Life Style in Asthma Management; Stress, home/workplace, and intellectual state

Prof. Dr. A. Füsun KalpaklıoğluTurkish Thoracic Society Meeting, Apr 6, 2013, Antalya

”Stress“ is the organism’s response to stressful conditions or stressors, consisting of a pattern of physiological and

psychological reactions.

“STRESS”

”Vagal-Bias”

Miller BD, et al. JACI 2009;124:66-73

•171 children , age 2 to 17 yr;• evaluated in ED for asthma attack•11 preselected film stressors•Correlation between depression, vagal bias, airway resistance

Social Networks as a new source of psychological stress?

• 18 y. M (fluticasone 250 mg BID, montelukast 10 mg )

“Facebook friend”“Friending”“Facebook profile”“Post-Facebook PEF”“Facebook: a new trigger for asthma?”

D’Amato G, et al. Lancet 2010; 376: 1740

• Facebook users 800 million (since 2011 increasing 30%)

• Twitter surpassed 500 million

• 65% online adults ,83% of 18-29 y. use social networks

”Virtual Relationship”

• Self-esteem• Facebook depression

& loneliness

“Cyberostracism”“Cyberbullying”

Social Networks and Asthma

D’Amato G, et al. Curr Opin 2013; 1: 87-91

Araujo L, et al. J Invest All Clin Imm 2012; 22: 22-34

Web-Based vs Standart Asthma Self-Management

Portal for Assessment and Self-Management of Asthma P’ASMA(www.pasma.med.up.pt)

PiKo: FEV1/PEF

Haczku A, et al. JACı 2010;125: 550-8

Corticosteroid Insensitivity

SOCIAL SUPPORT

HEALTH/FUNCTIONING Loneliness/isolation

Self efficacy

STRESSAsthma/Allergy

Letourneau N, et al. J Pediatr Nursing 2012; 27: 65-73

COPING Support

seeking

Intervening Processes Social learning

Social comparingSocial exchange

Relationship of social support to stress, coping and health

•28 Canadian adolescents•3 months of weekly online chat sessions

Hypotesis 1: Increase support-seeking copingHypothesis 2: Increase support satisfaction/ reduce support needsHypothesis 3: Increase support network sizeHypothesis 4: Decrease loneliness/social isolationHypothesis 5: Increase self-efficacy

Parental relationshipQuality/Conflict

Relation SecurityParenting

Biobehavioral ReactivityEmotional Dysregulation/ Depression

FAMILY

PATIENT

PARENT CHILD

Emotional Climate

Disease SeverityPSYCHOBIOLOGICAL MECHANISMS

Wood et al. 2000, 2008

BIOBEHAVIORAL Famiy Model

• PFT• Perceived Stress Scale

(PSS) F(1.54)=1.48,p=.23

Hockemeyer J, et al. Behavioral Med 2002; 27:161-72

• 60 p, 18-51 y• tape-recorded deep-breathing relaxation exercise,•a cognitive-behavioral treatment,•a 20-minute exercise to write about a stressful life event.

Stress Management in Asthma

Mancuso C, et al. J Asthma 2010; 47: 883-8

•180 patients, 84% F•M age 43 y,

Attitude for Asthma Management

Positive Attitude Self- Efficacy

Knowledge

Fukuhara A, et al. AJRCCM 2012; 186: 1309

3/11 Disaster in Fukushima&Asthma Control

ASTHMA

STRESS

ANXIETY

• Reduce stressors •Exercise•Delegate responsibility•Relaxation exercises; ie.muscle relaxation breathing

•SSRIs•Anxiolytics•Cognitive- behavioral tx

POOR COGNITION

POOR ADHERENCE

THER

APY

A+R(n=85)

COPD (n=50)

Total (n=135)

p

EPQR-A

Extraversion 3.7 (1.9) 2.8 (1.1) 3.3 (1.9) 0.01

Neuroticism 3.2 (1.8) 3.0 (1.8) 3.2 (1.7) 0.4

Psychoticism 0.9 (0.9) 0.9 (0.9) 0.9 (0.8) 0.8

MARS

Total score 21.3 (3.9) 20.6 (4.1) 21 (3.9) 0.4

Intentional score 17.6 (2.5) 16.8 (3.3) 17.3 (2.8) 0.2

Unintentional score 3.8 (1.0) 3.8 (1.1) 3.79 (1.0) 0.8

SF-36

PCS 65.7 (20.7) 51.0 (26.4) 60.6 (23.8) 0.001

MCS 61.8 (21.6) 54.8 (29.0) 59.3 (24.6) 0.2

Identifying Nonadherence

Kalkan IK, Baccioglu A, Kalpaklioglu AF. Invest Allergol Clin Immunol (accepted)

Extraversion F>M Adherence F<M Adherence not correlated w personality traits

57 (33M/24F) mild-to-moderate asthma

YOGA Group (29) CONTROL Group (28)4 hr/d/2 wkAsanas (postures)Prayanamas (breathing techs)Kriyas (cleansing techs)Meditation Shavasana (relaxation)

Asthma & Yoga

Vempati R, et al. BMC Pulm Med 2009; 9: 37

W 0 W 8 pFEV1 YOGA

C70.2±17.462.5±19.2

77.9± 17.2 59.9±19.1

0.009NS

AQOL YOGAC

3.72±1.23.64±1.1

5.46±1.14.5±1.5

0.013NS

% fall in FEV1 w exercise challenge

YOGAC

15.05±149.13±10.8

5.18±11.85.81±10.1

0.005NS

% change in 11-PGF2 excretion

YOGAC

17.6±18.616.6±21

16.8±19.720.7±23.5

0.490.84

Asthma & Yoga

”Breath is central to yoga because it is central to life”T. Krishnamacharya

Vempati R, et al. BMC Pulm Med 2009; 9: 37

Kalpaklioglu AF, et al. WAO J 2011; 4: 170

Ashma/Allergy Awareness

SYMPTOMS N (%)Nasal• Hay fever 142 (56.1)• Itchy nose 176 (69.6)• Runny nose 141 (55.7)• Nasal congestion 130 (51.4• Postnasal drip 119 (47)• Sneezing 196 (77.5• Poor sense of smell 96 (37.9)• Itchy eyes183 (72.3)• Watery/red eyes 157 (62.1)

Chest• Cough 156 (61.3)• Wheezing 131 (51.8)• Chest tightness 119 (47)• Shorthness of breath

130 (51.4)

Kalpaklioglu AF, et al. WAO J 2011; 4: 170

Ashma/Allergy Awareness

Brackbill RM, et al. JAMA 2009; 302: 502-16

Asthma & Sept 11, 2001 Disaster in WTC

Brackbill RM, et al. JAMA 2009; 302: 502-16

Asthma & Sept 11, 2001 Disaster in WTC

Szema AM, et al. JACI 2004; 113: 420-6

Clinical visits &Asthma prescriptions ,P<0.05Rescue inhalerOral steroid use, P>0.05

Clinical deterioration -Sept 11, 2001 Disaster in WTC

Martino and Prescott. Chest 2011;139:640-7

Epigenetic Regulation

DNA methylation is an epigenetic mechanism that can result in gene silencing

• Environmental exposures alter DNA methylation• Examples of epigenetic-environmental interaction:

– Diet– Allergens– Cigarette smoke– Air pollution– Ageing

This interaction has implications possibly for the asthma clinic, in the future.

Bowman et al. Expert Opin Ther Targets 2009;13:625-40, Yang I, AAAAI 2013

Gene silencing by DNA methylation

Fresno (n=62, high air pollution), Stanford (n=40, low air pollution)Secondhand smoke exposure (SHS); verified by urinary cotinine

Kohli et al. Clinical Epigenetics 2012;4:17, Yang L,. AAAI 2013AAP=ambient air pollution (PM2.5, PM10, PAH, ozone)

AAP SHS + 0 + 0

IFN- inCD4+CD25T effector cells

Secondhand smoke and ambient air pollution - CpG methylation and expression of IFN-

in T cells

Pieper MR, et al. Life Sci 2012; 91: 1113-8

The non-neuronal cholinergic system as novel drug target in the airways

Asthma & Smoking

Mancuso C, et al. J Gen Intern Med 2000; 15: 301-10

Depression/QoL/Intellectual State

Kalpaklioglu AF, et al. J Invest Allergol Clin Immunol 2008; 18: 168-173

•316 pts with asthma w/wo rhinitis•Correlation of HRQoL (SF-36 ) iwith sociodemographic data, educational state

QOL in Asthma & Intellectual State

Patients with asthma (w/wo rhinitis) experience physical and mental impairment

Kalpaklioglu AF, et al. J Invest Allergol Clin Immunol 2008; 18: 168-173

QOL in Asthma & Intellectual State

Gonzales-Barcala, et al. Multi Resp Med 2012; 7: 32

VAS

Factors influencing quality of life in Asthma

Busse W. JACı 2010;125: 529-37

Inner City Risk Factors in Asthma

CR

“one size fits all” NOT