September/October - West Virginia State Medical Association

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Scientific Article | Exercise Intolerance in Obese Children — is it Asthma? Robert A. Kaslovsky, MD Pediatric Pulmonary Division Chief, Baystate Children’s Hospital, Springfield, MA Stephen B. Sondike, MD Section Head, Adolescent Medicine, WVU Physicians of Charleston and Associate Professor of Pediatrics at WVU Charleston Division Stephanie Cummings, CMA Abstract This is a pilot study designed to examine the frequency of asthma in obese children who have exertional dyspnea. Obese children who complained of breathlessness with exercise and who denied asthma were invited to enroll. If there was evidence of airflow limitation on spirometry, nebulized albuterol was administered and spirometry was repeated. If there was no significant improvement or if the baseline spirometry was normal, exercise testing was performed. A total of 20 patients (ages from 8 to 16 years) with BMI from 22 to 61 were enrolled. Of the 19 who completed the study, 9 (47.3%) met criteria for asthma. Recognizing and treating asthma may lead to improved exercise tolerance and improved weight status in these obese individuals. Introduction Asthma is the most common chronic disease of childhood. It is estimated that 11.2% of the U.S. population has at some time been diagnosed with asthma, 1 and that about 5 million children across the U.S. are affected. 1 Asthma is the leading cause of school absenteeism due to chronic illness. 2 Untreated asthma may result in serious consequences, including lost school or work days, costly hospitalizations, and possibly death. Obesity (defined as body mass index > 95th percentile for age) is increasing in prevalence in children. Data from NHANES I (1971–1974) to NHANES 2003–2004 show increases in overweight among all age groups: Among preschoolaged children, aged 2–5 years, the prevalence of overweight increased from 5.0% to 13.9%; among schoolaged children, aged 6–11 years, the prevalence of overweight increased from 4.0% to 18.8%; and among school-aged adolescents, aged 12–19 years, the prevalence of overweight increased from 6.1% to 17.4%. 3 Given the increasing prevalence of both asthma and obesity in childhood, it is possible that a link exists between these two conditions. The medical literature has few studies that address this question. Gold et al examined the incidence of asthma in a longitudinal study of 9,828 children age 6 – 14 years in six US cities over a five year period. 4 Girls who were heavier at baseline were more likely to have asthma and the risk of developing asthma over the observation period increased with increasing BMI. Similarly, Castro- Rodriguez, et al found that girls who became overweight or obese between ages 6 and 11 were seven times more likely to develop new asthma between ages of 11 and 13 years. 5 A relationship between BMI at age 6 and wheezing prevalence at any age was not found. In an analysis of outcomes of childhood asthma in adolescent years, Guerra, et al found that the mean BMI was higher in a group with poorly controlled asthma 6 suggesting that obesity adversely affects asthma control. Other studies have suggested that weight reduction improves symptoms and lung function in obese adults with asthma. 6.7 Obese individuals often have exercise intolerance which is attributed to deconditioning. The present study sought to provide information on the prevalence of undiagnosed asthma in obese children who complain of shortness of breath with exercise. Methodology Children age 6 to 18 years were eligible for the study if they had BMI > 95th percentile for age, and exercise induced shortness of breath (see figure 1). The questions outlined in figure 2 were asked, and to qualify for the study, the first two questions had to be answered affirmatively, and the last three had to be answered “no”. Standard spirometry was performed at rest, with measurement of forced vital capacity (FVC), and forced exhaled volume in one second (FEV1). The reference values of Polgar 9 for pediatric patients were used, with normal values for these parameters and for the ratio of FEV1/FVC being greater than 80%. If the test was deemed abnormal, an inhaled bronchodilator (albuterol) was administered via jet nebulizer, and the test was test repeated after 10 to 15 minutes. An increase in 12% in FEV1 indicated a positive response to bronchodilator. If there was no response to bronchodilator, or if the test was deemed normal, patients were scheduled for an exercise challenge test, using a standard treadmill exercise protocol. 10 After completing the exercise protocol, spirometry was performed at 5, 10, 15, and 20 minutes, and a positive response was a drop in FEV1 > 12% from baseline for the diagnosis of exercise induced asthma to be made. If there was no drop in FEV1, the test was deemed normal, and the results were interpreted as unlikely to be asthma The proportion of tested children with asthma was calculated by dividing the number with either an abnormal spirometry with bronchodilator response, or a 12 West Virginia Medical Journal
| Scientific Article Figure 1. Flowchart of study design. Figure1: Flowchart of study design. Bronchodilator Repeat Spirometry in 15 minutes > 12 % Improvement Yes to Question 1 and 2 No to Question 3,4 and 5 FEV1 < 80% Predicted Asthma Figure 2. Screening Questionnaire Informed Consent Spirometry No Improvement Pulmonology Consult Asthma Study Flowchart Age 6 – 18 BMI > 95th %ile for age Give Questionnaire All other responses Treadmill Testing Not offered study FEV1 > 80% Predicted > 12 % decline in FEV1 with exercise and bronchodilator response Asthma 1) Do you get out of breath with exercise or physical activity? 10 < 12 % decline in FEV1 No Asthma 2) Do you have to stop exercising because of difficulty catching your breath? 3) Do you have asthma? 4) Are you using any inhalers/nebulizers or other treatments for breathing problems? 5) Has anyone prescribed Albuterol or other medications for breathing problems in the last year? If you answer “yes” to questions 1 and 2 and “no” to questions 3, 4, and 5 you will be eligible for the study. positive exercise test, by the total number of subjects enrolled. No other statistical analyses were performed. Results Twenty patients were entered into the study (see Table 1). Their ages ranged from 7 to 16 years, and BMI ranged from 22.1 Kg/m2 to 61.3, Kg/m2 and nine were male. Mean BMI was. 37.9 Kg/m2 . Of the 19 who completed the study, nine met criteria for asthma. Four had abnormal spirometry with significant bronchodilator response, another five had normal resting spirometry but had significant drop in FEV1 at exercise testing, and the remaining nine had normal spirometry and no drop in FEV1 post exercise. Discussion In this study, nearly half of the obese children and adolescents who become short of breath with exertion were found to have asthma. This finding suggests that many obese children are not just “deconditioned”, but may actually have exercise induced bronchospasm. Although several recent studies link obesity and asthma, to our knowledge this is the first prospective study that examines the frequency of asthma in obese children. Being able to exercise is an important factor in most weight loss programs. Gym coaches and teachers also tend to attribute obese students inability to exercise as being “out of shape”. Physicians and school officials alike should consider the possibility of asthma in children and adolescents who are overweight and who have difficulty exercising. The study was limited by several factors. First, the population eligible for enrollment was a very select one, drawing from obese patients who were referred for weight management to an adolescent cardiovascular fitness program. Other obese children not referred to the September/October 2010 | Vol. 106 13
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