{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,8,11]],"date-time":"2026-08-11T06:27:57Z","timestamp":1786429677066,"version":"build-2736575974"},"reference-count":38,"publisher":"Frontiers Media SA","license":[{"start":{"date-parts":[[2026,8,11]],"date-time":"2026-08-11T00:00:00Z","timestamp":1786406400000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":["frontiersin.org"],"crossmark-restriction":true},"short-container-title":["Front. Physiol."],"abstract":"<jats:sec>\n                    <jats:title>Background<\/jats:title>\n                    <jats:p>Diaphragmatic dysfunction contributes to exercise intolerance in COPD, but whether BMI shapes baseline function and response to exercise remains unclear. This secondary analysis characterized BMI-related diaphragmatic phenotypes and whether diaphragm thickening fraction (TFdi) links exercise training to functional improvement.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Methods<\/jats:title>\n                    <jats:p>Data were analyzed from 103 patients with stable COPD in a completed 2\u00d72 factorial randomized trial. Because no exercise-by-acupuncture interaction was detected for 4-week TFdi, participants were regrouped as exercise-exposed or non-exercise. Associations between BMI and baseline TFdi were assessed using restricted cubic splines and threshold models. Regression models estimated exercise effects on 4-week TFdi and 6-minute walk distance (6MWD), with BMI-stratified interaction and exploratory mediation analyses.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>BMI showed a nonlinear association with baseline TFdi, with an adjusted turning point at 23.7 kg\/m\u00b2. Below this threshold, BMI was positively associated with TFdi (\u03b2=0.05, 95% CI 0.03\u20130.08); above it, the association was negative (\u03b2=\u22120.05, 95% CI \u22120.07 to \u22120.03). Exercise was associated with higher 4-week TFdi (\u03b2=0.15, 95% CI 0.01\u20130.29) and longer 6MWD (\u03b2=59.61 m, 95% CI 10.65\u2013108.57). The TFdi response was most pronounced at BMI \u226525.0 kg\/m\u00b2, with borderline interaction evidence. Exploratory mediation suggested TFdi partially mediated exercise-related 6MWD gains, particularly in this BMI group.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusions<\/jats:title>\n                    <jats:p>This study integrates BMI phenotyping, diaphragm ultrasound, and mediation analysis to show that diaphragmatic function and exercise-induced diaphragmatic adaptation in COPD are BMI dependent. BMI may help identify patients most likely to derive diaphragmatic benefit from rehabilitation.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.3389\/fphys.2026.1900140","type":"journal-article","created":{"date-parts":[[2026,8,11]],"date-time":"2026-08-11T05:35:53Z","timestamp":1786426553000},"update-policy":"https:\/\/doi.org\/10.3389\/crossmark-policy","source":"Crossref","is-referenced-by-count":0,"title":["Body mass index\u2013related heterogeneity in diaphragm thickening fraction response to exercise training in stable chronic obstructive pulmonary disease"],"prefix":"10.3389","volume":"17","author":[{"given":"Yide","family":"Wang","sequence":"first","affiliation":[{"name":"Department of Rehabilitation, The Fourth Clinical Medical College of Xinjiang Medical University","place":["Urumqi, China"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Yidie","family":"Bao","sequence":"additional","affiliation":[{"name":"School of Rehabilitation Science, Shanghai University of Traditional Chinese Medicine","place":["Shanghai, China"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Xinliao","family":"Deng","sequence":"additional","affiliation":[{"name":"School of Rehabilitation Science, Shanghai University of Traditional Chinese Medicine","place":["Shanghai, China"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Hongxia","family":"Duan","sequence":"additional","affiliation":[{"name":"School of Rehabilitation Science, Shanghai University of Traditional Chinese Medicine","place":["Shanghai, China"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Hui","family":"Li","sequence":"additional","affiliation":[{"name":"School of Rehabilitation Science, Shanghai University of Traditional Chinese Medicine","place":["Shanghai, China"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jiachi","family":"Zhang","sequence":"additional","affiliation":[{"name":"School of Rehabilitation Science, Shanghai University of Traditional Chinese Medicine","place":["Shanghai, China"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jian","family":"Li","sequence":"additional","affiliation":[{"name":"School of Rehabilitation Science, Shanghai University of Traditional Chinese Medicine","place":["Shanghai, China"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Peijun","family":"Li","sequence":"additional","affiliation":[{"name":"School of Rehabilitation Science, Shanghai University of Traditional Chinese Medicine","place":["Shanghai, China"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Xiaodan","family":"Liu","sequence":"additional","affiliation":[{"name":"School of Rehabilitation Science, Shanghai University of Traditional Chinese Medicine","place":["Shanghai, China"]},{"name":"Institute of Rehabilitation Medicine, Shanghai Academy of Traditional Chinese Medicine","place":["Shanghai, China"]},{"name":"Engineering Research Center of Traditional Chinese Medicine Intelligent Rehabilitation, Ministry of Education","place":["Shanghai, China"]}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1965","published-online":{"date-parts":[[2026,8,11]]},"reference":[{"key":"B1","doi-asserted-by":"publisher","first-page":"3","DOI":"10.2147\/COPD.S341484","article-title":"Diaphragm ultrasound is an imaging biomarker that distinguishes exacerbation status from stable chronic obstructive pulmonary disease","volume":"17","author":"An","year":"2022","journal-title":"Int. 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