We now in fact think of chronic obstructive lung disease as what we call a systemic disorder meaning that it has effect on and interactions with other parts of the body. People with chronic obstructive lung disease do develop with greater likelihood heart disease, they develop bone wasting, there is loss of muscle mass in patients and that loss of muscle mass is present separate from that which might occur with deconditioning. So before somebody has taken to the chair or taken to the couch because of their breathing difficulty, they seem to have loss of skeletal muscle mass such as in the thighs or in the shoulders and that is important.
A patient, as they evolve and have their lung disease get worse may develop malnutrition, depression has been associated in greater incidence in people with chronic obstructive lung disease. I think overall a decrease in the quality of live has been demonstrated in people with chronic obstructive lung disease, and that decline in quality of life, as measured by formal quality of life questionnaires, progresses and worsens as the disease worsens and time goes by.