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What Is Causing the Asthma Epidemic?
In the United States, asthma cases have increased by more than 60 percent since the early 1980s, and asthma-related deaths have doubled to 5,000 a year. What is causing the asthma epidemic and what can we do to stem the tide?
A recent series of articles in the Journal of the American Chiropractic Association (JACA) delves into this question and offers advice from doctors of chiropractic and allergists who have helped control asthma symptoms in many patients. People in their 30s and older can remember that when they were young, it was very unusual for even one child in school to have asthma. Schoolchildren now often know several kids with asthma in a single class. The rapid increase in the number of young people with asthma was brought home to Dr. Scott Bautch, past president of the American Chiropractic Association's (ACA) Council on Occupational Health, when he went to a football game with his 13-year-old son: "Someone on the field had a breathing problem. It was hard to see whose son it was, and 15 parents ran to the field with inhalers."
So far, researchers don't know why cases of asthma are increasing at such an alarming rate. They hypothesize that a combination of genetics and some non-hereditary factors - such as increased environmental exposure to potential allergens - play a role. "Thirty years ago, Windex was the only cleaning solvent used by a few people. Now, we have a special cleaning solvent for every object," says Dr. Bautch. "In addition, furniture and carpets are produced with formaldehyde as a preservative, and people breathe it," he says.
Decreased air quality is coupled with the allergy-friendly modern house design, says Dr. William E. Walsh, MD, FACC, an allergist practicing in Minnesota: "Fifty years ago we lived in old, drafty houses, and the breeze dried and freshened the air, and cleared out mold and other allergens. Nowadays, our super-insulated houses don't breathe adequately. Making basements into a living space increases mold exposure because mold grows in any basement." Food has become another source of exposure to allergens. "Food manufacturers put more preservatives in foods now to store them longer," says Dr. Bautch.
Researchers hypothesize that an increase in vaccinations, cesarean births, and antibiotic intake may be playing a role, too. Asthma is a chronic disease; it can't be cured-only controlled. For best treatment results, both the primary care physician and an asthma specialist, such as an allergist or pulmonologist, should be involved. According to experts interviewed for the article, the treatment program, in addition to medication intake, should include reducing exposure to the substances that induce acute episodes and identifying specific allergens that affect the patient.
Allergens aren't the only culprit. Stress factors-such as moving to a new home, or changing jobs-may induce or aggravate asthma attacks. Even emotional expressions such as fear, anger, frustration, hard crying, or laughing can cause an attack as well. To reduce the patient's stress level and improve the patient's quality of life, alternative treatments should be incorporated into the treatment program. Various relaxation techniques, such as biofeedback, meditation, yoga, and stress management, as well as massage, chiropractic manipulation, breathing exercises, and acupuncture can be helpful.
A multi-site clinical trial on chiropractic management of asthma is underway in Australia. "The preliminary data are very encouraging. Chiropractic patients are showing decreases in physical asthma symptoms and cortisol levels," says Dr. Anthony Rosner, director of education and research for the Foundation of Chiropractic Education and Research. "Doctors of chiropractic can give a full-scale evaluation to asthma patients; assess their physical and neurological status, their lifestyle, diet, and stressors; and help the patients increase motor coordination, and improve the work of respiratory and gut muscles to increase the quality of life," says Dr. Gail Henry, a chiropractic neurologist, who practices in Houston, Texas. "Doctors of chiropractic can be a great addition to the healthcare team treating the asthma patient."
Asthma experts offer the following tips for asthma patients:
ABSTRACT By Michael Smithers
Dietary marine fatty acids (fish oil) for asthma in adults and children
Thien FCK, Woods R, Luca S, Abramson MJ. Cochrane Rev. Abstract, 2004
Background: Epidemiological studies suggest that a diet high in marine fatty acids (fish oil) may have beneficial effects on inflammatory conditions such as rheumatoid arthritis and possibly asthma.
Search Strategy: We searched the Cochrane Airways Group trials using the terms : marine fatty acids OR diet OR nutrition OR fish oil OR eicosapentaenoic acid OR EPA. We also searched bibliographies of retrieved trials and contacted fish oil manufacturers. Searches were current as of September 2003.
Selection Criteria: We included randomised controlled trials in patients with asthma more than two years of age. The study duration had to be in excess of four weeks. Double blind trials were preferred, but we also reviewed singleblind and open trials for possible inclusion. All three reviewersread each paper, blind to its identity. Decisions concerning inclusion were made by simple majority. We all performed quality assessment independently.
Data Collection and Analysis: The only comparison possible was between marine n3 fatty acid supplementation and placebo. There were insufficient trials to examine dietary manipulation alone.
Main results: Nine randomised controlled trials conducted between 1986 and 2001 satisfied the inclusion criteria. Seven were of parallel design and two were crossover studies. Eight compared fish oil with placebo while one compared high dose versus low dose marine n3 fatty acid supplementation. Two studies were conducted in children, while the remaining seven studies were conducted in adults. None of the included studies reported asthma exacerbations, health status, or hospital admissions.
There was no consistent effect on any of the analysable outcomes: FEV1, peak flow rate, asthma symptoms, asthma medication use or bronchial hyper-reactivity. One of the studies performed in children which combined dietary manipulation with fish oil supplementation showed improved peak flow and reduced asthma medication use. There were no adverse events associated with fish oil supplements.
Conclusions: There is little evidence to recommend that people with asthma supplement or modify their dietary intake of marine n3 fatty acids (fish oil) in order to improve their asthma control. Equally, there is no evidence that they are at risk if they do so.
Motor-Vehicle Occupant Fatalities and Restraint Use Among Children Aged 4-8 Years United States, 1994-1998 Morbidity and Mortality Weekly Report MMWR 49(7), 2000. 2000 Centers for Disease Control (CDC)
Abstract In the United States, more children aged 4-8 years die as occupants in motor-vehicle-related crashes than from any other form of unintentional injury. To reduce the number of deaths and injuries caused by motor-vehicle-related trauma, child passengers in this age group should be restrained properly in a vehicle's back seat. To characterize fatalities, restraint use, and seating position among occupants aged 4-8 years involved in fatal crashes, CDC analyzed 1994-1998 data from the Fatality Analysis Reporting System (FARS), which is maintained by the National Highway Traffic Safety Administration (NHTSA). This report summarizes the results of that analysis, which indicate that during 1994-1998, little change occurred in the death rate, restraint use, and seating position among children aged 4-8 years killed in crashes. Motor-vehicle occupants who died in crashes during 1994-1998 were included in the analysis of FARS data. FARS is a census of traffic crashes in which at least one occupant or nonmotorist (e.g., pedestrian) died within 30 days of a crash on a public road within the 50 states, District of Columbia, and Puerto Rico. FARS includes information about restraint use and seating position derived from police crash reports. Restraint use (e.g., seat belts, child-safety seats [CSSs], and belt-positioning booster seats) was reported as used or not used. Seating position was designated as front, back, other, or unknown. Injury death rates per 100,000 population were calculated using annual estimates from the Bureau of the Census.
During 1994-1998, 14,411 child occupants aged 4-8 years were involved in crashes where one or more fatalities occurred; of these, 2549 (17.7%) died. Approximately 500 child occupants died each year during the study period; the average annual age-specific death rate was 2.6 per 100,000 population. In 1994, restraint use among fatally injured children was 35.2% (177 of 503); in 1998, restraint use was 38.1% (201 of 527). The proportion of fatally injured children seated in the back seat of a vehicle involved in a crash was 50.1% (252 of 503) in 1994 and 53.7% (283 of 527) in 1998.
Commentary: During 1994-1998, child occupant death rates did not decrease, restraint use among fatally injured child occupants changed little, and the proportion of fatally injured children seated in the back seat of a motor vehicle involved in a crash remained fairly constant. Children aged 4-8 years represent a special population for motor-vehicle occupant protection. Having outgrown CSSs designed for younger passengers, children aged 4-8 years frequently sit unrestrained or are placed prematurely in adult seat belt systems. Public health and traffic safety organizations recommend that children in this age group be restrained properly in booster seats. This study found that nearly two thirds of fatally injured children were unrestrained at the time of the crash. Only 4%-6% of children aged 4-8 years used booster seats when riding in motor vehicles.
Belt-positioning booster seats raise a child so that the shoulder belt fits securely between the neck and arm and the lap belt lies low and flat across the upper thighs. Children do not fit in adult lap/shoulder belts without a booster seat until they are 58 inches tall and weigh 80 lbs. Children should ride in a booster seat from the time they graduate from their forward-facing CSS until approximately age 8 years or until they are tall enough for the knees to bend over the edge of the seat when the child's back is resting firmly against the seat back.
Despite recommendations for children to ride in the back seat whenever possible to reduce risk for injury in a crash, approximately one fourth of child passengers ride in the front seat. Riding in the back virtually eliminates injury risk from deployed front-seat passenger air bags and places the child in the safest part of the vehicle in the event of a crash.
As of January 1, 2000, 35 children aged 4-8 years have died while seated in front of air bags. Of these children, 31 (89%) were either unrestrained or improperly restrained. Riding in the back seat is associated with at least a 30% reduction in the risk for fatal injury . Approximately half of those children in this study who were fatally injured were sitting in the back seat.
The 50 states, District of Columbia, and Puerto Rico have child-passenger safety laws; however, substantial gaps in coverage exist for child passengers aged 4-8 years. For example, in 19 states, children this age can ride unrestrained in the back seat of a motor vehicle. In most states, children as young as age 4 years may use an adult seat belt. No state requires the use of booster seats for children who have outgrown their CSSs. Three states have laws requiring that children be seated in the back seat of passenger vehicles. The ages of the children covered by these laws vary by state.
The findings in this study are subject to at least three limitations. First, police crash reports overestimate restraint use; therefore, restraint use may be lower for children in this age group. Second, vehicle miles traveled have increased during 1994-1998; consequently, improvements in fatality rates may be masked by increased exposure to travel. Finally, increases in restraint use and resulting changes in occupant fatalities may require many years of investigation before they become apparent.
Reducing fatalities among motor vehicle occupants aged 4-8 years will require finding effective strategies to promote booster seat use and placement of children in the back seat. Public health and traffic safety efforts should be accelerated to increase appropriate occupant protection among children aged 4-8 years as a primary means to reduce fatal motor-vehicle--related injuries. Efforts are under way by CDC and others to determine the best ways to encourage booster seat use and to increase the prevalence of properly restrained children riding in the back seat.
Selenium supplementation for asthma
Background Selenium deficiency may be important in chronic asthma. Observational studies have demonstrated that patients with chronic asthma may have lower levels of selenium than their control. Nevertheless, selenium supplementation has not been recommended with drug therapy for asthma. This review systematically examines RCTs that evaluated the role of selenium supplementation in chronic asthma.
Objectives: Recognition that chronic asthma can be associated with selenium deficiency has led to the investigation of the role of selenium supplementation in reducing the symptoms and impact of chronic asthma. The objective of this review was to assess the efficacy of selenium supplementation as an adjunct to medication for the treatment of chronic asthma.
Search Strategy: We searched the Cochrane Airways Group trials register, MEDLINE/PUB MED, and EMBASE. Searches were current as of August 2003.
Selection Criterion: Randomized trials comparing patients with chronic asthma receiving selenium supplementation in conjunction with asthma medication, with patients taking asthma medication only.
Data collection and Analysis: Two reviewers applied the study inclusion guide
Main Results: One trial with a total of 24 patients suffering from chronic asthma was included. The study reported significant clinical improvement in the selenium supplemented group, as compared with the placebo group, in terms of a clinical evaluation. However, this improvement could not be validated by significant changes in separate objective parameters of lung function and airway hyperresponsiveness.
Conclusions: There is some indication that selenium supplementation may be a useful adjunct to medication for patients with chronic asthma. This conclusion is limited because of insufficient studies and lack of improvement in the clinical parameters of lung function.
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