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Lifestyle and Asthma
Friday, September 20
13.00pm-13.40pm
Holt et al, in Holgate, Allergy – 4th ed. 2012
AsthmaAllergies
3 four 50
3 risk factors
smoking, diet , physical inactivity
contribute to
4 common chronic diseases diabetes, CVD, some Ca, Lung Disease
which are responsible for
50% of the world’s mortality
Lifestyle and asthma
Diet Obesity Antioxidants Fibre
Smoking Breathing techniques Psychosocial variables
THE WESTERN DIET - Fuel for inflammation ?
Low antioxidant intake: Increased use of processed foods Low fruit, vegetable, whole grain intake Altered fatty acid profile: Low n-3:n-6 fatty acid ratio Low monounsaturated fat intake Higher %saturated fat Trans fats
Chronic ‘metabolic surplus’ (→ Obesity) Less Fibre
EosinophilicSputum
Non-Eosinophilic Sputum
Asthma and obesity: physiology
‘breathing space’
Farah C, Salome CM. Respirology 2011;17: 412-421
Asthma and obesity: physiology
Farah C, Salome CM. Respirology 2011;17: 412-421
‘breathing space’
Lost in obesity
XS substrate: caloric intake
Adipose tissue: function, cellular infiltration
Stable asthma, fast 12 hrs, then randomised to :High Fat food challenge:
48gm total fatLow Fat food challenge:
2.2 gm fat Assessed at 0, 2, 4 hrsBlood, sputum, FEV1
Wood LG, JACI 2011, 127:1133Copyright © 2011 American Academy of Allergy, Asthma & Immunology
Wood LG, JACI 2011, 127:1133
Impaired BronchodilatorRecovery after High Fat Meal
Adipose tissue, fat, drives inflammation
Biochim Biophys Acta 2011, 1810, 1120-6Lugogo N, Bappanad D, Kraft M,
Serum Leptin increased in asthma
Berthon B, Respirology, 2012
Weight loss in obese asthma ?
Randomised trial: asthma and obesity BMI>27
3 interventions: 1. diet: meal replacements 2. exercise: gym membership 3. diet+ exercise
Hayley Scott, Lisa Wood, Clin Exp Allergy 2013
Weight loss in obese asthma: is possible, and effective
Dietary Exercise Combined-1.75
-1.50
-1.25
-1.00
-0.75
-0.50
-0.25
0.00
0.25
0.50
0.75
p<0.001
p=0.040
p=0.152A
CQ
Ch
an
geDietary Exercise Combined
0.0
2.5
5.0
7.5
10.0
p<0.001 p<0.063 p<0.001
p<0.001 p=0.001
%W
eig
ht
Lo
ss
Hayley Scott, Lisa Wood
0
20
40
60
80
100
<5% Weight Loss 5-10% Weight Loss >10% Weight Loss
Per
cen
t o
f S
ub
ject
s
<0.5 increase in AQLQ
≥0.5 increase in AQLQ
How much weight do you need to lose to benefit asthma?
5 to 10%
What about children ?Weight loss in obese children with asthma: a randomized controlled trial
Jensen M, etal Clinical & Experimental Allergy 2013 :43:775,
Obesity and Asthma in Pregnancy
Obesity, Weight gain in pregnancy N=244, Age 28yrs Maintenance ICS 30% Smoker 17% Wt gain/week
0.5kg Gain>recommended
71%
0
5
10
15
20
25
30
35
40
45
weightgroup
healthy wt
overwt
obese%
Obesity increases asthma exacerbation risk in pregnancy
0.5
1
1.5
2
2.5
overwt
obese
Column 3
ICS
FeNO
OR
Obesity and Asthma Management
‘We should manage obesity like we manage smoking’
Barbiedull.deviantart.com
Antioxidants: fresh fruit and vegetables
Carotenoids
3
Epidemiological data has shown relationships between:- Dietary intake of Carotenoid-rich foods (Fruit, Vegetables and Tomatoes) and Asthma- Blood levels of Carotenoids
(lycopene, -carotene, lutein and -carotene) and FEV1
Carotenoids are:- antioxidants that act by scavenging free radicals- red/ orange pigments found in fruit and vegetables
e.g. Lycopene (tomatoes, watermelon) -carotene (carrots, mangoes)
Hypothesis
Carotenoid (lycopene) supplementation may protect
against asthma
Kaplan-Meier survival curve for time to exacerbation in subjects consuming different study diets.
Wood L G et al. Am J Clin Nutr 2012;96:534-543
FibrePrebioticsProbiotics
Lifestyle and asthma
Diet Obesity: risk factor for asthma, can be modified Antioxidants: low in asthma, can be replaced Fibre: watch this space!
Smoking and smoke free legislation Breathing techniques Psychosocial variables
Smoking
ASTHMA SEVERITY(“difficulty to treat”)
ASTHMA CONTROL
Current clinical control
Future risk
DISEASE ACTIVITY
ASTHMA PHENOTYPES
ExacerbationsLoss of FEV1
Noneosinophilic asthma
Smoking
0
10
20
30
40
50
60
70
80
EA NEA
ASTHMA SEVERITY(“difficulty to treat”)
ASTHMA CONTROL
Current clinical control
Future risk
DISEASE ACTIVITY
ASTHMA PHENOTYPES
ExacerbationsLoss of FEV1
Non-response to steroid
Noneosinophilic asthma
Smoking
IncreasedNeutrophils, IL-8
-0.8-0.7-0.6-0.5-0.4-0.3-0.2-0.1
00.10.20.3
Never Ex Smokers
FEV,lControl
Smoke-free legislation and asthma admissions In New Zealand, a 16% decline
Edwards E, NZ MoH 2006 Meta-analysis, average 24% reduction in
asthma admissions Tan CE Circulation 2012
Immediate reduction in asthma admissions adult 4.9%, children 9% UK, 4100 admissions prevented each year Sims M Thorax 2013;68:619. Millett C, Pediatrics 2013
Smoking, asthma, pregnancy
Effect of smoking on asthma exacerbations in pregnancy
Asthma n=80 Smokers 34%
Nonasthma n=46 Smokers 15%
Smokers lo dose, 4 PY
5-6 cigs/day
Murphy etal, Thorax, 2010
0
2
4
6
8
10
12
14
16
never ex smoker
eCO, ppm
Exacerbation rates
Never smoker Ex-smoker Current smoker0.0
0.2
0.4
0.6
0.8
1.0
1.2
1.4Mild exacerbationsSevere Exacerbations
Ex
ac
erb
ati
on
s p
er
Pre
gn
an
cy
Cumulative Exacerbations
0 10 20 30 400
10
20
30
Ex smokerCurrent Smoker
Never smoker
*
Gestational age (weeks)
No
. o
f s
ev
ere
ex
ac
erb
ati
on
s
a)
b)
Murphy Thorax 2010
Breathing techniques
Percentage of “severe asthma” Percentage of “severe asthma” patients with alternative or co-patients with alternative or co-existent diagnoses causing existent diagnoses causing symptomssymptoms
Thorax 2003; 58: 561–66
Eur Respir J 2003; 22: 478–83
-0.4
-0.2
0
0.2
0.4
0.6
0.8
Ovrall,p=0.018
Symptomsdomain,p=0.042
Activitiesdomain,p=0.007
EmotionsDomain,p=0.205
Environmentdomainp=0.018
Treatment, n=16
Control, n=15
Conclusion : over half the patients treated in the community for asthma who have symptoms suggesting dysfunctional breathing, show a clinically important improvement in QoL following a brief physiotherapy intervention of breathing retraining. The effect persists for 6 months.
Breathing techniques: elements of successful programmes Pattern
Increased abdominal Reduced clavicular Apnea [breathhold]
Rate reduced
Route Nasal vs oral
‘Felt sense of breath’ Hypoventilation,
Ancilliary Posture Relaxation Counselling/CBT
Psychosocial variables
1.00
0.75
0.50
0.25
0.00Pr
opor
tion
fre
e of
exa
cerb
atio
ns
Time (months)
3 6 9 12
Abbreviation: NAD: neither anxiety nor depression symptoms; A/D: either anxiety or depression symptoms; AD: anxiety and depression symptoms. HADS: Hospital anxiety and depression scale.
Wang G, et al. J Asthma. 2011; 48: 1041-50
Asthma with anxiety /depression = increased Exacerbation risk. Szechuan, China.
Psychosocial issues and Asthma in Pregnancy
Illness beliefs and anxiety are associated with:
Quality of lifeAsthma controlExacerbations
Preterm birthElective C section
Powell H, J Asthma 2011; 48:1032
Perceived control over asthma Perceived Control of Asthma Questionnaire
The perceived ability to deal with asthma symptoms and exacerbations
Greater perceived control of asthma reduced the risk of asthma exacerbation in
pregnancy, OR 0.9 for each 5 unit increase in PCAQ score,
women were 40% less likely to exacerbate during the remainder of pregnancy
Powell H, J Asthma 2013; 50:383
Perceived control over asthma Perceived Control of Asthma Questionnaire Reduced preterm birth OR 0.84, Reduced C-section OR 0.8 For each 5 unit increase in PCAQ score
women were 80% less likely to have a preterm delivery
Powell H, J Asthma 2013; 50:383
Lifestyle and asthma
Diet Obesity: risk factor for asthma, can be modified Antioxidants: low in asthma, can be replaced Fibre: watch this space!
Smoking and smoke free legislation effective
Breathing techniques, Psychosocial variables Needs more research, but intervention looks
promising
Lifestyle
Ancient Rome Otium: leisure time in which a person can
enjoy eating, playing, resting, contemplation, academic endeavours
‘It is better to lie on the naked ground and be at ease, than to have a golden coach and a rich table and be worried’ Epicurean proverb
Study DesignStudy Design
* ICS
Week
Group A video and exercises daily
Run-in
Group B video and exercises daily
-2 0 6 12 14 22 28
PEF PEF
* *16
ICS dose stable ICS dose reduction
ICS dose stable ICS dose reduction
30
PE
F
Wa
sh
ou
t
V1 V2 V3 V4 V5 V6 V7 V8 V9
PEF
Wee
k 12
Wee
k 14
Wee
k 16
Wee
k 22
Wee
k 28
0
0.5
1
1.5
2
2.5
Wee
k 6
Wee
k 30
Group A
Group BMedian Daily Reliever Median Daily Reliever UseUse
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