Reframing Asthma Management: Beyond Obesity and Steroids to a Holistic, Data-Driven Approach
By Dr. Jennifer A. Chambers, MD MBA FACP Chief Medical Officer
I recently read a journal article that speaks to the prevalence of comorbidities in persons with asthma, and the risk of exacerbations. I was surprised to see reference to obesity as an extremely common comorbidity and that it is highly associated with risk of severe asthma exacerbations. To be clear, this study utilized NHANES data and further details were not available regarding history of steroid use, limitations of physical activity for people with poorly managed asthma, and co-occurrence of depression. However, I am once again struck by the fact that obesity is seen as a cause of a problem without thinking through the realities of living with poorly controlled asthma. Our society has tended to stigmatize obesity (not unlike the stigmatization of mental health conditions) and we are just now learning so much more about the biology of obesity given the increased use of GLP-1 medications and their efficacy in managing obesity.
If obesity is indeed associated with risk of severe asthma exacerbation, let’s take a moment to further examine the root cause of this phenomenon. First, individuals with poorly managed asthma tend to be more sedentary, as shortness of breath does tend to decrease the ability to exercise–even moderately. Limited physical activity not only impacts weight, but stamina and cardiopulmonary health. It is a downward spiral of exacerbations requiring treatments that can contribute to further weight gain, and further limitation of physical activity. Not surprising.
What are some other confounding variables in this association? People with poorly managed asthma also tend to be prescribed oral steroids more frequently, which is a risk factor for weight gain, along with a myriad of other complications associated with frequent or long-term steroid use. Many of my hospitalized patients who required steroids also complained about the impact of steroid medications on their emotional health. Which brings me to another point: Depression is a very common comorbidity for persons with asthma, and frankly with the presence of any chronic illness. Given the impact of poorly managed asthma on quality of life, depression is not an unexpected complication, that often requires treatment with medications. Unfortunately, medications used to treat depression have a known risk of weight gain. However, the risk benefit here is in favor of treating depression despite the risk of weight gain.
Overall, in my opinion, it is not surprising that obesity is associated with severe asthma exacerbations. The bigger question is….why do we have so many individuals with poorly controlled asthma when there are clearly options for treatment and self-management education that can improve number and severity of exacerbations? My concern about associations like the one noted in the article is that obesity could be seen as a cause of the exacerbations, rather than the result of chronically under-managed asthma. We can and should do better; asthma is a chronic condition that requires a multi-pronged management strategy, such as that offered through the Nightingale program offered by Health Care Originals. We need to understand the body’s responses during physical activity, sleep, and environments. This can only be accomplished with a well-coordinated, data driven, patient-centric approach.
Let’s transform the approach to managing asthma as it has been done with other chronic conditions. When we approach people considering all dimensions of their life and health, we can improve not only the cost of care, but the quality of life for those living with asthma.