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Asthma and Obesity: Always Worse Together

Asthma and Obesity: Always Worse Together

  • Like tobacco use and allergen exposure, obesity should be viewed as a modifiable risk factor in asthma care, although mainstream clinical practice has yet to pursue this route.
  • Asthma affects 24.6 million Americans and >300 million people worldwide. Increased prevalence of both asthma and obesity in recent decades, with children a particular concern. Both asthma and obesity disproportionately affect minorities and urban dwellers.(1) Children ≥10 yrs and BMI > 85th percentile are among the highest risk groups for developing asthma.(2)
  • Obese asthma patients have lower quality of life, greater healthcare utilization, 5-fold increased risk of hospitalization during exacerbations.(2) Asthma-obesity link found in a large population study: Asthma prevalence increased 10% per unit increase in BMI in men and 7% in women. Risk for asthma in men increased 10% per unit increase in BMI between 25-30; similar value in women, 7%. Asthma reported more often by overweight/obese persons than those with normal BMI, even after adjusting for smoking, education, physical activity. (2)
  • Early onset atopic asthma: A classic T Helper 2 (Th2) mediated inflammatory disease. Cytokines made by fat tissue and leptin (elevated in obesity) could contribute to chronic inflammation in asthma. Later onset, non-atopic asthma: Obese patients are at increased risk. Adipose-related cytokines and restrictive physiology may both play roles. Breathing at low lung volumes may increase airway hyperresponsiveness and smooth muscle remodeling
  • Overlap of respiratory symptoms of asthma and compromised lung function related to obesity can obscure Dx. Obese patients with acute respiratory symptoms are more likely to receive misdiagnosis of asthma. Spirometry, other lung function tests (LFTs) are essential. Overdiagnosis: Risk of inappropriate treatment, undue expense. Studies show asthma can be ruled out with LFTs in one-third of patients with physician-diagnosed asthma. Underdiagnosis: Impaired perception of dyspnea, airflow obstruction in the obese may contribute
  • NHLBI asthma guidelines asthma do not differentiate drug choices or dosing for asthma in obese patients. One size fits all approach may not work: Multiple studies suggest obese with asthma have decreased response to standard treatment. Obese children may require ↑ doses of inhaled corticosteroids, larger amounts of ß-agonists. Weight loss, with/without surgery, can improve asthma control and lung function. Shared decision making can improve management, including avoidance of environmental triggers, treatment of comorbidities, and medication
  • Asthma and obesity are growing problems in children, and both disproportionately affect minorities and urban dwellers. Obese asthmatics have lower quality of life, greater healthcare utilization, and worse outcomes. Obesity may play a role in the development of early onset atopic asthma and later onset, non-atopic asthma. Diagnosing the obese asthmatic patient can pose a dilemma because of the overlap between respiratory symptoms of asthma and compromised lung function due to obesity. Obese asthmatics have less response to standard treatment; weight loss may be an important part of asthma management in primary care

Obesity and asthma are widespread in the US and they occur together more often than ever before. You see these "dual-diagnosis" patients in primary care. In these half-dozen slides, we look at this  dangerous combination and the particular challenges it poses to diagnosis and disease management.  

 

 

 

References

  1. Mohanan S, Tapp H, McWilliams A, et al. Obesity and asthma: pathophysiology and implications for diagnosis and management in primary care. Exp Biol Med (Maywood). 2014 Nov;239(11):1531-40. doi: 10.1177/1535370214525302. Epub 2014 Apr 9.
  2. Pradeepan S, Garrison G, Dixon AE. Obesity in asthma: approaches to treatment. Curr Allergy Asthma Rep. 2013 Oct;13(5):434-42. doi: 10.1007/s11882-013-0354-z.

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