Assessing the relationship between obesity and asthma in adolescent patients: a review

Figures & data

Table 1 Highlighted studies on obesity and asthma inception during late childhood and adolescence

Reference	Study population	Study design	Main findings	Notes
Romieu et al^Citation8	7851 children aged 2–16 years	Retrospective analysis of NHANES III dataset, cross-sectional data, BMI measured, asthma defined by parent report	Asthma risk OR 3.44 (95% CI 1.49–7.96) for BMI > 95th percentile compared with BMI 25th–49th percentile	Controlled for dietary intake, physical activity, sociodemographic factors
Wickens et al^Citation9	894 children aged 11–12 years	Cross-sectional study, BMI measured, asthma defined by parent report	BMI standard deviation score positively associated with wheezing ever, wheeze in the last 12 months, asthma controller medication use	New Zealand population
Castro-Rodriguez et al^Citation10	1246 children enrolled in birth cohort between 1980 and 1984	Prospective birth cohort study	Females who became overweight or obese between the ages of 6 and 11 years were seven times more likely to develop new asthma symptoms at age 11 (P = 0.0002)	Tuscon Children’s Respiratory Study. Same relationship not seen in males
Gold et al^Citation11	9828 children aged 6–14 years	Prospective cohort study	Girls in the top quintile of BMI at entry and top quintile of BMI change during 5-year follow-up period were more likely to have asthma (OR 2.24, 95% CI 1.05–4.78 and 2.20, 95% CI 1.13–4.28)	Adjusted for study site, race, age, parental education, maternal smoking, single parent family. Relationship not seen in boys
Flaherman and Rutherford^Citation15	Meta-analysis of four studies, including 15,703 children	Meta-analysis	High bodyweight during middle childhood RR 1.5 for subsequent asthma (95% CI 1.2–1.8)	BMI ≥ 85th percentile for age compared with <85th percentile reference group
Gilliland et al^Citation17	3792 children without asthma in 4th, 7th, and 10th grades at enrollment	Prospective cohort study, annual assessments for 4 years	New onset asthma risk higher in overweight (RR 1.52, 95% CI 1.14–2.03) or obese (RR 1.60, 95% CI 1.08–2.36)	Stronger relationship in nonallergic children
Ho et al^Citation18	4052 adolescents aged 13–15 years with asthmalike symptoms at enrollment	Prospective cohort study, 12-month follow-up	Physician-diagnosed asthma during the follow-up period was higher in girls who were overweight at enrollment (OR 1.75, 95% CI 1.18–2.61)	No significant relationship seen in obese girls or overweight/obese boys

Abbreviations: BMI, body mass index; CI, confidence interval; NHANES, National Health and Nutrition Examination Survey; OR, odds ratio; RR, relative risk

Table 2 Highlighted studies on obesity and lung function

Reference	Study population	Study design	Main findings	Notes
Tantisira et al^Citation22	1041 children aged 5–12 years	Cross-sectional analyses of data collected during enrollment in a randomized controlled trial	Increasing BMI was associated with decreasing FEV1/FVC	No association found between BMI and other measures of asthma severity
Kattan et al^Citation23	368 adolescents aged 12–20 years	Analysis of data from a randomized controlled trial	BMI was positively associated with FEV1 in boys, and negatively associated with FEV1/FVC in boys and girls	Other measures of adiposity (percentage body fat) did not add additional information
Chen et al^Citation24	718 children aged 6–17 years	Cross-sectional study	Increased waist circumference was associated with decreased FEV1/FVC	No relationship seen between BMI and FEV1/FVC
Musaad et al^Citation25	1123 children aged 5–18 years followed in a specialty asthma clinic	Cross-sectional	Obesity measures explained 8%–24% of the variance in FEV1 in children with allergic rhinitis, and 2%–31% of the variance in children without allergic rhinitis	Obesity measures included BMI percentile, waist circumference, and conicity index. Adjusted for race, age, gender, and income

Abbreviations: BMI, body mass index; FEV₁, forced expiratory volume in I second; FVC, forced vital capacity.

Table 3 Highlighted studies on obesity and asthma exacerbations

Reference	Study population	Study design	Main findings	Notes
Quinto et al^Citation28	32,321 children aged 5–17 years	Retrospective cohort study using electronic health records	Increased odds for multiple asthma exacerbation outcomes, including oral corticosteroid prescription: OR 1.21 (95% CI 1.13–1.29) for overweight; OR 1.28 (95% CI 1.21–1.36) for obese compared with normal weight children	Adjusted for demographics, parental education, asthma controller use and GERD
Kattan et al^Citation23	386 minority adolescents aged 12–20 years	Sub-study of placebo-controlled randomized clinical trial	Females with a BMI above the 85th percentile had increased risk for exacerbations: OR 2.49, 95% CI 1.25–5.14	1-year clinical trial during which asthma medications were managed by asthma specialist
Carroll et al^Citation29	884 ED visits for acute asthma, children aged 2–18 years	Retrospective chart review	Overweight children 1.76 times more likely to be admitted to hospital (95% CI 1.23–2.51)	Overweight defined as weight for age > 95th percentile, not BMI, because height measurements not routinely taken in ED
Ginde et al^Citation30	672 children aged 5–17 years, presenting to ED for acute asthma	Multicenter prospective cohort study	No relationship between BMI and exacerbation severity
Carroll et al^Citation32	2009 children aged 2–18 years admitted to an ICU for acute asthma	Retrospective medical record review	Obese children had longer ICU length of stay (116 ± 12 hours vs 69 ± 57 hours, P = 0.02) and hospital length of stay (9.8 ± 7.0 days vs 6.5 ± 3.4 days, P < 0.01)	Similar severity of exacerbation at time of admission

Abbreviations: BMI, body mass index; CI, confidence interval; ED, emergency department; GERD, gastroesophageal reflux disease; ICU, intensive care unit; OR, odds ratio.

Table 4 Highlighted studies on obesity and asthma severity and control

Reference	Study population	Study design	Main findings	Notes
Musaad et al^Citation25	1123 children aged 5–18 years followed in a specialty asthma clinic	Cross-sectional study	Central obesity was associated with 2.63-fold increased odds of moderate to severe asthma (95% CI 1.19–5.82) in children with allergic rhinitis	Additional analyses using structural equation modeling also suggested that there was a stronger relationship between asthma and central obesity than overall obesity
Quinto et al^Citation28	32,321 children aged 5–17 years	Retrospective cohort study using electronic health records	Obesity associated with increased prescriptions for short-acting rescue medications for asthma (OR 1.17, 95% CI 1.06–1.29)
Lang et al^Citation20	43 adolescents aged 12–17 years (total study population 490 children, adolescents, and adults)	Post hoc analysis of subset of participants in a randomized controlled trial of therapy step-down strategies	Obese females aged 12–17 years had worse Asthma Control Questionnaire scores than nonobese females (P = 0.008)	There was also a trend toward lower FEV1 values in obese females
Kattan et al^Citation23	386 minority adolescents aged 12–20 years	Sub-study of placebo-controlled randomized clinical trial	Higher BMI associated with increased asthma symptom days in females only (R = 0.18, P = 0.02)	Asthma medications were adjusted by specialist providers during 1-year clinical trial
Ross et al^Citation37	108 children aged 4–18 years followed in specialty asthma clinic	Prospective cohort study	No relationship between BMI percentile and asthma severity in adjusted analyses	Sleep-disordered breathing was associated with asthma severity. Relationship strongest in children with BMI z-score ≥ 2

Abbreviations: BMI, body mass index; CI, confidence interval; FEV₁, forced expiratory volume in I second; OR, odds ratio.

Table 5 Hypothesized mechanisms linking obesity and asthma

Hypothesized mechanisms linking obesity and asthma	Selected references
Mechanical effects of obesity on airway physiology	^Citation46,Citation47
Shared inflammatory signaling abnormalities	^Citation48^–^Citation56
Shared alterations in oxidative/antioxidant signaling	^Citation57,Citation58
Effect of adipokines on airway biology and immune regulation	^Citation52,Citation64^–^Citation67
Altered metabolic signaling	^Citation59^–^Citation63
Comorbid conditions, including sleep-disordered breathing and gastroesophageal reflux disease	^Citation36,Citation37,Citation68^–^Citation73

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