPD, and explored the relationship between the GOLD grouping and nutritional status. Methods: A cross-sectional research design was used in this study. A total of 116 subjects were recruited at a medical center in northern Taiwan. For the combined COPD assessment, we selected the COPD assessment test (CAT) scale for assessing symptom, and used lung function and the history of exacerbation to assess the risk of exacerbation. The nutritional status was evaluated using the Mini Nutritional Assessment (MNA) questionnaire and body composition was measured with a body fat analyzer (Tanita BC-565-WH, Japan). Data were analyzed with SPSS version 20.0 for Windows. Independent t-test and one-way ANOVA were used to compare the values for the different groups. Multiple linear regression analysis was used to test which variables were associated with the indicators of nutritional status. A p-value of less than 0.05 was considered statistically significant. Results: The subjects were mostly men (96.6%) and had a mean age of 70.6 (SD=10.9) years. Underweight (BMI<20kg/m2) occurred in 15.5% of the COPD patients. The nutritional status indicators of the elderly patients (>75years old) were worse than in younger patients, particularly in terms of BMI, FFM and fat-free mass index (FFMI). Patients who did not work had worse FFM and FFMI result, because most of them were older retirees. The nutritional statuses of COPD patients with comorbidities were unnecessarily worse. This was due to the fact that many COPD patients may also have metabolic syndrome. Exacerbation frequency was significantly associated with the MNA scores (p<0.001). FEV1/FVC% of lung function was positively correlated with FFM (r=0.229, p=0.014). In terms of the GOLD grouping, 32.8% of the subjects were classified in group A, 25.9% were classified in group B, 17.2% were classified in group C, and 24.1% were classified in group D. Close to seventy percent of the patients in groups C and, D were malnourished and at risk for malnutrition (68.8% according to the MNA and 66.7% according to the MNA-T1). The MNA scores were generally lower with increasing COPD severity according to GOLD grouping (p<0.001). In multiple linear regression analysis, the MNA scores were related to the severity of COPD base on GOLD grouping. The severer the COPD, the less the MNA scores. For the other indicators of nutritional status (BMI, fat%, FFM and FFMI), the COPD severity according to GOLD grouping was not a significant predicator. Conclusions: We used the MNA questionnaire and body composition measurements to assess the nutritional status of COPD patients in this study. After determining which patients might be at risk of malnutrition, we needed to provide nutritional support and follow-up. The GOLD grouping were significantly associated with MNA scores, so we suggested that nutritional assessments and dietary health education should be conducted for COPD patients classified in groups C and D of the GOLD grouping in order to improve the health status and prognosis for each of these patients.