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Original research
Long-term effect of asthma on the development of obesity among adults: an international cohort study, ECRHS
  1. Subhabrata Moitra1,2,3,4,
  2. Anne-Elie Carsin2,3,4,
  3. Michael J Abramson5,
  4. Simone Accordini6,
  5. Andre F S Amaral7,
  6. Josep Anto2,3,4,
  7. Roberto Bono8,
  8. Lidia Casas Ruiz9,10,
  9. Isa Cerveri11,
  10. Leda Chatzi12,13,14,
  11. Pascal Demoly15,16,
  12. Sandra Dorado-Arenas17,
  13. Bertil Forsberg18,
  14. Frank Gilliland13,
  15. Thorarinn Gislason19,20,
  16. Jose A Gullón21,
  17. Joachim Heinrich22,23,
  18. Mathias Holm24,
  19. Christer Janson25,
  20. Rain Jogi26,
  21. Francisco Gómez Real27,28,
  22. Debbie Jarvis29,
  23. Bénédicte Leynaert30,31,
  24. Dennis Nowak22,
  25. Nicole Probst-Hensch32,33,
  26. José Luis Sánchez-Ramos34,
  27. Chantal Raherison-Semjen35,
  28. Valerie Siroux36,
  29. Stefano Guerra37,
  30. Manolis Kogevinas2,3,4,
  31. Judith Garcia-Aymerich2,3,4
  1. 1Division of Pulmonary Medicine, Department of Medicine, Faculty of Medicine & Dentistry, University of Alberta, Edmonton, Alberta, Canada
  2. 2Non-Communicable Diseases and Environment Programme, ISGlobal, Barcelona, Spain
  3. 3Universitat Pompeu Fabra (UPF), Barcelona, Spain
  4. 4CIBER Epidemiología y Salud Pública (CIBERESP), Barcelona, Spain
  5. 5School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
  6. 6Unit of Epidemiology and Medical Statistics, Department of Public Health and Community Medicine, University of Verona, Verona, Italy
  7. 7National Heart and Lung Institute, Imperial College London, London, UK
  8. 8Department of Public Health and Pediatrics, University of Turin, Torino, Italy
  9. 9Epidemiology and Social Medicine, University of Antwerp, Antwerpen, Belgium
  10. 10Centre for Environment and Health, Department of Public Health and Primary Care, KU Leuven, Leuven, Belgium
  11. 11Unit of Respiratory Diseases, IRCCS Policlinico San Matteo, University of Pavia, Pavia, Italy
  12. 12Department of Social Medicine, University of Crete, Rethimno, Greece
  13. 13Department of Preventive Medicine, USC Keck School of Medicine, Los Angeles, California, USA
  14. 14Department of Genetics & Cell Biology, Maastricht University, Maastricht, The Netherlands
  15. 15Department of Pulmonology, Division of Allergy, University Hospital of Montpellier, Montpellier, France
  16. 16Inserm, Sorbonne Université, Equipe, EPAR - IPLESP, Paris, France
  17. 17Osakidetza Basque Health Service, Department of Respiratory Medicine, Galdakao University Hospital, Galdakao, Spain
  18. 18Section of Sustainable Health, Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden
  19. 19Department of Sleep, Landspitali - The National University Hospital of Iceland, Reykjavik, Iceland
  20. 20Faculty of Medicine, University of Iceland, Reykjavik, Iceland
  21. 21Department of Pneumology, Universitary Hospital San Agustín, Avilés, Spain
  22. 22Institute and Outpatient Clinic for Occupational, Social and Environmental Medicine, Ludwig Maximilians University Munich, University Hospital Munich, Munich, Germany
  23. 23Institut of Epidemiology, Helmholtz Zentrum München, German Research Center for Environmental Health, Oberschleissheim, Germany
  24. 24Department of Public Health and Community Medicine, Institute of Medicine, University of Gothenburg, Gothenburg, Sweden
  25. 25Department of Medical Sciences, Respiratory, Allergy and Sleep Research, Uppsala University, Uppsala, Sweden
  26. 26Lung Clinic, Tartu University Hospital, Tartu, Estonia
  27. 27Department of Gynaecology and Obstetrics, Haukeland University Hospital, Bergen, Norway
  28. 28Department of Clinical Science, University of Bergen, Bergen, Norway
  29. 29MRC Centre for Environment and Health, Imperial College London, London, UK
  30. 30Inserm - U1168, VIMA (Aging and Chronic Diseases. Epidemiological and Public Health Approaches), INSERM, Villejuif, France
  31. 31UMR-S 1168, Université de Versailles Saint-Quentin-en-Yvelines - UVSQ, Saint-Quentin-en-Yvelines, France
  32. 32Department Epidemiology and Public Health, Swiss Tropical and Public Health Institute, Basel, Switzerland
  33. 33Department of Clinical Research, University of Basel, Basel, Switzerland
  34. 34Department of Nursing, University of Huelva, Huelva, Spain
  35. 35INSERM U1219, Institute of Public Health and Epidemiology, CHU de Bordeaux, Bordeaux, France
  36. 36Team of Environemental Epidemiology, Inserm U1209, Univ Grenoble Alpes, La Tronche, France
  37. 37Arizona Respiratory Center, University of Arizona Medical Center - University Campus, Tucson, Arizona, USA
  1. Correspondence to Dr Subhabrata Moitra, Division of Pulmonary Medicine, Department of Medicine, Faculty of Medicine & Dentistry, University of Alberta, Edmonton, AB T6G 2R3, Canada; moitra{at}ualberta.ca

Abstract

Introduction Obesity is a known risk factor for asthma. Although some evidence showed asthma causing obesity in children, the link between asthma and obesity has not been investigated in adults.

Methods We used data from the European Community Respiratory Health Survey (ECRHS), a cohort study in 11 European countries and Australia in 3 waves between 1990 and 2014, at intervals of approximately 10 years. We considered two study periods: from ECRHS I (t) to ECRHS II (t+1), and from ECRHS II (t) to ECRHS III (t+1). We excluded obese (body mass index≥30 kg/m2) individuals at visit t. The relative risk (RR) of obesity at t+1 associated with asthma at t was estimated by multivariable modified Poisson regression (lag) with repeated measurements. Additionally, we examined the association of atopy and asthma medication on the development of obesity.

Results We included 7576 participants in the period ECRHS I-II (51.5% female, mean (SD) age of 34 (7) years) and 4976 in ECRHS II-III (51.3% female, 42 (8) years). 9% of participants became obese in ECRHS I-II and 15% in ECRHS II—III. The risk of developing obesity was higher among asthmatics than non-asthmatics (RR 1.22, 95% CI 1.07 to 1.38), and particularly higher among non-atopic than atopic (1.47; 1.17 to 1.86 vs 1.04; 0.86 to 1.27), those with longer disease duration (1.32; 1.10 to 1.59 in >20 years vs 1.12; 0.87 to 1.43 in ≤20 years) and those on oral corticosteroids (1.99; 1.26 to 3.15 vs 1.15; 1.03 to 1.28). Physical activity was not a mediator of this association.

Conclusion This is the first study showing that adult asthmatics have a higher risk of developing obesity than non-asthmatics, particularly those non-atopic, of longer disease duration or on oral corticosteroids.

  • Asthma
  • Asthma Epidemiology
  • Clinical Epidemiology

Data availability statement

Data are available on reasonable request.

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Data availability statement

Data are available on reasonable request.

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Footnotes

  • Twitter @Subha_Moitra

  • SM and A-EC contributed equally.

  • Collaborators ECRHS I Co-ordinating Centre (London): P Burney, S Chinn, C Luczynska†, D Jarvis, E Lai. Project Management Group: P Burney (Project leader-UK), S Chinn (UK), C Luczynska† (UK), D Jarvis (UK), P Vermeire† (Antwerp), H Kesteloot (Leuven), J Bousquet (Montpellier), D Nowak (Hamburg), J Prichard† (Dublin), R de Marco† (Verona), B Rijcken (Groningen), JM Anto (Barcelona), J Alves (Oporto), G Boman (Uppsala), N Nielsen (Copenhagen), P Paoletti (Pisa). ECRHS II Steering Committee: U. Ackermann-Liebrich (University of Basel, Switzerland); N. Kuenzli (University of Basel, and University of Southern California, Los Angeles, USA); J.M. Antó and J. Sunyer (Institut Municipal d’ Investigació Médica (IMIM-IMAS), Universitat Pompeu Fabra (UPF), Spain); P. Burney (project leader), S Chinn, D. Jarvis, J. Knox and C. Luczynska (King’s College London, UK); I. Cerveri (University of Pavia, Italy); R. de Marco† (University of Verona, Italy); T. Gislason (Iceland University Hospital, Iceland); J. Heinrich and M. Wjst (GSF-Institute of Epidemiology, Germany); C. Janson (Uppsala University, Sweden); B. Leynaert and F. Neukirch (Institut National de la Sante' et de la Recherche Meidicale (INSERM),France); J. Schouten (University of Groningen, The Netherlands); C. Svanes (University of Bergen, Norway); P. Vermeire† (University of Antwerp, Belgium). Principal Investigators and senior scientific teams: Australia: (M. Abramson, E.H Walters, J. Raven); Belgium: South Antwerp and Antwerp City (P. Vermeire, J. Weyler, M. van Sprundel, V. Nelen); Estonia: Tartu (R. Jõgi, A. Soon); France: Paris (F. Neukirch, B. Leynaert, R. Liard, M. Zureik), Grenoble (I. Pin, J. Ferran-Quentin), Bordeaux (A. Taytard, C.Raherison), Montpellier (J.Bousquet, PJ Bousquet); Germany: Erfurt (J. Heinrich, M. Wjst, C. Frye, I. Meyer); Iceland: Reykjavik (T. Gislason, E. Bjornsson, D. Gislason, K.B Jörundsdóttir); Italy: Turin (R. Bono, M. Bugiani, P.Piccioni, E. Caria, A. Carosso, E. Migliore, G. Castiglioni), Verona (R. de Marco†, G. Verlato, E. Zanolin, S. Accordini, A. Poli, V. Lo Cascio, M. Ferrari, I. Cazzoletti), Pavia (A. Marinoni, S. Villani, M. Ponzio, F. Frigerio, M. Comelli, M. Grassi, I. Cerveri, A. Corsico); Norway: Bergen (A. Gulsvik, E. Omenaas, C. Svanes, B. Laerum); Spain: Albacete (J. Martinez-Moratalla Rovira, E. Almar, M. Arévalo, C. Boix, G González, J.M. Ignacio García, J. Solera, J Damián), Galdakao (N. Muñozguren, J. Ramos, I. Urrutia, U. Aguirre), Barcelona (J. M. Antó, J. Sunyer, M. Kogevinas, J. P. Zock, X. Basagaña, A. Jaen, F. Burgos, C. Acosta), Huelva (J. Maldonado, A. Pereira, J.L. Sanchez), Oviedo (F. Payo, I . Huerta, A. de la Vega, L Palenciano, J Azofra, A Cañada); Sweden: Göteborg (K. Toren,L. Lillienberg, A. C. Olin, B. Balder, A. Pfeifer-Nilsson, R. Sundberg), Umea (E. Norrman, M. Soderberg, K.A Franklin, B. Lundback, B. Forsberg, L. Nystrom), Uppsala (C. Janson, G. Boman, D. Norback, G. Wieslander, M. Gunnbjornsdottir); Switzerland: Basel (N. Küenzli, B. Dibbert, M. Hazenkamp, M. Brutsche, U. Ackermann-Liebrich); United Kingdom: Ipswich (D. Jarvis, R. Hall, D. Seaton), Norwich (D. Jarvis, B. Harrison). ECRHS III Principal Investigators and senior scientific teams: Australia: Melbourne (M.Abramson, G. Benke, S. Dharmage, B. Thompson, S. Kaushik, M Matheson). Belgium: South Antwerp & Antwerp City (J. Weyler, H.Bentouhami, V. Nelen). Estonia: Tartu (R. Jõgi, H.Orru). France: Bordeaux (C. Raherison, P.O Girodet) Grenoble (I. Pin, V. Siroux, J.Ferran, J.L Cracowski) Montpellier (P. Demoly, A.Bourdin, I. Vachier) Paris (B. Leynaert, D. Soussan, D. Courbon, C. Neukirch, L. Alavoine, X. Duval, I. Poirier). Germany: Erfurt (J. Heinrich, E. Becker, G. Woelke, O. Manuwald) Hamburg (H. Magnussen, D. Nowak, A-M Kirsten). Iceland: Reykjavik (T. Gislason, B. Benediktsdottir, D. Gislason, E.S Arnardottir, M. Clausen, G. Gudmundsson, L. Gudmundsdottir, H. Palsdottir, K. Olafsdottir, S. Sigmundsdottir, K. Bara-Jörundsdottir). Italy: Pavia (I .Cerveri, A.Corsico, A. Grosso, F. Albicini, E. Gini, E.M Di Vincenzo, V. Ronzoni, S. Villani, F. Campanella, M. Gnesi, F. Manzoni, L. Rossi, O. Ferraro) Turin: (M. Bugiani, R. Bono, P. Piccioni, R. Tassinari, V. Bellisario, G. Trucco) Verona: (R de Marco†, S. Accordini, L. Calciano, L. Cazzoletti, M. Ferrari, A.M Fratta Pasini, F. Locatelli, P. Marchetti, A. Marcon, E. Montoli, G. Nguyen, M. Olivieri, C. Papadopoulou, C.Posenato, G. Pesce, P. Vallerio, G. Verlato, E. Zanolin). Norway: (C. Svanes, E. Omenaas, A. Johannessen, T. Skorge, F. Gomez Real). Spain: Albacete (J. Martinez-Moratalla Rovira, E. Almar, A. Mateos, S. García, A. Núñez, P.López, R. Sánchez, E Mancebo), Barcelona: (J-M. Antó, J.P Zock, J Garcia-Aymerich, M Kogevinas, X. Basagaña, A.E. Carsin, F. Burgos, C. Sanjuas, S Guerra, B. Jacquemin, P. Davdand) Galdakao: (N. Muñozguren, I. Urrutia, U. Aguirre, S. Pascual), Huelva:(J Antonio Maldonado, A. Pereira, J. Luis Sánchez, L. Palacios, Oviedo: (F. Payo, I. Huerta, N. Sánchez, M. Fernández, B. Robles). Sweden: Göteborg (K. Torén, M. Holm, J-L Kim, A-C. Olin, A. Dahlman-Höglund), Umea (B. Forsberg, L. Braback, L Modig, B Järvholm, H Bertilsson, K.A Franklin, C Wahlgreen), Uppsala: (B Andersson, D Norback, U Spetz Nystrom, G Wieslander, G.M Bodinaa Lund, K Nisser); Switzerland: Basel (N.M. Probst-Hensch, N. Künzli, D. Stolz, C. Schindler, T. Rochat, J.M. Gaspoz, E. Zemp Stutz, M.Adam, C. Autenrieth, I. Curjuric, J. Dratva, A. Di Pasquale, R. Ducret-Stich, E. Fischer, L. Grize, A. Hensel, D. Keidel, A. Kumar, M. Imboden, N. Maire, A. Mehta, H. Phuleria, M. Ragettli, M. Ritter, E. Schaffner, G.A Thun, A. Ineichen, T. Schikowski, M. Tarantino, M. Tsai. UK: London (P. Burney, D. Jarvis, S. Kapur, R. Newson, J. Potts), Ipswich: (N. Innes), Norwich: (A. Wilson).

  • Contributors SM, A-EC, MK and JG-A conceived the study design, analysed the results, interpreted the data, and drafted the manuscript. SG interpreted the data; drafted the article or revised it; provided intellectual content of critical importance to the work described. All other authors revised the manuscript and provided critical comments. SM, A-EC, and JG-A are the guarantors and accept full responsibility for the finished work and/or the conduct of the study, had access to the data, and controlled the decision to publish.

  • Funding The following grants helped to fund the local studies. Australia: Asthma Foundation of Victoria, Allen and Hanbury's, Belgium: Belgian Science Policy Office, National Fund for Scientific Research, Estonia: Estonian Science Foundation, grant no 1088, France: Ministère de la Santé, Glaxo France, Insitut Pneumologique d'Aquitaine, Contrat de Plan Etat-Région Languedoc-Rousillon, CNMATS, CNMRT (90MR/10, 91AF/6), Ministre delegué de la santé, RNSP, France; GSF, Germany: Bundesminister für Forschung und Technologie, Italy: Ministero dell'Università e della Ricerca Scientifica e Tecnologica, CNR, Regione Veneto grant RSF n. 381/05.93, Norway: Norwegian Research Council project no. 101422/310, Spain: Fondo de Investigación Sanitaria (#91/0016-060-05/E, 92/0319 and #93/0393), Hospital General de Albacete, Hospital General Juan Ramón Jiménez, Dirección Regional de Salud Pública (Consejería de Sanidad del Principado de Asturias), CIRIT (1997 SGR 00079) and Servicio Andaluz de Salud, Sweden: The Swedish Medical Research Council, the Swedish Heart Lung Foundation, the Swedish Association against Asthma and Allergy, Switzerland: Swiss national Science Foundation grant 4026-28099, UK: National Asthma Campaign, British Lung Foundation, Department of Health, South Thames Regional Health Authority. Coordination: The co-ordination of this work was supported by the European Commission and the authors and participants are grateful to the late C. Baya and M. Hallen for their help during the study and K. Vuylsteek and the members of the COMAC for their support. Financial Support: Australia: National Health and Medical Research Council; Belgium: Antwerp: Fund for Scientific Research (grant code, G.0402.00), University of Antwerp, Flemish Health Ministry; Estonia: Tartu Estonian Science Foundation grant no 4350; France: (All) Programme Hospitalier de Recherche Clinique—Direction de la Recherche Clinique (DRC) de Grenoble 2000 number 2610, Ministry of Health, Ministère de l’Emploi et de la Solidarité, Direction Génerale de la Santé, Centre Hospitalier Universitaire (CHU) de Grenoble, Bordeaux: Institut Pneumologique d’Aquitaine, Grenoble: Comite des Maladies Respiratoires de l’Isere, Montpellier: Aventis (France), Direction Regionale des Affaires Sanitaires et Sociales Languedoc-Roussillon, Paris: Union Chimique Belge- Pharma (France), Aventis (France), Glaxo France; Germany: Erfurt GSF—National Research Centre for Environment and Health, Deutsche Forschungsgemeinschaft (grant code, FR1526/1-1), Hamburg: GSF—National Research Centre for Environment and Health, Deutsche Forschungsgemeinschaft (grant code, MA 711/4-1); Iceland: Reykjavik, Icelandic Research Council, Icelandic University Hospital Fund; Italy: Pavia GlaxoSmithKline Italy, Italian Ministry of University and Scientific and Technological Research (MURST),Local University Funding for Research 1998 and 1999, Turin: Azienda Sanitaria Locale 4 Regione Piemonte (Italy), Azienda Ospedaliera Centro Traumatologico Ospedaliero/Centro Traumatologico Ortopedico—Istituto Clinico Ortopedico Regina Maria Adelaide Regione Piemonte, Verona: Ministero dell’Universita' e della Ricerca Scientifica (MURST), Glaxo Wellcome spa; Norway: Bergen: Norwegian Research Council, Norwegian Asthma and Allergy Association, Glaxo Wellcome AS, Norway Research Fund; Spain: Fondo de Investigacion Santarias (grant codes, 97/0035-01,99/0034-01 and 99/0034 02), HospitalUniversitario de Albacete, Consejeria de Sanidad, Barcelona: Sociedad Espanola de Neumologı'a y Cirugı'a Toracica, Public Health Service(grant code, R01 HL62633-01), Fondo de Investigaciones Santarias (grant codes, 97/0035-01, 99/0034-01, and 99/0034-02), Consell Interdepartamentalde Recerca i Innovacio' Tecnolo'gica (grant code, 1999SGR 00241) Instituto de Salud Carlos III; Red deCentros de Epidemiologı'a y Salud Pu'blica, C03/09,Redde Basesmoleculares y fisiolo'gicas de lasEnfermedadesRespiratorias,C03/011and Red de Grupos Infancia y Medio Ambiente G03/176, Huelva: Fondo de Investigaciones Santarias (grant codes, 97/0035-01, 99/0034-01, and 99/0034-02), Galdakao: Basque Health Department, Oviedo: Fondo de Investigaciones Sanitaria (97/0035-02, 97/0035, 99/0034-01, 99/0034-02, 99/0034-04, 99/0034-06, 99/350, 99/0034--07), European Commission (EU-PEAL PL01237), Generalitat de Catalunya (CIRIT 1999 SGR 00214), Hospital Universitario de Albacete, Sociedad Española de Neumología y Cirugía Torácica (SEPAR R01 HL62633-01) Red de Centros de Epidemiología y Salud Pública (C03/09), Red de Bases moleculares y fisiológicas de las Enfermedades Respiratorias (C03/011) and Red de Grupos Infancia y Medio Ambiente (G03/176);97/0035-01, 99/0034-01, and99/0034-02); Sweden: Göteborg, Umea, Uppsala: Swedish Heart Lung Foundation, Swedish Foundation for Health Care Sciences and Allergy Research, Swedish Asthma and Allergy Foundation, Swedish Cancer and Allergy Foundation, Swedish Council for Working Life and Social Research (FAS); Switzerland: Basel Swiss National Science Foundation, Swiss Federal Office for Education and Science, Swiss National Accident Insurance Fund; UK: Ipswich and Norwich: Asthma UK (formerly known as National Asthma Campaign). Coordination: The coordination of this work was supported by the European Commission, as part of their Quality of Life programme, (Grant code: QLK4-CT-1999-01237). Financial Support: Australia: National Health & Medical Research Council. Belgium: Antwerp South, Antwerp City: Research Foundation Flanders (FWO), grant code G.0.410.08.N.10 (both sites). Estonia: Tartu- SF0180060s09 from the Estonian Ministry of Education. France: (All) Ministère de la Santé. Programme Hospitalier de Recherche Clinique (PHRC) national 2010. Bordeaux: INSERM U897 Université Bordeaux segalen, Grenoble: Comite Scientifique AGIRadom 2011. Paris: Agence Nationale de la Santé, Région Ile de France, domaine d’intérêt majeur (DIM). Germany: Erfurt: German Research Foundation HE 3294/10-1 Hamburg: German Research Foundation MA 711/6-1, NO 262/7-1. Iceland: Reykjavik, The Landspitali University Hospital Research Fund, University of Iceland Research Fund, ResMed Foundation, California, USA, Orkuveita Reykjavikur (Geothermal plant), Vegagerðin (The Icelandic Road Administration (ICERA). Italy: All Italian centres were funded by the Italian Ministry of Health, Chiesi Farmaceutici SpA, in addition Verona was funded by Cariverona foundation, Education Ministry (MIUR). Norway: Norwegian Research council grant no 214123, Western Norway Regional Health Authorities grant no 911631, Bergen Medical Research Foundation. Spain: Fondo de Investigación Sanitaria (PS09/02457, PS09/00716, PS09/01511, PS09/02185, PS09/03190), Servicio Andaluz de Salud, Sociedad Española de Neumología y Cirurgía Torácica (SEPAR 1001/2010). Fondo de Investigación Sanitaria (PS09/02457), Barcelona: Fondo de Investigación Sanitaria (FIS PS09/00716), Galdakao: Fondo de Investigación Sanitaria (FIS 09/01511) Huelva: Fondo de Investigación Sanitaria (FIS PS09/02185) and Servicio Andaluz de Salud Oviedo: Fondo de Investigación Sanitaria (FIS PS09/03190). Sweden: All centres were funded by The Swedish Heart and Lung Foundation, The Swedish Asthma and Allergy Association, The Swedish Association against Lung and Heart Disease, Swedish Research Council for health, working life and welfare (FORTE) Göteborg: Also received further funding from the Swedish Council for Working life and Social Research. Umea also received funding from Vasterbotten Country Council ALF grant. Switzerland: The Swiss National Science Foundation (grants no 33CSCO-134276/1, 33CSCO-108796, 3247BO-104283, 3247BO-104288, 3247BO-104284, 3247-065896, 3100-059302, 3200-052720, 3200-042532, 4026-028099) The Federal office for forest, environment and landscape, The Federal Office of Public Health, The Federal Office of Roads and Transport, the canton’s government of Aargan, Basel-Stadt, Basel-Land, Geneva, Luzern, Ticino, Valais and Zürich, the Swiss Lung League, the canton's Lung League of Basel Stadt/ Basel, Landschaft, Geneva, Ticino, Valais and Zurich, SUVA, Freiwillige Akademische Gesellschaft, UBS Wealth Foundation, Talecris Biotherapeutics GmbH, Abbott Diagnostics, European Commission 018996 (GABRIEL), Wellcome Trust WT 084703MA. UK: Medical Research Council (Grant Number 92091). Support also provided by the National Institute for Health Research through the Primary Care Research Network. Coordination: The coordination was funded through the Medical Research Council (Grant Number 92091).

  • Competing interests SM reports Long-Term Research fellowship and Young Scientist Sponsorship from the European Respiratory Society, outside the submitted work. MJA holds investigator-initiated grants for unrelated research from Pfizer and Boehringer-Ingelheim. He has undertaken an unrelated consultancy for and received assistance with conference attendance from Sanofi and has also received a speaker’s fee from GSK, outside the submitted work. PD reports personal fees from ALK, Stallergenes Greer, IQVIA, Chiesi, AstraZeneca, Thermo Fisher Scientific, Ménarini, Bausch & Lomb, Mylan, ASIT Biotech, Novartis, Sanofi, Regeneron, outside the submitted work. RJ reports grants from Estonian Research Council Personal Research Grant no 562, during the conduct of the study; personal fees from Consultancy, grants from Grants/grants pending, personal fees from Payment for lectures, personal fees from Travel/accommodations/meeting expenses, outside the submitted work. CR-S reports personal fees from ALK, Astra Zeneca, GSK, Novartis, outside the submitted work.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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