A feasibility trial of a digital mindfulness-based intervention to improve asthma-related quality of life for primary care patients with asthma

Association between higher morning preference and better health-related quality of life in asthma

Background

Circadian preference for eveningness has been linked to a higher risk of asthma and allergies, but its association with health-related quality of life (HRQL) in asthma has not been studied yet.

Objective

We aimed to investigate the associations between individual circadian preference and HRQL in asthma.

Methods

Among 691 adult asthma patients from Canada, India, New Zealand, and the United Kingdom, a digital questionnaire was administered to capture demographic information, social and psychologic attributes, comorbidities, and medication adherence. Circadian preference and HRQL were assessed by the reduced version of the morningness-eveningness questionnaire (rMEQ) and the short form of the chronic respiratory questionnaire, respectively. We analyzed the association between chronotype and HRQL using mixed-effect linear regression models.

Results

Of all participants, 59% were female with a mean (standard deviation) age of 49 (17) years. Median (interquartile range) rMEQ total score was 17 (14-19). Mean (standard deviation) dyspnea, fatigue, emotional function, and mastery scores were 5.94 (1.2), 4.38 (1.3), 5.05 (1.3), and 1.96 (1.1), respectively. In regression analysis, a higher rMEQ total score (higher morningness) was associated with less fatigue (β = 0.06; 95% confidence interval, 0.04 to 0.09) and better emotional function (β = 0.03; 95% confidence interval, 0.004 to 0.06), and these associations were mediated by less anxiety, depression, and alcohol abuse, and better sleep quality.

Conclusion

Morning orientation is associated with better HRQL in patients with asthma. The results suggest that working with patients to promote schedules and habits related to morningness may be beneficial.

Piloting co-developed behaviour change interventions to reduce exposure to air pollution and improve self-reported asthma-related health

BACKGROUND

Exposure to air pollution can exacerbate asthma with immediate and long-term health consequences. Behaviour changes can reduce exposure to air pollution, yet its 'invisible' nature often leaves individuals unaware of their exposure, complicating the identification of appropriate behaviour modifications. Moreover, making health behaviour changes can be challenging, necessitating additional support from healthcare professionals.

OBJECTIVE

This pilot study used personal exposure monitoring, data feedback, and co-developed behaviour change interventions with individuals with asthma, with the goal of reducing personal exposure to PM2.5 and subsequently improving asthma-related health.

METHODS

Twenty-eight participants conducted baseline exposure monitoring for one-week, simultaneously keeping asthma symptom and medication diaries (previously published in McCarron et al., 2023). Participants were then randomised into control (n = 8) or intervention (n = 9) groups. Intervention participants received PM2.5 exposure feedback and worked with researchers to co-develop behaviour change interventions based on a health behaviour change programme which they implemented during the follow-up monitoring week. Control group participants received no feedback or intervention during the study.

RESULTS

All interventions focused on the home environment. Intervention group participants reduced their at-home exposure by an average of 5.7 µg/m³ over the monitoring week (-23.0 to +3.2 µg/m³), whereas the control group had a reduction of 4.7 µg/m³ (-15.6 to +0.4 µg/m³). Furthermore, intervention group participants experienced a 4.6% decrease in participant-hours with reported asthma symptoms, while the control group saw a 0.5% increase. Similarly, the intervention group's asthma-related quality of life improved compared to the control group.

IMPACT STATEMENT

This pilot study investigated a novel behaviour change intervention, utilising personal exposure monitoring, data feedback, and co-developed interventions guided by a health behaviour change programme. The study aimed to reduce personal exposure to fine particulate matter (PM2.5) and improve self-reported asthma-related health. Conducting a randomised controlled trial with 28 participants, co-developed intervention successfully targeted exposure peaks within participants' home microenvironments, resulting in a reduction in at-home personal exposure to PM2.5 and improving self-reported asthma-related health. The study contributes valuable insights into the environmental exposure-health relationship and highlights the potential of the intervention for individual-level decision-making to protect human health.

Mindfulness improves psychological health and supports health behaviour cognitions: Evidence from a pragmatic RCT of a digital mindfulness-based intervention

BACKGROUND

Mindfulness-based interventions can improve psychological health; yet the mechanisms of change are underexplored. This pre-registered remote RCT evaluated a freely accessible digital mindfulness programme aiming to improve well-being, mental health and sleep quality. Health behaviour cognitions were explored as possible mediators.

METHODS

Participants from 91 countries (N = 1247, Mage = 27.03 [9.04]) were randomized to 30 days of mindfulness practice or attention-matched control condition. Measures of well-being, depression, anxiety, stress, sleep quality, barriers self-efficacy, self-regulation and behavioural predictors (e.g., attitudes and behavioural intentions) were taken at baseline, 1-month (post-intervention) and 2-months (follow-up). Linear regression examined intervention effects between and within groups. Longitudinal mediation analyses explored indirect effects through health behaviour cognitions.

RESULTS

Three hundred participants completed post-intervention measures. Those receiving mindfulness training reported significantly better well-being (Mdifference = 2.34, 95%CIs .45-4.24, p = .016), lower depression (Mdifference = -1.47, 95%CIs -2.38 to -.56, p = .002) and anxiety symptoms (Mdifference = -.77, 95%CIs -1.51 to -.02, p = .045) than controls. Improvements in well-being and depression were maintained at follow-up. Intervention effects on primary outcomes were mediated by attitudes towards health maintenance and behavioural intentions. Mediating effects of attitudes remained when controlling for prior scores in models of depression and well-being.

CONCLUSIONS

Digital, self-administered mindfulness practice for 30 days meaningfully improved psychological health, at least partially due to improved attitudes towards health behaviours and stronger behavioural intentions. This trial found that digital mindfulness is a promising and scalable well-being tool for the general population, and highlighted its role in supporting health behaviours.

Understanding the impact of breathing pattern disorders in difficult-to-treat asthma

INTRODUCTION

Difficult-to-treat asthma is defined as asthma that is uncontrolled despite high-level treatment or requires such treatment to maintain good control and reduce exacerbations. Breathing pattern disorders (BPD) have been reported as a comorbidity in ~ 24-42% % of patients with difficult-to-treat asthma. This narrative review will assess the association, impact, and management of BPD in difficult-to-treat asthma.

AREAS COVERED

We outline current understandings of the nature of difficult-to-treat asthma and BPD. We then review the impact of BPD on difficult-to-treat asthma and Multidisciplinary Team (MDT) approaches to assessing and managing BPD in this patient group. A comprehensive literature search was performed by an asthma specialist MDT including physiotherapists, psychologists, and physicians to create a holistic perspective on this subject.

EXPERT OPINION

BPD exerts significant negative impacts across multiple domains in patients with difficult-to treat asthma. There is a need for further observational, interventional, qualitative and quantitative research to develop better diagnosis, treatment, and awareness of the impacts of BPD including health economic analysis. Studies should develop multimodal approaches that better treat both BPD and associated comorbidities within the multimorbidity framework of difficult-to-treat asthma. Recognizing and addressing BPD should be key elements in future difficult-to-treat asthma management guidelines and clinical practice.

Quality of life and its association with predictors in lung transplant recipients: a latent profile analysis

Backgrounds

Improving quality of life (QOL) is one of the main aims of lung transplantation (LTx). There is a need to identify those who have poor quality of life early. However, research addressing inter individual quality of life variability among them is lacking. This study aims to identify group patterns in quality of life among lung transplant recipients and examine the predictors associated with quality of life subgroups.

Methods

In total, 173 lung transplant recipients were recruited from one hospital in Guangdong Province between September 2022 and August 2023. They were assessed using the Lung Transplant Quality of Life scale (LT-QOL), Mindful Attention Awareness Scale (MAAS), Life Orientation Test-Revised scale (LOT-R), and Positive and Negative Affect Scale (PANAS). Latent profile analysis was used to identify QOL subtypes, and logistic regression analysis was used to examine the associations between latent profiles and sociodemographic and psychosocial characteristics.

Results

Two distinct QOL profiles were identified: "low HRQOL" profile [N = 53 (30.94%)] and "high HRQOL" profile [N = 120 (69.06%)]. Single lung transplant recipients, and patients who reported post-transplant infection, high levels of negative emotion or low levels of mindfulness and optimism were significantly correlated with the low QOL subgroup.

Conclusion

Using the domains of the LT-QOL scale, two profiles were identified among the lung transplant recipients. Our findings highlighted that targeted intervention should be developed based on the characteristics of each latent class, and timely attention must be paid to patients who have undergone single lung transplantation, have had a hospital readmission due to infection, exhibit low levels of optimism, low levels of mindfulness or high negative emotions.

The impact of mindfulness apps on psychological processes of change: a systematic review

Mindfulness-based interventions (MBIs) have demonstrated therapeutic efficacy for various psychological conditions, and smartphone apps that facilitate mindfulness practice can enhance the reach and impact of MBIs. The goal of this review was to summarize the published evidence on the impact of mindfulness apps on the psychological processes known to mediate transdiagnostic symptom reduction after mindfulness practice. A literature search from January 1, 1993, to August 7, 2023 was conducted on three databases, and 28 randomized controlled trials involving 5963 adults were included. Across these 28 studies, 67 outcome comparisons were made between a mindfulness app group and a control group. Between-group effects tended to favor the mindfulness app group over the control group in three psychological process domains: repetitive negative thinking, attention regulation, and decentering/defusion. Findings were mixed in other domains (i.e., awareness, nonreactivity, non-judgment, positive affect, and acceptance). The range of populations examined, methodological concerns across studies, and problems with sustained app engagement likely contributed to mixed findings. However, effect sizes tended to be moderate to large when effects were found, and gains tended to persist at follow-up assessments two to six months later. More research is needed to better understand the impact of these apps on psychological processes of change. Clinicians interested in integrating apps into care should consider app-related factors beyond evidence of a clinical foundation and use app databases to identify suitable apps for their patients, as highlighted at the end of this review.

Resting state functional connectivity changes following mindfulness-based stress reduction predict improvements in disease control for patients with asthma

BACKGROUND

The staggering morbidity associated with chronic inflammatory diseases can be reduced by psychological interventions, including Mindfulness-Based Stress Reduction (MBSR). Proposed mechanisms for MBSR's beneficial effects include changes in salience network function. Salience network perturbations are also associated with chronic inflammation, including airway inflammation in asthma, a chronic inflammatory disease affecting approximately 10% of the population. However, no studies have examined whether MBSR-related improvements in disease control are related to changes in salience network function.

METHODS

Adults with asthma were randomized to 8 weeks of MBSR or a waitlist control group. Resting state functional connectivity was measured using fMRI before randomization, immediately post-intervention, and 4 months post-intervention. Using key salience network regions as seeds, we calculated group differences in change in functional connectivity over time and examined whether functional connectivity changes were associated with increased mindfulness, improved asthma control, and decreased inflammatory biomarkers.

RESULTS

The MBSR group showed greater increases in functional connectivity between salience network regions relative to the waitlist group. Improvements in asthma control correlated with increased functional connectivity between the salience network and regions important for attention control and emotion regulation. Improvements in inflammatory biomarkers were related to decreased functional connectivity between the salience network and other networks.

CONCLUSIONS

Increased resting salience network coherence and connectivity with networks that subserve attention and emotion regulation may contribute to the benefits of MBSR for patients with asthma. Understanding the neural underpinnings of MBSR-related benefits in patients is a critical step towards optimizing brain-targeted interventions for chronic inflammatory disease management.

Mind-body internet and mobile-based interventions for depression and anxiety in adults with chronic physical conditions: A systematic review of RCTs

This review summarizes the effectiveness of scalable mind-body internet and mobile-based interventions (IMIs) on depression and anxiety symptoms in adults living with chronic physical conditions. Six databases (MEDLINE, PsycINFO, SCOPUS, EMBASE, CINAHL, and CENTRAL) were searched for randomized controlled trials published from database inception to March 2023. Mind-body IMIs included cognitive behavioral therapy, breathwork, meditation, mindfulness, yoga or Tai-chi. To focus on interventions with a greater potential for scale, the intervention delivery needed to be online with no or limited facilitation by study personnel. The primary outcome was mean change scores for anxiety and depression (Hedges' g). In subgroup analyses, random-effects models were used to calculate pooled effect size estimates based on personnel support level, intervention techniques, chronic physical condition, and survey type. Meta-regression was conducted on age and intervention length. Fifty-six studies met inclusion criteria (sample size 7691, mean age of participants 43 years, 58% female): 30% (n = 17) neurological conditions, 12% (n = 7) cardiovascular conditions, 11% cancer (n = 6), 43% other chronic physical conditions (n = 24), and 4% (n = 2) multiple chronic conditions. Mind-body IMIs demonstrated statistically significant pooled reductions in depression (SMD = -0.33 [-0.40, -0.26], p<0.001) and anxiety (SMD = -0.26 [-0.36, -0.17], p<0.001). Heterogeneity was moderate. Scalable mind-body IMIs hold promise as interventions for managing anxiety and depression symptoms in adults with chronic physical conditions without differences seen with age or intervention length. While modest, the effect sizes are comparable to those seen with pharmacological therapy. The field would benefit from detailed reporting of participant demographics including those related to technological proficiency, as well as further evaluation of non-CBT interventions. Registration: The study is registered with PROSPERO ID #CRD42022375606.

App-Based Mindfulness for Attenuation of Subjective and Physiological Stress Reactivity in a Population With Elevated Stress: Randomized Controlled Trial

BACKGROUND

Stress-related mental health disorders have steadily increased and contributed to a worldwide disease burden with up to 50% experiencing a stress-related mental health disorder worldwide. Data suggest that only approximately 20%-65% of individuals receive treatment. This gap in receiving treatment may be attributed to barriers such as limited treatment access, negative stigma surrounding mental health treatment, approachability (ie, not having a usual treatment plan or provider), affordability (ie, lack of insurance coverage and high treatment cost), and availability (ie, long waits for appointments) leaving those who need treatment without necessary care. To mitigate the limited access mental health treatment, there has been a rise in the application and study of digital mental health interventions. As such, there is an urgent need and opportunity for effective digital mental health interventions to alleviate stress symptoms, potentially reducing adverse outcomes of stress-related disorders.

OBJECTIVE

This study examined if app-based guided mindfulness could improve subjective levels of stress and influence physiological markers of stress reactivity in a population with elevated symptoms of stress.

METHODS

The study included 163 participants who had moderate to high perceived stress as assessed by the Perceived Stress Scale (PSS-10). Participants were randomly allocated to 1 of 5 groups: a digital guided program designed to alleviate stress (Managing Stress), a digital mindfulness fundamentals course (Basics), digitally delivered breathing exercises, an active control intervention (Audiobook), and a Waitlist Control group. The 3 formats of mindfulness interventions (Managing Stress, Basics, and Breathing) all had a total duration of 300 minutes spanning 20-30 days. Primary outcome measures were perceived stress using the PSS-10, self-reported sleep quality using the Pittsburgh Sleep Quality Index, and trait mindfulness using the Mindful Attention Awareness Scale. To probe the effects of physiological stress, an acute stress manipulation task was included, specifically the cold pressor task (CPT). Heart rate variability was collected before, during, and after exposure to the CPT and used as a measure of physiological stress.

RESULTS

The results showed that PSS-10 and Pittsburgh Sleep Quality Index scores for the Managing Stress (all P<.001) and Basics (all P≤.002) groups were significantly reduced between preintervention and postintervention periods, while no significant differences were reported for the other groups. No significant differences among groups were reported for Mindful Attention Awareness Scale (P=.13). The physiological results revealed that the Managing Stress (P<.001) and Basics (P=.01) groups displayed reduced physiological stress reactivity between the preintervention and postintervention periods on the CPT. There were no significant differences reported for the other groups.

CONCLUSIONS

These results demonstrate efficacy of app-based mindfulness in a population with moderate to high stress on improving self-reported stress, sleep quality, and physiological measures of stress during an acute stress manipulation task.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05832632; https://www.clinicaltrials.gov/ct2/show/NCT05832632.

The effect of yoga on pulmonary function in patients with asthma: A meta-analysis

BACKGROUND

Asthma is one of the most common non-communicable diseases. Yoga with physical postures, breathing exercises, meditation, and relaxation may play an essential role in the complementary management of lower respiratory diseases. The study aimed to evaluate the impact of yoga (posture, breathing exercises, and meditation) on pulmonary function tests, asthma control tests, and health-related quality of adult asthmatic patients.

METHODS

MEDLINE, PubMed, Embase, Cochrane, Scopus, Google Scholar, ResearchGate, Clinical Key, and Academia electronic search engines were explored to search the relevant literature. The present study included adult asthmatic patients (age -18 and 60 years) with mild to moderate asthma, per GINA (Global Initiative for Asthma) guidelines. The effect of yoga was assessed on the following outcomes; pulmonary function tests, including FeV1 (Forced expiratory volume 1 s), FVC (Forced vital capacity), FeV1/FVC, peak expiratory flow rate (PEFR), health-related quality of life, and asthma control test. A fixed-effect model was applied to compute significance for statistical heterogeneity. P-value <0.05 was considered for statistical significance.

RESULTS

Finally, fifteen articles were included for meta-analysis. The forest plot for overall effect of yoga intervention and usual care favors the yoga intervention for improvement in pulmonary function as FeV1 (SMD = 0.96, CI = 0.77-1.14, I2 = 54%), FVC (SMD = 0.35, CI = 0.14-0.55, p = 0.11, I2 = 50%), Fev1/FVC (SMD = 0.18, CI = -0.38-0.02, p = 0.02, I2 = 50%), PEFR (SMD = 0.38, CI = 0.18-0.58, p = 0.0003, I2 = 0%), asthma control test (SMD = 0.16, CI = 0.15-0.48, p = 0.31, I2 = 86%) and health-related quality of life (SMD = 0.26, CI = 0.18-0.34, p = 0.02, I2 = 51%) of asthmatic patients.

CONCLUSION

This meta-analysis provides a moderate level of evidence regarding yoga as a complementary therapy in managing mild to moderate asthmatic patients. It also adds to the current knowledge of the same.

Exiting the Anthropocene: Achieving personal and planetary health in the 21st century

Planetary health provides a perspective of ecological interdependence that connects the health and vitality of individuals, communities, and Earth's natural systems. It includes the social, political, and economic ecosystems that influence both individuals and whole societies. In an era of interconnected grand challenges threatening health of all systems at all scales, planetary health provides a framework for cross-sectoral collaboration and unified systems approaches to solutions. The field of allergy is at the forefront of these efforts. Allergic conditions are a sentinel measure of environmental impact on human health in early life-illuminating how ecological changes affect immune development and predispose to a wider range of inflammatory noncommunicable diseases (NCDs). This shows how adverse macroscale ecology in the Anthropocene penetrates to the molecular level of personal and microscale ecology, including the microbial systems at the foundations of all ecosystems. It provides the basis for more integrated efforts to address widespread environmental degradation and adverse effects of maladaptive urbanization, food systems, lifestyle behaviors, and socioeconomic disadvantage. Nature-based solutions and efforts to improve nature-relatedness are crucial for restoring symbiosis, balance, and mutualism in every sense, recognizing that both personal lifestyle choices and collective structural actions are needed in tandem. Ultimately, meaningful ecological approaches will depend on placing greater emphasis on psychological and cultural dimensions such as mindfulness, values, and moral wisdom to ensure a sustainable and resilient future.

Clinically relevant effects of Mindfulness-Based Stress Reduction in individuals with asthma

Background

Psychological distress and comorbid psychopathology contribute to exacerbation risk in patients with asthma. Thus, interventions designed to reduce stress and improve emotion regulation, such as Mindfulness-Based Stress Reduction (MBSR), may augment standard care. Few studies have addressed this question and a paucity of data exists to determine the ability of MBSR to impact clinical outcomes in asthma.

Methods

This randomized controlled trial investigated effects of MBSR training on asthma control and airway inflammation, in relation to psychological symptoms, in adults with asthma. Participants were randomized to an 8-week MBSR training (n = 35) or wait-list control group (n = 34). Clinically relevant asthma assessments, including Asthma Control Questionnaire and inflammatory biomarkers, were collected at baseline and six approximately-monthly follow-ups. Self-reported mindfulness, distress, depression, and anxiety symptoms were assessed at baseline, post-intervention, and study completion. Chronic stress level was determined at baseline only.

Results

Asthma control improved significantly in individuals randomized to MBSR, relative to wait-list controls (p = .01; effect size d = 0.76), which was maintained at 4mo post-intervention. 32% of MBSR participants achieved a clinically significant improvement, based on the ACQ6 Minimally Important Difference, relative to 12% of wait-list participants. Moreover, MBSR-related improvement in asthma control was associated with a reduction in distress (p = .043) and the intervention was most efficacious for those with the highest baseline depressive symptoms (p = .023). Importantly, MBSR also reduced levels of exhaled nitric oxide, a biomarker of airway inflammation, relative to wait-list controls (p < .05).

Conclusion

Supporting and extending extant evidence of mind-body relationships in asthma and the benefits of stress reduction for these patients, this is, to the best of our knowledge, the first RCT to demonstrate that training in MBSR improves clinically relevant asthma outcomes. MBSR may thus be a valuable addition to optimal asthma management, particularly for those with comorbid psychopathology.

Clinical trial registration

NCT02157766.

Experiences of exercise in patients with asthma: qualitative analysis of discussions in a UK asthma online community

BACKGROUND

Engagement with exercise in adults with asthma is suboptimal. Limited information is available regarding factors affecting engagement with exercise.

AIM

To explore experiences of exercise and linked unmet needs in adults with asthma.

DESIGN & SETTING

Qualitative thematic analysis of posts in a UK asthma online community, written between 2015 and 2020.

METHOD

Posts were identified using keywords searches. Posts in the 'Exercise' topic section were additionally included. Thematic analysis of posts was undertaken.

RESULTS

143 relevant posts were analysed. 92 participants were identified through posts (11M, 33F, 48 gender not stated, aged 26-73 years). Emerging themes included: fear of experiencing asthma symptoms during exercise, lack of information about how to deal with symptoms, external barriers, emotional response, and involvement of healthcare providers. Environmental factors, concomitant life stressors, distrust of healthcare professionals and embarrassment of displaying asthma symptoms during exercise were barriers to engagement. Facilitators included experiencing positive health outcomes following exercise and positive discussions regarding exercise with healthcare professionals. Strategies participants developed to enable exercise were warming up, increasing reliever and preventer inhalers when exercising and finding exercises felt as enjoyable.

CONCLUSION

Future interventions to address fears of exercise-induced physical symptoms, and clear instructions on the use of inhalers when exercising are needed. Exploring patients' attitudes to exercise in clinical consultations, especially in primary care, may be beneficial.