COPD a worsening health issue worldwide – and in Kentucky

What the news
means for you

David M. Mannino, MD
Pulmonologist

COPD is, in essence, a disease of survivors. If a person who has other risk factors for COPD lives into old age, that person is much more likely to develop a respiratory disease. COPD is also a disease that has its origins in childhood and manifests itself in older adults. Eighteen-year-olds who smoke don’t have COPD, but 30 or 40 years down the road they may.

“People who have COPD are more likely to have diabetes, heart disease, hypertension or lung cancer.”

To prevent COPD, we need to target children and teens. To make a difference we have to use every tool available. For example, UK is launching a tobacco-free medical campus, and that sends a message. In addition, insurers should be more aggressive in getting smokers into the best available tobacco treatment programs.

The reality is that even after many people stop smoking, lung function continues to decline. Some people who have never smoked develop COPD from being around smokers or growing up in a house heated by coal. In Eastern Kentucky, for example, COPD is related to early life exposure to smoke from wood stoves, which are still used to heat many homes in the region.

Women and COPD
The BOLD study showed that the incidence of COPD is increasing faster among women than among men. I see more women than men in my practice at the Kentucky Clinic. Part of the reason for this increase is that smoking didn’t become popular among women until the 1940s or 1950s. Also, more women are surviving into old age.

We still don’t know whether women are more susceptible than men to COPD. There is some evidence that they may be and some evidence that they may not be. We’ve also seen that lung cancer rates have increased among women, and COPD is itself a risk factor for lung cancer.

COPD and other diseases
What is surprising to researchers now is the relationship between COPD and a number of other diseases. We’re seeing evidence that people who have COPD are more likely to have diabetes, heart disease, hypertension or lung cancer. I think a lot of the focus of medicine over the next few years will be on COPD and a number of these polymorbid diseases.

Although we think of COPD as a lung disease, it affects other parts of the body as well. Patients with COPD are more likely to have chronic inflammatory infection not only in the lungs but also elsewhere in the body, and this infection is related to an increased risk for stroke and heart disease.

Diagnosing and treating COPD
Many patients don’t come in for treatment because they think their symptoms are just the result of aging. People who have very advanced COPD know they have it because their symptoms are severe. We really need to focus more attention on those patients with the more mild to moderate forms of the disease who haven’t yet been diagnosed because this is the time when lifestyle interventions can do the most good. Spirometry should also be more routinely available to patients older than 40 who have a history of smoking or have respiratory symptoms.

Treatment for COPD involves first staging the disease and developing a plan for intervention. Naturally, if the patient is a smoker, you try to help them quit. Then an exercise program is set up. If the patient’s blood oxygen level is low, oxygen should be given. Bronchodilators and steroids may also be prescribed. Also important are pulmonary rehabilitation programs that teach patients breathing exercises and show them how to perform physical tasks.

Ultimately, we would like to approach COPD as a public health problem through awareness, surveillance, and partnerships with universities, churches and other organizations. We’ve been able to see a decrease in the incidence of heart disease by using this approach.

"Many other chronic diseases are related to lifestyle, among them cardiovascular disease and diabetes, but we don’t take the same judgmental approach toward people who have these diseases."

A lot of shame and blame have been associated with COPD, as if the victims have brought it on themselves. There’s an element of truth to that belief, but even though many patients have done the right thing and stopped smoking, their lung function continues to decline. Some people who have never smoked develop the disease.

Many other chronic diseases are related to lifestyle, among them cardiovascular disease and diabetes, but we don’t take the same judgmental approach toward people who have these diseases. This judgmental attitude permeates even federal policy. Historically, COPD and lung cancer have been far down on the list for federal research funding, yet they kill more people than many other diseases in the country. Fortunately, that is beginning to change.

Dr. Mannino is a pulmonary and critical care specialist and an associate professor in both the UK College of Medicine and the UK College of Public Health.

COPD a worsening health issue worldwide – and in Kentucky

Chronic obstructive pulmonary disease is a serious health problem for more people worldwide than previously reported, according to a recent study. The results of the Burden of Obstructive Lung Disease (BOLD) Initiative, published in the Sept. 1 issue of The Lancet, also reveal that Kentucky’s rate of COPD is among the highest in the world.

COPD is expected to be the third leading cause of death in this country by 2020.

David M. Mannino, MD, a University of Kentucky professor of preventive medicine and environmental health, was a co-author of the study as a member of a research group led by Sonia Buist, MD, at the Oregon Health and Science University.

An editorial appearing in the same issue of The Lancet states that COPD has not received the attention it deserves despite the fact that it is the fifth leading cause of death in high-income countries.

“It is underdiagnosed, undertreated, and underfunded and neglected by the public, pharmaceutical industry, and physicians alike when compared with other major killers,” the editorialist writes. “This neglect is sadly due in part to the perception that COPD is a self-inflicted smokers’ disease that affects only elderly people and has no effective treatment.”

Prevalence of COPD
COPD kills more than 120,000 Americans a year and is expected to be the third leading cause of death in this country by 2020. It is actually a group of diseases characterized by airflow obstruction that can be associated with breathing-related symptoms such as chronic cough and wheezing. COPD is often underdiagnosed because it comes on gradually, is progressive and may not cause substantial symptoms in its early stages.

Researchers in the worldwide BOLD study interviewed nearly 9,500 subjects older than 40 years about their respiratory symptoms, health status and exposure to COPD risk factors. They obtained spirometry results from 8,775 of those subjects. A spirometer is a noninvasive device that measures how well the lungs exhale. Values are based on age, height, ethnicity and sex and are expressed as percentages. A result below 80 percent is considered abnormal.

Overall, more than 10 percent of the subjects had advanced COPD, defined as stage II or higher (men, 11.8 percent; women, 8.5 percent). The prevalence of advanced COPD increased with age: It affected fewer than 5 percent of subjects in their 40s but as many as 47 percent of men and 33 percent of women age 70 or older. The highest overall prevalence of advanced COPD, 19 percent, was found in Cape Town, South Africa. According to Dr. Mannino, the prevalence of advanced COPD among subjects from southeastern Kentucky was 14 percent, the second highest of any group in the BOLD study.

Risk factors
Smoking is the No. 1 cause of COPD worldwide. The World Health Organization estimates that in high-income countries, 73 percent of the deaths caused by COPD are related to smoking, whereas that number is 40 percent in low- and middle- income nations.

The authors of the BOLD study found that COPD rates were higher among heavy smokers, but they point out there are other risk factors. Among these are genetic factors, occupational gases, dust, vapors and fumes; indoor air pollutants caused by burning organic matter for cooking and heating; and outdoor air pollutants. Aging, bacterial or viral infections, asthma, gender, inadequate nutrition and poor access to health care are also associated with a higher prevalence of COPD.

The relatively high number of women with COPD raises the question of whether women may be genetically more susceptible than men to the disease. This question has not yet been answered.

Passive smoking also plays a role in COPD, according to another research report in the same issue of The Lancet. In that study, the 28 percent of subjects who had never smoked but had been exposed to smoke for more than 40 hours each week for a period of five years or more were 48 percent more likely than unexposed subjects to have COPD.

In a separate review appearing in The Lancet, Mannino and Buist note that, even if all smokers in the country gave up cigarettes immediately, the rates of COPD would continue to increase for the next 20 years because the disease is progressive.

“The challenge we will all face in the next few years will be implementation of cost-effective prevention and management strategies to stem the tide of this disease and its cost,” they conclude.

For more information, or to make an appointment with a UK HealthCare physician, please call UK Health Connection at 1-800-333-8874