Four consonants flanked on both sides by the letter A place asthma among the words that kids try to say 10 times in a row without taking a breath. Come to think of it, that might be a useful technique for pulmonary auscultation, to screen for subtle cases of asthma. Let me know how it works if you try it out. It's the subtle, largely asymptomatic cases rather than the acutely life-threatening cases on which I would like to focus in this column.
The evidence with which I have familiarized myself converges with a strong message for anyone with a "touch of asthma." Even though their asthma might only require an inhaler now and again, it's strongly in the best interest of their total health to treat their asthma with a full-court press (i.e., aggressively). No matter how subtle and infrequent the symptoms, for someone with asthma who wants to make an investment in their health, focusing on eliminating asthma is likely to be an excellent investment opportunity.
Prevent Lung Damage Caused by Wheezing
First of all, to the body, wheezing isn't whimsical music. It's the sound of alveoli being damaged. In mild cases, the body is able to dispatch its repair mechanisms and no residual harm is done. However, who really knows how long that "grace period" lasts? It might be compared to the risk of damaging tires from glass and nails while driving on the shoulder of the highway.
Close the 'Open Door' Policy with Respiratory Toxins
Except with some obvious associations such a cigarette smoking, industrial smog, and occupational exposures, we tend to overlook toxins' entering the body from the respiratory route compared with the oral route of ingestion.
Here's one reason to be suspicious of respiratory toxins: Fish have gills. The toxigenic potential of newly synthesized chemicals is usually tested only in the marine ecosystem. Therefore potentially toxigenic chemicals taken up primarily by the respiratory route could be/have been overlooked.
The gastrointestinal tract has developed an extremely sophisticated ability to distinguish toxigenic metals from minerals, and xenobiotics from endogenously synthesized chemicals. The respiratory tract hasn't experienced equivalent evolutionary pressures to discern and block uptake of airborne pollutants. The respiratory route is therefore thought to be the route of exposure more vulnerable to toxins.
Asthma impairs the already limited respiratory barriers to toxins. Said differently, it is probable that if two people are exposed to air pollution, the person with asthma will take in more toxins.
Suspect Gastrointestinal Toxins
Patients whose asthma is triggered by gastroesophageal reflux are often prescribed proton pump inhibitors or other medications to neutralize stomach acid. The distinct disadvantage of this approach is that the stomach needs to be acidic to support overall health. Reduced acidity (elevated pH) reduces ability to absorb minerals including those needed for prevention of asthma, prevent uptake of metal toxins, and break down immunogenic peptides.
Food allergies, sensitivities, intolerances, and reactivities are more common among people with asthma, although these are widespread in the general population too. Atopy has a well-demonstrated genetic link. However, since asthma and food allergies are rapidly becoming more prevalent, looking closer at the modifiable risk factors is an important clinical and public health endeavor.
One hypothesis involves mercury, a common exposure from respiratory and gastrointestinal routes. One way that mercury exerts its toxic effects is by presenting food moieties and other safe particles to the immune system so that the immune system regards them as harmful. The faulty autoimmune signaling may linger long after the mercury has been removed.
Hiding a Diagnosis of Asthma Behind a Prescription Medication Is Like Trying to Hide Broccoli in a Glass of Milk.
Who hasn't had a patient use this line of reasoning: I don't have high cholesterol (asthma, fill in the blank medical condition) ever since my doctor prescribed me a statin (an inhaler, fill in the blank medication)? I am impressed with the influence presumably led by the pharmaceutical industry to "overlook" that medications have side effects and that most medications treat the symptoms rather than the underlying cause.
The US Food and Drug Administration voices concern over a class of asthma medications called long-acting beta-agonists (LABAs). Not only was the measured efficacy less than anticipated in LABA monotherapy, but life-threatening side effects further tipped the risk-benefit balance. Since April 2011, the FDA is requiring postmarket safety trials for LABAs. For some patients, the regulatory findings meant that they would return to a medical regimen including inhaled corticosteroids.
The side effects of corticosteroids are fairly well known. Preventing weight gain and muscle loss become especially important in children with asthma, especially since asthma can limit exercise capacity and weight gain tends to make asthma worse.
Monoclonal antibody therapies for asthma are on the horizon. While their therapeutic potential is great, side effects have been significant setbacks for these and similar biologics. In other words, it remains smarter to eat the broccoli than try to hide it.
Approaches to Preventing Asthma Recurrence
- Optimize vitamin D, which has been shown to be immune system modulating.
- Eat sufficient omega-3 fats to protect intestinal cells. Eliminate trans fats.
- Incorporate prebiotics and probiotics into the diet itself, and if that is not possible, supplement with fiber and probiotic supplements. Healthful microorganisms work in several ways to protect the integrity of the gastrointestinal tract and its large immune system.
- Eat sufficient omega-3 fats to protect intestinal cells. Eliminate trans fats.
- Eat lots of carbohydrates, which should be all the colors of the rainbow. Eliminate refined carbohydrates such as added sugar and white breads. The naturally occurring colorful components of foods, many of them bioactive polyphenolic compounds, can stabilize the mast cells associated with allergies. In contrast, starches in high quantities prime the intestine for allergenic responses.
- Optimize mineral intake. As a rule of thumb, the body replete with minerals absorbs fewer metal toxins. Since mercury promotes food allergies and selenium can block both its absorption and its actions in the body, selenium supplementation may be especially beneficial.
- Stay hydrated so that linings throughout the body are hydrated. In addition to drinking fluids, breathe them. Use a room humidifier at nighttime to humidify the air, but be careful not to encourage mildew.
- Avoid breathing pollutants indoors and out. The lungs respond differently to potential allergen exposures than the intestines do. Scientists determine which of the millions of synthetic chemicals are detrimental to human health in part by studying their effects in the marine ecosystem, where chemicals travel through water rather than air and many species have gills instead of lungs. I recommend a high-end HEPA filter for those with even the slightest allergies to indoor air pollutants.
- Do not take antihistamines (H1 blockers), even over-the-counter medications, without considering the side effects. Two frequently overlooked side effects are that: (1) these medications are drying and drying out the body's tissues makes allergies of all kinds worse long-term; (2) antihistamines block the satiety hormone leptin, thereby increasing appetite and promoting weight gain, which may also make allergies worse.
- Don't take medication for heartburn such as H2 blockers and proton pump inhibitors with any frequency without first considering the potential side effects. Stomach acid is essential for digestion, and blocking it reduces the absorption of several nutrients, among them, protein. While protein insufficiency can be a consideration for some people, the primary concern is that the poorly digested protein then entering the immune-rich small intestines promotes food allergies.
- Early detection of food allergies, especially gluten sensitivity, can help prompt treatment.
Evidence for additional interventions is emerging:
- The phytonutrient curcumin, studied for its role in reducing inflammation, may also be, based on animal studies, a heavy–metal chelating agent. Both mechanisms are potentially valuable in asthma.
- Chlorella is a chlorophyll- and mineral-rich nutrient and has roles in detoxification.
- Asthma may be influenced by modern shifts in the physical forces around us – be they ionizing radiation from air travel, nonionizing radiation from the technology surrounding us, or reduced sunlight exposure and outdoor time. At the theoretical level, these forces influence our metabolism and can potentially influence asthma directly, although I am aware of little research outside of studies about physical exertion, latitude, vitamin D synthesis, altitude, and emotional stress.
Ingrid Kohlstadt, MD, MPH, has been elected a Fellow of the American College of Nutrition and the American College of Preventive Medicine, and is an associate at the Johns Hopkins Bloomberg School of Public Health. She recently completed a two-year appointment at the FDA working in the Office of the Commissioner, and published one of Medscape Public Health's "Top Ten CMEs for 2010." Dr. Kohlstadt is the founder and chief medical officer of INGRIDients Inc., editing Food and Nutrients in Disease Management (CRC Press; Jan 2009) and Scientific Evidence for Musculoskeletal, Bariatric and Sports Nutrition (CRC Press; 2006).