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Burney et al1 recently presented an ecological analysis of Burden of Obstructive Lung Disease (BOLD) study data to investigate the association between chronic obstructive pulmonary disease (COPD) prevalence and mortality with smoking and poverty. It is striking that no association was observed between the national prevalence rates of COPD and airflow limitation. This raises serious questions about the accuracy of COPD diagnosis, and suggests that COPD was considerably overdiagnosed. Despite this, the authors’ main conclusion is that the high COPD mortality in low-income countries is associated with spirometric restriction, but the case for this is unconvincing.
There are several methodological reasons why the findings need …