Lifestyle and Asthma
Friday, September 20
13.00pm-13.40pm
Asthma
Allergies
Holt et al, in Holgate, Allergy – 4th ed. 2012
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
Eosinophilic
Sputum
Non-Eosinophilic
Sputum
Asthma and obesity: physiology
‘breathing space’
Farah C, Salome CM. Respirology
2011;17: 412-421
Asthma and obesity: physiology
‘breathing space’
Lost in obesity
Farah C, Salome CM. Respirology 2011;17: 412-421
XS substrate: caloric intake
Adipose tissue: function,
cellular infiltration
Effects of a Hi fat food challenge
in Asthma Wood LG, JACI 2011;127:1133
Stable asthma, fast 12 hrs,
then randomised to :
High Fat food challenge:
48gm total fat
Low Fat food challenge:
2.2 gm fat
Assessed at 0, 2, 4 hrs
Blood, sputum, FEV1
Wood LG, JACI 2011, 127:1133
Copyright © 2011 American Academy of Allergy, Asthma & Immunology
Impaired
Bronchodilator
Recovery
after High Fat Meal
Wood LG, JACI 2011, 127:1133
Adipose tissue, fat, drives
inflammation
Biochim Biophys Acta 2011, 1810, 1120-6
Lugogo 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
p<0.001
p=0.001
10.0
5.0
2.5
0.75
0.0
p<0.001
p<0.063
p<0.001
Dietary
Exercise
Combined
p=0.040
0.50
0.25
ACQ Change
%Weight Loss
7.5
p<0.001
p=0.152
0.00
-0.25
-0.50
-0.75
-1.00
-1.25
-1.50
-1.75
Hayley Scott, Lisa Wood
Dietary
Exercise
Combined
How much weight do you need
to lose to benefit asthma?
100
<0.5 increase in AQLQ
≥0.5 increase in AQLQ
Percent of Subjects
80
5 to 10%
60
40
20
0
<5% Weight Loss
5-10% Weight Loss
>10% Weight Loss
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%
45
Smoker 17%
40
Wt gain/week
% 35


0.5kg
Gain>recommended

71%
healthy wt
overwt
obese
30
25
20
15
10
5
0
weightgroup
Obesity increases asthma
exacerbation risk in pregnancy
2.5
2
OR
1.5
1
0.5
overwt
obese
Column 3
ICS
FeNO
Obesity and Asthma Management
‘We should manage obesity like we manage
smoking’
Barbiedull.deviantart.com
Antioxidants: fresh fruit and
vegetables
Carotenoids
Carotenoids are:
- antioxidants that act by scavenging free radicals
- red/ orange pigments found in fruit and vegetables
e.g. Lycopene (tomatoes, watermelon)
b-carotene (carrots, mangoes)
Epidemiological data has shown relationships between:
- Dietary intake of Carotenoid-rich foods
(Fruit, Vegetables and Tomatoes) and Asthma
- Blood levels of Carotenoids
(lycopene, b-carotene, lutein and a-carotene) and FEV1
3
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
Fibre
Prebiotics
Probiotics
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 CONTROL
Current clinical
control
Future risk
Exacerbations
Loss of FEV1
80
70
ASTHMA SEVERITY
60
(“difficulty to treat”)
50
40
30
DISEASE ACTIVITY
20
10
0
EA
NEA
ASTHMA PHENOTYPES
Noneosinophilic
asthma
Smoking
ASTHMA CONTROL
Current clinical
control
0.3
0.2
0.1
0
-0.1
-0.2
-0.3
-0.4
-0.5
-0.6
-0.7
-0.8
Future risk
ASTHMA SEVERITY
(“difficulty to treat”)
DISEASE ACTIVITY
FEV,l
Control
ASTHMA PHENOTYPES
Never
Ex
Smokers
Exacerbations
Loss of FEV1
Non-response to
steroid
Increased
Neutrophils, IL-8
Noneosinophilic
asthma
Smoking
Smoke-free legislation and asthma
admissions

In New Zealand, a 16% decline


Meta-analysis, average 24% reduction in
asthma admissions


Edwards E, NZ MoH 2006
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
eCO, ppm
16

Asthma n=80


Nonasthma n=46


Smokers 15%
Smokers


Smokers 34%
lo dose, 4 PY
5-6 cigs/day
14
12
10
8
6
4
2
0
never
Murphy etal, Thorax, 2010
ex
smoker
Exacerbation rates
Exacerbations per
Pregnancy
1.4
Mild exacerbations
Severe Exacerbations
1.2
1.0
0.8
0.6
0.4
0.2
0.0
Never smoker Ex-smoker Current smoker
b)
Cumulative Exacerbations
No. of severe
exacerbations
30
Never smoker
Ex smoker
Current Smoker *
20
10
0
0
10
20
30
40
Gestational age (weeks)
Murphy Thorax 2010
Breathing techniques
Percentage of “severe asthma” patients
with alternative or co-existent diagnoses
causing symptoms
Thorax 2003; 58: 561–66
Eur Respir J 2003; 22: 478–83
0.8
0.6
0.4
0.2
Treatment, n= 16
Control, n= 15
0
-0.2
-0.4
Ovrall,
p=0.018
Symptoms
domain,
p=0.042
Activities
domain,
p=0.007
Emotions
Domain,
p=0.205
Environment
domain
p=0.018
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




Rate


Increased abdominal
Reduced clavicular
Apnea [breathhold]
reduced
Route

Nasal vs oral

‘Felt sense of breath’


Hypoventilation,
Ancilliary



Posture
Relaxation
Counselling/CBT
Psychosocial variables
Proportion free of exacerbations
Asthma with anxiety /depression = increased
Exacerbation risk. Szechuan, China.
Proportion free of exacerbations
0.00
0.25
0.50
0.75
A1.00
3
6
Time since baseline
(months)
9
Time (months)
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
12
Psychosocial issues
and Asthma in Pregnancy
Illness beliefs and anxiety are
associated with:
Quality of life
Asthma control
Exacerbations
Preterm birth
Elective 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




Smoking and smoke free legislation


Obesity: risk factor for asthma, can be modified
Antioxidants: low in asthma, can be replaced
Fibre: watch this space!
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 Design
Group A video and exercises daily
ICS dose stable
Run-in

ICS dose reduction
Group B video and exercises daily
PEF
Week
-2
0
V1 V2
ICS dose reduction
PEF
PEF
Washout
ICS dose stable
PEF
*
*
22
6
12
14 16
V3
V4
V5 V6
*
V7
ICS 
28 30
V8 V9
2.5
Group A
Median Daily Reliever
Use
Group B
2
1.5
1
0.5
Week 30
Week 28
Week 22
Week 16
Week 14
Week 12
Week 6
0