1. Integrative Approach to Asthma

2. Asthma prevalence is rising worldwide better diagnosis air pollution allergies dietary factors hygiene hypothesis obesity antibiotics in 1 st year

3. Asthma prevalence in Canada 1978-1996

4. Asthma morbidity and mortality Asthma prevalence: 8.4% of persons >12 years >12% of children ages 0-9 Millions of office visits >50,000 hospital admissions/year >500 deaths in Canada/year Significant costs: Quality of life Medications Health care system

5. Key features of asthma Variable air flow obstruction Airway hyper-responsiveness Cellular inflammation

6. Asthma is a heterogenous condition exerciseallergensinfections

7. Integrative approach begins with good conventional care Education Recognize triggers Clear treatment plan Optimize asthma control Minimize visits to ER, life threatening episodes

8. Integrative therapy for asthma Prevention Diet Botanical medicines Mind/body therapies TCM

9. Asthma Prevention: dietary fats The kinds of dietary fats consumed during pregnancy may have a significant impact on childhood asthma risk An increase in omega 3 fat consumption from oily fish has been found to be beneficial Fried fish sticks (high in trans fats) have been found to increase risk Consumption of fatty fish > once per week in childhood may also be protective

10. Asthma prevention: breast feeding Exclusive breast feeding has been found to childhood asthma by 30- 50% A 50% reduction has been found in high risk children Encourage exclusive breast feeding x 6 months

11. Modifying the severity of exercise induced asthma (EIA) Low salt diet omega 3 fatty acids omega 6 fatty acids Increase dietary antioxidant vitamins, especially vitamin C

12. Low salt diet Higher salt intakes in a population are proportional to the prevalence & severity of asthma Several RCTs have shown: Low salt diet improved lung function High salt diet worsened lung function

13. Sodium Recommended sodium intake is 1500mg/day (or definitely < 2400mg/day) 1 teaspoon of salt = 2358mg Average North American diet contains over 3900mg/day 75% of sodium in our diet comes directly from foods: tinned soups, snacks, processed meats, restaurant meals

14. Essential fatty acids There are two main groups of essential fatty acids: omega 6 and omega 3 North American diets are generally overloaded with omega 6 fats and deficient in omega 3 fats (ratio n-6:n-3 12-40:1) The ideal ratio of n-6 to n-3 fats is thought to be ~ 1-2:1 Diets high in omega 6 fats can promote inflammation

15. Fish oil (EPA+DHA) reduces inflammation 1997 AJCN: >40% of the asthmatic responders showed a complete resolution of airway hyper- responsiveness. The others showed no change. 2003 AJRCCM: Elite athletes with exercise induced asthma who supplemented with 3.2g/day EPA and 2.2g/day DHA showed a marked improvement in post exercise pulmonary function Omega 3 fatty acids in EIA

16. Linoleic acid (LA) Gamma-linolenic acid (GLA) Arachidonic acid (AA) Alpha-linolenic acid (LNA) Eicosapentanoic acid (EPA) Docosahexanoic acid (DHA) Omega 6 pathway Omega 3 pathway Omega 6 pathway Omega 3 pathway Delta-6 desaturase Elongase PG1 PG2 PG3 Safflower, sunflower, corn, peanut oils Flax, walnuts, hemp, canola Salmon, halibut sardines, herring Evening primrose oil Meat, butter Salmon, halibut, sardines, herring

17. Cell membrane composition after omega 3 fatty acid supplementation Study EPA DHA (as % total neutrophil FA content) *Arm, et al. 10 wk 3.2 EPA+2.2 DHA 0.2 2.2 2.6** 2.6 *Lee, et al. 6 wk 3.2 EPA+2.2 DHA <0.1 1.7 1.5** 2.0

18. Antioxidants & EIA Ascorbic acid is the major airway antioxidant useful in EIA: 50-80% response also effectiveness of bronchodilators (500mg vitamin C 1.5 hrs prior to exercise) -carotene (found in dark green and dark orange vegetables): benefit seen in ~50% Lycopene (best source is cooked tomatoes): 45% in FEV

19. Anti-inflammatory diet Abundant fruits and vegetables Healthy fats: olive oil, nuts, fatty cold water fish, fish oil Low glycemic index/load carbohydrates Green tea, turmeric, ginger

20. Boswellia serrata Ayurvedic medicine- gum resin and bark used Boswellic acids inhibit leukotriene synthesis (anti-inflammatory effect) This herb has been used for arthritis, inflammatory bowel disease and asthma In a 6 week study of 40 asthmatics, 70% showed improved lung function Usual dose is 400-800mg tid More studies are needed to assess long term safety

21. Butterbur (Petasites hybridus) Rhizome (root) is used Spasmolytic and anti-inflammatory Used for: migraine prophylaxis, hayfever & asthma In a study of 80 people, butterbur decreased asthma symptoms by 47- 65% Important: Butterbur may contain hepatotoxic pyrrolizidine alkaloids. Use clinically tested product such as Petadolex (free of PAs) Usual adult dose is 50mg 3 times per day

22. Ginkgo biloba Leaf is used (seed used in TCM) Ginkgolides: anti-inflammatory, neuroprotective, anti-oxidant KEY FACT: Reduces airway hyper-responsiveness and bronchospasm An 8 week study showed a 15% improvement in lung function

23. Ephedra (Ma huang) Traditional TCM: stems are used medicinally KEY FACT: Has been misused for weight loss and as stimulant (herbal ecstasy) Alpha and beta adrenergic effects: can increase heart rate and also cause bronchodilation Contraindicated in heart disease, hypertension, glaucoma Should only be used by an experienced practitioner of traditional Chinese Medicine

24. Licorice (Glycyrrhiza glabra) Often used in TCM in combination with other herbs Root is used medicinally Anti-inflammatory, anti-tussive, expectorant Licorice can reduce the need for steroids (Steroid sparing effect) Safe dose is 1-1.5 gm crude licorice/day Use only under the supervision of an experienced health care provider

25. Marijuana (Cannabis sativa)

26. Leaves and flower buds are dried and smoked Contains delta 9- tetrahydrocannabinol (THC) Marijuana was used as a bronchodilator in the mid 1800s Inhaled marijuana has been found to have bronchodilator activity greater than an inhaled beta-agonist

27. Mind/body therapy Hypnosis: 50% of children with asthma have shown improvement after 1 or 2 short hypnosis sessions Journaling: improved FEV for 4 months

28. Journaling results JAMA April 14, 1999 Vol 281, No 14

29. Relaxation & breathing exercises Identify stress Teach relaxation Yoga/meditation Osteopathy

30. Traditional Chinese medicine Treatment is individualized and usually involves: dietary advice, a botanical formula, chi gong, acupuncture IKPA (invigorating kidney for preventing asthma) tablets: significant improved lung function in asthma Wenyang Tonglulo mixture also found effective Acupuncture: studies show mixed results

31. Integrative asthma therapy Anti-inflammatory diet Fish oil Low salt diet Vitamin C May consider the use of Boswellia or Butterbur Mind/body therapy: hypnosis/journaling

32. Mind body CDs or MP3s Guided imagery: Belleruth Naparstek www.healthjourneys.com Self hypnosis: Steve Gurgevich www.tranceformation.com