摘要
背景:
营养不良是慢性阻塞性肺疾病(COPD)的常见并发症,由于营养评价方法和研究人群不同,COPD的营养不良流行病学资料各不相同, Congleton等以低于90%的理想体重为营养不良的判断标准,报道COPD患者营养不良发生率为36%,Schols等以
瘦组织群减少为判断标准,营养不良发生率为20%,Sahebjami H等以BMI<20Kg/m2为评价营养不良的标准,营养不良发生率为23%,Leban等报道呼吸衰竭病人的营养不良发生率为60%,需要机械通气的呼吸衰竭病人营养不良发生率更是高达74%。而国内陈国忠等人以BMI<18.5Kg/ m2为标准,营养不良发生率为41.3%,由此可见不同的研究尚没有统一的结果,而对于慢性阻塞性肺疾病病情程度与营养状况的关系,国内更少见报告。因此,迫切需要一种客观、全面、准确的评价方法。我们对患者分别以人体测量、主观全面评价法、微型营养评定法和NRS2002进行营养评估,以期寻找一种适合COPD患者的营养评价方法。本研究拟通过对COPD患者的营养评价,进一步明确COPD病情程度与营养状况的关系。
目的:
探讨COPD病情严重程度与营养状况的关系;分析比较主观全面评价法、微型营养评定法和NRS-2002在评估慢性阻塞性肺疾病患者营养状况的效力,选择一种简单、方便、快捷并适合于COPD的营养评价方法。
方法:
根据2007年中华医学会制订的COPD诊治指南(修订版)和全球COPD防治倡议(GOLD)2006年修订版的标准入选病人,包括住院和门诊病人,对所有病人进行肺功能检测、生活质量评分和膳食调查,采用人体测量进行营养评价,同时采用主观全面评价法(SGA)、微型营养评定法(MNA)和NRS2002法三种简易营养评价法进行评价,并通过统计分析比较人体测量与三种营养评价法的优劣。
结果:
1.在2010年7月至2011年4月随机入选病人146例,男性123例,女性23例,平均年龄71.74±9.59岁.
2.营养不良评价结果:
(1)人体测量的评价结果:146例COPD病人,74例(50.68%)为营养正常,72例为营养不良,营养不良发生率49.32%,47例(32.19%)为轻中度营养不良,25例(17.12%)为重度营养不良。
(2)SGA结果:146例COPD病人,68例(46.58%)为营养正常,78例为营养不良,营养不良发生率53.42%,54例(36.99%)为轻中度营养不良,24例(16.44%)为重度营养不良,其结果与人体测量结果进行卡方检验,Kappa值=0.6113,提示两种方法一致性程度较好(P<0.005)。
(3)MNA结果:146例COPD病人,62例(42.47%)为营养正常,把营养不良风险和营养不良都定义为营养不良,84例为营养不良,营养不良发生率57.53%,29例(19.86%)为存在营养不良风险,55例(37.67%)为营养不良,其结果与人体测量结果进行卡方检验,Kappa值= 0.4364,提示两种方法一致性程度较好(P<0.005)。
(4)NRS-2002营养评价结果:146例COPD病人,75例(51.37%)为营养正常,71例为营养不良,营养不良发生率48.63%,48例(32.88%)为轻中度营养不良,23例(15.75%)为重度营养不良,其结果与人体测量结果进行卡方检验,Kappa值=0.6501,提示2种评价方法结果一致性程度较好(P<0.005)。
以人体测量结果作为判断营养不良的标准,SGA的灵敏度为93.06%,特异度为85.14%,准确度为89.04%,Youder指数0.7820;MNA的灵敏度为100%,特异度为83.78%,准确度91.78%,Youder指数0.8378;NRS2002的灵敏度84.72%,特异度86.48%,准确度85.62%,Youder指数0.7120。
3.营养不良与COPD病情的关系:
不同病情阶段营养不良发生率:II级患者69例,47例(32.19%)为营养正常,22例为营养不良,营养不良发生率31.88%,其中19例(13.01%)为轻中度营养不良,3例(2.05%)为重度营养不良,;III级患者51例,22例(15.07%)为营养正常,29例为营养不良,营养不良发生率56.86%,其中20例(13.70%)为轻中度营养不良,9例(6.16%)为重度营养不良;IV级患者26例,5例(3.42%)为营养正常,21例为营养不良,营养不良发生率80.77%,其中8例(5.48%)为轻中度营养不良,13例(8.90%)为重度营养不良。对该资料行线性趋势检验,线性回归分量(Kendall相关系数为0.425)61.2306,P<0.005,偏离线性回归分量2.0604,0.500
4.COPD临床分期与营养状况的关系急性期77例患者,30例(20.55%)为营养正常,47例为营养不良,营养不良发生率61.04%,其中29例(19.86%)为轻中度营养不良,18例(12.33%)为重度营养不良;稳定期69例患者,44例(30.14%)为营养正常,25例为营养不良,营养不良发生率21.92%,其中18例(12.33%)轻中度营养不良,7例(4.79%)为重度营养不良。对两组资料行Wilcoxon秩和检验,单侧P<0.005。
5.营养不良与肺功能的关系营养正常组的FEV1、FVC、FEV1/FVC、FEV1%分别为1.10±0.40 2.02±0.55、54.25±8.83、50.61±12.03,营养不良组的FEV1、FVC、FEV1/FVC、FEV1%分别为0.85±0.32、1.78±0.39、47.41±11.93、42.33±14.86,两组比较差异有统计学意义(P<0.05)。
6.营养不良与生活质量评分营养正常组SGRQ评分为44.19±14.79,营养不良组SGRQ评分为50.04±12.99,P=0.012,差异有统计学意义;II、III、IV各级患者的SGRQ评分分别为41.71±14.01 50.41±12.54 54.76±12.49。II级与III级、IV级患者比较SGRQ评分有统计学意义(P<0.05),III级与IV级差异无统计学意义(P>0.05)。急性期SGRQ评分49.91±12.98,稳定期SGRQ评分43.91±14.90,二者相比差异有统计学意义(P<0.05)。SGRQ评分与MNA评分进行相关分析,相关系数r=?0.370,P=0.000。
7.营养不良与能量摄入的关系:日均摄入能量营养正常组为1449.51±324.12Kcal,大于营养不良组1264.59±374.27Kcal(P<0.05);急性期1192.25±297.33Kcal,少于稳定期1543.64±335.41Kcal(P<0.05);II级1416.85±338.90 Kcal,III级1380.61±326.53 Kcal,IV级1159.27±420.93 Kcal,II与III之间差异无统计学意义(P>0.05),II与IV、III与IV之间均有统计学意义(P<0.05)。MNA评分与能量摄入进行相关分析,相关系数r=0.378,P=0.000。
结论
1.COPD合并营养不良相当普遍,尤其见于急性发作期和严重气道阻塞的患者,营养不良发生率与疾病的严重程度相关。SGA、MNA和NRS-2002三种方法均适合于COPD的营养评价,而MNA灵敏度较高,推荐MNA作为COPD患者营养状况的初筛方法。
2.气道阻塞越严重,营养状况越差;营养状况越差,其GOLD分级越高。
3.营养不良组膳食摄入减少,病情的急性发作和气道阻塞程度的增加进一步减少了膳食摄入。
Backgroud
Malnutrition is a well-known complication of COPD.The prevalence of nutritional depletion in patients with COPD is quite variable, according to the method of nutritional assessment and the population studied. Note that in the article by Congleton, prevalence was defined on the basis of ideal body weight being <90% of the predicted,COPD patients with malnutrition was 36%; while in the article by Schols ,it was based on reduced fat-free mass. He reported prevalence values of 20%. Sahebjami H and coworkers think that it was based on BMI <20Kg/m2 for malnutrition, malnutrition rate was 23%; Leban and coworkers reported that patients with respiratory failure, malnutrition rate of 60%, respiratory failure requiring mechanical ventilation of patients the incidence of malnutrition is as high as 74%; While Chen Guozhong et al to BMI <18.5Kg / m2 for the standard, malnutrition was 41.3%, This shows the different results of research was still no uniform, and the relationship between chronic obstructive pulmonary disease severity and nutritional status was the more rare reports of domestic.Urgent need for an objective, comprehensive and accurate evaluation, Our patients were measured by anthropometric, subjective global assessment, micro-nutrient nutritional assessment and NRS2002 to find a suitable method of nutritional assessment in patients with COPD. This study evaluated the nutritional status of COPD patients,and the relationship between COPD severity and nutritional status of requires further clear.
Objective
To explore the relationship between COPD severity and nutritional status; to evaluate the value of three subjective methods of nutritional assessment:subjective global assessment of nutrition (SGA),mini—nutritiona1 assessment(MNA),Nutrition risk screening-2002(NRS-2002) in patients with chronic obstructive pulmonary disease (COPD),choose a simple, convenient, fast and suitable method of nutritional assessment in COPD.
Methods
The nutritional evaluation( Anthropometric、subjective methods of nutritional assessment : subjective global assessment of nutrition (SGA),mini—nutritiona1 assessment(MNA),Nutrition risk screening-2002(NRS-2002))、pulmonary function, quality of life score and dietary survey were examined in patients with COPD by GOLD and the revised diagnostic criteria of Chinese Respiratory College in 2007. SGA,MNA and NRS2002 were used respectively to assess the nutritiona1 status in these patients.To evaluate the value of these methods with the standard of anthropometric result.
Results
1.146 patients were selected in July 2010 to April 2011, 9.59±123 cases of male, 23 female, mean age of 71.74±9.59years.
2. Malnutrition evaluation results
(1).Anthropometric evaluation results, 146 cases of COPD patients, 74 case (50.68%) for the normal nutrition, 72 case for the malnutrition, malnutrition rate was 49.32%,47 cases (32.19%) for the mild to moderate malnutrition, 25 cases(17.12%) for severe malnutrition.
(2).Subjective global nutritional assessment results, 146 cases of COPD patients, 68 cases(46.58%) for the normal nutrition, 78 cases for the malnutrition, malnutrition rates was 53.42 %, 54 cases (36.99%) for mild to moderate malnutrition, 24 cases (16.44%) for severe malnutrition, the results of measurement with the aothropometric chi-square test, Kappa values = 0.6113, suggesting that both methods can still consistent level (P <0.005).
(3).Mini nutritional assessment results, 146 cases of COPD patients, 62 cases (42.47%) for the normal nutrition, the risk of malnutrition and malnutrition are defined as malnutrition,84 cases for the malnutriton, malnutrition rates was 57.53%,29 cases (19.86%) for the existence of the risk of malnutrition, 55 cases(37.67%)for malnutrition, the results of measurement with the aothropometric chi-square test,Kappa value = 0.4364, indicating that both methods can still consistent level (P <0.005).
(4).NRS-2002 nutrition assessment results, 146 cases of COPD patients, 75 cases (51.37%) for the normal nutrition, 71 cases for the malnutrition, malnutrition rates was 48.63%,48 cases (32.88%) for mild to moderate malnutrition, 23 cases (15.75%) for severe malnutrition, the results of measurement with the aothropometric chi-square test, Kappa Value = 0.6501, indicating that both methods can still consistent level (P <0.005).
anthropometric standards for judging malnutrition, SGA sensitivity was 93.06% and specificity was 85.14%, accuracy was 89.04%, Youder index was 0.7820; MNA sensitivity was 100% and specificity was 83.78%, accuracy was 91.78 %, Youder index was 0.8378; NRS2002 sensitivitywas 84.72% and specificity was 86.48%, accuracy was 85.62%, Youder index was 0.7120.
3. The relationship between malnutrition and COPD Patients with grade II was 69 cases, 47(32.19%) cases for normal nutrition, 22cases for malnutrion, the incidence of malnutrition in the level was 31.88%,19(13.01%)cases for mild to moderate malnutrition, 3 (2.05%)cases for severe malnutrition,; III Grade was 51 patients, 22(15.07%) patients for normal nutrition, 29 cases for malnutrion , the incidence of malnutrition in the level of 56.86%,20(13.70%) cases for mild to moderate malnutrition, 9 (6.16%)cases for severe malnutrition; IV grade was 26 patients, 5 (3.42%) cases for normal nutrition, 21 cases for malnutrion, the incidence of malnutrition in the level of 80.77%,8(5.48%) cases for mild to moderate malnutrition, 13(8.90%) cases for Severe malnutrition;Linear trend of the column test, linear regression 61.2306(Kendall=0.425), P <0.005, deviation from the linear regression component 2.0604,0.500 4.The relationship between clinical stage of COPD and the nutritional status There were 77 patients in acute stage, 30(20.55%)cases for normal nutrition, 44 cases for malnutrition , the malnutrition rate of 61.04% ,29(19.86%) cases with mild to moderate malnutrition, 18(12.33%) cases of severe malnutrition;there were 69 ptients in the stable stage,44(30.14%)cases for the normal nutrition,25 (17.12%)case for malnutrition,the malnutrition rate of 36.23% ,18(12.33%) cases for mild to moderate malnutrition, 7(4.79%)cases for severe malnutrition, the malnutrition rate of 36.23%.Two columns of Wilcoxon rank sum test, unilateral P <0.005.
5. Normal nutrition group,lung function FEV1、FVC、FEV1/FVC and FEV1% were 1.10±0.40、2.02±0.55、54.25±8.83 and 50.61±12.03 malnourished group FEV1、FVC、FEV1/FVC and FEV1%,respectively was 0.85±0.32、1.78±0.39、47.41±11.93 and 42.33±14.86, The difference between the two groups was significant (P <0.05).
6.Malnutrition and quality of life In normal nutrition group SGRQ, score was 44.19±14.79 ; In malnourished group SGRQ score was 50.04±12.99,P=0.012, malnutrition group and normal nutrition had significant difference; II, III, IV levels in patients with SGRQ;SGRQ scores were 41.71±14.01 50.41±12.54 54.76±12.49 .Class II and Class III, IV stage patients were significantly different (P <0.05), III and IV grade level had no significant difference (P> 0.05). The acute group was 49.91±12.98, The stabe group was 43.91±14.90, both compared to significant difference (P<0.05); SGRQ score and MNA score correlation analysis, r=- 0.370, P = 0.000.
7. The relationship between malnutrition and energy intake normal group was 1449.51±324.12Kcal, malnutrition group was 1264.59±374.27Kcal , The difference of two groups was significant (P <0.05); The acute group was 1192.25±297.33Kcal The stabe group was 1543.64±335.41Kcal, both compared to significant difference (P<0.05); II level in patients was1416.85±338.90 Kcal, III level in patients was 1380.61±326.53 Kcal, IV level1159.27±420.93 Kcal, It was no significant difference between II and III (P> 0.05), II and IV, III and IV were significantly different (P <0.05 .). MNA score and energy intake, correlation analysis, r = 0.378, P = 0.000.
Conclusion
1. Malnutrition is a well-known complication of COPD,Notably in the acute exacerbation and in patients with severe airway obstruction, The incidence of malnutrition and disease severity was positively correlated.SGA, MNA, and NRS-2002 are three methods of nutritional assessment for COPD, in which the sensitivity of MNA 100%, MNA is recommended in patients with COPD as a nutritional Status of screening methods.
2.More severe airway obstruction, the worse nutritional status;the worse nutritional status, the higher the GOLD classification.
3.Malnourished group reduced dietary intake, acute exacerbation of the disease and airway obstruction to further reduce the degree of increase in dietary intake.
引文
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2. Schols AM, Slangen J, Volovics L, et al. Weight loss is a reversible factor in the prognosis of chronic obstructive pulmonary disease. Am J Respir Crit Care Med 1998; 157: 1791–1797
3. Schols AMWJ, Broekhuizen R, Weling-Scheepers CA,Wouters EF. Body composition and mortality in chronic obstructive pulmonary disease. Am J Clin Nutr 2005; 82:53–59.
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8. Guigoz Y,Vellas BJ,Garry PJ.Mini nutritional assessment:A practical assessment tool for grading thenutritionalstate of elderly patients[J]. Facts Res Gerontol,1994,4(Suppl 2):15—59.
9. Kondrup J,Allison SP,Elia M,et al,ESEPN Guidelines for nutrition screening 2002[J] Clin Nutr,2003,22(4):415-521
10. Ezzell L,Jensen GI.Malnutrition in chronic obstructive pulmonary disease.Am J Clin Nutr,2000,72(6):1415—1416.
11.Laaban JP.Nutrition and chronic respiratory failure. AnnIntern Med,2000,151(7):542-548.
12.Congleton J. The pulmonary cachexia syndrome: aspects of energy balance. ProcNutr Soc 1999; 58: 321–328.
13. Schols AMWJ. Pulmonary cachexia. Int J Cardiol 2002; 85:101–110.
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15.陈国忠,曹霞,于昌平等慢性阻塞性肺疾病的炎症反应与体重指数密切相关.临床肺科杂志,2010.15-06
16.Sergi G, Coin A, Marin S, et al. Body composition and resting energy expenditure in elderly male patients with chronic obstructive pulmonary disease. Respir Med 2006;100: 1918–1924.
17.Congleton J. The pulmonary cachexia syndrome: aspects of energy balance. Proc Nutr Soc 1999; 58: 321–328.
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