Prevalence of and factors associated with adult-onset asthma in different ethnic groups: The HELIUS study

The frequency of asthma and its related factors: results of the enrolment phase of Tabari cohort study

INTRODUCTION

A large portion of the world's population has asthma. This study aimed to ascertain asthma prevalence and related factors in the Tabari cohort study (TCS).

METHODS

The TCS included 10,255 35-70-year-olds from urban and mountainous Sari (northern Iran) between June 2015 and November 2017. Education, occupation, domicile, socioeconomic position, history of psychiatric disorders, smoking (including hookah smoking), opium usage, and daily physical activity level were determined.

RESULTS

The final analysis included 9939 individuals. The asthma rate was 7.4%. Multiple factors increased asthma risk, according to statistical analysis. These factors included being female (OR, 1.337; 95% CI, 1.142-1.565), retired (OR, 1.553; 95% CI, 1.205-2.002), living in the city (OR, 1.268; 95% CI, 1.083-1.484), using opioids (OR, 1.689; 95% CI, 1.299-2.197), having lower socioeconomic status (SES) (OR, 0.723; 95% CI, 0.579-0.903), history of psychiatric disorders (OR, 2.313; 95% CI, 1.826-2.930), and aged 60-70 (OR, 2.325; 95% CI, 1.765-3.064), and BMI above 30 kg/m2 (OR, 1.499; 95% CI, 1.220-1.841). Several factors increased asthma probability in multivariate regression analysis. These factors include being female (OR = 1.389, p = 0.015), ages between 60 and 70 (OR = 2.034, p < 0.001), using opioids (OR = 1.940, p < 0.001), lower SES (OR = 0.738, p = 0.012), history of psychiatric disorders (OR = 2.035, p < 0.001), BMI above 30 kg/m2 (OR = 1.518, p < 0.001), and being a smoker (OR = 1.337, p = 0.056).

CONCLUSION

This study has identified that the prevalence of asthma in the Tabari cohort group is high. In addition, it was demonstrated that various factors are related to asthma.

[Diagnosis and treatment of asthma: a guideline for respiratory specialists 2023 - published by the German Respiratory Society (DGP) e. V.]

The management of asthma has fundamentally changed during the past decades. The present guideline for the diagnosis and treatment of asthma was developed for respiratory specialists who need detailed and evidence-based information on the new diagnostic and therapeutic options in asthma. The guideline shows the new role of biomarkers, especially blood eosinophils and fractional exhaled NO (FeNO), in diagnostic algorithms of asthma. Of note, this guideline is the first worldwide to announce symptom prevention and asthma remission as the ultimate goals of asthma treatment, which can be achieved by using individually tailored, disease-modifying anti-asthmatic drugs such as inhaled steroids, allergen immunotherapy or biologics. In addition, the central role of the treatment of comorbidities is emphasized. Finally, the document addresses several challenges in asthma management, including asthma treatment during pregnancy, treatment of severe asthma or the diagnosis and treatment of work-related asthma.

A EUFOREA comment on a lost comorbidity of asthma

"Epidemiology of comorbidities and their association with asthma control" (Tomisa, G., Horváth, A., Sánta, B. et al. Epidemiology of comorbidities and their association with asthma control. Allergy Asthma Clin Immunol 17, 95 (2021). https://doi.org/10.1186/s13223-021-00598-3 ) is an interesting paper reflecting data collection from more than 12,000 asthmatic patients in Hungary regarding their condition and associated comorbidities. We found it valuable that the paper provides an overview of asthma comorbidities not usually considered in similar reports. Nevertheless, we believe that chronic rhinosinusitis (CRS) with or without nasal polyps (CRSwNP or CRSsNP) should have been listed due to its high incidence and prevalence, its association with asthma which is also endorsed in both GINA and EPOS, as well as in several peer-reviewed scientific papers, and to reflect the role of this comorbidity in poor control and a most severe presentation of asthma for the patient. Consequently, several targeted therapies (especially monoclonal antibodies) used for several years in severe forms of asthma are now indicated also for the effective treatment of nasal polyps.

Diet quality, food intake and incident adult-onset asthma: a Lifelines Cohort Study

PURPOSE

Dietary factors have been suggested as drivers of the rising prevalence of adult-onset asthma, but evidence is inconclusive, possibly due to the complex interrelation with obesity. We aim to explore the relation of diet quality and food intake with incident adult-onset asthma in normal weight and overweight adults of the prospective population-based Lifelines Cohort Study.

METHODS

Incident adult-onset asthma was defined as self-reported asthma at ± 4-year follow-up, in adults free of airway disease at baseline. Diet quality scores and food group intake were assessed at baseline. Log-binomial regression analyses were used to estimate adjusted relative risks (RR) between dietary intake (per portion) and incident adult-onset asthma, in categories of BMI (cutoff: 25 kg/m²).

RESULTS

477 incident asthma cases (75% female, 62% overweight) and 34,698 controls (60% female, 53% overweight) were identified. Diet quality-assessed by the Lifelines Diet Score and Mediterranean Diet Score-was not associated with incident adult-onset asthma in the two BMI groups. Although the dietary intake of several food groups differed between cases and controls, after adjustment for confounders only few remained associated with adult-onset asthma, including red and processed meat (RR: 0.93 per 15 g intake; 95% CI 0.86-0.99) in the normal weight group and intake of cheese (RR 1.09 per 20 g intake; 95% CI 1.00-1.17) and vegetables (RR 1.10 per 50 g intake; 95% CI 1.00-1.21) in the overweight group.

CONCLUSION

The results of this study question the role of food as a 'simple' predictor of adult-onset asthma and call for an integrative approach, including a range of modifiable lifestyle factors and further asthma phenotyping.

Risk factors associated with comorbid asthma in patients with chronic rhinosinusitis with nasal polyps: a cross-sectional study

Background

Although 20–60% of patients with chronic rhinosinusitis with nasal polyps (CRSwNP) have asthma, the risk factors associated with comorbid asthma are not clear. The aim of the study was to investigate the factors associated with asthma, and develop a practical scoring system to screen asthma comorbidity in CRSwNP patients.

Methods

This report describes a cross-sectional study with consecutive CRSwNP patients. Two cohorts of CRSwNP patients named “modelling” group and “validation” group were investigated respectively. Logistic regression analysis was performed based on demographic and clinical data collected from patients in the modelling group to determine the risk factors associated with asthma, and establish a scoring system for screening comorbid asthma. Receiver operating characteristic curve was constructed to evaluate the screening system; the optimal cut-off point was established by means of the Yoden Index. The consistency between the diagnosis of asthma by the Global Initiative for Asthma (GINA) criteria and by the screening system was assessed by Kappa value in the validation group.

Results

Totally 150 patients in modelling group and 78 patients in validation group were enrolled. Female gender (odds ratio [OR] = 6.4; P < 0.001), allergic rhinitis (OR = 2.9; P = 0.021), serum total (T)-immunoglobulin (Ig) E ≥ 69.0kU/L (OR = 12.0; P < 0.001), and blood eosinophil count  ≥ 0.35 × 10⁹/L (OR = 4.0; P = 0.001) were shown to be independent risk factors for asthma in patients with CRSwNP. Based on these variables, a scoring system (FAIE) ranging from 0(no risk) to 6(high risk); was developed. The area under the receiver operating characteristic curve of the system was 0.823, and the optimal cut-off value was 3 points, with sensitivity 83.8% and specificity 68.6% for screening asthma. The asthma comorbidity determined with FAIE score ≥ 3 points in the validation group, was moderately consistent with that defined by GINA (Kappa = 0.513, P < 0.001), with sensitivity 76.9% and specificity 74.4%.

Conclusions

Female gender, allergic rhinitis, serum T-IgE level, and blood eosinophil count are independent risk factors for asthma comorbidity in patients with CRSwNP, and the FAIE system may be practical for screening comorbid asthma in these patients.

Associations Between Child Maltreatment, Inflammation, and Comorbid Metabolic Syndrome to Depressed Mood in a Multiethnic Urban Population: The HELIUS Study

Background

Child maltreatment is a common negative experience and has potential long-lasting adverse consequences for mental and physical health, including increased risk for major depressive disorder (MDD) and metabolic syndrome. In addition, child maltreatment may increase the risk for comorbid physical health conditions to psychiatric conditions, with inflammation as an important mediator linking child maltreatment to poor adult health. However, it remains unresolved whether experiencing child maltreatment increases the risk for the development of comorbid metabolic syndrome to MDD. Therefore, we investigated whether child maltreatment increased the risk for comorbid metabolic syndrome to depressed mood. Subsequently, we examined whether C-reactive protein (CRP), as an inflammatory marker, mediated this association. In addition, we investigated whether effects differed between men and women.

Methods

Associations were examined within cross-sectional data from the multiethnic HELIUS study (N = 21,617). Adult residents of Amsterdam, Netherlands, self-reported on child maltreatment (distinct and total number of types experienced before the age of 16 years) as well as current depressed mood (PHQ-9 score ≥ 10), and underwent physical examination to assess metabolic syndrome. The CRP levels were assessed in N = 5,998 participants. Logistic and linear regressions were applied for binary and continuous outcomes, respectively. All analyses were adjusted for relevant demographic, socioeconomic, and lifestyle characteristics, including ethnicity.

Results

A higher number of maltreatment types as well as distinct types of emotional neglect, emotional abuse, and sexual abuse were significantly associated with a higher risk for current depressed mood. Child maltreatment was not significantly associated with the risk for metabolic syndrome in the whole cohort, nor within individuals with depressed mood. As child maltreatment was not significantly associated with the CRP levels, subsequent mediation analyses were not performed. No significant moderating effects by sex were observed.

Conclusion

In this multiethnic urban cohort, child maltreatment was associated with a higher risk for depressed mood. Contrary to our expectations, child maltreatment was not significantly associated with an increased risk for metabolic syndrome, neither in the whole cohort nor as a comorbid condition in individuals with depressed mood. As the data were cross-sectional and came from a non-clinical adult population, longitudinal perspectives in relation to various stages of the investigated conditions were needed with more comprehensive assessments of inflammatory markers.

Obesity, Inflammation, and Severe Asthma: an Update

Purpose of Review

Obesity-associated difficult asthma continues to be a substantial problem and, despite a move to address treatable traits affecting asthma morbidity and mortality, it remains poorly understood with limited phenotype-specific treatments. The complex association between asthma, obesity, and inflammation is highlighted and recent advances in treatment options explored.

Recent Findings

Obesity negatively impacts asthma outcomes and has a causal link in the pathogenesis of adult-onset asthma. Imbalance in the adipose organ found in obesity favours a pro-inflammatory state both systemically and in airways. Obesity may impact currently available asthma biomarkers, and obesity-associated asthma specific biomarkers are needed. Whilst surgical weight loss interventions are associated with improvements in asthma control and quality of life, evidence for pragmatic conservative options are sparse. Innovative approaches tackling obesity-mediated airway inflammation may provide novel therapies.

Summary

The immunopathological mechanisms underlying obesity-associated asthma require further research that may lead to novel therapeutic options for this disease. However, weight loss appears to be effective in improving asthma in this cohort and focus is also needed on non-surgical treatments applicable in the real-world setting.

Prevalence of and risk factors for asthma among people aged 45 and older in China: a cross-sectional study

Background

Asthma is one of the most prevalent chronic respiratory diseases worldwide. This study aimed to determine the updated prevalence of and risk factors for asthma among individuals aged 45 and older in mainland China.

Methods

The data for this study came from the fourth wave of the China Health and Retirement Longitudinal Study (CHARLS) conducted by the National School of Development of Peking University in 2018. The CHARLS is a nationally representative survey targeting populations aged 45 and over from 28 provinces/cities in mainland China. A representative sample of 19,816 participants was recruited for the study using a multistage stratified sampling method. The prevalence of asthma was determined across different characteristics. The potential risk factors were examined by multivariable logistic regressions.

Results

A total of 18,395 participants (8744 men and 9651 women) were eligible for the final data analysis. The estimated prevalence of asthma among Chinese people aged ≥ 45 years in 2018 was 2.16% (95% CI 1.96–2.38). The prevalence of asthma significantly differed according to race (P = 0.002), with an overall rate of 2.07% (95% CI 1.86–2.29) in Han paticipants and 3.32% (95% CI 2.50–4.38) in minority participants. Furthermore, the minority ethnicities (OR = 1.55 [95% CI 1.12–2.14], P = 0.008), older age (60–69 years group: OR = 1.85 [95% CI 1.17–2.92], P = 0.008; ≥ 70 years group: OR = 2.63 [95% CI 1.66–4.17], P < 0.001), an education level of middle school or below (middle-school education: OR = 1.88 [95% CI 1.15–3.05], P = 0.011; primary education: OR = 2.48 [95% CI 1.55–3.98], P < 0.001; literate: OR = 2.53 [95% Cl 1.57–4.07], P < 0.001; illiterate: OR = 2.78 [95% CI 1.72–4.49, P < 0.001]), smoking (OR = 1.37 [95% CI 1.11–1.68], P = 0.003), and residence in North (OR = 1.52 [95% CI 1.11–2.09], P = 0.01) or Northwest China (OR = 1.71 [95% CI 1.18–2.49], P = 0.005) were associated with prevalent asthma.

Conclusions

Asthma is prevalent but underappreciated among middle-aged and elderly people in China. A number of risk factors were identified. These results can help to formulate correct prevention and treatment measures for asthma patients.

Different effects of smoking on atopic and non-atopic adult-onset asthma

BACKGROUND

Both tobacco smoking and atopy increase the risk of adult-onset asthma. We studied if there are differences in the effects of smoking on the risks of atopic and non-atopic adult-onset asthma, and if gender modifies these effects.

METHODS

The Finnish Environment and Asthma Study (FEAS) includes 521 incident cases of adult-onset asthma and 932 population-based controls, aged 21 to 63 years, recruited from a geographically defined area of Pirkanmaa, South Finland. Asthma was defined based on symptoms and lung function measurements, atopy by IgE antibodies to common aeroallergens and smoking by the study questionnaire.

RESULTS

Altogether 212 cases were atopic, and 251 cases were non-atopic. Regular smoking increased the risk of atopic asthma (adjusted OR 1.24, 95% CI 0.83-1.85), this effect was seen in women (aOR 1.77, 1.06-2.95) but not in men (aOR 0.75, 0.39-1.45). Among regular smokers, the amount smoked was lowest among women with atopic asthma. Recent quitting of smoking was related to increased risk of both atopic (aOR 4.91, 2.26-10.65) and non-atopic (aOR 4.37, 1.87-10.21) asthma. Having quitted smoking over a year ago was related to increased risk of non-atopic asthma (aOR 1.57, 1.08-2.28), mainly in men (aOR 2.03, 1.06-3.88).

CONCLUSIONS

In women, rather small amounts of regular smoking increase the risk of atopic asthma. However, for non-atopic asthma, the smoking induced risk continues for longer after quitting, especially in men. In conclusion, the effects of smoking on the risks of atopic and non-atopic asthma differ, and gender modifies these effects.

Respiratory and Neurological Disease across Different Ethnic Groups Is Influenced by the Microbiome

Acute and chronic upper respiratory illnesses such as asthma, and allergic rhinitis (AR) have been linked to the presence of microorganisms in the nose. Microorganisms can exist in symbiotic or commensal relationships with the human body. However, in certain cases, opportunistic pathogens can take over, leading to altered states (dysbiosis) and causing disease. Thus, the microflora present in a host can be useful to reflect health status. The human body contains 10 trillion to 100 trillion microorganisms. Of these populations, certain pathogens have been identified to promote or undermine wellbeing. Therefore, knowledge of the microbiome is potentially helpful as a diagnostic tool for many diseases. Variations have been recognized in the types of microbes that inhabit various populations based on geography, diet, and lifestyle choices and various microbiota have been shown to modulate immune responses in allergic disease. Interestingly, the diseases affected by these changes are prevalent in certain racial or ethnic populations. These prevalent microbiome variations in these groups suggest that the presence of these microorganisms may be significantly associated with health disparities. We review current research in the search for correlations between ethnic diversity, microbiome communities in the nasal cavity and health outcomes in neurological and respiratory functions.

Association between Green Space Structure and the Prevalence of Asthma: A Case Study of Toronto

Asthma is a chronic inflammatory disease that can be caused by various factors, such as asthma-related genes, lifestyle, and air pollution, and it can result in adverse impacts on asthmatics' mental health and quality of life. Hence, asthma issues have been widely studied, mainly from demographic, socioeconomic, and genetic perspectives. Although it is becoming increasingly clear that asthma is likely influenced by green spaces, the underlying mechanisms are still unclear and inconsistent. Moreover, green space influences the prevalence of asthma concurrently in multiple ways, but most existing studies have explored only one pathway or a partial pathway, rather than the multi-pathways. Compared to greenness (measured by Normalized Difference Vegetation Index, tree density, etc.), green space structure-which has the potential to impact the concentration of air pollution and microbial diversity-is still less investigated in studies on the influence of green space on asthma. Given this research gap, this research took Toronto, Canada, as a case study to explore the two pathways between green space structure and the prevalence of asthma based on controlling the related covariates. Using regression analysis, it was found that green space structure can protect those aged 0-19 years from a high risk of developing asthma, and this direct protective effect can be enhanced by high tree diversity. For adults, green space structure does not influence the prevalence of asthma unless moderated by tree diversity (a measurement of the richness and diversity of trees). However, this impact was not found in adult females. Moreover, the hypothesis that green space structure influences the prevalence of asthma by reducing air pollution was not confirmed in this study, which can be attributed to a variety of causes.

Asthma Across the Ages: Adults

Asthma is a common disease affecting approximately 300 million people worldwide, across all age ranges. Despite advances in asthma outcomes of the last few decades, there remains room for improvement in asthma management and for patient outcomes, particularly in older patients. The heterogeneity of asthma is now well recognized, and is known to complicate response to treatment and patient behavior and impact health outcomes. Asthma and its heterogeneity change according to age. Asthma affects people differently across the life span. In adults, prevalence is highest among those in middle age; however, mortality is greater in the older age group. In this clinical commentary, we describe how age impacts asthma prevalence and incidence, outcomes, disease expression, and approach to management in adulthood and in older patients.

Revisiting Late-Onset Asthma: Clinical Characteristics and Association with Allergy

The Global Initiative for Asthma (GINA) 2020 defines late-onset asthma (LOA) as one of the clinical phenotypes of asthma wherein patients, particularly women, present with asthma for the first time in adult life, tend to be non-allergic and often require higher doses of inhaled corticosteroids (ICS) or are relatively refractory to corticosteroid treatment. In this review, we examine the published literature improve the understanding of the following aspects of LOA: 1) the age cut-off for its diagnosis; 2) its distinct clinical phenotypes, characteristics and risk factors; and 3) its association with allergic comorbidities and conditions. Overall, our review reveals that clinicians and researchers have used multiple age cut-offs to define LOA, with cut-off ages ranging from >12 years to ≥65 years. LOA has also been classified into several distinct phenotypes, some of which drastically differ in their clinical characteristics, course and prognosis. Although LOA has traditionally been considered non-allergic in nature, our review indicates that it is commonly associated with allergic features and comorbidities. Our findings suggest that there is an urgent need for the development of more clear clinical practice guidelines that can provide more clarity on the definition and other aspects of LOA. In addition, the association of LOA and allergy needs to be re-examined to frame a more optimal treatment strategy for patients with LOA.

Potentially avoidable hospitalization for asthma in children and adolescents by migrant status: results from the Italian Network for Longitudinal Metropolitan Studies

Background

Global migration toward Europe is increasing. Providing health assistance to migrants is challenging because numerous barriers limit their accessibility to health services. Migrants may be at a greater risk of developing asthma and receiving lower quality healthcare assistance than non-migrants. We aim to investigate whether immigrants as children and adolescents have higher rates of potentially avoidable hospitalization (PAH) for asthma compared to Italians.

Methods

We performed a retrospective longitudinal study using six cohorts of 2–17-year-old residents in North and Central Italy from 01/01/2001 to 31/12/2014 (N = 1,256,826). We linked asthma hospital discharges to individuals using anonymized keys. We estimated cohort-specific age and calendar-year-adjusted asthma PAH rate ratios (HRRs) and 95% confidence intervals (95%CIs) among immigrants compared to Italians. We applied a two-stage random effect model to estimate asthma PAH meta-analytic rate ratios (MHRRs). We analyzed data by gender and geographical area of origin countries.

Results

Three thousand three hundred four and 471 discharges for asthma PAH occurred among Italians and immigrants, respectively. Compared to Italians, the asthma PAH cohort-specific rate was higher for immigrant males in Bologna (HRR:2.42; 95%CI:1.53–3.81) and Roma (1.22; 1.02–1.45), and for females in Torino (1.56; 1.10–2.20) and Roma (1.82; 1.50–2.20). Asthma PAH MHRRs were higher only among immigrant females (MHRRs:1.48; 95%CI:1.18–1.87). MHRRs by area of origin were 63 to 113% higher among immigrants, except for Central-Eastern Europeans (0.80; 0.65–0.98).

Conclusion

The asthma PAH meta-analytic rate was higher among female children and adolescent immigrants compared to Italians, with heterogeneity among cohorts showing higher cohort-specific PAH also among males, with some differences by origin country. Access to primary care for children and adolescent immigrants should be improved and immigrants should be considered at risk of severe asthma outcomes and consequently targeted by clinicians.