Sunday, September 21, 2008

Pursuing Weight Loss Among Obese Asthma Sufferers: Time for Disease Management Organizations to Step Up

Most physicians are well aware of the association between obesity and asthma. While persons with obesity may complain of shortness of breath or have altered lung function because of their anatomy, it's been clear for a long time that there's more to the story. Genes promoting both may occur together, leading to a disposition to develop both diseases. Obesity provokes a systemic "inflammatory" state which may involve the airways leading to bronchospasm. Increased levels of leptin may also lower the threshold for airways to become reactive. Dietary factors may be responsible for both the increase in asthma incidence as well as the development of obesity. Persons with obesity tend to be more prone to gastroesophageal reflux, which can also provoke airway irritation and asthma.

Just because there is an association, however, doesn't necessarily mean one causes the other. Yet, that just may be the case here. Obesity tends to predate the development of asthma and there have been reports that reductions in body weight tend to lead to a reduction in asthma severity. Obesity may be guilty as charged.

The likely causal link and the benefit from weight loss should be of great interest to disease management organizations. They're probably on the phone right now asking thousands of enrollees if they are using their peak flow meters, if they have access to a rescue plan and if they are being compliant with their inhalers. The association of obesity and asthma, however, probably hasn't been enough for the DMOs to start asking about their asthma enrollees' BMI and, if obesity is present, readiness to enter a weight loss program.

Well, maybe after reading this article by Eneli and colleagues, it may be time to pursue obesity as a modifiable risk factor in asthma care management and start asking patients about weight. Eneli et al performed a literature review and found there are 15 studies on the topic and all have shown an improvement in at least one asthma outcome measure when there was obesity-reducing weight loss.

The Disease Management Care Blog recognizes that purists would argue that a prospective randomized clinical trial comparing weight loss to no weight loss among asthma sufferers is necessary first, preferably using an outcome of interest (for example, emergency room utilization) to the DMOs. Others may wish to wait until organizations such as the NQF or the NCQA get around to establishing weight loss among persons with asthma one of their measures. Or maybe they're hoping that the managed care organizations they contract with don't bring it up.

The DMCB disagrees. The causal link between obesity and asthma makes too much sense to wait. Asking height and weight among persons with asthma is a start (if medical records are not readily available). If the BMI is elevated, an assessment of readiness to change lifestyle may be warranted. If the patient is ready, DMOs have programs available that can help, or the physician can be alerted, or the patient can be referred.

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