Analysis Effect of Nutrition Intake on Lung Function of Active Smoker and Non Smoker

Smoking is major cause of respiratory disorders and the data report in 2012 shows in Indonesia there are 384.058 cases of disesase caused by cigarettes. Nicotine and other substance in cigarette smokes are known that will affect nutritional intake and lung function of active smokers. This study observed healthy adult males aged 18-40 who were divided into two groups of active smokers with minimal 2 years exposure to filter type cigarettes and nonsmoker in 2018. Purpose of this study are to analyze the influence of smoking on nutrition intake and lung function and compared the results with nonsmoker groups. Data from 63 respondents in each group showed significant differences in nutrition intake and lung function (%FVC dan %FEV1) (p=0,001) in both groups. Results of this study showed an average caloric intake of 1787,37 calories and decreased the value of %FVC and %FEV1 respectively 90,48% and 96,83% of respondents in the active smokers group. Results of correlation test showed there is a significant relationship between nutritional intake on lung function.


Introduction
Smoking is main cause of lunge disease, from cough to cancer. WHO mentioned that Indonesia is on third rank of largest smoker worldwide under China and India. Based on the data by WHO in 2011, number of smoker in Indonesia was 36.1% of the population. Most of the smoker start smoking on age 10-18 years old (Kemenkes, 2013). There are sufficient data mentioning cigarette smoke contain complex component reaching 4800 compound variations.
Cigarette smoke flow from mouth to respiration then reach the alveoli. When the smoke flow further to respiratory line, more gas is absorbed and particles are deposited on using handheld spirometer to find out lungs function value (Jackson et al., 2008;Shim et al., 2014). Data obtained is used as reference of education regarding nutrition improvement to prevent health problem (Plotnikoff et al., 2015).

Method
Research conducted is analytic observation research with cross sectional design and pusposive sampling. The research was conducted in Surabaya Selatan from January to March 2018. Total respondents number on two research group are 126 persons. Inclusion criterias are: a. willing to be research subject and fill the agreement letter (informed consent) b. Male respondent ages 18-40 years old (Johns et al., 2014) c. Respondent used minimum has high school education background (Florence, 2017) d. Smoke filtered cigarette ≥1 everyday and has been smoking for at least 2 years (Jain et al., 2009) e. On non smoker group, contains respondents have never smoke or try smoking not more than 100 pcs cigarettes (Sharma & Ravi, 2010). Exclusion criterias are: a. Subject with concomitant respiratory disease and respiratory obstructive (MacIntyre, 2009) b. Respondent with gastrointestinal disorder (Rizzi et al., 2016), vegetarian or fasting (Stang & Story, 2005).
This research use interview guidance in form of open question list. Open question used are interview and nutrition intake evaluation by questionnaire to do 24 hours recall thus it can be known kind of food and drink consumed by respondent on both group. The result then processed with Nutrisurvey 2007 application. Based on Permenkes no. 75 year 2013, nutritional adequacy rate for adult male is 2675 calories for age 18-29 years old and 2725 calories for age 30-40 years old.
The spirometry is used to evaluate lungs function of sample in active smoker and non smoker group. Lungs function evaluation with handheld spirometer (CONTEC™ SP10) will test the FVC dan %FEV 1 value. First an audio visual example is presented to the respondent to properly do the measurement procedure. On spirometric measurement, the patient is directed to be relax and breathe in until the chest is full and breathe out as fast and as hard as able (Cheung & Cheung, 2015). Normal value for %FVC is >75% and >80% for %FEV 1 et al., 2012). Nicotine also causes decrease of meal portion though it does not affect hunger sensation (McGovern & Benowitz, 2011). To central nerve system, nicotine modulated the line regulating several aspects in meal intake. Regulation of meal habit and metabolism level of brain taken place at hypothalamus, integrating peripheral signal of replete feeling, as well as affects motivation and central emotion (Raatz et al., 2017). The leptin is released from adipose tissue later work centrally to suppress meal intake and increase metabolism level (Tan et al., 2013).
Appropriate nutrition intake is a preventive therapy to prevent the injury of respiratory line such as inflammation, obstructive and deficit of lungs function. Low appetite of smoker causes insufficient nutrition required to maintain lungs health thus increase the risk of COPD (Chronic Obstructive Pulmonary Disease) (Sorli-Aguilar & Martin-Lujan, 2016). Malnutrition is condition where deficiency occure, over or unbalance nutrition intake and energy on someone. Over nutrition is when micronutrient and macronutrient intake are over leading to body mass index increase. Under nutrition is when deficiency of energy protein and micronutrient occure (Itoh et al., 2013).
Malnutrition affect structure, elasticity and function of lungs. Malnutrition on patient having pulmonary disease has worse prognosis compare to patient with well nutrition (McKeever et al., 2008). Nutrition intake is associtated with FEV 1 (Forced Expiratory Volume in one second) on smoker. The FEV 1 value can be seen from lungs function examination by spirometry. The spirometry usage objective is to find out any respiratory disease and help to monitor respond to therapy and direct the decision of further therapy and intervention (Yeh et al., 2008). The research by spirometry will show FVC (Forced Vital Capacity) value and FEV 1 indicated in litre (L) or % (Nurjanah et al., 2014).
This research is conducted to find out effect of nutrition intake to lungs function on active smoker and non smoker in Surabaya Selatan by evaluation of individual diet which was 24 hours recall as a questionnaire in estimating kind and frequence of meal and (Antwi et al., 2011) . Ethical code approval by Institutional Ethical Committee University of Surabaya (No: 004/KE/XII/2017).

Results and Discussion
Evaluation of nutrition intake on active and non smoker was conducted by 24 hours recall method. The method was conducted three times to evaluate the nutrition intake on work day and once on the weekend. Based on research by Rothuosen (2012), 24 hours recall method has better performance compare to food report when assesting individual nutrition intake. 24 hours recall is conducted three times since three time measurement can represent individual eating habit for a month (Rankin et al., 2011). Weekend nutrition data taken can indicate macronutrient intake larger than work days (Sun et al., 2010). This research uses male respondent since in Indonesia highest prevalence of smoker is male which is 67%, when respondent selection start from 18 years due to company regulation PP no 109 year 2012, legal age for smoking in Indonesia is 18 years old WHO, 2012). Limit age 40 years old is due to decreased ability of expiration and inspiration of respiratory system, decreased diaphragm strength to 13% and decreased muscle strength to 20% on age over 40 years old (Lowery et al., 2013).
Interview result then processed with Nutrisurvey thus obtain the average calorie intake for three days. Comparation between two groups then analyzed with Mann Whitney non parametric statistic test due to abnormal data distribution which was 0,001 (p<0,05) when tested using SPSS 23.00 for windows with kolmogrov-smirnov method indicating significant difference (p=0,001) regarding nutrition intake between active smoker and non smoker. Lack of nutrition intake on active smoker group is caused by nicotine having complex effect to norefinephrine, dopamine, serotonine and γ-aminobutyric acid by central nerve affects brain in the pretension to eat and metabolism (McGovern & Benowitz, 2011). Accute respond from this hormone is highly consistant by activating the system to decrease appetite and metabolism (Andresson & Arner, 2001). Meal habit and nicotine are in same Primary Nerve System PNS line. Meal habit dominantly controlled by interaction between lateral hypothalamus and acumbent nucleus in mesolimbic system and coordination between neotransmitter such as dopamine, serotonine and opioid system (Saper et al., 2002). Nicotine releases dopamine on some brain areas include the "reward" system which are mesolimbic, corpus striatum, frontal cortex and ventral tegmental area (Benowitz, 2010). Meal habit consider as psychological reaction to resist stress on some persons. Nicotine has shown effectiveness in decreasing anxiety then will cover or decrease the willingness to eat, thus when smoke consumption is stopped the anxiety and appetite increase (Picciotto & Corrigall, 2002).
The research also indicate that number of respondent on active smoker group experienced severe deficiency as many as 39 respondents. This supported the statement by Mineur et.al. (2011) mentioning active smoker will have nutrition intake decrease compare to non smoker. Aligned with Chen et al. (2012) mentioning there is reduction of appetite on active smoker with hoemostatis and reward mechanism. On this research result obtained was only 4% of active smoker group comply to nutritional adequacy rate (AKG) determined by government. As research by Nayu stating nutrition intake on adult male individu reduced to 240 calories (Ikeda et al., 2016). Other research also mentioned on adult male nutrition requirement deficience is occurred every day (Borg et al., 2015). Handheld spirometer usage begin with input the datas of body height and weight, sex, age, and smoking or not smoking on the spirometer. The examination of lungs function was done maximum on 3pm and during the process respondent would be asked to repeat 3 times and best value was taken (OSHA, 2013). The result indicated that 90.48% of the respondents in active smoker group have %FVC value decrease and 96.83% have %FEV 1 value decrease while on non smoker group is also found lungs function decrease where 41.27% of the respondents have %FEV 1 value decrease below 80%.
After compare %FVC and %FEV 1 value of both group by Mann Whitney non parametric statistic analysis, due to abnormal data distribution on the values where %FVC (0.001) and %FEV 1 (0.006) thus resulting significant difference between the groups regarding the %FVC and %FEV 1 value. This is aligned with research by Dwarakanath et al. (2014), Helal (2014) and Tantisuwat & Thaveeratitham (2014) stating there is significant difference of %FVC and %FEV 1 value between active smoker group and non smoker group, where the value of lungs function test for active smoker is lower than non smoker.
Smoking cause respiration obstruction and acute change on lungs include alteration in breathing flow resistance, irritation and smoking on early adult individual will affect respiration function. Inhalation of particles contained by smoke increase the lungs function capacity physiological reduction. Each time the smoke is inhaled will make tha active smoker to be exposed by free radical particles which is main source of oxidative stress and inflammation (Sorlí-Aguilar et al., 2015).
The large decrease of %FVC value on active smoker respondent can be affected by the strength of respiration muscle, where it is affected by smoke free radical on vascular system causing blood supply reduction to respiration muscle affecting lungs function. The reduction of %FEV 1 value on respondent is depended on number of consumption and duration of smoking along the life (minimum 2 years) since the reduction of %FEV 1 value mainly caused by accumulation of cigarette's tobacco consumption (Isabel et al., 2005) Respiration obstructive disorder caused by genetical or environmental factor. Though smoke exposure said as environmental factor, yet 25-45% of COPD patient said to not have smoking history. Only 20% smoker diagnosed of PPOK an around 10% smoker having The reduction of %FEV 1 value. There for it is said that other than smoke, environmental factor afftecting it which is nutrition intake should be considered in the occurance of Obstructive Pulmonary Disease (Wald et al., 2014). Breathing is an activity of endurance and muscle fibre is part of the body affecting it. On human diaphragm, 75% or more of the muscle fibre should be on well condition to properly function to maintain respiration endurance. Pump performance is highly important since it will affect the availability and requirement during respiration. Sufficient energy is required to adapt when there was an alteration in ventilator requirement, able to cause pumping malfunction or failure (Schols, 2015).
Due to diaphragm is the most importance muscle in respiration pump, the reduction of the strength is an important clinical sign on an individual since it indicated the occurrence of diaphragm fatigue when the load increase during respiration occurred (Barker et al., 2014). Primary determinant of fatigue is the strength and duration of diaphragm contraction. The strength is indicated with pressure ratio given by diaphragm in one time breath until maximum pressure able to produce by it. When malnutrition decrease the maximum pressure then the ratio of diaphragm pressure in one time breath compare to maximum pressure will increase and the individual tend to has diaphragm fatige causing reduction of lungs function until respiration failure (Jacobs Jr & Kalhan, 2016). Based on Rabinovich (2004), on individual malnutrition will occure an alteration of respiration muscle function affecting the strength and endurance of lungs function during expiration and inspiration. The decreasing of diaphragm muscle strength will also reduce the respiration vital capacity value, and the weakened of expiration causes the increase of residual volume and the alteration of diaphragm optimum strength then finally reduce the efficiency.

Conclusion
There is significant difference on nutrition intake (p=0,001) when both research group were compared. The lungs function value which are %FVC dan %FEV 1 on active smoker group and non smoker group also indicate significant difference with p= 0,001. On correlation test between nutrition intake and lungs function indicate significant relation (p=0,001) between both variables. The limitation of this research is the kind of nutrient unobserved able to affect intake of lungs function value. Maintain normal lungs function can be obtained by improving life habit like stop smoking and proper nutrition intake as advised by daily nutrition adequacy rate (AKG) » Dr. Songpol Tornee