Asthma in Obese Patients : Challenges and Outcomes

Presented by : Aarzoo Ali Kaif , 2nd Year MBBS , AIIMS Kalyani ( Medicoz Community Editors Pick )♦♦♦

Patient Profile:

• Name: Arpita Ghosh
• Age: 45 years
• Gender: Female
• Occupation: Homemaker
• Location: Kalyani, West Bengal, India
• BMI: 36 kg/m² (Obese, Class II)
• Medical History:
  • Diagnosed with asthma at age 30
  • Hypertension, Type 2 Diabetes Mellitus (diagnosed 5 years ago)
  • History of seasonal allergies
• Family History:
  • Father with Type 2 Diabetes
  • Mother with asthma

Background

Asthma is a chronic inflammatory disease of the airways that leads to recurrent episodes of wheezing, breathlessness, and coughing. The prevalence of asthma is increasing in urban areas, including Kalyani, near AIIMS, due to rising pollution levels and lifestyle changes. Obesity, which is prevalent in the Indian population, exacerbates asthma symptoms and complicates management. According to recent studies conducted in various Indian cities, asthma prevalence ranges from 12-15%, with a notable association between obesity and worsened asthma outcomes .

In Kalyani, where the pollution levels and urbanization have been increasing, asthma cases are becoming more common. Obesity further compounds these issues, presenting significant challenges in both diagnosis and treatment.

Presentation and Symptoms

Mrs. Arpita Ghosh presented with the following symptoms over the past six months:

• Daily wheezing and chest tightness, particularly noticeable in the mornings and evenings
• Frequent shortness of breath during routine activities such as household chores and walking
• Chronic fatigue and poor sleep quality, exacerbated by nocturnal asthma symptoms
• Increased reliance on short-acting beta-agonists (SABA) (3–4 times daily)
• Weight gain of 5 kg in the past year despite attempts at dietary control

Her asthma had been previously managed with inhaled corticosteroids (ICS) and rescue inhalers. However, over the past year, her symptoms significantly worsened, leading to more frequent clinic visits.

Diagnostic Evaluation

• Pulmonary Function Tests (PFTs):
  • FEV1 (Forced Expiratory Volume in 1 second) at 65% of predicted value, indicating moderate persistent asthma.
  • FEV1/FVC (Forced Vital Capacity) ratio was decreased, confirming obstructive airway disease.
• Body Mass Index (BMI):
  • 36 kg/m², classifying her as Obese, Class II.
• Blood Tests:
  • Elevated eosinophil count, indicative of an allergic component to asthma.
  • HbA1c of 8.1%, reflecting poorly controlled Type 2 Diabetes Mellitus.
• Allergen Sensitivity Testing:
  • Positive for dust mites and pollen.
• Chest X-ray and CT Scan:
  • No structural abnormalities were observed, but airway thickening consistent with chronic asthma was noted.

Challenges in Management

1. Systemic and Airway Inflammation: Obesity enhances systemic inflammation, which exacerbates asthma. Adipose tissue releases inflammatory cytokines such as leptin and adiponectin, leading to increased airway inflammation and exacerbation of asthma symptoms .
2. Reduced Lung Function: Obesity reduces lung volumes, particularly functional residual capacity (FRC) and expiratory reserve volume (ERV). Mrs. Ghosh’s excess abdominal weight interferes with diaphragmatic movement, worsening breathlessness and causing air trapping in the lungs .
3. Pharmacological Issues: The effectiveness of inhaled corticosteroids can be reduced in obese patients due to altered drug distribution and absorption. Additionally, systemic corticosteroids used during exacerbations can worsen insulin resistance, complicating diabetes management .
4. Comorbidities: Ghosh’s diabetes and hypertension further complicate asthma management. Uncontrolled diabetes increases susceptibility to infections and exacerbates asthma, while corticosteroids can exacerbate blood glucose levels .
5. Psychological Factors: The coexistence of obesity and asthma can contribute to significant stress and anxiety. Mrs. Ghosh reported high stress levels related to her health conditions, which affected her adherence to treatment and led to emotional eating, further worsening her asthma and weight .

Management Plan

1. Lifestyle Modifications:
   • Weight Loss Program: Referral to a dietitian for a structured weight loss plan aimed at gradual weight reduction to improve lung function and asthma control.
   • Physical Activity: Low-impact aerobic exercises such as walking and yoga, tailored to avoid asthma exacerbations while promoting weight loss.
2. Pharmacological Adjustments:
   • Step-up Asthma Therapy:
     • Initiation of a combination of inhaled corticosteroids (ICS) with a long-acting beta-agonist (LABA) to improve asthma control.
     • Addition of Montelukast, a leukotriene receptor antagonist, to manage allergic asthma triggered by dust mites and pollen.
   • Diabetes Management: Adjustment of oral antidiabetic medications to improve glycemic control while ensuring no interference with asthma medications.
   • Hypertension Management: Continued use of ACE inhibitors with regular monitoring to prevent drug interactions with asthma treatments.
3. Behavioral and Psychological Support:
   • Counseling for stress management and emotional eating. Introduction of relaxation techniques and breathing exercises to improve psychological wellbeing and adherence to treatment.
4. Education and Monitoring:
   • Education on proper inhaler techniques, asthma self-management, and reducing allergen exposure.
   • Regular follow-ups every three months to monitor asthma control, weight management, and diabetes management.

Outcomes

After six months of the implemented management plan:

• Weight Loss: Ghosh lost 3.5 kg, leading to improved lung function and reduced asthma symptoms.
• Improved Asthma Control: FEV1 increased to 75% of the predicted value, with a significant reduction in the frequency of asthma exacerbations. Use of rescue inhalers decreased to once daily.
• Better Glycemic Control: HbA1c decreased to 7.4%, indicating improved diabetes management. The combined approach of dietary changes and asthma management positively impacted her overall health.

Mrs. Ghosh reported a significant improvement in her quality of life, including better sleep, increased physical activity, and enhanced confidence in managing her asthma, diabetes, and hypertension. The multidisciplinary approach effectively addressed both her respiratory and metabolic issues.

Discussion and Key Takeaways

Managing asthma in obese patients requires a comprehensive approach that addresses both asthma and obesity simultaneously. Obesity exacerbates asthma through increased systemic inflammation, reduced lung function, and altered medication pharmacokinetics. Comorbid conditions such as diabetes and hypertension add complexity to treatment, making a multifaceted management plan essential. In urban areas like Kalyani, where environmental factors and obesity rates contribute to the burden of asthma, addressing lifestyle, medication, and psychological aspects is crucial for achieving optimal outcomes.

References

1. Sutherland ER, et al. “Obesity and Asthma: The Role of Systemic Inflammation.” J Allergy Clin Immunol, 2020.
2. Shore SA, et al. “Obesity, Airway Hyperresponsiveness, and Inflammation in Asthma.” Proc Am Thorac Soc, 2021.
3. Peters U, et al. “Obesity and Its Impact on Asthma Pharmacotherapy: A Review.” Chest, 2022.
4. Dixon AE, et al. “Asthma and Obesity: Mechanisms and Treatment Considerations.” Curr Opin Pulm Med, 2023.
5. Agarwal AN, et al. “Asthma in Indian Cities: Epidemiology and Risk Factors.” Indian Journal of Chest Diseases, 2022.
6. Mukherjee M, et al. “Prevalence of Asthma in Urban Kolkata: The Role of Pollution.” Indian Journal of Respiratory Medicine, 2023.
7. Basu S, et al. “Impact of Obesity on Asthma Outcomes in Indian Populations.” Indian Journal of Allergy, Asthma, and Immunology, 2022.
8. Chakraborty S, et al. “Asthma Management in Obese Patients: Insights from a Study in West Bengal.” Journal of Clinical and Diagnostic Research, 2023.
9. Das S, et al. “The Role of Environmental Factors in Worsening Asthma Among Obese Individuals in Indian Urban Areas.” Journal of Environmental Health Science & Engineering, 2023.