July 2012 Newsletter

26 July 2012

This month's newsletter highlights a new survey revealing “alarming” lack of understanding among adult asthma patients, vitamin D and lung function, and wheeze and asthma.

New survey reveals “alarming” lack of understanding among adult asthma patients

A new survey of Australian asthma patients has revealed surprising shortfalls in awareness of symptoms and a laid-back attitude towards asthma.

While 88 per cent of adults surveyed described their asthma as average or lower severity, six out of ten felt their asthma got ‘out of control’ at least once every six months.

More than a quarter of respondents had experienced an asthma attack in the last month, with 87 per cent experiencing symptoms in the previous 12 months including waking up due to shortness of breath, experiencing shortness of breath due to cold weather, and other symptoms of asthma attacks. Despite this, 95 per cent of respondents said their asthma was well managed.

“There is an alarming difference between adults’ perception of their asthma management and the reality. It appears they aren’t fully aware of their symptoms and don’t register that they shouldn’t be just part of having asthma,” said Associate Professor Noela Whitby AM, Chairman, National Asthma Council Australia.

The online survey of 1,011 Australian adults aged 18-45 who had been diagnosed with asthma by a doctor, was released to support the launch of a national asthma education program endorsed by National Asthma Council Australia and The Pharmacy Guild of Australia and developed by GlaxoSmithKline Australia, called “There’s nothing normal about asthma symptoms”.

“Poorly controlled asthma can restrict people’s participation in everyday activities. Indeed, one in four respondents had missed work due to their asthma, a similar number reduced their level of exercise and one in ten avoided holidays, socialising or going out,” said Dr Simon Bowler, National Medical and Scientific Advisory Committee Chair, Asthma Australia.

“Our message to Australians with asthma is that this need not be the case and taking a laidback approach might not be the best way to manage symptoms.”

Asthma is a chronic inflammatory condition that affects over two million Australians,1 with one of the highest prevalence rates in the world.2 People with asthma report higher levels of psychological distress3 and a poorer quality of life compared to other people4.

Asthma death rates in Australia are high by international standards, although asthma is not a leading cause of mortality.5 In 2010-11, there were 37,696 hospitalisations for asthma, with a noticeable peak during the winter months amongst adults with asthma.6 In contrast, GP visits for asthma decreased in 2010-11 compared to previous years, suggesting asthma is being managed less frequently in general practice.5

Less than half of adults’ surveyed believed asthma needed ongoing treatment and 64 percent were unaware that over time, poorly controlled asthma and repeated attacks have the potential to cause permanent changes to the lungs.7,8,9

According to national treatment guidelines, asthma is best managed in consultation with a doctor, who may recommend a reliever medication to relieve symptoms. For people with frequent symptoms, a preventer medication to control or prevent symptoms, taken regularly, is likely to be required.10

The survey found respondents were more likely to take vitamin supplements than use preventer medication daily (42 per cent and 25 per cent respectively), despite the importance of preventing asthma symptoms.

Of those surveyed that do use preventer medication (52 per cent), half didn’t use it correctly. Some 55 per cent of this group said they didn’t think their asthma was serious enough to warrant using it as recommended and 32 per cent believed they controlled their asthma well enough using reliever medication.

“This research provides some valuable clues as to what is happening after people leave the doctor’s surgery,” said Associate Professor Whitby. ”That is, they are making their own decisions about how to manage their asthma without necessarily seeing the bigger picture.

“We need to make sure that adults with asthma are managing their asthma well and are able to recognise when their symptoms are getting out of control in order to minimise long-term risks, rather than relying on quick fix relief,” said Associate Professor Whitby.

“Regularly waking at night, needing to use your reliever more than three times a week and not being able to perform to capacity in a range of tasks - this is not what we would think of as well-controlled asthma. If you recognise this is happening, you need to go and see your doctor.”

References:

1 Australian Bureau of Statistics. National Health Survey: Summary of Results, 2007-2008 (Reissue). Cat. no. 4364.0. Canberra: ABS, 2009.
2 Australian Centre for Asthma Monitoring. Asthma in Australia 2011. AIHW Asthma Series no. 4. Cat. no. ACM 22. Canberra: AIHW, 2011.
3 Australian Institute of Health and Welfare. Australia's Health 2010. Australia's health no. 12. Cat. no. AUS 122. Canberra: AIHW, 2010.
4 Australian Institute of Health and Welfare. Asthma. Available at: http://www.aihw.gov.au/asthma/ Last accessed: 26 June 2012
5 Australian Institute of Health and Welfare. Australia's Health 2012. Australia's health series no. 13. Cat. no. AUS 156. Canberra: AIHW, 2012.
6 Australian Institute of Health and Welfare. Australian Hospital Statistics 2010–11. Health Services Series no.43. Cat. no. HSE 117. Canberra: AIHW, 2011.
7 Bai TR, Vonk JM, Postma DS et al. Severe exacerbations predict excess lung function decline in asthma. Eur Respir J 2007; 30: 452–6.
8 Brightling CE, Gupta S, Gonem S et al. Lung damage and airway remodelling in severe asthma. Clin Exp Allergy 2011; 42: 638–49.
9 Fitzgerald JM. Targeting lung attacks. Thorax 2011; 66: 365–6.
10 National Asthma Council Australia. Asthma Management Handbook 2006. Melbourne: NAC, 2006.

For more information

Survey factsheet

Get your puff back

‘There’s nothing normal about asthma symptoms’ is a national education program endorsed by National Asthma Council Australia and The Pharmacy Guild of Australia and developed and funded by GlaxoSmithKline Australia. The program challenges an attitude common among adults with asthma - that asthma symptoms are nothing out of the ordinary and don’t need to be addressed.

The education program launched during the winter season, a peak time for asthma exacerbations. It is being supported by national advertisements in TV and print media with the motivating message of 'get your puff back'.

For more information visit: www.getyourpuffback.com.au

Does your child have asthma?

Researchers at the University of Sydney are investigating a new psychological intervention for children with asthma. In doing this study, they hope to learn more about how best to help and support children to manage their asthma.

Parents of 8-12 year olds in the Sydney area who would like help to manage their child’s asthma are invited to participate in the study.

The study aims to evaluate the effectiveness of a cognitive behavioural treatment (CBT) program to help children cope better with asthma. CBT is a form of group treatment which helps children learn ways to better cope with their symptoms to try and reduce the impact of asthma on their quality of life. The program will help children learn skills to manage the physical symptoms of asthma, as well as stress, which has been shown to worsen asthma. Although CBT has not been specifically shown to be helpful to children with asthma, it has been found to be effective for children with a range of other health problems. This study will help work out whether or not it is also helpful for children with asthma.

For more information, please phone 02 9351 5952 or email [email protected]

To read more about clinical trials for asthma, go to: Asthma Trials

Vitamin D deficiency and poorer lung function

Vitamin D deficiency is associated with poorer lung function in children with asthma treated with inhaled corticosteroids, according to researchers in Boston, USA.

"In our study of 1,024 children with mild to moderate persistent asthma, those who were deficient in vitamin D levels showed less improvement in pre-bronchodilator forced expiratory volume in 1 second (FEV1) after one year of treatment with inhaled corticosteroids than children with sufficient levels of vitamin D," said Ann Chen Wu, MD, MPH, assistant professor in the Department of Population Medicine at Harvard Medical School and Harvard Pilgrim Health Care Institute. "These results indicate that vitamin D supplementation may enhance the anti-inflammatory properties of corticosteroids in patients with asthma."

The study was conducted using data from the Childhood Asthma Management Program, a multi-center trial of asthmatic children between the ages of five and 12 years who were randomly assigned to treatment with budesonide (inhaled corticosteroid), nedocromil, or placebo. Vitamin D levels were categorized as deficient (≤ 20 ng/ml), insufficient (20-30 ng/ml), or sufficient (> 30 ng/ml).

Among children treated with inhaled corticosteroids, pre-bronchodilator FEV1 increased during 12 months of treatment by 330 ml in the vitamin D insufficiency group and 290 ml in the vitamin D sufficiency group, but only 140 ml in the vitamin D deficient group.

Compared with children who were vitamin D sufficient or insufficient, children who were vitamin D deficient were more likely to be older, be African American, and have higher BMI. Compared with being vitamin D deficient, being vitamin D sufficient or insufficient was associated with a greater change in pre-bronchodilator FEV1 over 12 months of treatment after adjustment for age, gender, race, BMI, history of emergency department visits, and season that the vitamin D specimen was drawn.

The study had some limitations, including a small sample size of 101 vitamin D deficient children, and the investigators only studied vitamin D levels at one time point.

"Our study is the first to suggest that vitamin D sufficiency in asthmatic children treated with inhaled corticosteroids is associated with improved lung function," said Dr Wu. "Accordingly, vitamin D levels should be monitored in patients with persistent asthma being treated with inhaled corticosteroids. If vitamin D levels are low, supplementation with vitamin D should be considered."

Reference

Wu AC, Tantisira K, Li L et al. The effect of vitamin D and inhaled corticosteroid treatment on lung function in children. Am J Respir Crit Care Med 2012; published online as doi:10.1164/rccm.201202-0351OC

Vitamin D may protect against lung function impairment and decline in smokers

Vitamin D deficiency is associated with worse lung function and more rapid decline in lung function over time in smokers, suggesting that vitamin D may have a protective effect against the effects of smoking on lung function, according to a new study from researchers in Boston.

"We examined the relationship between vitamin D deficiency, smoking, lung function, and the rate of lung function decline over a 20 year period in a cohort of 626 adult white men from the Normative Aging Study," said lead author Nancy E. Lange, MD, MPH, of the Channing Laboratory, Brigham and Women's Hospital. "We found that vitamin D sufficiency (defined as serum vitamin D levels of >20 ng/ml) had a protective effect on lung function and the rate of lung function decline in smokers."

In the study, vitamin D levels were assessed at three different time points between 1984 and 2003, and lung function was assessed concurrently with spirometry.

In vitamin D deficient subjects, for each one unit increase in pack-years of smoking, mean forced expiratory volume in one second (FEV1) was 12 ml lower, compared with a mean reduction of 6.5 ml among subjects who were not vitamin D deficient. In longitudinal models, vitamin D deficiency exacerbated the effect of pack years of smoking on the decline in FEV1 over time.

No significant effect of vitamin D levels on lung function or lung function decline were observed in the overall study cohort, which included both smokers and non-smokers.

"Our results suggest that vitamin D might modify the damaging effects of smoking on lung function," said Dr. Lange. "These effects might be due to vitamin D's anti-inflammatory and anti-oxidant properties."

The study has some limitations, including that the data is observational only and not a trial, that vitamin D levels fluctuate over time, and that the study has limited generalizability due to the cohort being all elderly men.

"If these results can be replicated in other studies, they could be of great public health importance," said Dr. Lange. "Future research should also examine whether vitamin D protects against lung damage from other sources, such as air pollution."

"While these results are intriguing, the health hazards associated with smoking far outweigh any protective effect that vitamin D may have on lung function ," said Alexander C. White MS, MD, chair of the American Thoracic Society's Tobacco Action Committee. "First and foremost, patients who smoke should be fully informed about the health consequences of smoking and in addition be given all possible assistance to help them quit smoking."

Reference

Lange NE, Sparrow D, Vokonas P, Litonjua AA. Vitamin D deficiency, smoking, and lung function in the Normative Aging Study. Am J Respir Crit Care Med 2012; published online as doi:10.1164/rccm.201110-1868OC

“To wheeze or not to wheeze”: That is not the question

The diagnosis of asthma in young children is difficult and based on clinical assessment of symptoms and results of physical examination. Respiratory wheeze has traditionally been used to define asthma in young children.

Danish researchers sought to compare the qualitative diagnosis of wheeze with a quantitative global assessment of significant troublesome lung symptoms during the first three years of life as a predictor of asthma by age seven years.

For the study children born to mothers with asthma (n = 411) were followed prospectively to age seven years. Parents were instructed to visit the research clinic during the first three years of life each time the child had significant troublesome lung symptoms for three days. At the clinic, a research physician performed a physical examination, including auscultation for wheeze and excluding differential diagnoses. They tested whether wheeze was independently associated with asthma at age seven years after adjusting for the total number of episodes.

The researchers found that 313 children had full follow-up by age seven years. In a multivariable analysis the total number of acute clinic visits for asthma symptom was significantly associated with later asthma (P < 0.0001), whereas the presence of wheeze at these visits was not (P = 0.5). The total number of acute clinic visits for significant troublesome lung symptoms was also significantly associated with later asthma in children who had never presented with any wheeze (P = 0.03).

The  study authors concluded that a quantitative global assessment of significant troublesome lung symptoms in the first three years of life is a better predictor of asthma than assessment of wheeze. Doctor-diagnosed wheeze is not a prerequisite for the diagnosis of asthma, and relying on the symptom of wheeze will likely be an important cause of undertreatment.

Reference

Skytt N, Bønnelykke K, Bisgaard H. “To wheeze or not to wheeze”: That is not the question. J Allergy Clin Immunol. 2012 Jul 3. doi:10.1016/j.jaci.2012.04.043

Asthma and obesity: does weight loss improve asthma control? a systematic review.

Obesity is a major health problem, and obesity is associated with a high incidence of asthma and poor asthma control. The authors systematically reviewed the current knowledge of the effect on overall asthma control of weight reduction in overweight and obese adults with asthma.

Weight loss in obese individuals with doctor-diagnosed asthma is associated with a 48%-100% remission of asthma symptoms and use of asthma medication. Published studies, furthermore, reveal that weight loss in obese asthmatics improves asthma control, and that especially surgically induced weight loss results in significant improvements in asthma severity, use of asthma medication, dyspnoea, exercise tolerance, and acute exacerbations, including hospitalizations due to asthma.

Furthermore, weight loss in obese asthmatics is associated with improvements in level of lung function and airway responsiveness to inhaled methacholine, whereas no significant improvements have been observed in exhaled nitric oxide or other markers of eosinophilic airway inflammation.

The authors concluded that overweight and obese adults with asthma experience a high symptomatic remission rate and significant improvements in asthma control, including objective measures of disease activity, after weight loss. Although these positive effects of weight loss on asthma-related health outcomes seem not to be accompanied by remission or improvements in markers of eosinophilic airway inflammation, it has potentially important implications for the future burden of asthma.

Reference

Juel CT, Ali Z, Nilas L, Ulrik CS. Asthma and obesity: does weight loss improve asthma control? a systematic review. J Asthma Allergy. 2012;5:21-26. Epub 2012 Jun 7.

Missed sleep and asthma morbidity in urban children

According to US researchers children living in urban environments have many risk factors for disrupted sleep, including environmental disturbances, stressors related to ethnic minority status, and higher rates of stress and anxiety. Asthma can further disrupt sleep in children, but little research has examined the effects of missed sleep on asthma morbidity.

A study was undertaken to examine the associations among missed sleep, asthma-related quality of life (QoL), and indicators of asthma morbidity in urban children with asthma from Latino, African American, and non-Latino white backgrounds. Given the importance of anxiety as a trigger for asthma symptoms and the link between anxiety and disrupted sleep, the associations among anxiety, asthma morbidity indicators, and missed sleep were also tested.

Parents of 147 children ages 6 to 13 years completed measures of asthma morbidity and missed sleep, parental QoL, and child behavior.

Researchers found higher reports of missed sleep were related to more frequent school absences, more activity limitations, and lower QoL across the sample. The associations between missed sleep and asthma morbidity were stronger for Latino children compared with non-Latino white and African American children. For children with higher anxiety,
the associations between missed sleep and asthma morbidity were stronger than for children with lower anxiety.

The authors concluded that their results offer preliminary support for missed sleep as a contributor to daily functioning of children with asthma in urban neighborhoods. Missed sleep may be more relevant to Latino families. Furthermore, anxiety may serve as a link between sleep and asthma morbidity because higher anxiety may exacerbate the effects of disrupted sleep on asthma.

Reference

Daniel LC, Boergers J, Kopel SJ, Koinis-Mitchell D. Missed sleep and asthma morbidity in urban children. Ann Allergy Asthma Immunol. 2012; 109: 41-6.

Last reviewed August 2013