As a child, all Renu (name changed) needed was a quick-relief inhaler during winters to take care of her asthma. At 51, this Pune-based entrepreneur needs a double dose of inhaler corticosteroids to deal with her persistent wheezing. “She was not responding to conventional treatment because she was obese at 85 kg. So, while we increased her dosage, we strictly put her on a weight loss programme to ease the pressure on her lungs,” says Dr Sundeep Salvi, Director of the Pulmocare Research and Education (PURE) Foundation chest clinic in Pune.
What is the link between asthma and obesity?
Traditionally, asthma was believed to be a genetic disease triggered by environmental factors like allergens and air pollution. The windpipes, that allow air to go in and out of the lungs, swell up and produce extra mucus, making breathing difficult. However, more recently, the link between asthma and obesity is gaining more recognition. According to the Global Initiative of Asthma (GINA), which releases the annual strategy report on World Asthma Day (first Tuesday of May) every year, obesity increases both the prevalence and incidence of asthma and worsens asthma control.
Dr Salvi, who is a member of the global scientific committee of GINA set up by the WHO, the National Institute of Health, and National Heart, Lung and Blood Institute, USA, says that the first study on the subject was done in India in September-October 2021. It had shown that overweight and obese children had a 79 per cent greater risk of asthma than healthy children.
A study conducted by PURE Foundation, in collaboration with the Delhi-based Lung Care Foundation and CSIR-Indian Institute of Genomics and Integrative Biology, reported that adolescent school children from Delhi had a very high prevalence of asthma (29 per cent or roughly one in three children).
The team concluded that this was linked only with obesity rather than traditional allergens from plants (pollens from flowering plants) and animal sources (cat and dog allergens). Air pollution increases the risk of developing asthma on its own, which is now well-established. “Air pollution also indirectly causes obesity. How? The tiny particulate matter in the atmosphere contains chemicals called obesogens or weight gain compounds which, when inhaled, enter into the blood circulation from the lungs and damage the endocrine system. This causes weight gain,” says Dr Salvi.
Obese asthmatics are difficult to treat, proper assessment required
Obese asthmatics are more difficult to treat and generally respond poorly to inhaler medication that is otherwise very effective in non-obese individuals, Dr Salvi says. According to Dr Jayashree Todkar, bariatric and metabolic consultant and surgeon, obesity treatments are not just about regulating inches or kilos. “All system improvements that have been impacted by obesity need to be done. Scientific-based treatments like bariatric surgery resolve asthma in more than 70 per cent of patients,” she says.
Obesity is strongly associated with chronic fatigue and breathlessness/shortness of breath on even a small amount of exertion. “Obesity-induced hypoventilation is a multifactorial syndrome found commonly in patients with central obesity (waist circumference > 100 cm in men and >90 cm in women ) and/or Body Mass Index of > 33kg/m2.
High intra-abdominal pressure, the inability of the lower lobes of the lungs to fully expand, associated hypertension and preload on the heart are mainly the causative factors. A particular feature of central obesity is acid reflux or gastroesophageal reflux disease (GERD) which leads to recurrent irritation of the throat, spillover of acid into the trachea and then causing an intractable cough and irritation of the breathing pipe. Many label it incorrectly as bronchial asthma but it fails to respond unless the causative central obesity is treated scientifically. Hence proper assessment of asthma in obesity is required,” Dr Todkar adds. According to studies, there are an estimated 135 million people in India who have general obesity, 153 million have abdominal obesity and 107 million have combined obesity
India contributes to 17 per cent of the world’s asthma burden
India is home to over 30 million asthmatics, accounting for nearly 17 per cent of the world’s asthma burden. India also contributes to a disproportionate 43 per cent of the world’s asthma deaths. This is because of underdiagnosis, wrong diagnosis, and wrong treatment. “Denial of the diagnosis, lack of knowledge, along with myths, misbeliefs and social stigmas associated with asthma and its treatment, aggravate the problem. Moreover, there are highly effective treatments but very few take the right treatment and do so regularly. Inhalation therapy is the safest, fastest and most effective treatment for asthma. However, less than 10 per cent of asthmatics in India use it regularly,” says Dr Salvi.
While most viral infections are known to exacerbate asthma, COVID-19 was an exception
One of the reasons for this was the use of inhaled corticosteroids by asthmatics, which surprisingly showed benefits in treating the COVID-19 infection. The use of inhaled corticosteroids skyrocketed during the COVID-19 pandemic and likely saved many lives. “The pandemic taught us about the life-saving efficacy of wearing masks. This habit should continue even today, especially among asthmatics to minimise the exposure to viruses and air pollutants that are major triggers,” Dr Salvi says.
The rise of childhood asthma
Dr Zafar Ahmad Iqbal, Director, Pulmonology, Critical Care and Sleep Studies, Fortis Hospital Mohali, is worried about the increase in childhood asthma and calls for early interventions. “If managed well, such attacks can be prevented. More than 50 per cent children outgrow their asthma by the time they reach adolescence,” he says. “The common childhood symptoms include a whistling or wheezing sound when breathing out. Some children also experience shortness of breath while playing or even during routine work along with chest congestion or tightness. An asthma attack happens when a child has a viral infection during sleep, or is exposed to cold air, pollens, pets, perfumes, dust and so on. This causes fatigue and may affect the child’s routine and performance,” he adds.
Dr Iqbal recommends that childhood asthma be identified, diagnosed and treated appropriately with bronchodilators under the supervision of an expert. “Parents must not heed the myth that inhalers are a habit-forming practice. Due to this, the symptoms are not controlled early and hence, the child may require life-long treatment,” he explains.
Bronchodilators and inhaled corticosteroids are given through the inhalation route as these have negligible side effects and ensure appropriate drug delivery to the lungs. “Inhalers help prevent any systemic adverse effects. Introducing certain lifestyle changes such as maintaining low humidity at home, keeping indoor air clean, reducing pet dander (animals shedding tiny flakes from their skin), dust control and reducing cold air exposure can help prevent asthma attacks. Take care of the diet and ensure it is rich in Vitamin D. These include milk, eggs, beta carotene-rich vegetables such as carrots and leafy greens, and magnesium-rich foods like spinach and pumpkin seeds. Regular exercise such as yoga also helps maintain good health. A child should be symptom-free to have normal lungs in adult life,” says Dr Iqbal.