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Developing a Holistic Treatment Program for Asthmatics
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
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