There is considerable evidence in accepted science that many everyday factors affect the expression and severity of asthma. These factors are our life habits, the things we do every day—and how we do them—like eating, drinking, elimination, sleeping, physical activity and emotional attitude. All of these habits and mundane acts can be studied and understood within the framework of standard physiology and biochemistry.
Asthma is a chronic condition. The susceptibility of the asthmatic to increased symptoms and exacerbations depend on many factors relating to basal health, as well as asthma specific factors. Studies of these everyday components of life reveal a strategy to prevent or control asthma, including provisions for stress prevention, adrenal normalization, virus prevention, immune system stabilization, healthy eating and drinking habits, and for a high general state of health. Such a strategy does not preclude the taking of medication.
The Mechanism of Asthma
Asthma is considered to be a disease of inflammation, resulting in constriction of the muscles surrounding the airways, increased cell permeability, swelling and mucous production. Asthma is predisposed by genetic conditions, though not assured. [1]
The mechanism of allergy and many asthma triggers is an overreaction by elements of the immune system to apparently harmless stimuli such as pollen or cat dander. The primary culprit is the IgE-mast cell reaction which attacks these antigens by exploding (degranulating) and releasing powerful toxins, such as histamine. In asthma, this precipitates a secondary reaction (late phase reaction) whereby the immune system mobilizes an array of cells and substances—including cytokines and (autocoids) eicosanoids such as leukotrienes—to keep up the attack on the “invader”. The result is that healthy tissues are damaged and the characteristic inflammation of asthma tends to become self perpetuating and, in time, chronic.
Controlling Inflammation
Two main classes of drugs—beta agonists (Proventil, Ventolin, Serevent, etc.) and corticosteroids (Aerobid, Azmacort, Prednisone, etc.)— have long been effective, within limits, in controlling inflammation and other asthma symptoms. They are modelled on the respective actions of the hormones epinephrine and cortisol, both produced in the body’s adrenal glands. Man made drugs are effective precisely because they mimic the action of the body’s own hormones. That is, the body’s own adrenal hormones provide a basal level of protection against asthma: “There have been hundreds of studies over the past 20 years evaluating adrenoceptor function on lymphocytes, monocytes, granulocytes and mast cells. With some exceptions, stimulation of b-adrenoceptors evokes an inhibitory signal in these cells. Thus it can be reasoned that endogenous catecholamines [epinephrine, norepinephrine] may serve to inhibit the conditions of asthma not only by evoking bronchial smooth muscle relaxation, but also by inhibiting the immune processes leading to inflammation.” [2] Endogenous corticosteroids [cortisol, DHEA] play a complementary and equally important role, acting “as a major feedback control on immune responses.” [3]
These hormones act at receptor sites on cells . For asthmatics, most important are smooth muscle cells and mast cells, both of which contain substantial numbers of beta2 adrenergic receptors. Epinephrine’s action on beta2 adrenergic receptors is a calming or relaxing, resulting in more open airways and less reactive mast cells. Cortisol prevents the formation of inflammatory mediators (made by and within the cells) associated with late-phase reactions. Other adrenal hormones such as DHEA may modify these more abundant hormones, epinephrine and cortisol.
The Role of Stress and Emotional Factors
In the early development of the human body, stress was mostly physical and acute—a life or death struggle, a terrified flight from danger, an encounter with intense cold. Once stress was less common, more dramatic and physical, with physical consequences. Now, tens of thousands of years later, while our diet and lifestyle has changed drastically, our bodies still tend to assess situations as “fight or flight”, even with stresses associated with work in an office.
Most asthma authorities recognize an emotional component of asthma. “The role of stress and psychological factors in asthma is important but not fully defined. There is emerging evidence that stress can play an important role in precipitating exacerbations of asthma and possibly act as a risk factor for an increase in the prevalence of asthma.” [4] All stress responses are not exactly equal but the basic mechanism is clear: most psychological and other stresses have very real physiological effects, resulting in “activation of adrenal . . . hormone synthesis, and in the subsequent secretion of corticosteroids and catecholamines respectively.” [5] Even in daily eating cycles (the response varying according to types of food eaten), a rapid reduction of blood glucose “provokes a compensatory response from the adrenal medulla- epinephrine is released stimulating hepatic glucose output.” [6]
In biology “Exposing cells to an excess of hormones for a sustained period typically results in a decreased number of receptors for that hormone per cell. This . . . is referred to as downregulation.” [7] That is, increased stimulation of a biological organism—in this case the hypothalamopituitary (HPA) axis and beta-adrenergic receptors in the airways—leads to decreased sensitivity. Chronic, psychological or low level stress leads to elevated levels of hormonal epinephrine and cortisol in the blood, and consequently a reduction of beta2 adrenergic receptors in target cells. The body’s endogenous stress hormones or their man-made pharmaceutical homologues have less effect when target cells have fewer or less sensitive suitable receptors. In addition, the chronic response of epinephrine, cortisol and other hormones stimulates the production of TH2 cells over TH1—a critical cytokine relationship—resulting in the tendency to express asthmatic and allergic responses. [8]
Over time, conditions of chronic low level stress may lead to a depletion of one or more nutritional cofactors necessary for the production of stress hormones. A chronic deficit of any of these nutrients—including vitamin C, pantothenic acid, magnesium, tyrosine and zinc—will tend to spiral into increased stress as the adrenals strive to respond. Elevated levels circulating cortisol also cause protein breakdown (which can lead to muscle wasting) as well as reduced lymphocyte production and general immune system suppression, leaving the body more generally vulnerable to respiratory viral and other infections. Rebounding low levels of these circulating hormones tend to leave the asthmatic more susceptible to asthma exacerbations.
In the best conditions, circulating adrenal hormones control and prevent the expression of asthma symptoms. The immune system and the modulating HPA axis responding to occasional stresses tend to grow strong and stay healthy—just as muscles grow from exercise—especially when met with physical activity, good nutrition and a positive attitude. Current studies suggest that one reason for increasing incidence of asthma is that hyper-clean, antiseptic environments in childhood do not allow the child’s immune system the necessary challenges and stresses needed to develop fully.
While we think of stress as being mostly emotional, physiological stresses are perhaps more common. Stimulant consumption, suboptimal hydration/excess diuresis, chronic high blood insulin, inadequate sleep, nutritional deficiencies and imbalances—are all associated with, if not the cause of, low-level stress. Most of these factors are within conscious human control. And by every standard, reduced stress favors better asthmatic and overall health.
Genetics
Asthma is considered to have an hereditary component but it is not limited by genetics. “Thus, normal subjects [non-asthmatics] become asthmatic following inhalation of 10 ng of histamine whereas asthmatics respond to 0.5 nanograms or less. The idea that hyperreactivity is a response to chronic allergen challenge is strongly supported….” [9] That is, an asthmatic reaction can be induced in normal, healthy people by single factors. Perhaps in real life, chronic challenges are creating the increasing number of asthmatics who have no apparent inherited predisposition.
Conversely, the genetic tendency involved in asthma and allergy may not be a life sentence of suffering and dependence on medication. In one classic study, a species of rat was bred to have a genetic malformation of the inner ear, resulting in diminished balance and body righting reflexes. It was found that this problem could be fully overcome by feeding the rats high levels of the mineral manganese. This same inner ear abnormality was induced in normal rats by feeding them a diet deficient in manganese. According to pioneer nutritionist Dr. Roger Williams, “It is entirely reasonable to suppose that although individual humans may have very high requirements for specific nutrients, when these needs are met, the individual can prosper ….” [10]
While asthma is not a simple matter of nutritional deficiencies, “generally, nutrient deficiencies are associated with impaired immune responses . . . … [including] secretory antibody and cytokine production . . . … Paradoxically, obesity and excess intake of nutrients are also associated with reduced immune function.” [11] It is clear that genetics predispose but are not necessarily the ultimate determinant of asthmatic health status.
Therapeutic Options
There is no proven cure for asthma. In today’s therapy there is only avoidance of allergens and triggering factors, and there are many medications to relieve the sometimes life threatening symptoms. [12].
Do any other options exist? “Although alternative healing methods may be popular, . . . their scientific basis has not been established. . . . The most widely known complementary alternative medicine methods are acupuncture, homeopathy, herbal medicine and Ayurvedic medicine (which includes transcendental meditation, herbs and yoga).” [13] A study funded by the NIH finds “hundreds of unproved treatment programs are used which rely on complementary and alternative medicine for the management of asthma ….” [14] including, in addition to those listed above, nutrition. There is no mention whatsoever of food, nutrition or physical conditioning in 146 pages of official Guidelines for the Diagnosis and Management of Asthma. According to these official NHLBI guidelines, the only factors which “have been shown to increase asthma symptoms and/or precipitate asthma exacerbations” include inhalant allergens; occupational exposures to sensitizing gases, chemicals or dusts, irritants such as tobacco, indoor/outdoor pollution, rhinitis, sinusitis, gastroesophageal reflux, sensitivity to aspirin, NSAIDs, sulfites, viral respiratory infections and stress. [15]
While the physiology outlined previously in this paper is accepted science, its practical, non-pharmaceutical therapeutic conclusions are rarely in evidence in the daily treatment programs of asthmatics. There is, in official long term asthma management, no strategy to prevent viral respiratory infections. The benefits of good physical conditioning (long term) are well known but generally ignored due to fear of exercise induced bronchoconstriction. Nutrition is relegated to the orphan status of “alternative” medicine in spite of the fact that it has a solid basis in biochemistry and there are hundreds of peer reviewed studies assessing nutritional effects pertinent to asthma. One clinical text states, “The secretion of ACTH (and thus of glucocorticoids), HGH and digestive hormones is dependent on the type and rhythm of food intake.” And yet there is no further mention of food in the entire book. [16]
Some asthma authorities believe there are significant affective factors other than those officially recognized: …”A lack of antioxidants in the diet would therefore favor oxidant-induced inflammatory mechanisms, and this may underlie the recent trends for an increase of asthma prevalence and morbidity…. It is also [a matter of] less fish, the balance of omega 3 and 6 fatty acids, and excess salt. In addition there are other risk factors, such as increasing allergens and decreasing exposure to bacteria and minor bacterial infections in childhood.” [17] Transient IgA deficiency is strongly implicated as a contributing factor to asthma. [18] “Numerous studies have suggest that behavioral conditioning, stress, exercise and sexual activity can have major effects on immunity…. [19] Many additional factors relating directly or indirectly to asthma are found in peer reviewed literature. [To be expanded.]
Variable Sensitivity and Immunologic Loading
Asthma—before it reaches a chronic stage—is known to be “spontaneously reversible” in most instances. That is, the body has a natural ability to recover from symptoms after a time. Many asthmatics experience symptom free periods for months at a time. [20] How does the patient recover? Under what conditions can a chronic asthmatic remain symptom-free for periods of time or apparently recover completely—”grow out” of asthma?
It is known that “a number of factors must contribute to allergy [italics added]. The hypothesis of allergic breakthrough suggests that the clinical symptoms of allergy are seen only when an arbitrary level of immunological activity is exceeded.” [21] So in asthma: as the loading of negative factors increases, the asthmatic becomes more liable to express symptoms such as wheezing, coughing, mucous production— up to the point at which the late phase reaction begins its cascade. And the severity of the late phase reaction is also surely subject to modification by common events and behavioral choices, such as dietary lipid intake. [22] [23]
If there are many potential causative factors in everyday life other than from proximity to reactive environmental agents, then the asthmatic’s susceptibility to exacerbations may be variable from week to week or even day to day, depending much on the events and choices made in daily life.
Even if the exact mechanism by which asthma occurs is not perfectly understood, measures can be taken to improve the functioning of the systems involved: calm or stabilize the immune systems; strengthen the respiratory system and the epithelium; rest and strengthen the HPA axis; achieve a high level of nutrition; and maintain a high level of physical conditioning and rest, among other things. Avoidance of known negative factors is obviously good sense, but a proactive, expanded notion of “avoidance”— a strategy of optimizing all possible factors is needed. [See Appendix 1]
Practical Long Term Therapy for a Chronic Condition
The point is often made that 30% of all asthmatics are smokers, implying that if we cannot even change this clearly detrimental habit, we can hardly hope to influence other less obviously bad habits. In addition there are another 30-40% of asthmatics who will be highly resistant to changing any habits, including those that surely contribute to asthma morbidity such as overeating, lack of physical conditioning, poor sleep, insufficient hydration, chronic ingestion of stimulants and so on.
But the last one- third of all asthmatics includes most children whose best outcome would be to “outgrow” asthma forever. This group represents the steady increase in new asthmatics. On the present path, asthmatic children will gradually become medication- dependent asthmatics. And yet a child certainly has a better chance of developing really healthy habits than older people do of changing them There can be no more important reason to pursue this course of study.
If a program of “optimization” of basic life factors can have a significant effect on the health levels of asthmatics—by the measure of reduced need for medication [24] and improved quality of life— then the problem is to decide what set of habits are generally very healthy for asthmatics. An effective treatment protocol based on manipulating the patient’s lifestyle into very healthy habits would surely be a valuable tool. As of now, there is more than sufficient evidence to begin:
Accumulation and review of lifestyle studies pertinent to asthmatics.
Further and wide ranging study of these basic life factors.
Studies of asthmatics who have “outgrown” asthma or who control their asthma without medication.
The development of a healthy lifestyle program, available for any patient, but particularly for children.
FOOTNOTES
[1] Guidelines for the Diagnosis and Management of Asthma, National Heart, Lung and Blood Institute, 1997
[2] Asthma and Rhinitis, Busse and Holgate, Eds. Undem and Myers, 1995; 707-8
[3] Immunology, Roitt, I., Brostoff, J and Male, D., Mosby International, Ltd., 1998, p 178
[4] Guidelines, op. cit. p101
[5] Hormones, Baulieu, E-E and Kelly, P.A., Eds., Chapman and Hall, 1990, p245
[6] Nutrition and Neurotranmitters, Chafetz, Michael D., 1990; see also Understanding Normal and Clinical Nutrition , Whitney, E.N., Cataldo, C.B., Rolfes, S.R., West Publishing Co, 1991, p848
[7] Medical Physiology,. Rhoades, R.A. and Tanner, G.A.; Little Brown and Co, 1995, p646
[8] Immunology, op. cit., p125
[9] Immunology, op. cit.. p314
[10] Nutrition Against Disease, Roger J. Williams, Pitman Publishing Corp, 1971, p.59
[11] Immunology, op. cit., p295
[12] Guidelines, op. cit.., page 1
Official guidelines for the management of asthma are:
- measure and monitor lung function to assess severity
- avoid, reduce or eliminate factors that cause asthma
- undertake comprehensive pharmacologic therapy
- educate the patient concerning the previous recommendations
[13] Guidelines ,op. cit., p67
[14] Hackman, R.M, Stern, J.S, and Gershwin, M.E., Clin Rev Al and Imm, v14, 1996, pp321- 336)
[15] Guidelines, op. cit., pp 41-51
[16] Hormones, op. cit.., p 35
[17] Barnes, PJ. Mechanisms of Action in Glucocorticoids in Asthma 1996, Am J Respir Crit Care Med; 154: 521-527
[18] Immunology, op. cit., p315
[19] Understanding Allergy, Sensitivity & Immunity, Joneja, J.W. and Bielory, L, Rutgers University Press, 1994, p266
[20] Rachelefsky, G: J Allergy and Clin Immunology, 84; 72-89, 1989
[21] Immunology, op. cit. p315
[22] Broughton, KS et al. Reduced asthma symptoms with n-3 fatty acid ingestion are related to 5-series leukotriene production. AM J Clin Nutr, 65: 1011-1017; 1997
[23] Hodge, L, et al. Consumption of oily fish and childhood asthma risk, Medical Journal of Australia, 164: 137-140; 1996
[24] Guidelines, op. cit., p81, “The aim of asthma therapy is to maintain control of asthma with the least amount of medication and hence minimal risk of adverse effects…”
Appendix 1
STRESS—resolve and reduce stress—
PSYCHological stresses have PHYSIological effects—the secretion of varying quantities of “stress hormones”, epinephrine and cortisol among others. Much has been written on resolving and reducing emotional/psychological stress and need not be repeated here.
PHYSIological effects of daily habits/chronic stressors such as caffeine, suboptimal hydration/excess diuresis, high sugar diets, nutritional deficiencies and imbalances
DIETETIC factors—
[1] Foods that have general
A) Negative effects (beyond known IgE reactive foods)—food allergies, “intolerances”, lectins; high blood insulin levels; other hormonal imbalances
B) Positive effects—5 to 9 servings of fruit and vegetables daily
[2] Caloric intake vs. expenditure,
[3] Chronic or excessive intake of
A) stimulants such as coffee, colas, other drugs
B) medication, alcohol, non stimulating drugs
C) salt; animal products; sugar and simple carbohydrates
[4] Hydration, diuresis
[5] Digestion, assimilation and elimination—”leaky gut” (breaches in the intestinal wall); intestinal flora; stomach acidity; effects of NSAIDs
[6] Rhythms and time of eating
[7] Nutrition in diet and supplementation—
A) Blood and tissue antioxidant levels
B) Lipid factors—balance of Essential fatty acids (omega 3, omega 6), blood insulin levels and other factors influencing autocoid (e.g. leukotriene) formation
C) Mineral balances including Ca—Mg and Na—K
D) nutrient deficiencies or imbalances—low Se, ascorbate and others
SLEEP; level of restedness
Level of PHYSICAL CONDITIONING, overweight, ratio of protein to fat in body composition
BREATHING habits
ATTITUDE—emotional, psychological factors, both positive and negative
SIDE EFFECTS from Medications
About the author:
I have had severe “attacks” of asthma since the age of two. Throughout childhood, my asthma was treated with Tedral (the standard for the 50’s, a mix of ephedrine, theophylline and barbiturate) aminophylline and loving care. As a child, I realized that the attacks would subside after 10-14 days, regardless of medication. This awareness became my emotional edge: the certainty (unwarranted as it may have been) that I would recover my natural state of health after a time. Between these attacks I lived a very normal, active young life, without maintenance medications (other than a few years of immunotherapy, anti-allergy shots). Incidence of these attacks decreased in my teenage years. After reaching the age of 18, I declined to use drugs or see doctors, mainly due to pigheadedness but also due to a desire to learn to control the problem in a natural way. I learned much but very slowly. By age 40, I learned to adjust my life habits to avoid getting sick and have had no full blown attacks since that time.
In the twelve years since, I have become healthier. My peak flows are between 65 and 70% (400+ l/min) of what is supposed to be normal for my age and height. I suspect this is an accurate reflection of my diminished lung capacity, due to scarring from past years of coughing. I run a 3 mile cross country route when possible, in 25–30 minutes, and have little difficulty breathing—heavy pollen in the air slows me down slightly. In the high pollen months of summer I take a rare puff of Aerobid (corticosteroid inhaler), and it helps.
I have always been highly allergenic, especially to tree, grass and weed pollens, in addition to having severe allergies to cat, cockroach and dust mite dander. While recent tests (six years ago) show this to be unchanged, I express minimal symptoms, sometimes a slightly runny nose, occasional sneezes and, rarely, slightly tighter airways. My symptoms are variable: in best condition, I’m unaffected. In pollen season I treat myself very well or suffer symptomatic consequences. There is no doubt that I’m still susceptible to asthma exacerbations, given sufficient negative circumstances .
My personal treatment program includes a diet rich in fruit and vegetables; fish and quality oils; a good level of physical conditioning, excellent hydration, clean air, minimal stimulants, one multivitamin daily and other regular/occasional supplements. Emotional stability, a positive outlook, an active lifestyle and love are all important assets for anyone’s good health.
While my knowledge is incomplete, I believe the subject matter is so urgent that it cannot wait for my perfect erudition. There will be errors within this work. Please do not let them deflect you from whatever else may be of value. I would be grateful for corrections, improvements, further education, better science and general editing.
– John Hepler, March, 2001