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