Freitas and colleagues (2017) investigated the effect of exercise training in a weight-loss program on asthma control, quality of life, inflammatory markers, and lung function. Fifty-five obese patients with asthma completed either a weight-loss program with exercise (aerobic and resistance muscle training) or a weight-loss program with breathing and stretching exercises. For both groups, the weight-loss program included calorie reduction and psychological support. After 3 months, the group that included the aerobic exercise demonstrated improved asthma control and greater weight loss. This group also had improved lung function with a significant increase in FEV1, FVC, and expiratory reserve volume, and decreased fractional exhaled nitric oxide showing decreased airway inflammation. A reduction in airway and systemic inflammation was also noted. This study demonstrates that exercise training associated with a weight- loss program leads to greater weight loss and improvements in aerobic capacity and strength, resulting in better clinical control of asthma compared to patients who underwent the same weight-loss program without exercise training. These results highlight that weight reduction is important for the management of asthma in obese adults and has additional anti-inflammatory Implications for healthcare professionals Healthcare professionals need to be cognizant that obese asthma phenotypes are characterized by more symptoms, worse control, more frequent and severe exacerbations, reduced response to corticosteroids, and lower quality of life (Di Genova et al., 2018). However, the management of asthma in obese patients is largely similar to nonobese patients. Potential differences include reduced responsiveness to standard controller medications, thresholds for determination of asthma phenotype to guide biologic therapy, importance of comorbidities, and the role of weight reduction (Dixon & Nyenhuis, 2021). Although asthma medication guidelines do not differ for lean and obese patients, obese patients with asthma may be less responsive to standard therapies. All patients with asthma should have quick relief rescue therapy and be instructed in the correct inhaler technique. However, some studies reveal that a portion of obese adolescents of African or Hispanic descent may be less responsive to inhaled beta agonists than their nonobese peers (Dixon & Nyenhuis, 2021). Patients with persistent asthma should be treated with controller medication. Inhaled glucocorticoids, which reduce the frequency of asthma symptoms, improve asthma-related quality of life, and reduce the risk of severe asthma exacerbations, have been shown to have diminished effects in obese patients over the age of 5 years, but not among preschool children. Combination therapy with inhaled glucocorticoids and a long-acting beta agonist has also been found to be less effective in achieving asthma control in obese compared with nonobese subjects (Dixon & Nyenhuis, 2021). Unfortunately, many patients with obesity have severe asthma. It is important to avoid long-term treatment with systemic glucocorticoids if possible because of the side effects of weight gain and metabolic dysfunction, which are likely to worsen disease in this cohort. These patients should be evaluated for biologic agents (Dixon & Nyenhuis, 2021). Weight loss needs to be incorporated into the treatment plan, with a multidisciplinary approach recommended. Physical activity should be increased with adherence to dietary guidelines and evaluating vitamin D supplementation. To state the obvious, prevention of childhood obesity by promoting a healthy diet and physical activity is essential to reduce the burden to this population (Di Genova et al., 2018). Holderness and colleagues (2017) found that in children with poorly controlled asthma (3 to 10 years), only 39% participated in 1 or more hours of physical exercise per day. Additionally, 85% of these children did not walk to and from school, 38% did not have any recess in school, and 35% reported no safe place to exercise. More children with very poorly controlled asthma symptoms than children with milder symptoms reported limitations in gym class and even in mild activities. Children with activity limitations were at significantly greater risk of being overweight or obese, underscoring the
effects that contribute to improved asthma control in these patients. The CDC (2021f) recommends that children and adolescents should engage in a minimum of 60 min of physical activity daily. Most of this exercise should be either moderate- or vigorous-intensity aerobic physical activity and should include vigorous-intensity physical activity at least 3 days a week. Muscle-strengthening physical activity and bone-strengthening activities should be done at least 3 days per week. Parents can assist their children in having opportunities to engage in physical activity before and after school. Parents can work with their child’s school to draft policies about health and wellness to ensure that all children’s needs are addressed. Volunteering to walk with students to school will encourage a safe environment for physical activity and model behavior that the children can emulate. Parents can also identify community resources that provide intramural and club activities that can be held on school grounds. Parents’ active involvement with their children will also encourage physical activity, such as watching their child participate in a sport or planning a family event that involves physical activity. need to optimize asthma control and provide opportunity for increased physical activity both in school and at home. Evidence-based practice! Okoniewski and colleagues (2019) conducted a systematic review of the literature to investigate whether weight loss in people with obesity and asthma resulted in improvements in asthma-related outcomes, including asthma-related quality of life. The researchers evaluated findings from randomized controlled clinical trials involving overweight/obese children or adults with asthma. Four studies for children and six for adults were identified for inclusion in their review. All interventions investigated weight loss, ranging from dietary restrictions to exercise training and cognitive behavioral therapy. The duration of interventions ranged from 8 weeks to 18 months. All studies reported successful improvements in weight or BMI, improvements in asthma-related quality of life and, to some degree, asthma control. Studies with adults also reported improvements in lung function (FEV1, FVC, TLC). These findings suggest that weight loss in subjects with obesity and asthma may improve asthma outcomes (Okoniewski et al., 2019). Although asthma is more common in persons who are obese, it is important for the healthcare professional to be aware that the respiratory symptoms associated with obesity can mimic the symptoms of asthma. Symptoms because of deconditioning, mechanical restriction, and/or sleep apnea related to obesity need to be distinguished. Individuals who are obese who report dyspnea on exertion need objective confirmation of an asthma diagnosis (e.g., spirometry performed pre- and postbronchodilator use). Additionally, the healthcare professional should assess age-adjusted BMI and ask about diet and physical activity (GINA, 2021). As with other persons with asthma, inhaled corticosteroids are indicated for individuals who are obese and have asthma, but the healthcare professional needs to be cognizant that the effect of the inhaled steroid may be reduced as a result of the interaction between asthma and obesity. Weight reduction should be addressed. Studies have found that a 5% to 10% weight loss improved asthma control and quality of life (GINA, 2021). Several national organizations offer recommendations for clinical interventions and treatments for children and adults who are overweight or obese, including the American Academy of Pediatrics, the National Association of Pediatric Nurse Practitioners, and the American Heart Association.
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