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What you can tell lung disease patients

Smoking cessation has now become a maxim in community practice, but pharmacists can give plenty of other lifestyle advice to their respiratory patients, says Tristan Learoyd

By Tristan Learoyd

Smoking cessation has now become a maxim in community practice, but pharmacists can give plenty of other lifestyle advice to their respiratory patients, says Tristan Learoyd

Among the most prevalent diseases presented in community pharmacies are asthma and chronic obstructive pulmonary disease. Each is characterised by shortness of breath, whether transient (asthma) or permanent (COPD).

Although there is significant genetic involvement in the development of lung diseases, a number of other factors could also influence pathogenesis. Lifestyle advice primarily focuses on smoking cessation and is highly beneficial, but not every patient smokes. Other issues that pharmacists can advise on could include weight loss, nutrition and exercise.

Weight control and avoiding fast food

Pharmacists should be familiar with the established link between obesity and asthma. Commonly cited potential mechanisms include airway smooth muscle dysfunction from thoracic restriction, physical reduction in cardiovascular space, oxidative stress, and obesity-related co-morbidities mediating asthma symptom development. The dietary picture is complex with highest prevalence of asthma recorded in western nations, where the lowest rates of physical activity are observed.1

Reduced fruits, vegetables and fish, and increased saturated fats and fast foods appear to increase the risk of asthma at all ages.2,3 Saturated fats may increase activation of the immune system and increase circulating inflammatory mediators associated with asthma, such as IL-6, TNFa, and leptin.4–7

Studies reveal that within hours of eating a high-fat load, a pro-inflammatory state is created with excess oxidative stress — an underlying cause of lung disease.

The effects of a diet high in fat may, however, also depend on the relative composition of fatty acids. The typical western high-fat diet contains up to 25 times more omega-6 (n-6) polyunsaturated fatty acids (PUFA) — which although essential, have been linked to hyperinsulinaemia, atherosclerosis and carcinogenesis — than protective n-3 PUFAs.8 n-6 PUFAs are found in eggs and most vegetable oils, while n-3 PUFAs are contained in cold water fish (eg, salmon and tuna), mussels, and various seeds.

Largely due to its ability to prevent fat absorption, fibre has been associated with anti-inflammatory properties and protection against allergic diseases such as asthma.9

High regular intake of the sugary carbonated drinks that are so often associated with fast food diets have also been linked with asthma. Efforts to reduce regular intake of such drinks may benefit respiratory patients.10
With both obesity and fast food increasing the likelihood of exacerbations in asthma, weight loss in asthmatic patients who are overweight can be confidently recommended.11

It should be noted, however, that although a high fat intake may be associated with pulmonary risk factors, substitution with low-fat products may prove problematic. For example, in one study low-fat yoghurt intake was directly related to increased risk of both asthma and allergic rhinitis in children, while whole milk appeared protective for early-life outcomes.12

Obesity, and the lifestyle associated with it, can predispose an individual to a greater likelihood of COPD and lung cancer.13 However, because COPD is associated with weight loss as forced expiratory volume (FEV1) declines, eating well and often should be promoted to COPD patients.

There is moderate-quality evidence that nutritional supplementation through high calorie shakes promotes significant weight gain among patients with COPD, especially if malnourished. Improvements in six-minute walking tests, skinfold thickness and quality of life have all been observed with supplementation in controlled trials.14

Nutrition

The modern diet contains a number of bronchoconstrictors and bronchodilators and it may be useful for patients to be aware of this. Certain nutritional entities can trigger bronchoconstriction via IgE and non IgE pathways and common foods documented as causing asthma symptoms in sensitive individuals include eggs, fish, peanuts, soy, yeast, cheese, wheat and rice.

Preservatives and flavourings may also be trigger factors for bronchoconstriction. For example, sodium metabisulphite (used in wine production and less commonly as an excipient in oral medicines) can trigger bronchoconstriction via ingestion or inhalation. To compound matters, the potent neural stimulant effects of sulphites have been shown to reduce the efficacy of inhaled corticosteroids in asthma.15

Turning to flavourings, there have long been various health complaints involving monosodium glutamate. In China, 1,486 men and women were assessed for intake of this seaweed derivative and no association with asthma was found. However, the study was supported by the International Glutamate Technical Committee and the research paper contains significant methodological errors rendering the findings inconclusive.16

Alcohol and caffeine are among the bronchodilators found in foodstuffs. Low doses of alcohol are likely to cause short-term local vasoconstriction, and mechanical widening of the bronchi, combined with the release of catecholamine bronchodilators. The bad news is that high doses of alcohol are associated with nasal congestion, excessive secretion and rebound bronchoconstriction.

Caffeine is a precursor to the phosphodiesterase inhibitor theophylline, giving rise to bronchodilation.Contraindications such as tachycardia and a range of CYP450 interactions, including with theophylline, however, negate its clinical use or the recommendation of a cafe culture lifestyle in respiratory disease.
Lemon juice, garlic, horseradish, eucalyptus and pineapple are among the old wives’ tales of natural bronchodilators but there is little evidence to support their recommendation.

Many vitamins and minerals, and especially antioxidants, have appeared in the mainstream media as potential cures for respiratory ailments. These are discussed in the Panel.

Antioxidants The antioxidant system, which is equipped to protect the lung from damaging oxidants, is impaired in asthma17 and antioxidants could deter asthma and its progression.18 A combination of antioxidants in susceptible individuals has been shown to be more successful than administration singularly. For example, vitamin A, C, and E together have been shown to ameliorate ozone-induced bronchoconstriction.19 The evidence base is not such that a pharmacist could recommend vitamin formulations to asthma patients, but the benefits of a diet high in fruit and vegetables can be explained. In COPD oxidative processes lend themselves to the idea that dietary antioxidants may have a key role in slowing FEV1 decline. Researchers in China have reported a positive association among 3,085 subjects between vitamin C intake and FEV120 and other studies also suggest a use for vitamin C in COPD.


Vitamin D Vitamin D is closely associated with defence against respiratory pathogens, an important trigger in asthma and COPD exacerbations. It could also improve response to steroid therapy.21,22 Cross-sectional data in children suggest a significant negative association between vitamin D and asthma symptoms, and a significant positive association between the vitamin and both lung function and steroid response.23,24


Minerals Magnesium supplementation may have a direct action on the electrical potential governing bronchial smooth muscle. It has been shown to relax airway smooth muscle in vitro, to dilate asthmatic airways in vivo, to inhibit cholinergic neuromuscular transmission, to stabilise mast cells and T lymphocytes, and to stimulate nitric oxide and prostacyclin generation.25 These effects have not been confirmed in subsequent studies, but high magnesium intake is certainly associated with improvement in symptom scores.26,27 Magnesium is obtained principally from cereals, nuts, green vegetables and dairy products.

Selenium-containing foods correlate negatively with the risk of wheezing. Similarly, low intake of zinc (and carotenoids) by pregnant women is associated with more risk of wheezing and childhood asthma.9 Data also suggest that there may be a link between the ratio of dietary sodium and potassium in the prevalence of self-reported bronchitis.28


Nitrates During the summer of sport in 2012, the influence of dietary nitrate supplementation through foods such as radishes, beetroots, and leafy vegetables became topical. Pre-Olympic studies had shown a 1–2 per cent improvement in time trials for competitive cyclists after the consumption of 0.5L of beetroot juice three hours before competition.29

However, a recent study found that elite cross country skiers showed no benefit in their performance after supplementation.30 The benefits of dietary nitrate to patients with asthma or COPD remain largely untested. In vivo, nitric oxide (NO) formed from dietary nitrate plays an important role in a wide range of physiological processes. It has been suggested that NO plays a role in bronchodilation, but may also reduce salbutamol-induced bronchodilation.31

Despite theories otherwise, NO production is independent of meat consumption. NO bioactivity can be altered by statins, l-arginine and exercise.32 Conversely, airborne particles containing nitrates are associated with the oxidative stress commonly seen in asthma and COPD pathogenesis.33


Probiotics
Probiotics have some promise in the mediation of asthma, but the evidence is not conclusive enough to support recommendation.


Stanol esters
Plant stanol ester enriched foods and plant polysaccharides (eg, elecampane) may also have a role in the amelioration of asthma symptoms through the regulation of T-helper cells and IgE mediated bronchodilation, respectively, but more research is needed.34,35


Exercise

At first glance exercise, especially competitive sport, would appear a contraindication in lung disease. However, as Olympic champions Bradley Wiggins and Rebecca Adlington, who have asthma, have proven, this is not the case. Exercise is beneficial in both asthma and COPD if kept within aerobic range and the environmental conditions are correct. Indeed, it is part of pulmonary rehabilitation in COPD.

Exercise can result in significant improvement in a COPD sufferer’s quality of life and is indicated for patients with normal exercise capacity not just those who have been admitted to hospital. Exercise can improve FEV1 and reduce oxygen requirements by improving skeletal muscle efficiency. Aerobic exercise — beyond 60 per cent of the maximum working heart rate — sees the most dramatic improvement in cardiovascular efficiency. However, rates above 40 per cent attributed to a jog or brisk walk in a healthy individual, or simply a walk in patients with COPD, can improve oxygen use.

Exercise may also produce protective effects against lung disease, although extreme levels of chronic exercise in poor conditions can remodel bronchi walls and lead to asthma.36 For example, asthma prevalence is
particularly high among elite cyclists and attributed to the many miles they spend on the roads training and inhaling cold dry air that contains nitric oxide, diesel particle A and exhaust fumes.

Exercise recommended to patients with asthma or COPD should involve exertion around the aerobic zone, if possible, or simply walking any possible distance for COPD sufferers with low predicted FEV1 values. Activities that are the most beneficial for lung and skeletal muscle development, such as swimming, running or fast walking, should be recommended.

Outdoor sports can be recommended to people with exercise-induced asthma if precautions (eg, administration of 200µg inhaled salbutamol 15 minutes before exercise or an adequate warm up) are taken. Hyper-responsive patients should avoid chemical irritants, such as heavily polluted areas or highly chlorinated swimming pools.37–39

Complementary options

Pharmacists might be asked about complementary therapies such as the Buteyko method, which is a combination of breathing exercises to reduce the frequency and depth of respiration and dietary modifications. The breathing technique has been shown to improve symptoms and reduce bronchodilator use in small scale studies but does not appear to change bronchial responsiveness or lung function in asthma, and therefore cannot be recommended with confidence.40

Acupuncture appears to have regulatory effects on mucosal and cellular immunity in patients with allergic asthma, via IgA and IgE pathways. It may well prove a useful adjunctive therapy for allergic asthma.41

Yoga derived techniques have shown benefits to respiratory conditions over four to 15 weeks, improving functional exercise capacity in people with COPD compared with no intervention. However, yoga shows no consistent effects on dyspnoea or quality of life. No advantage has been shown over walking and running.42

Other areas

Further advice that pharmacists can give patients with lung conditions include avoiding extremes of temperature, getting vaccinated for influenza and taking time to relax. Practical tips on living with COPD or asthma are available on the British Lung Foundation and Asthma UK websites.

Key points

  • Unhealthy diets appear to increase the risk of asthma and chronic obstructive pulmonary disease.
  • Exercise is beneficial in both asthma and COPD if kept within aerobic range and the environmental conditions are correct.
  • Pharmacists can advise patients on avoiding extremes of temperature, getting vaccinated for influenza and taking time to relax.


About the author

Tristan Learoyd PhD, MRPharmS, worked for Respiratory Education UK and is now a medical advisor at Chiesi Ltd

References

References
1    Lang JE. (2012). Obesity, Nutrition, and Asthma in Children Pediatric Allergy, Immunology, and Pulmonology 2012;25:2
2    Nagel G, Weinmayr G, Kleiner A, et al. (2010) Effect of diet on asthma and allergic sensitisation in the International Study on Allergies and Asthma in Childhood (ISAAC) Phase Two Thorax 65:516-522
3    Ellwood P, Innes Asher M, García-Marcos L, et al. (2013) Do fast foods cause asthma, rhinoconjunctivitis and eczema? Global findings from the International Study of Asthma and Allergies in Childhood (ISAAC) Phase Three Thorax 68:351-360
4    Mantzioris E, Cleland LG, Gibson RA, et al. (2000) Biochemical effects of a diet containing foods enriched with n-3 fatty acids. Am J Clin Nutr 72:42–48.
Martindale S, McNeill G, Devereux G, et al. (2005) Antioxidant intake in pregnancy in relation to wheeze and eczema in the first two years of life. Am J Respir Crit Care Med 171:121–128.
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8    Emelyanov A, Fedoseev G, Krasnoschekova O, et al. (2002) Treatment of asthma with lipid extract of New Zealand green-lipped mussel: a randomised clinical trial. Eur Respir J 20:596–600.
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23    Brehm JM, Celedon JC, Soto-Quiros ME, et al. (2009) Serum vitamin D levels and markers of severity of childhood asthma in Costa Rica. Am J Respir Crit Care Med 179:765–771.
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30    Peacock O, Tjønna AE, James P, et al. (2012) Dietary nitrate does not enhance running performance in elite cross-country skiers. Med Sci Sports Exerc. 44(11):2213-9.
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33    Manney S, Meddings CM, Harrison RM, et al. (2012) Association between exhaled breath condensate nitrate + nitrite levels with ambient coarse particle exposure in subjects with airways disease. Occup Environ Med.  69(9):663-
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35    Danilets MG, Belska NV, Bel'sky YP, et al. (2008) Effects of plant water-soluble polysaccharides on the production of immunoglobulins E and G1 by lymphocytes of mice sensitized with ovalbumin. Bull Exp Biol Med.  Nov;146(5):585-7.
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Citation: The Pharmaceutical Journal DOI: 10.1211/PJ.2013.11129485

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