Low socioeconomic status relates to asthma and wheeze, especially in women

Paternal adverse childhood experiences are associated with a low risk of atopy in the offspring

AIM

Parental adverse childhood experiences (ACE) might affect the offspring health through intergenerational inheritance. The aim of this study was to investigate how paternal ACE associate with offspring sensitisation and allergic rhinitis (AR).

METHODS

The study included 590 Finnish father-child dyads from the FinnBrain Birth Cohort Study. Outcomes were offspring sensitisation against allergens and AR at age 5.5 years. Paternal ACE up to 18 years were assessed using the Trauma and Distress Scale (TADS) with the lowest quarter as the reference group.

RESULTS

Of the children, 317 (54%) were males. Sensitisation occurred in 162/533 (30%) and AR in 122/590 (21%). Paternal TADS (median 17 points; interquartile range 11-27) was inversely associated with the risk of sensitisation. Children whose fathers scored the highest quarter had the lowest risk of sensitisation (adjusted odds ratio 0.42; 95% confidence interval 0.24-0.75), followed by those in the second highest quarter (0.58; 0.34-0.99). The association between the highest quarter and reduced risk of AR was similar.

CONCLUSION

Paternal ACE were associated with a low risk of offspring sensitisation and AR, suggesting paternal childhood stress might influence immune responses in their offspring.

Characteristics of asthma in an older adult population according to sex and control level: why are asthma symptoms in older women not well-controlled?

OBJECTIVE

The older adult population in Turkey has increased by 22.6% in the last 5 years, and the characteristics of such patients with asthma remain uninvestigated. Therefore, we aimed to evaluate the characteristics of older adults with asthma according to sex and asthma control status to provide an in-depth overview of asthma in this population in Turkey.

METHODS

The data of older adults (age 65 years and over) with asthma were obtained from a multicenter, cross-sectional asthma database registry (Turkish Adult Asthma Registry, TAAR) funded by the Turkish Thoracic Society. Comparisons were made based on sex and asthma control levels using the Global Initiative for Asthma (GINA) Asthma Symptom Control Questionnaire.

RESULTS

Of the 2053 (11.5%) patients registered with the TAAR, 227 were older adults (median age, 69 (8), women, 75.8% (n = 172)). Of these, 46.5% (n = 101) had obesity to some degree. Compared with men, women had lower education, income levels, and employment rates. Additionally, women exhibited a higher prevalence of obesity, hypertension, and thyroid gland disease than men. Being female (OR: 2.99; 95% CI: 1.307-6.880), the presence of gastroesophageal reflux disease (OR: 2.855; 95% CI: 1.330-6.130), and a predicted forced expiratory volume in the first-second value lower than 80% (OR: 2.938; 95% CI: 1.451-5.948) were associated with poorly controlled asthma.

CONCLUSIONS

Herein, older adults comprised 11.5% of adult patients with asthma. Being female poses a disadvantage in terms of both asthma prevalence and control in the older adult asthmatic population owing to the prevalence of comorbidities and socioeconomic sex-related distinguishing factors.

A Harmonised Approach to Curating Research-Ready Datasets for Asthma, Chronic Obstructive Pulmonary Disease (COPD) and Interstitial Lung Disease (ILD) in England, Wales and Scotland Using Clinical Practice Research Datalink (CPRD), Secure Anonymised Information Linkage (SAIL) Databank and DataLoch

Background

Electronic healthcare records (EHRs) are an important resource for health research that can be used to improve patient outcomes in chronic respiratory diseases. However, consistent approaches in the analysis of these datasets are needed for coherent messaging, and when undertaking comparative studies across different populations.

Methods and Results

We developed a harmonised curation approach to generate comparable patient cohorts for asthma, chronic obstructive pulmonary disease (COPD) and interstitial lung disease (ILD) using datasets from within Clinical Practice Research Datalink (CPRD; for England), Secure Anonymised Information Linkage (SAIL; for Wales) and DataLoch (for Scotland) by defining commonly derived variables consistently between the datasets. By working in parallel on the curation methodology used for CPRD, SAIL and DataLoch for asthma, COPD and ILD, we were able to highlight key differences in coding and recording between the databases and identify solutions to enable valid comparisons.

Conclusion

Codelists and metadata generated have been made available to help re-create the asthma, COPD and ILD cohorts in CPRD, SAIL and DataLoch for different time periods, and provide a starting point for the curation of respiratory datasets in other EHR databases, expediting further comparable respiratory research.

Level of Education Modifies Asthma Mortality in Norway and Sweden. The Nordic EpiLung Study

Background and Aim

The relationship between socioeconomic status (SES), asthma and mortality is complex and multifaceted, and it is not established if educational level modifies the association between asthma and mortality. The aim was to study the association between asthma and mortality in Sweden and Norway and to what extent educational level modifies this association.

Participants and Methods

Within the Nordic EpiLung Study, >56,000 individuals aged 30-69 years participated in population-based surveys on asthma and associated risk factors in Sweden and Norway during 2005-2007. Data on educational level and 10-year all-cause mortality were linked by national authorities. The fraction of mortality risk attributable to asthma was calculated, and Cox regression was used to estimate hazard ratios (HR) and 95% confidence intervals (95% CI) for mortality related to asthma, stratified by educational level.

Results

In total, 5.5% of all deaths was attributed to asthma. When adjusted for potential confounders, the HR for mortality related to asthma was 1.71 (95% CI 1.52-1.93). Those with primary level of education had higher hazard of all-cause death related to asthma than those with tertiary level (HR 1.80, 95% CI 1.48-2.18, vs HR 1.39, 95% CI 0.99-1.95).

Conclusion

Asthma was associated with an overall 71% increased all-cause mortality and 5.5% of deaths can be attributed to asthma. Educational levels modified the risk of mortality associated with asthma, with the highest risk among those with primary education.

Is there still a social gradient in respiratory symptoms? A population-based Nordic EpiLung-study

BACKGROUND

Respiratory symptoms are a common public health issue that can partly be attributed to preventable risk factors, such as tobacco smoking and occupational exposure, which are more common in individuals with lower socioeconomic status.

OBJECTIVE

Our aim was to evaluate the social gradient in respiratory symptoms in Nordic countries.

METHODS

This study included participants aged 30-65 years from five cross-sectional population-based questionnaire surveys in 2016 in Finland and Sweden (N = 25,423) and in 2017-2019 in Norway (N = 27,107). Occupational skill levels 1 and 2 (occupations requiring compulsory education) were combined and compared to skill levels 3 and 4 (occupations requiring upper secondary and tertiary education). Meta-analysis was conducted to obtain pooled age- and sex adjusted odds ratios (aORs) of associations between occupational skill and the respiratory symptoms including recurrent wheeze, dyspnoea, and productive cough.

RESULTS

In the meta-analysis, recurrent wheeze, dyspnoea, and productive cough showed a social gradient. The participants with occupational skill 1 and 2 had higher risk for recurrent wheeze (aOR 1.78, 95% CI 1.34-2.22) and dyspnoea (aOR 1.59, 95% CI 1.29-1.90) compared to occupational skill 3 and 4 in Sweden and Finland. Similarly increased risk was observed for combined assessment of dyspnoea and wheeze (aOR 1.05, 95% CI 1.03-1.07) in Norway. In a meta-analysis including all three countries, the aOR for productive cough was 1.31 95% CI 1.07-1.56.

CONCLUSIONS

Occupations with lower, compared to higher, skill levels were associated with an increased risk of recurrent wheeze, dyspnoea, and productive cough.

Climate Change, Exposome Change, and Allergy: A Review

Climate change is a major threat to human respiratory health and associated allergic disorders given its broad impact on the exposome. Climate change can affect exposure to allergens, such as pollen, dust mites, molds, as well as other factors such as temperature, air pollution, and nutritional factors, which synergistically impact the immune response to these allergens. Exposome change can differentially exacerbate allergic reactions across subgroups of populations, especially those who are more vulnerable to environmental stressors. Understanding links between climate change and health impacts can help inform how to protect individuals and vulnerable populations from adverse health effects.

Interaction of smoking and social status on the risk of respiratory outcomes in a Swedish adult population: A Nordic Epilung study

BACKGROUND

Evidence abounds on the independent roles of social class and smoking in relation to obstructive airway diseases, but data are sparse on the impact of their interaction. We evaluated whether and to what extent social class and smoking interact in relation to risk of respiratory diseases in adults.

METHODS

Data from the population-based studies, West Sweden Asthma Study (WSAS, n = 23,753) and Obstructive Lung Disease in Northern Sweden studies (OLIN, n = 6519), were used, constituting randomly selected adults aged 20-75 years. Bayesian network analysis was used to estimate the probability for the interaction between smoking and socioeconomic status in relation to respiratory outcomes.

RESULTS

Occupational and educational SES modified the association between smoking and the probability of allergic and non-allergic asthma. Former smokers who were at intermediate non manual employees and manual workers in service had higher probability of allergic asthma compared to professionals and executives. Furthermore, former smokers with primary education had higher probability of non-allergic asthma than those with secondary and tertiary education. Similarly, former smokers among professionals and executives had higher probability of non-allergic asthma than manual and home workers and primary educated. Likewise, allergic asthma due to former smoking was higher among highly educated compared to low educated.

CONCLUSIONS

Beyond their independent roles, socioeconomic status and smoking interact in defining the risk of respiratory diseases. Clearer understanding of this interaction can help to identify population subgroups at most need of public health interventions.

Socioeconomic inequalities in asthma and respiratory symptoms in a high-income country: changes from 1996 to 2016

Objective: Low socioeconomic status based both on educational level and income has been associated with asthma and respiratory symptoms, but changes over time in these associations have rarely been studied. The aim was to study the associations between educational or income inequality and asthma and respiratory symptoms among women and men over a 20-year period in northern Sweden. Methods: The study was performed within the Obstructive Lung disease in Northern Sweden (OLIN) research program. Mailed questionnaire surveys were administered to a random sample of adults (20-69 years of age) living in Sweden, in 1996, 2006 and 2016. Data on educational level and income were collected from the national integrated database for labor market research. Results: The educational inequality associated with asthma and asthmatic wheeze tended to decrease from 1996 to 2016, while it increased for productive cough, the latter among men not among women. The income inequality decreased for productive cough, especially for women, while no clear overall trends were found for asthmatic wheeze and asthma, apart from a decrease in income inequality regarding asthma among men. Conclusion: The patterns for socioeconomic inequality differed for asthma and wheeze compared to productive cough, and the results emphasize that education and income do not mirror the same aspects of socioeconomic inequality in a high-income country. Our findings are important for decision makers, not the least on a political level, as reduced inequality, e.g. through education, could lead to reduced morbidity.

Socioeconomic status associates with worse asthma morbidity among Black and Latinx adults

BACKGROUND

Asthma disproportionately affects African American/Black (AA/B) and Hispanic/Latinx (H/L) patients and individuals with low socioeconomic status (SES), but the relationship between SES and asthma morbidity within these racial/ethnic groups is inadequately understood.

OBJECTIVE

To determine the relationship between SES and asthma morbidity among AA/B and H/L adults with moderate to severe asthma using multidomain SES frameworks and mediation analyses.

METHODS

We analyzed enrollment data from the PeRson EmPowered Asthma RElief randomized trial, evaluating inhaled corticosteroid supplementation to rescue therapy. We tested for direct and indirect relationships between SES and asthma morbidity using structural equation models. For SES, we used a latent variable defined by poverty, education, and unemployment. For asthma morbidity, we used self-reported asthma exacerbations in the year before enrollment (corticosteroid bursts, emergency room/urgent care visits, or hospitalizations), and Asthma Control Test scores. We tested for mediation via health literacy, perceived stress, and self-reported discrimination. All models adjusted for age, sex, body mass index, ethnicity, and comorbidities.

RESULTS

Among 990 AA/B and H/L adults, low SES (latent variable) was directly associated with hospitalizations (β = 0.24) and worse Asthma Control Test scores (β = 0.20). Stress partially mediated the relationship between SES and increased emergency room/urgent care visits and worse asthma control (β = 0.03 and = 0.05, respectively). Individual SES domains were directly associated with asthma morbidity. Stress mediated indirect associations between low educational attainment and unemployment with worse asthma control (β = 0.05 and = 0.06, respectively).

CONCLUSIONS

Lower SES is directly, and indirectly through stress, associated with asthma morbidity among AA/B and H/L adults. Identification of stressors and relevant management strategies may lessen asthma-related morbidity among these populations.

Improving Medication Adherence in Asthma

In little over a generation, the ingenuity of scientists and clinician researchers has developed inhaled medications and pathway-specific biological agents that control the inflammation and physiology of asthma. Unfortunately, whether it is because of cost or difficulty understanding why or how to use inhaled medications, patients often do not take these medications. The consequences of poor treatment adherence, loss of control and exacerbations, are the same as if the condition remained untreated. Furthermore, poor adherence is difficult to detect without direct measurement. Together this means that poor treatment adherence is easily overlooked and, instead of addressing the cause of poor adherence, additional medicines may be prescribed. In other words, poor treatment adherence is a risk for the patient and adds cost to healthcare systems. In this article, we discuss the rationale for and the delivery of successful interventions to improve medication adherence in asthma. We contextualize these interventions by describing the causes of poor treatment adherence and how adherence is assessed. Finally, future perspectives on the design of new interventions are described.

Additive effects of coexisting respiratory comorbidities on overall or respiratory mortality in patients with asthma: a national cohort study

Asthmatic patients are generally considered to have an increased risk of mortality compared with subjects without asthma. However, this issue has been less evaluated using nationally representative data. Moreover, it is unclear whether respiratory comorbidities other than chronic obstructive pulmonary disease (COPD) are associated with increased mortality in asthmatic patients compared with subjects without. Using a nationally representative sample database, we performed a retrospective cohort study of patients with asthma and age-sex-matched control cohort. We estimated the hazard ratio (HR) and stratified the asthma cohort based on respiratory comorbidities. During a median 8.9-year follow-up, the overall mortality rate was higher in the asthma cohort than in the control cohort (p < 0.001). The hazard ratio (HR) for overall mortality in the asthma cohort compared with the control cohort was 1.13. The effects of asthma on overall mortality were more evident in males, patients under medical aid, and subjects with COPD. Respiratory comorbidities were significantly associated with increased risk of overall mortality in asthmatic patients compared with controls (adjusted HRs; 1.48 for COPD, 1.40 for bronchiectasis, 4.08 for lung cancer, and 1.59 for pneumonia). While asthma and lung cancer showed an additive effect only on overall mortality, asthma and other respiratory comorbidities (COPD, pneumonia, and bronchiectasis) had additive effects only on respiratory mortality. Patients with asthma had a higher overall mortality rate compared with subjects without asthma. Respiratory comorbidities showed an additive effect on overall or respiratory mortality in patients with asthma.

Understanding socio-economic inequalities in the prevalence of asthma in India: an evidence from national sample survey 2017-18

Background

Today, over 300 million people reside with asthma worldwide and India alone is home for 6% of children and 2% of adults suffering from this chronic disease. A common notion of disparity persists in terms of health outcomes across the poor and better-off section of the society. Thus, there is a need to explore socio-economic inequality in the contribution of various factors associated with asthma prevalence in India.

Methods

Data for the study were carved out from the 75th round of National Sample Survey (NSS), collected by the National Sample Survey Organization (NSSO) during 2017–18. The sample size for this study was 555,289 individuals, for which data was used for the analysis. Descriptive statistics were used to show the distribution of the study population. Further, bivariate and multivariate analysis was performed to identify the factors associated with Asthma prevalence. The concentration index was used to measure the inequality. Further, we used decomposition analysis to find the contribution of factors responsible for socio-economic status-related inequality in asthma prevalence.

Results

The prevalence of asthma was 2 per 1000 in the whole population; however, the prevalence differs by age groups in a significant manner. Age, sex, educational status, place of residence, cooking fuel, source of drinking water, household size and garbage disposal facility were significantly associated with asthma prevalence in India. It was found that asthma was more concentrated among individuals from higher socioeconomic status (concentration index: 0.15; p < 0.05). While exploring socio-economic inequality for asthma, richest wealth status (53.9%) was the most significant contributor in explaining the majority of the inequality followed by the urban place of residence (37.9%) and individual from age group 45–65 years (33.3%). Additionally, individual aged 65 years and above (27.9%) and household size less than four members (14.7%) contributed in explaining socio-economic inequality for asthma.

Conclusion

Due to the heterogeneous nature of asthma, associations between different socio-economic indicators and asthma can be complex and may point in different directions. Hence, considering the concentration of asthma prevalence in vulnerable populations and its long-term effect on general health, a comprehensive programme to tackle chronic respiratory diseases and asthma, in particular, is urgently needed.

Childhood onset asthma is associated with lower educational level in young adults - A prospective cohort study

BACKGROUND

Asthma is associated with low socioeconomic status among both children and adults, and adolescents with asthma report more school absenteeism than those without. However, it is unclear whether asthma in childhood and adolescence affects socioeconomic status in adulthood.

METHODS

Within the Obstructive Lung disease In Northern Sweden Studies, all children in grade 1 and 2 in three municipalities were invited to a questionnaire survey, 97% participated (n = 3430). They were followed annually until age 19, and thereafter at age 28 years. In this study, participants at ages 8 y, 12 y, 19 y and 28 y (n = 2017) were included. Asthma was categorized into childhood onset (up to age 12 y) and adolescent onset (from 12 to 19 y). Data for assessment of socioeconomic status was collected at 28 y and included educational level, occupation, and occupational exposure to gas, dust and/or fumes (GDF).

RESULTS

Childhood onset asthma was associated with having compulsory school as the highest educational level at age 28 y, also after adjustment for sex, smoking and BMI at age 19 y and socioeconomic factors in childhood (OR 4.84 95%CI 2.01-11.65), and the pattern was the same among men and women. However, we found no significant associations between asthma in childhood or adolescence and socioeconomic groups, occupational groups or occupational exposure to GDF at age 28 y.

CONCLUSIONS

Even though asthma in high-income countries, such as Sweden, is well recognised and treated, this study highlight that childhood onset asthma may have a negative long-term effect with regard to educational level in young adulthood.