profiles of chronic obstructive lung disease: characteristics of stable chronic obstructive lung...

CE: Namrta; MCP/200212; Total nos of Pages: 8;

MCP 200212

REVIEW

CURRENTOPINION Profiles of chronic obstructive lung disease:

characteristics of stable chronic obstructive lungdisease in different parts of Asia

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a b
Bhome Arvind and Brashier Bill
Purpose of review

This review discusses the recent Asian chronic obstructive lung disease (COPD) studies that characterizestable COPD, to understand its peculiarities.

Recent findings

Asian research has improved our understanding of COPD. Household air pollution (HAP) is as important assmoking. Smoking in Asia is varied, and noncigarette smoking exposure remains under-investigated.Prevalence studies are often questionnaire based. Spirometry-based prevalence needs study. Burden ofobstructive lung disease studies are getting published. Female COPD in Asia is predominantly HAPinduced. The patients are underweight, milder ’Global Initiative for Obstructive Lung Disease- class’ andhave compromised health-related quality of life often with depression and anxiety, but other comorbiditiesdo occur and are getting defined.Nonsmokers‘ COPD is often associated with small airway thickening, less emphysema, but considerablemorbidity. Asian COPD may have an eosinophilic component, but its significance is unknown. There isgenetic predisposition among some Asians to COPD, and among some patients to lung cancer. Theemerging pandemic of lifestyle diseases demands that metabolic and cardiovascular comorbidities inCOPD need investigation.

Summary

COPD in Asia is increasing and burdensome. It is affecting both sexes; is caused by HAP as much assmoking; causes poor quality of life and intense psychological burden; and is associated with uniquepatho-physiology, which will require research and action.

Keywords

chronic obstructive lung disease characteristics, chronic obstructive lung disease in Asia, nonsmokers’chronic obstructive lung disease, phenotypes of chronic obstructive lung disease

INTRODUCTION

That chronic obstructive lung disease (COPD) is amajor killer in Asia is no longer the news [1

&

,2]. Butthe picture of COPD in Asia is still emerging. Thepurpose of this review is to characterize stable COPDin Asia at the current state of our knowledge.

aIndian Coalition for the study of Obstructive Lung Diseases and bChestResearch Foundation, Kalyaninagar, Pune, India

Correspondence to Dr Bhome Arvind B., 401 Yashod Apartments, CTSNo.70B/1B, Erandawane, Pune 411004, India. Tel: +91 9371026216,91 0 20 25667718, 91 0 20 24338988; e-mail: [email protected], [email protected]

Curr Opin Pulm Med 2014, 20:000–000

DOI:10.1097/MCP.0000000000000033

CHRONIC OBSTRUCTIVE LUNG DISEASEIN ASIA: MORE HETEROGENEOUS THANELSEWHERE?

The WHO Global Infobase on COPD mortalityshows that Asia is in the highest category of morethan 43.9/100 000 age-standardized mortality range(China 124.6, India 90.4, Vietnam 80.2, Pakistan68.2, Bangladesh 63.9, Indonesia 55.5, Malaysia50.0 and Sri Lanka 60.8). Some countries of the

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Association of South Southeast Asian Nations(ASEAN) (Thailand 37.2 and Philippines 25.3) arebetter, whereas Singapore (13.7), Korea (16.7) andJapan (4.2) certainly match the West and fare betterthan the Americas (USA 25.2 and Canada 16.9)(Fig. 1) [1

&

]. This means there are 556 000 and1 354 000 deaths per year in India and China,respectively, that is, more than 20% and about

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mailto:[email protected]




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KEY POINTS

� COPD in Asia is burdensome and threatens to nullifygrowth and prosperity of Asia.

� COPD in Asia is more heterogeneous than elsewhere inthe world; because of the contribution of HAP, uniquecausative agents, unique smoking habits, poverty andthe use of solid liquid fuels for cooking, heatingand lighting.

� The patho-physiology of smokers’ and nonsmokers’COPD is unique and needs better characterization forbest care at affordable cost.

� Asians have unique susceptibility to COPD and tocomorbidities, may respond differently to drugs, andneed alternative approaches to smoking cessation,pollution control and comprehensive care strategies.

Obstructive, occupational and environmental diseases

50% of world deaths (2 748 000 annually) [2]. Thedifferences within Asia are not ‘gross domestic prod-uct- dependent’ alone.

The Global Burden of Disease Study 2010 pro-vides unique insight into this aspect. Globally, thechildhood nutritional and communicable diseasesare decreasing, although life-style diseases areincreasing. COPD contributes two of every three

Estimated age standardized death rate (per 100 000), chro

Source: Mathers, C.D., C. Benard, K.M. Iburg, M. Inoue, D. Ma Fat, K Shibuya, C. Sand H. Xu, Global burden of Diseases: data sources, methods and results., 2008

The boundaries and names shown and the designations used on this map do not implany opinion whatsoever on the part of the World Health Organisation concerning the lcountry, territory, city or area or of its authorities, or concerning the delimitation of its boundaries. Dotted lines on maps represent approximate border lines for which there agreement. © WHO 2013. All rights reserved

I

USA 25.2

Canada 16.9 EU Scandina

FIGURE 1. Diversity in age standardized death rates from COPDReproduced with permission from [1&].

2 www.co-pulmonarymedicine.com

cases of pulmonary morbidity. Disability adjustedlife years (DALYs) due to COPD are ranked third,fifth and ninth in China, India and ASEAN, respect-ively, as compared with ninth globally. In East Asia,Japan and South Korea, the DALYs due to COPD aredecreasing but those due to cancer are increasing[3

&&

].The ‘comparative risk association’ analysis as

part of the same Global Burden of Disease 2010study looked at 67 risk factors. Particulate matterless than 2.5 microns (PM2.5), household air pollu-tion (HAP) and ozone are proven contributorsto COPD DALYs. PM2.5 levels in Asia often exceed5–30 mg/m3, which are levels proven to be disease-causing elsewhere. Thus, HAP ranks first, third andfifth in South Asia, ASEAN and China, respectively,but fourth globally. PM2.5 ranks fourth, sixth andninth in China, South Asia, Japan and Korea,respectively, but ninth globally. Tobacco smoke isranked at second place in Asia as well as globally[4

&&

].HAP is caused by solid fuels, liquid fuels (kero-

sene) and heating or lighting fuels (Wick lamps –carbon black). The studies on HAP differ in samplesize, design and methodology, and some recentextensive systematic reviews and meta-analysis exist[5

&&

] (Fig. 2). HAP and kerosene contribute greatly toCOPD in Asia [6,7].

nic obstructive pulmonary disease, both sexes, 2004

Mortality(per 100 000)

tein, N. Tomijima

y the expression ofegal status of anyfrontiers ormay not yet be full

Distribution of country rate

< 10.6

10.6 < 16.3

16.3 < 25.2

25.2 < 38.1

38.1 < 43.9

Not available

≥ 43.9

0.6 10.616

.325

.238

.143

.912

4.6

ndia 90.4

China 124.6

Indonesia 55.5

Vietnam 80.2

Singapore 13.7Japan 4.2, Korea 16.7

via < 16.3

in Asia both sexes. COPD, chronic obstructive lung disease.

Volume 20 � Number 00 � Month 2014


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COPO: doctor diagnosed

Overall (I2 = 97.3%; p < 0.001)

Subtotal (I2 = 96.9%; p < 0.001)

Subtotal (I2 = 91.8%; p < 0.001)

Kiraz et al.Døssing et al.Orozco et al.

Orozco-Levi et al.

Orozco-Levi et al.

Dennis et al.

Regalado et al.

Zhong et al.

Liu et al.Liu et al.

Liu et al.Liu et al.

Xu et al.Xu et al.Chapman et al.Sezer et al.

Ekici et al.Caballero et al.

Studies separated by diagnosis criteria

COPD: lung function

OR (95% CI)

17.40 (10.55–28.70)28.90 (8.71–95.90)

4.50 (1.43–14.20)3.90 (1.67–9.10)3.10 (1 .63–5.90)2.80 (0.84–9.30)2.50 (1.56–4.00)2.40 (1 .99–2.90)1.80 (0.54–6.00)1.70 (1 .20–2.40)1.60 (0.80–3.20)1.50 (0.52–4.30)1.50 (0.49–4.60)1.40 (1.31–1.50)2.96 (2.01–4.37)

6.60 (2.16–20.20)520 (4.74–5.70)1.30 (0.77–2.20)

1 2 3 45 8 10 20 30

0.70 (0.45–1.10)229 (0.70–7.52)

2.80 (1.85–4.23)

Weight %

4.346.214.475.315.864.336.276.734.336.52

4.735.73

4.556.8176.18

4.556.806.156.3123.82

100.00

BiomassWoodWood and charcoalWoodBiomassCoalBiomassWoodWoodBiomass

BiomassCoal

CharcoalBiomass

BiomassCoalCoalFirewood/straw

TurkeySaudi ArabiaSpainColumbiaChinaChinaTurkeyColumbiaSpainChina

MexicoChina

SpainChina

TurkeyChinaChinaChina

Log of odds ratio

2003199420061996200720072005200819962007

20062007

20062007

2004200520072007

Forest plot showing risk of COPD inpopulation exposed to solid fuels

Overall (I2 = 68.9%; p < 0.001)

Studies OR (95% CI)

1 2 3 4 5 7 10 20 30

Weight %

Turkey

Pakistan

Pakistan

Bolivia

Brazil

Brazil

India

India

Iran

Nepal

India

Pakistan

Turkey

Turkey

Turkey

Pakistan

Mexico

Log of odds ratio

2003

2003

1994

1994

1991

2007

2007

2002

2005

2007

2007

1996

1996

1999

1994

1984

2000

4.83

6.30

6.10

5.38

7.49

100.00

2.33

6.69

6.79

6.20

8.67

9.12

0.69

4.48

4.29

7.61

5.70

7.32

Uzun et al.

Kiraz et al.

Menezes et al.

Menezes et al.

Behera and Jindal

Akhtar et al.

Akhtar et al.

Golshan et al.

Ekici et al.

Akhtar et al.

Akhtar et al.

Dutt et al.

Perez-Padilla et al.

Albalak et al.

QUreshi

Pandey

Cetinkaya et al.

3.36 (1.80–6.26)

1.90 (1.20–3.01)

1.49 (0.92–2.41)

1.30 (0.74–2.27)

1.18 (0.83–1.67)

2.32 (1.92–2.80)

3.32 (1.12–9.88)

2.51 (1.64––3.83)

2.91 (1.92–4.40)

2.50 (1.56–4.00)

2.38 (1.88–3.01)

2.01 (1.67–2.42)

4.17 (0.46–38.02)

3.90 (2.00–7.60)

2.50 (1.25–5.00)

2.10 (1.50–2.94)

7.87 (4.67–13.26)

1.96 (1.36–2.82)

40

Forest plot showing risk of chronic bronchitisin population exposed to solid fuels

FIGURE 2. Meta-analysis of 23 studies of HAP in COPD. Ten studies reported COPD based on both physician diagnosis andspirometry, 11 reported chronic bronchitis based on respiratory questionnaire data and two reported both COPD and CB. Thepooled effect estimate for lung function diagnosed COPD (OR 2.96) was greater than those diagnosed by a doctor (OR2.29), with a combined pooled effect estimate of 2.80 for COPD (left panel). The pooled effect estimate for CB was 2.32(right panel). COPD, chronic obstructive lung disease; OR, odds ratio; HAP, household air pollution. Modified with permissionfrom Kurmi OP, Semple S, Simkhada P, et al. COPD and chronic bronchitis risk of indoor air pollution from solid fuel: asystematic review and meta-analysis. Thorax 2010; 65:221–228.

Profiles of chronic obstructive lung disease in Asia Arvind and Bill

CURRENT GAPS IN KNOWLEDGE OFCHRONIC OBSTRUCTIVE LUNG DISEASEIN ASIAMany prevalence studies of COPD from Asia arepoor in methodology. Recently, McKay et al. [8]attempted to estimate the COPD prevalence inIndia, and could not identify a single study withspirometric definition of COPD. Large populationsurveys from the Middle East and North Africaregion [the BREATHE study, a ten country studywith the Arabic acronym BREATHE – Algeria, Egypt,Jordan, Lebanon, Morocco, Saudi Arabia, Syria,Tunisia, Turkey, United Arab Emirates and Pakistan][9], based on symptoms questionnaires but notspirometry, indicate low prevalence. The sameapplies to the ‘Indian study on epidemiology ofasthma, respiratory symptoms and chronic bronchi-tis in adults’ (INSEARCH; 11 Indian cities), with aprevalence of 3.49% [10].

Luckily, the Burden of Obstructive Lung Disease(BOLD) protocol has generated uniformity in studydesigns, providing realistic data using postbroncho-dilator FEV1/FVC (forced expiratory volume in1 s/forced vital capacity ratio) of less than 70%, froman increasing number of Asian countries joiningcontinuously; a recent addition was Kashmir, NorthIndia, with 19% prevalence [11]. Many population-based studies, however, indicate rampant under-diagnosis [12–14]. The causes may be lack of

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spirometry equipment, skills or knowledge, notprobing the variety of smoking choices availableduring surveys, and nonsmokers’ COPD.

SMOKING AND CHRONIC OBSTRUCTIVELUNG DISEASE IN ASIA

A recent Global Adult Tobacco Survey (GATS) indi-cated smoking rates vary from 64% in Indonesia to22% in Nepal (men), and 10% in the Philippines to1% in Bangladesh (women). India has 111.2 millionsmokers (99.9 men and 11.3 women) consuming105 billion cigarettes and 553 billion bidis annually.The GATS China report indicates that 53% of menand 2.4% of women are smokers (86% daily), withthe COPD age group (>45 years) smoking heavily[15].

Many Asians smoke tobacco through filterlesslocal cigarettes (bidis), water pipes (hookahs/shisha)and kerkets (Fig. 3). The bidi is common inIndia, with tobacco rolled in Tendu leaves (Diospyroselanoxylon). The bidi produces three times morecarbon monoxide and five times more tar comparedwith a cigarette. To keep it lit, one has to take deepinspirations. Burnt tobacco and Tendu leavesgenerate more particulates and toxins that depositmore distally in the small airways and lung paren-chyma. The Global Youth Tobacco Study-India(2005 – 10–13 year-old youths) showed 8.3% were

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Havana cigar, handcrafted pipe,ancient chutta and cigarette

Relative sizes bidi unfiltered,bidi filtered-herbal, cigarette

Sitting hukkah/shisha- Water pipe

Portable hukkah/shisha

FIGURE 3. Smoking choices for Asians.


smokers (2.3% bidis), of which 12.5% were frequentsmokers and 50% nicotine dependent [16]. Tenduleaves emit naphthoquinones, coumarins andvolatile organic compounds. Bidis generate hydro-gen cyanide, phenols and polyaromatic hydrocar-bons. Water-pipe smoking (hookah/shisha) allows alarger smoke volume inhalation (50–100�), highernicotine dose (10�), contains carcinogens, carbonmonoxide and aldehydes, and is associated withCOPD, cancer and periodontitis [11,17–21]. A retro-spective study showed that water-pipe smoking pre-disposes to ischaemic heart disease (IHD) and COPDsimilar to cigarette smoking [22]. A meta-analysis ofsix studies showed that compared with nonsmokers,water-pipe smokers had poorer lung functionsimilar to cigarette smokers, with nicotine cravingbeing equally high [23].

NONSMOKERS’ CHRONIC OBSTRUCTIVELUNG DISEASE IN ASIA

HAP-induced COPD has been gathering attentionlately. A meta-analysis of 23 studies on HAP-inducedCOPD and chronic bronchitis showed good corre-lation of pulmonary function tests and physiciandiagnosis, with questionnaire method coming third[5

&&

] (Fig. 2). Presumably, Asian COPD in women isHAP induced.

This nonsmokers’ COPD is similar to smokers’COPD in clinical features, spirometry, inflammationand systemic manifestations. It is more likely tohave small airway obstruction than emphysema[5

&&

,24&&

]. A computed tomography (CT) functionalimaging study of biomass exposed and nonexposed


female COPD patients did prove that the biomassexposed patients have less emphysema and moreair-trapping with less symptoms such as cough, butmore desaturation and may have bronchial hyper-responsiveness (BHR) [25]. The Asian Network ofObstructive Lung Disease (ANOLD) study showedthat COPD patients exposed to biomass and dustyjobs had more frequent symptoms, more severeairflow limitation and poorer quality of life thanthose not exposed [26]. The patho-physiology ofnonsmokers’ COPD is still evolving, with probablysame level of oxidative stress as smokers’ COPD.Also, new toll-like receptor and apoptosis-basedpathways are being investigated for the mechanismof HAP-induced COPD [27

&

]. This will help us tobetter understand nonsmokers’ COPD.

THE CLINICAL PROFILE OF CHRONICOBSTRUCTIVE LUNG DISEASE IN ASIA:VARIATION WITHIN ASIA

The BREATHE study showed that 47.5% of COPDpatients were frequent exacerbators, 5.5% wereseverely dyspnoeic, 28.4% reported lost workdays,47.9% found routine exhausting, 37.5% dreadedsocializing, 31.7% avoided family gatherings, and42.3–53.2% reported psychological distress withCOPD Assessment Test scores of 16.2�9.1–20.9�10.2 suggesting poor health-related qualityof life (hrQOL) [28]. The ANOLD study (922 COPDpatients and seven cities– pulmonology clinics)showed that smokers’ COPD was largely of ‘GlobalInitiative for Obstructive Lung Disease (GOLD) classII’ disease severity, 40% had cough, 48–49% had



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phlegm, 21–22% were classified as chronic bronchi-tis, 71–72% had wheeze; and dyspnoea on theMedical Research Council scale was I to II for many(> 50%), grade IV for 6% and grade 0 for 15%. Themedian Saint George’s Respiratory Questionnairescore was 36.2 with variation among countries.Philippines had worse hrQOL and dyspnoea thanJapan, maybe because of different healthcare sys-tems. The best hrQOL was in China and the worst inthe Philippines, although the Japanese hrQOL beingworse than the Chinese needs further analysis [26].

THE CLINICAL PROFILE OF CHRONICOBSTRUCTIVE LUNG DISEASE IN ASIAVERSUS THE WEST

An Indian study measured hrQOL and dyspnoea –both by two methods each – and found good cor-relation with severity of disease, but not with age,comorbidities, illiteracy and smoking quantity, rais-ing questions whether Indian patients do havepoorer hrQOL than Western ones for the sameGOLD category [29]. Whether hrQOL indicatesCOPD care or socio-cultural issues is also not clear.All Asian COPD studies report lower BMI for thesame GOLD class as the West, suggesting poor prog-nosis with higher mortality, but dietary and anthro-pometric differences need to be ruled out.

SPUTUM CYTOLOGY PHENOTYPES

The high eosinophil count in induced sputum evenin smokers’ COPD seen in Asia may resembleasthma. A Chinese study showed that eosinophilsin induced sputum cannot differentiate betweenasthma and COPD even though COPD is primarilynoneosinophilic (< 3% eosinophils) [30]. Thereason is unknown and may indicate a reversiblecomponent. As most studies of COPD exclude indi-viduals with reversible airflow obstruction and diag-nosed asthma, HAP and endotoxins in poorlyventilated homes may also cause recruitment ofeosinophils. Previously, a Japanese study of 33COPD patients showed increased eosinophiliccationic protein – suggesting eosinophilic inflam-mation as in asthma, although HAP may not have arole in Japan. Conversely, recent COPD data fromNepal (high HAP) showed patients with sputumneutrophilia as opposed to eosinophilia in inducedsputum [31]. Currently, it would be premature tosuggest any evidence of geographic variation ininflammation, although eosinophils may have animportant role in the pathogenesis of Asian COPDindicating steroid responsiveness and/or BHR assuggested by a Chinese study in the past (54.5%of 33 COPD patients showing BHR). This BHR inCOPD may not be related to noneosinophilic


factors, and the correlation between presence ofeosinophils and BHR or airflow has not beenproven yet.

FUNCTIONAL IMAGING PHENOTYPES

COPD phenotype definition by CT functional imag-ing has been studied by many researchers world-wide. Most studies describe emphysema with threeprimary high resolution CT phenotypes in COPD, Atype (airway dominant and emphysema absent), Etype (emphysema dominant) and M type (mixed).The A phenotype mostly includes nonsmokers withhigher BMI, eosinophils in sputum, wheeze andresponse to steroids. The E type usually has fixedairway obstruction, refractory to steroids and nocough with sputum. The M phenotype usually hasthe lowest spirometry, higher airway inflammationand is more bronchodilator and inhaled corticoste-roids responsive thanA and E.This approachemploysemphysema severity indices based on low attenu-ation area percentages. Previously, researchers haveshownthatemphysematous phenotypes E and M fareworse than A phenotype in terms of BMI, dyspnoea,spirometry parameters, lower inspiratory capacity/total lung capacity (IC/TLC) ratio and higher residualvolume (RV)/TLC ratio [higher dynamic hyperinfla-tion (DHI)], and the E phenotype is the worstamong them in terms of dyspnoea, spirometry,DHI and IC/TLC ratio.

Additionally, the luminal area and wall areapercentages as CT parameters of bronchial wallthickening have been shown to correlate withFEV1%, with luminal area and wall area percentagesof sixth-generation bronchus correlating better withFEV1% than third, as COPD affects smaller airwayspredominantly. The Hokkaido study had earlierdescribed phenotypes of COPD based on emphy-sema severity and showed the poor correlationbetween FEV1% or GOLD class and emphysema,but good correlation of emphysema severity withlow BMI and poorer hrQOL. Nishimura et al. [32

&&

]from the same group recently demonstrated that CTand diffusion factor in lung for carbon monoxide(DLCO)-based emphysema severity can differentiaterapid annual FEV1 decliners from slow decliners andsustainers (nondecliners). This was never possiblewith FEV1%-based GOLD classification. A studyfrom Taiwan last year, correlated CT with 6-minwalking distance and lung function, and showedthat walking ability of COPD patients negativelycorrelated with emphysema severity but positivelywith inspiratory capacity and FEV1% predicted.This could mean that COPD causes DHI and venti-lation perfusion defects, which together decreaseeffort tolerance. The emphysema severity can



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reduce the anaerobic threshold and maximal oxy-gen utilization during exercise in COPD patients.The presence of emphysema reduces the IC/TLCratio and increases the RV/TLC ratio, which arephysiological markers of DHI. However, emphy-sema may not be able to predict the mortality ofCOPD in Asia [33]. Fan et al. [34] have recentlycombined CT and MRI imaging to calculate notonly the emphysema index but also perfusiondefects in the lungs and correlated the same withspirometry, TLC and DLCO, to show that perfusiondefects and poorer lung function occur with E andM phenotypes but not with A.

Kurashima et al. [35&

] focused attention on Di(inner diameter) and Ai (luminal area) from third,fifth and sixth-generation bronchi to show thatasthma airways are narrower than COPD, andfifth-generation Di and Ai correlated best withmid-expiratory flow rates of 50 and 25%, whereaswall area percentage was increased in COPD but notin asthma. There are no data on functional imagingof indoor-air pollution and dusty occupationphenotypes of COPD, specifically, even thoughCamp et al. [24

&&

] and Kurmi et al. [5&&

] have shownthat these phenotypes have more small airwaythickening than emphysema.

COMORBIDITY PATTERN OF ASIANCHRONIC OBSTRUCTIVE LUNG DISEASE

The profile of stable Asian COPD differs in thisaspect as well, both from the West and within Asia.

Metabolic syndrome

COPD affects multiple systems. A Korean NationalHealth and Nutrition Study showed prevalence ofmetabolic syndrome in men with only abdominalobesity [36].

Anxiety and depression in chronic obstructivelung disease

Sekhar et al. [37] showed that 56% of COPD indi-viduals had at least two comorbidities, 50% haddepression, 44% anaemia, 32% hypertension, 15%diabetes and 7% IHD. Han et al. [38] demonstratedthat alexithymia is quite common in COPD. InTaiwan, depression increased 1.88-fold in COPD[39]. Sharma et al. [40] evaluated the mental healthof 391 Indian patients and found a higher psychi-atric comorbidity of 44.8% (anxiety 20.6%, depres-sion 13.2% and obsessive disorder 4.6%). A studyfrom Guangzhou of 7995 patients showed thatself-reported physician diagnosis of COPD andsymptom perception are the main determinantsof depression but not FEV1 [41]. In a Xuzhou study


of 1100 patients, there was increased anxiety,depression and poor hrQOL [42]. In rural China,7597 patients showed that age, dyspnoea and lungfunction were related to anxiety (r¼0.972) anddepression (r¼0.989) [43]. A prospective geriatricstudy from Singapore recently showed that highlevels of interleukin-6 and C-reactive proteininduced depression and enhanced risk of broncho-spasm independent of smoking status, BMI andother inflammatory diseases [44]. These comorbid-ities cause a vicious cycle of immobilization, lostautonomy, low self-esteem, emotional lability,exacerbation and systemic inflammation.

Lung cancer and chronic obstructive lungdisease: shared cause, shared prevalence?

Lung cancer and COPD have a shared causeof smoke exposure, and hence their association isoften investigated. Previous COPD, emphysema andchronic bronchitis were associated with a cancerdiagnosis (odds ratio of 1.29, 1.55 and 1.22, respect-ively), and asthma with decreased odds in a retro-spective study [45]. A review of lung cancer patientsfrom Fudan showed that 21.6% had spirometricdischarge diagnosis of COPD [46].

Such association forms the basis of genotypingstudies as well, and CHRNA3 was associated withCOPD and lung cancer in China and Korea[47

&

,48&

], whereas a study from Hong Kong didnot find increased risk of lung cancer in non-smoking females when compared with smokers(male/female) [49].

Miscellaneous comorbidities

Other comorbidities described in some studies weregastroesophageal reflux disease [50,51], psoriasis[52] and osteoporosis [53], but this does not meana cause–effect relationship.

CONCLUSION

With so much heterogeneity in Asian COPD,phenotype definition holds the key to maximizetherapeutic benefits. The multiple ongoing cohortstudies may enable us to characterize COPD leadingto personalized treatment and rehabilitation, andreduce the burden of DALYs by reducing smoking,ambient and household pollution, thus helpingAsians achieve healthy prosperity.

Acknowledgements

B.A.B. represents India at the Asian Network forObstructive Lung Diseases (ANOLD) and is principalinvestigator for the proposed ICOLD study in Indiaand convener of Indian Coalition for Obstructive Lung



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Disease: a multiinstitutional pan-national initiativeinvolving Chest Research Foundation, Pune; NationalInstitute of Epidemiology, Chennai; Indian Instituteof Genomics and Integrative Biology, New Delhi;Sher-e-Kashmir Institute of Medical Sciences, Srina-gar, Kashmir; North Eastern Indira Gandhi Instituteof Health and Medical Sciences, Shillong, Meghalaya.He gratefully acknowledges the support of these organ-izations.B.B. is director of academics and molecular and basicresearch at Chest Research Foundation, Pune and isPrincipal Coordinator for the ICOLD study network.He joins the principal author in acknowledging the sup-port of the above organizations.

Conflicts of interest

There are no conflicts of interest.

REFERENCES AND RECOMMENDEDREADINGPapers of particular interest, published within the annual period of review, havebeen highlighted as:
& of special interest&& of outstanding interest
1.&

Mathers CD, Bernard C, Iburg KM, et al. Updated projections of globalmortality and burden of disease, 2002-2030: Data sources, methods andresults. Evidence and Information for Policy Working Paper, World HealthOrganization, October 2005. WHO Global Infobase updated on 20th January2011. Available online: https://apps.who.int/infobase/Index.aspx. [Accessed10 November 2013].

An important overview of the global mortality estimates and projections for the nextcouple of decades.2. Bhome AB. COPD in India: iceberg or volcano? J Thorac Dis 2012; 4:298–

309.3.

&&

Murray CJL, Vos T, Lozano R, et al. Disability-adjusted life years (DALYs) for291 diseases and injuries in 21 regions, 1990–2010: a systematic analysisfor the Global Burden of Disease Study 2010. Lancet 2012; 380:2197–2223.

This is a must read for anyone who wants to understand the disease burdendynamics of 291 causes of disease and injuries expressed as DALYs in, 20 agegroups, both sexes, 187 countries from 1990–2005 to 2010 in a global burdenseries capturing premature mortality, prevalence and severity of ill-health. Thearticle is in a series of articles that has shaped global health policy over the last twodecades and is a unique global collaboration spanning across all continents andmost countries.4.

&&

Lim SS, Vos T, Abraham D, et al. A comparative risk assessment of burden ofdisease and injury attributable to 67 risk factors and risk factor clusters in 21regions, 1990–2010: a systematic analysis for the Global Burden of DiseaseStudy 2010. Lancet 2012; 380:2224–2260.

This is in the same league as [3&&

] It quantifies disease burden – deaths andDALYs – in terms of 67 risk factors and their clusters causing those diseases ofglobal significance. This exercise has been done comparing how these risks havechanged with the changing disease profiles from 1990 to 2010. A must read forthe clarity of understanding the global health issues and formulating the policy forprevention and mitigation.5.

&&

Kurmi OP, Lam KBH, Ayres JG. Indoor air pollution and the lung in low- andmedium-income countries. Eur Respir J 2012; 40:239–254.

This article is in a series on air pollution and lung disease of special importance,as it provides a comprehensive review of literature on indoor pollutionand discusses issues relevant to understand the scattered literature on thesubject with multiple variables. Although not Asia specific, it contains a veryuseful discussion on many Asian studies. A must read for anyone interested innonsmokers’ COPD.6. Lam NL, Smith KR, Gauthier A. Kerosene: a review of household uses and

their hazards in low and middle income countries. J Toxicol Environ Health BCrit Rev 2012; 15:396–432.

7. Lam N, Chen Y, Weyant C, et al. Household light makes global heat: highblack carbon emissions from kerosene wick lamps. Environ Sci Technol 2012;46:13531–13538.

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24.&&

Camp PG, Ramirez-Venegas A, Sansores RH. COPD phenotypes in biomasssmoke- versus tobacco smoke-exposed Mexican females. Eur Respir J 2013;doi: 10. 1183/09031936.00206112 [Epub ahead of print].

This study tested nonsmoker biomass exposed COPD female patients andcontrolled matched ex-smoker COPD female patients never exposed to biomassfuel with CT functional imaging software and proved that biomass exposed COPDpatients had very little emphysema (0.7 versus 2.3, P¼0.001) and more airwaywall thickening with air trapping (2.6 versus 1.5, P¼0.02) as compared withsmoking-induced COPD patients, and also had lower symptom scores, hrQOLand more desaturation at rest and exercise (P<0.05).25. Gonzalez-Garcıa M, Torres-Duque CA, Bustos A, et al. Bronchial hyper-

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27.&

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This animal exposure experiment by Indian and US researchers mimicked humanexposure to wood smoke and cow-dung cakes by replicating the same in mice to firstestablish the effect of acute exposure resulting in robust proinflammatory cytokineproduction, neutrophilic inflammation, airway resistance and hyper-responsiveness,all of which were higher in cow-dung exposed mice in comparison to wood smokeexposed. As opposed to this, subchronic exposure resulted in more changes in woodsmoke exposed mice than cow-dung exposed mice; and were characterized byeosinophilic inflammation, PM-specific antibody responses and alveolar destruction.Mechanisms that underlie this were studied by using mice deficient in 5 receptors[toll-like receptors (TLR)-2,3,4,5 and IL-1R], of which three receptors were found todemonstrate inflammatory responses via My88 on exposure to wood smoke or cow-dung, viz. IL-1R, TLR-4 and TLR-2. The authors conclude that subchronic exposure toPM collected from households burning biomass fuel elicits a persistent pulmonaryinflammation largely through activation of TLR and IL-1R pathways, which couldincrease the risk for chronic respiratory diseases.28. Uzaslan E, Mahboub B, Beji M, et al., BREATHE Study Group. The burden

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47.&

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The authors wanted to test two single nucleotide polymorphisms (SNPs)(rs6495309 and rs1051730) located in nicotinic acetylcholine receptor a-3(CHRNA3) gene in the Chinese population, to explore whether there existcommon predictor risks for COPD and lung cancer as both diseases have ashared cause. The said SNPs were genotyped in 1511 COPD patients, 1559 lungcancer patients and 1677 controls in South and East China. They found that thers6495309CC and rs6495309CT/CC variant genotypes were associated withincreased risks of COPD (OR¼1.32) and lung cancer (OR¼1.57), respectively.The rs6495309CC genotype contributed to more rapid decline of annual FEV1 inboth COPD cases and controls (P¼0.05), and it was associated with advancedstages of COPD (P¼0.033); the rs6495309CT/CC genotypes conferred a poorsurvival for lung cancer ( hazard ratio¼1.41). The luciferase assays further showedthat nicotine and other tobacco chemicals had diverse effects on the luciferaseactivity of the rs6495309C or T alleles. However, none of these effects were foundfor another SNP, rs1051730G>A. The data show a statistical association andsuggest biological plausibility that the rs6495309T>C polymorphism contributedto the increased risks and poor prognosis of both COPD and lung cancer.48.&

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53. Rittayamai N, Chuaychoo B, Sriwijitkamol A. Prevalence of osteoporosis andosteopenia in Thai COPD patients. Med Assoc Thai 2012; 95:1021–1027.


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