Poor Asthma Control in Obese Children May Be Overestimated Because of Enhanced Perception of Dyspnea

doi:10.1016/j.jaip.2012.10.006

The Journal of Allergy and Clinical Immunology: In Practice

Volume 1, Issue 1, January 2013, Pages 39-45.e2

https://doi.org/10.1016/j.jaip.2012.10.006 Get rights and content

Background

Although studies in adults have shown a non-T_H2 obese asthma phenotype, whether a similar phenotype exists in children is unclear.

Objective

We hypothesized that asthmatic children with obesity, defined as a body mass index above the 95th percentile for age and sex, would have poorer asthma control as well as decreased quality of life, increased health care utilization, and decreased pulmonary function measures as a function of increased T_H1 versus T_H2 polarization.

Methods

This study involved a post hoc analysis of cross-sectional data from 269 children 6 to 17 years of age enrolled in the National Heart, Lung, and Blood Institute Severe Asthma Research Program. Children answered questionnaires and underwent spirometry, plethysmography, exhaled nitric oxide determination, and venipuncture for T_H1/T_H2 cytokine determination. Asthma control was defined according to national asthma treatment guidelines that are based on prespecified thresholds for lung function and symptom frequency.

Results

Fifty-eight children (22%) were overweight and 67 (25%) were obese. Obese children did not have poorer asthma control but were more likely to report nonspecific symptoms such as dyspnea and nocturnal awakenings. Obese children did have decreased asthma-related quality of life and increased health care utilization, but this was not associated with airflow limitation. Instead, obese children had decreased functional residual capacity. A unique pattern of T_H1 or T_H2 polarization was not observed.

Conclusions

Poor asthma control in obese children with asthma may be overestimated because of enhanced perception of nonspecific symptoms such as dyspnea that results from altered mechanical properties of the chest wall. Careful assessment of physiologic as well as symptom-based measures is needed in the evaluation of obese children with respiratory symptoms.

Section snippets

Methods

This study involved post hoc analysis of cross-sectional data from children 6 to 17 years of age with physician-diagnosed asthma enrolled in the National Heart, Lung, and Blood Institute (NHLBI) Severe Asthma Research Program30, 31 at Emory University in Atlanta, Georgia. All children had historical evidence (within the previous year) of airway hyperresponsiveness to methacholine or at least 12% reversibility in the forced expiratory volume in 1 second (FEV₁) after short-acting bronchodilator

Results

Of the 269 children enrolled, 46% (n = 125) were overweight or obese as shown in Table I. Although age and sex did not differ between groups, children who were overweight or obese were more likely to be of African American or multiracial ancestry. Obese children also had a higher frequency of obstructive sleep apnea and gastroesophageal reflux disease. However, other clinical features such as parental history of asthma, medication use, allergic sensitization, and exhaled nitric oxide

Discussion

In this highly characterized sample of children with physician-diagnosed and confirmed asthma, we failed to observe associations between obesity and a composite variable of asthma control as defined by current asthma treatment guidelines.³⁶ Instead, children with obesity had a high frequency of comorbid conditions and nonspecific symptoms such as dyspnea and nocturnal awakenings that were not accompanied by greater airflow limitation or airway resistance. Although asthma-related quality of life

References (43)

S.J. Szefler
Advancing asthma care: the glass is only half full!
J Allergy Clin Immunol
(2011)
S. Pakhale et al.
A comparison of obese and nonobese people with asthma: exploring an asthma-obesity interaction
Chest
(2010)
S. Scott et al.
Risk of misdiagnosis, health-related quality of life, and BMI in patients who are overweight with doctor-diagnosed asthma
Chest
(2012)
E.R. Sutherland et al.
Body mass index and phenotype in subjects with mild-to-moderate persistent asthma
J Allergy Clin Immunol
(2009)
F. Holguin et al.
Obesity and asthma: an association modified by age of asthma onset
J Allergy Clin Immunol
(2011)
M. Kattan et al.
Asthma control, adiposity, and adipokines among inner-city adolescents
J Allergy Clin Immunol
(2010)
K.B. Quinto et al.
The association of obesity and asthma severity and control in children
J Allergy Clin Immunol
(2011)
J.I. Peters et al.
Impact of obesity in asthma: evidence from a large prospective disease management study
Ann Allergy Asthma Immunol
(2011)
J.E. Lang et al.
Does age impact the obese asthma phenotype? Longitudinal asthma control, airway function, and airflow perception among mild persistent asthmatics
Chest
(2011)
D. Rastogi et al.
Obesity-associated asthma in children: a distinct entity
Chest
(2012)

S.J. Kopel et al.

Asthma symptom perception and obesity in children

Biol Psychol

(2010)

E. Forno et al.

Decreased response to inhaled steroids in overweight and obese asthmatic children

J Allergy Clin Immunol

(2011)

R. van Gent et al.

Excessive body weight is associated with additional loss of quality of life in children with asthma

J Allergy Clin Immunol

(2007)

L.J. Akinbami et al.

Trends in asthma prevalence, health care use, and mortality in the United States, 2001-2010

NCHS Data Brief

(2012)

C.L. Ogden et al.

Prevalence of obesity and trends in body mass index among US children and adolescents, 1999-2010

JAMA

(2012)

N.L. Lugogo et al.

Does obesity produce a distinct asthma phenotype?

J Appl Physiol

(2010)

F. Holguin et al.

Obesity, asthma, and oxidative stress

J Appl Physiol

(2010)

M.E. Jensen et al.

Obesity and childhood asthma: mechanisms and manifestations

Curr Opin Allergy Clin Immunol

(2012)

R.A. Watson et al.

Postural changes in lung volumes and respiratory resistance in subjects with obesity

J Appl Physiol

(2005)

T.J. Sutherland et al.

The effect of adiposity measured by dual-energy X-ray absorptiometry on lung function

Eur Respir J

(2008)

D.D. Sin et al.

Obesity is a risk factor for dyspnea but not for airflow obstruction

Arch Intern Med

(2002)

Cited by (41)

Altered Symptom Perception in Children With Asthma Is Associated With Poor Childhood Opportunity and Adverse Outcomes
2024, Journal of Allergy and Clinical Immunology: In Practice
Effective asthma self-management requires that children recognize their asthma symptoms when they occur. However, some children have altered symptom perception, which impairs their ability to respond to their asthma symptoms in a timely manner.
To characterize the prevalence and features of altered symptom perception in children aged 5 to 18 years. We hypothesized that children with altered symptom perception would have more features of uncontrolled asthma, more health inequity, and poorer longitudinal asthma outcomes over 12 months.
Children (N = 371) completed an outpatient research visit for clinical characterization. Altered symptom perception was defined by discordance between child responses on the 6-item Asthma Control Questionnaire and medical provider–elicited symptoms. Electronic medical records were reviewed for 12 months for the occurrence of an asthma exacerbation treated with systemic corticosteroids and an asthma exacerbation prompting an emergency department visit.
Approximately 15% of children had altered symptom perception and their asthma features were similar to those of children with uncontrolled asthma. Children with altered symptom perception were uniquely distinguished by non-White race and more severe prior exacerbations. These children also resided in ZIP codes with the poorest childhood opportunity (ie, poorest education, health and environmental features, and socioeconomic features). Outcomes of children with altered symptom perception were equally disparate with approximately 2-fold higher odds of a future exacerbation and approximately 3-fold higher odds of an emergency department visit for asthma.
Altered symptom perception is present in a small but significant number of children with asthma and is related to poorer childhood opportunity and other health inequities that require additional intervention.
Management of the pediatric patient with asthma and obesity
2024, Annals of Allergy, Asthma and Immunology
Asthma and obesity are 2 of the most significant chronic diseases of childhood. Both are major public health problems that have been increasing in prevalence. Obesity increases the risk of developing asthma in children, and in children with asthma, obesity increases asthma severity and morbidity. The nature of this relationship is complex and not fully understood, but some pediatric patients with “obesity-related asthma” may represent a phenotype that differs from the more classical, atopic pediatric asthma. In this review, we investigate and discuss some of the currently available literature regarding treatment for asthma complicated by obesity in the pediatric population. We cover the importance of healthy lifestyle modifications, management of obesity-related comorbidities, and the potential role of nutritional supplementation or modification. We then review recent literature, mostly in adults, investigating the potential role of obesity or diabetes medications in the management of patients with asthma who have obesity. Finally, we discuss some of the necessary next steps before these potential new treatments can be considered as part of the standard clinical management of asthma.
Obesity Is Associated with Sustained Symptomatology and Unique Inflammatory Features in Children with Asthma
2022, Journal of Allergy and Clinical Immunology: In Practice
Citation Excerpt :
We also acknowledge that obese patients may have higher medication requirements due to differing symptom perceptions irrespective of lung function.80 Indeed, we have previously shown that obese children with asthma have decreased functional residual capacity, which may result in overestimation of asthma symptoms due to enhanced perception of dyspnea resulting from altered mechanical properties of the chest wall.81 Unfortunately, lung volumes were not measured in the present study, so physiological underpinnings of asthma symptoms cannot be adequately addressed.
Obesity complicates the clinical manifestations of asthma in children. However, few studies have examined longitudinal outcomes or markers of systemic inflammation in obese asthmatic children.
We hypothesized that obese children with asthma would have: (1) poorer clinical outcomes over 12 months, (2) decreased responsiveness to systemic corticosteroid administration, (3) greater markers of systemic inflammation, and (4) unique amino acid metabolites associated with oxidative stress.
Children 6 to 17 years of age (lean, N = 257; overweight, N = 99; obese, N = 138) completed a baseline visit and follow-up visit at 12 months. Outcome measures included asthma control, quality of life, lung function, and exacerbations. A subset received intramuscular triamcinolone and were re-evaluated at 7(+7) days. Leptin, adiponectin, C-reactive protein, total cholesterol, interleukin (IL)-1β, IL-6, IL-17, interferon gamma, tumor necrosis factor alpha, monocyte-chemoattractant protein-1, and amino acid metabolites were also quantified in plasma as potential biomarkers of outcomes in obese children.
Obesity was associated with more symptoms, poorer quality life, and more exacerbations that persisted over 1 year despite greater medication requirements. Obese children also had minimal clinical improvement in asthma control and lung function after intramuscular triamcinolone. Leptin, C-reactive protein, and amino acid metabolites associated with glutathione synthesis and oxidative stress differed in obese children. Within the obese group, lower concentrations of arginine-related metabolites also distinguished uncontrolled from controlled asthma at 12 months.
Obesity is associated with poorer asthma outcomes and unique systemic inflammatory features that may not be adequately modified with conventional asthma therapies. Novel approaches may be needed given increased symptoms and unique inflammation and oxidative stress in obese children with asthma.
Childhood Asthma Risk with Moderate Exercise: Good News for Most!
2022, Journal of Allergy and Clinical Immunology: In Practice
Effects of obesity on the oxygen cost of breathing in children
2021, Respiratory Physiology and Neurobiology
The objective of this study was to examine the effects of obesity on the oxygen (O₂) cost of breathing using the eucapnic voluntary hyperpnea (EVH) technique in 10- and 11-year-old children. Seventeen children (8 without and 9 with obesity) underwent EVH trials at two levels of ventilation for assessing the O₂ cost of breathing (slope of oxygen uptake, $\dot{V} O_{2}$ vs. minute ventilation) and a dual energy x-ray absorptiometry scan. Resting and EVH $\dot{V} O_{2}$ was higher in children with obesity when compared with children without obesity (P = 0.0096). The O₂ cost of breathing did not statistically differ between children without (2.09 ± 0.46 mL/L) and with obesity (2.08 ± 0.64 mL/L, P = 0.99), but the intercept was significantly greater in children with obesity. Chest mass explained 85 % of the variance in resting $\dot{V} O_{2}$ in children with obesity. Higher resting energy requirements, attributable to increased chest mass, can increase the absolute metabolic costs of exercise and hyperpnea in children with obesity.
Paediatric obesity-related asthma: Disease burden and effects on pulmonary physiology
2021, Paediatric Respiratory Reviews
The prevalence of asthma and obesity in children has been steadily increasing globally over the past several decades, with increased concern in low and middle income countries. In this review, we summarize the current literature on these two parallel epidemics and explore the relationship between paediatric obesity and asthma in the paediatric population. Finally, we focus on the current literature as it relates to underlying physiologic alterations and changes in pulmonary function for children with obesity and asthma.

View all citing articles on Scopus

: This study was funded by National Institutes of Health RO1 NR012021; the National Heart, Lung, and Blood Institute Severe Asthma Research Program U10 HL109164; and the National Center for Advancing the Translational Sciences award no. UL1TR000454.

: Conflicts of interest: W. G. Teague has received consultancy and lecture fees from Merck and Genentech/Novartis and has received payment for developing education presentations from Not One More Life. A. M. Fitzpatrick has received consultancy fees from MedImmune and Merck. The rest of the authors declare that they have no relevant conflicts of interest.

: Cite this article as: Sah PK, Teague WG, Demuth KA, Whitlock DR, Brown SD, Fitzpatrick AM. Poor asthma control in obese children may be overestimated because of enhanced perception of dyspnea. J Allergy Clin Immunol: In Practice 2013;1:39-45. http://dx.doi.org/10.1016/j.jaip.2012.10.006.

View full text

Original articlePoor Asthma Control in Obese Children May Be Overestimated Because of Enhanced Perception of Dyspnea

Background

Objective

Methods

Results

Conclusions

Section snippets

Methods

Results

Discussion

J Allergy Clin Immunol

Chest

Chest

J Allergy Clin Immunol

J Allergy Clin Immunol

J Allergy Clin Immunol

J Allergy Clin Immunol

Ann Allergy Asthma Immunol

Chest

Chest

Biol Psychol

J Allergy Clin Immunol

J Allergy Clin Immunol

Trends in asthma prevalence, health care use, and mortality in the United States, 2001-2010

NCHS Data Brief

Prevalence of obesity and trends in body mass index among US children and adolescents, 1999-2010

JAMA

Does obesity produce a distinct asthma phenotype?

J Appl Physiol

Obesity, asthma, and oxidative stress

J Appl Physiol

Obesity and childhood asthma: mechanisms and manifestations

Curr Opin Allergy Clin Immunol

Postural changes in lung volumes and respiratory resistance in subjects with obesity

J Appl Physiol

The effect of adiposity measured by dual-energy X-ray absorptiometry on lung function

Eur Respir J

Obesity is a risk factor for dyspnea but not for airflow obstruction

Arch Intern Med

Original article
Poor Asthma Control in Obese Children May Be Overestimated Because of Enhanced Perception of Dyspnea