Self-reported racial/ethnic discrimination and bronchodilator response in African American youth with asthma

Association between e-cigarette use and asthma among US adolescents: Youth Risk Behavior Surveillance System 2015-2019

BACKGROUND

Previous studies have suggested that e-cigarette use, which has increased rapidly among US adolescents, may cause respiratory distress. This cross-sectional study aimed to investigate the factors associated with e-cigarette use and the relationship between e-cigarette use and asthma among US adolescents.

METHODS

Data from the Youth Risk Behavior Surveillance System between 2015 and 2019 were analyzed, and multivariable logistic regression was used to identify demographic and behavioral factors associated with e-cigarette use. Stratified analyses were conducted to assess the relationship between e-cigarette use and asthma among adolescents by previous combustible product use.

RESULTS

This study found that Hispanic adolescents had lower odds of e-cigarette use than White adolescents in Texas, with factors such as age, substance use, and depression being associated with use. In the US, male gender, previous combustible and substance use, and depression were associated with higher odds of ever using e-cigarettes, while current use was associated with several factors including age and White race. E-cigarette use was significantly associated with asthma among adolescents who have never used combustible products in both Texas and the entire US after adjusting for covariates (OR 1.32, 95% CI 1.06-1.66 and OR 1.18, 95% CI 1.02-1.37, respectively).

CONCLUSION

The findings from this study can be used to inform public health strategies and policies aimed at reducing e-cigarette use and its associated health risks among adolescents.

Impact of Social Determinants on the Burden of Asthma and Eczema: Results from a US Patient Survey

Introduction

Little is known about how patients with asthma and eczema perceive their medical care and burden of disease. A survey was conducted to evaluate the perceptions among the general patient population with asthma and/or eczema regarding disease and treatment burden and barriers to adequate care.

Methods

An online survey was completed by market research panelists in the USA between March 24, 2020 and April 6, 2020. Eligible participants were at least 18 years of age and endorsed a diagnosis of asthma and/or eczema. Survey responses are described for all participants, by designated racial/ethnic groups, and by income level.

Results

In all, 841 participants completed the survey (asthma, n = 554; eczema, n = 398; both, n = 111; White, n = 421; Black, n = 252; Hispanic, n = 95; low income [less than $15,000/year], n = 99; higher income [at least $15,000/year], n = 713). More Black and Hispanic participants than White participants, and more participants with low income than higher income, endorsed health literacy as a barrier (e.g., filling out official documents, understanding written materials). Participants with low income were less likely than participants with higher income to have an asthma action plan (42% vs 53%, respectively) and to discuss asthma control with their healthcare provider (54% vs 69%). Black and Hispanic participants were more likely than White participants to have an emergency department visit (52% and 49% vs 31%, respectively) or hospitalization (31% and 39% vs 16%) for asthma within the last 12 months. Participants reporting low income indicated that they experienced eczema symptoms more frequently than participants with higher income; 35% of low-income participants vs 15% of higher-income participants reported that they had not tried any eczema treatments. Participants in all racial/ethnic and income-level groups reported that their asthma or eczema impacted their lifestyle and daily activities.

Conclusion

More effective and culturally informed communication and education strategies to improve health information uptake and shared decision-making are needed to reduce the burdens of disease and treatment in highly impacted populations.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12325-021-02021-0.

Disparities in asthma and eczema outcomes have been described in various populations. However, little is known about how these patient populations perceive their disease management or disease burden. A survey of 841 adults across diverse demographic groups in the USA with asthma and/or eczema was conducted to evaluate overall perceived disease burden and to specifically understand burden experiences by marginalized populations. In general, all participants indicated that asthma and eczema have a negative physical, emotional, and social impact on their lives. Some participants who identified as Black or Hispanic, and those with low income (less than $15,000/year), indicated greater difficulties in filling out paperwork or understanding written materials related to their condition than White participants or those with higher incomes. Black and Hispanic participants tended to receive asthma care in the emergency department or urgent care more than White participants and had more emergency department visits and hospitalizations than White Participants. Participants with low income were less likely to discuss their asthma management with their doctor than those with higher incomes and also indicated potential undertreatment of eczema. These results indicate that Black, Hispanic, or low-income patients may experience barriers to health equity. These barriers include lack of effective communication methods and materials to meet the needs of all patients, as well as the overall lack of quality healthcare access. These challenges must be addressed to overcome social disparities in health.

Bullying and lifetime asthma among children and adolescents in the United States

PURPOSE

To examine the association of experiencing bullying within the past year with the prevalence of lifetime childhood asthma in US children and adolescents; and whether this associations vary with sex of the child and select socioeconomic indicators.

METHODS

We performed secondary analysis of data from the 2018 National Survey of Children's Health participants aged 6 to 17 years (n=19,766). We used log-binomial regression to examine the association between bullying and lifetime childhood asthma before and after controlling for select covariates. We also tested interactions of bullying with sex and select socioeconomic indicators.

RESULTS

Children who experience bullying have a significantly increased probability of having asthma in adjusted analyses. The probability of childhood asthma increased with the frequency of bullying with PRs starting at 1.28 (95%CI:1.06, 1.55) for children bullied 1-2 times per year to 1.59 (95%:1.22, 2.09) for those being bullied at least 4 times per month. This association did not differ with sex of the child and select socioeconomic indicators.

CONCLUSION

We found that children who experienced bullying had a greater probability of having asthma relative to those who never experienced bullying. These finding highlight the impact of psychosocial stressors on asthma as a nontraditional trigger in children with asthma.

Structural racism and its pathways to asthma and atopic dermatitis

Black, Latinx, and Indigenous people in the United States experience a disproportionate burden of asthma and atopic dermatitis. The study of these disease disparities has focused on proximal socioenvironmental exposures and on the biomechanistic (including genetic) differences between racial and ethnic groups. Although biomedical research in allergy and immunology stands to benefit from the inclusion of diverse study populations, the narrow focus on biologic mechanisms disregards the complexity of interactions across biologic and structural factors, including the effects of structural racism. Structural racism is the totality of ways in which society fosters discrimination by creating and reinforcing inequitable systems through intentional policies and practices sanctioned by government and institutions. It is embedded across multiple levels, including the economic, educational, health care, and judicial systems, which are manifested in inequity in the physical and social environment. In this review, we present a conceptual framework and pull from the literature to demonstrate how structural racism is a root cause of atopic disease disparities by way of residential segregation, socioeconomic position, and mass incarceration, which may lead to aberrations in the innate and adaptive immune response and the augmentation of physiologic stress responses, contributing to a disproportionate disease burden for racial and ethnic populations.

Temporal changes in allostatic load patterns by age, race/ethnicity, and gender among the US adult population; 1988-2018

The objective of this study is to provide an assessment of allostatic load (AL) burden among US adults across race/ethnicity, gender, and age groups over a 30-year time period. We analyzed data from 50,671 participants of the National Health and Nutrition Examination Survey (NHANES) years 1988 through 2018. AL score was defined as the sum total for abnormal measures of the following components: serum albumin, body mass index, serum C - reactive protein, serum creatinine, diastolic blood pressure, glycated hemoglobin, systolic blood pressure, total cholesterol, and serum triglycerides. We performed modified Poisson regression to estimate the adjusted Relative Risks (aRRs) of allostatic load, and generalized linear models to determine adjusted mean differences accounting for NHANES sampling weights. Among US adults aged 18 or older, the prevalence of high AL increased by more than 45% from 1988 to 1991 to 2015-2018, from 33.5% to 48.6%. By the latest period, 2015-2018, Non-Hispanic Black women (aRR: 1.292; 95% CI: 1.290-1.293) and Latina women (aRR: 1.266; 95% CI: 1.265-1.267) had higher risks of AL than non-Hispanic White women. Similar trends were observed among men. Age-adjusted mean AL score among NH-Black and Latinx adults was higher than for NH-Whites of up to a decade older regardless of gender. From 1988 through 2018, Adults aged 40 years old and older had over 2-fold increased risks of high AL when compared to adults 18-29 years old. After 30-years of collective data, racial disparities in allostatic load persist for NH-Black and Latinx adults.

Pregnancy associated epigenetic markers of inflammation predict depression and anxiety symptoms in response to discrimination

Latina mothers, who have one of the highest fertility rates among ethnic groups in the United States (US), often experience discrimination. Psychosocial influences during pregnancy, such as discrimination stress, promotes inflammation. However, the role of epigenetic markers of inflammation as a mediator between, and predictor of, maternal discrimination stress and neuropsychiatric outcomes has not been extensively studied. The current study investigates the role of DNA methylation at FOXP3 Treg-cell-specific demethylated region (TSDR), as a marker of regulatory T (Treg) cells that are important negative regulators of inflammation, and the promoter of tumour necrosis factor-alpha (TNF-α) gene, an important pro-inflammatory cytokine, in relation to discrimination stress during pregnancy and depression and anxiety symptomatology.

A sample of 148 Latina women residing in the US (mean age 27.6 years) were assessed prenatally at 24–32 weeks’ gestation and 4–6 weeks postnatally for perceived discrimination exposure (Everyday Discrimination Scale, EDS), emotional distress (depression, anxiety, perinatal-specific depression), acculturation, and acculturative stress. DNA methylation levels at the FOXP3 and TNFα promoter regions from blood samples collected at the prenatal stage were assessed by bisulphite pyrosequencing.

Regression analyses showed that prenatal EDS associated with postnatal emotional distress, depression and anxiety symptoms only in those individuals with higher than mean levels of FOXP3 TSDR and TNFα promoter methylation; no such significant associations were found in those with lower than mean levels of methylation for either. We further found that these relationships were mediated by TNFα only in those with high FOXP3 TSDR methylation, implying that immunosuppression via TNFα promoter methylation buffers the impact of discrimination stress on postpartum symptomatology. These results indicate that epigenetic markers of immunosuppression and inflammation play an important role in resilience or sensitivity, respectively, to prenatal stress.

Chronic stress and asthma in adolescents

OBJECTIVE

First, to review and critically discuss published evidence on psychosocial stressors, stress, and asthma in adolescents and, then, discuss potential future directions in this field.

DATA SOURCES

The data source is the National Library of Medicine (PubMed database).

STUDY SELECTIONS

A literature search was conducted for human studies on stressors or stress and asthma between 2000 and 2020. Studies that were published in English, contained a full text, and included adolescents were considered for inclusion in this review.

RESULTS

Compared with the available body of evidence in children and adults, relatively few studies have been published in adolescents. Current evidence suggests that exposure to stressors (at the individual, family, and community levels) or stress (acute and chronic) is associated with asthma and worse asthma outcomes, but such evidence must be cautiously interpreted owing to limitations in the design or the analytical approach of the published studies.

CONCLUSION

Future large studies with a prospective design should determine whether and how stressors or stress causes or worsens asthma in adolescents. At present, clinicians should assess exposure to stressors (eg, violence or abuse) and screen for anxiety and depressive disorders when caring for adolescents with asthma in addition to providing referrals to social workers or mental health professionals when appropriate. Public health policies are needed to reduce psychosocial stressors, such as gun violence and racism, in adolescents.

An epistatic interaction between pre-natal smoke exposure and socioeconomic status has a significant impact on bronchodilator drug response in African American youth with asthma

BACKGROUND

Asthma is one of the leading chronic illnesses among children in the United States. Asthma prevalence is higher among African Americans (11.2%) compared to European Americans (7.7%). Bronchodilator medications are part of the first-line therapy, and the rescue medication, for acute asthma symptoms. Bronchodilator drug response (BDR) varies substantially among different racial/ethnic groups. Asthma prevalence in African Americans is only 3.5% higher than that of European Americans, however, asthma mortality among African Americans is four times that of European Americans; variation in BDR may play an important role in explaining this health disparity. To improve our understanding of disparate health outcomes in complex phenotypes such as BDR, it is important to consider interactions between environmental and biological variables.

RESULTS

We evaluated the impact of pairwise and three-variable interactions between environmental, social, and biological variables on BDR in 233 African American youth with asthma using Visualization of Statistical Epistasis Networks (ViSEN). ViSEN is a non-parametric entropy-based approach able to quantify interaction effects using an information-theory metric known as Information Gain (IG). We performed analyses in the full dataset and in sex-stratified subsets. Our analyses identified several interaction models significantly, and suggestively, associated with BDR. The strongest interaction significantly associated with BDR was a pairwise interaction between pre-natal smoke exposure and socioeconomic status (full dataset IG: 2.78%, p = 0.001; female IG: 7.27%, p = 0.004)). Sex-stratified analyses yielded divergent results for females and males, indicating the presence of sex-specific effects.

CONCLUSIONS

Our study identified novel interaction effects significantly, and suggestively, associated with BDR in African American children with asthma. Notably, we found that all of the interactions identified by ViSEN were "pure" interaction effects, in that they were not the result of strong main effects on BDR, highlighting the complexity of the network of biological and environmental factors impacting this phenotype. Several associations uncovered by ViSEN would not have been detected using regression-based methods, thus emphasizing the importance of employing statistical methods optimized to detect both additive and non-additive interaction effects when studying complex phenotypes such as BDR. The information gained in this study increases our understanding and appreciation of the complex nature of the interactions between environmental and health-related factors that influence BDR and will be invaluable to biomedical researchers designing future studies.

Racial/Ethnic-Specific Differences in the Effects of Inhaled Corticosteroid Use on Bronchodilator Response in Patients With Asthma

American Thoracic Society guidelines recommend inhaled corticosteroid (ICS) therapy, plus a short-acting bronchodilator, in patients with persistent asthma. However, few prior studies have examined the efficacy of this combination in children of all racial/ethnic groups. We evaluated the association between ICS use and bronchodilator response (BDR) in three pediatric populations with persistent asthma (656 African American, 916 Puerto Rican, and 398 Mexican American children). The association was assessed using multivariable quantile regression. After adjusting for baseline forced expiratory volume in one second and use of controller medications, ICS use was significantly associated with increased BDR only among Mexican Americans (1.56%, P = 0.028) but not African Americans (0.49%, P = 0.426) or Puerto Ricans (0.16%, P = 0.813). Our results demonstrate that ICS augmentation is disproportionate across racial/ethnic groups, where improved BDR is observed in Mexican Americans only. This study highlights the complexities of treating asthma in children, and reinforces the importance of investigating the influence of race/ethnicity on pharmacological response.

Bronchodilators in subjects with asthma-related comorbidities

Asthma is often associated with different comorbidities such as cardiovascular diseases, depression, diabetes mellitus, dyslipidaemia, osteoporosis, rhinosinusitis and mainly gastro-oesophageal reflux disease and allergic rhinitis. Although bronchodilators play an important role in the treatment of asthma, there is no overall description of their impact on comorbid asthma, regardless of whether favourable or negative. This narrative review examines the potential effects of bronchodilators on comorbidities of asthma.

Validation of Asthma Control Assessment Among Urban Adolescents Using the Asthma Control and Communication Instrument

BACKGROUND

The National Institutes of Health guidelines recommend questionnaires to assess asthma control, but there are few self-reported asthma morbidity surveys validated among urban, African American, Hispanic, and/or poor adolescents. The Asthma Control and Communication Instrument (ACCI) is a 12-item self-reported questionnaire previously validated among a diverse adult population, but not among adolescents.

OBJECTIVE

To assess the ability of the ACCI to accurately describe asthma control in an urban adolescent population.

METHODS

Between November 13, 2014, and March 2, 2017, we collected information using the ACCI, the Asthma Control Test, the Pediatric Asthma Quality of Life Questionnaire, and lung function among adolescents enrolled in a school-based asthma intervention study. The ACCI measure of asthma control was validated by evaluating accuracy (on the basis of receiver operating characteristic curve), internal reliability, and concurrent and discriminative validity.

RESULTS

We collected information on 280 adolescents (mean age, 13.4 years; 56% males; and 51% African American). ACCI control showed good internal reliability and strong concurrent and discriminative validity with the Asthma Control Test and the Pediatric Asthma Quality of Life Questionnaire. The accuracy of the ACCI in classifying adolescents with uncontrolled asthma was good (area under the curve, 0.83; 95% CI, 0.79-0.88).

CONCLUSION

The ACCI, a clinical tool developed to assist communication about asthma control, has demonstrated strong construct validity as a self-reported questionnaire within an urban, African American, and Hispanic sample of adolescents. It has the potential to assist in the assessment of asthma control in urban, minority, and/or poor adolescents.

One size does not fit all: Links between shift-and-persist and asthma in youth are moderated by perceived social status and experience of unfair treatment

The links between low socioeconomic status and poor health are well established, yet despite adversity, some individuals with low socioeconomic status appear to avoid these negative consequences through adaptive coping. Previous research found a set of strategies, called shift-and-persist (shifting the self to stressors while persisting by finding meaning), to be particularly adaptive for individuals with low socioeconomic status, who typically face more uncontrollable stressors. This study tested (a) whether perceived social status, similar to objective socioeconomic status, would moderate the link between shift-and-persist and health, and (b) whether a specific uncontrollable stressor, unfair treatment, would similarly moderate the health correlates of shift-and-persist. A sample of 308 youth (Meanage = 13.0, range 8-17), physician diagnosed with asthma, completed measures of shift-and-persist, unfair treatment, asthma control, and quality of life in the lab, and 2 weeks of daily diaries about their asthma symptoms. Parents reported on perceived family social status. Results indicated that shift-and-persist was associated with better asthma profiles, only among youth from families with lower (vs. higher) parent-reported perceived social status. Shift-and-persist was also associated with better asthma profiles, only among youth who experienced more (vs. less) unfair treatment. These findings suggest that the adaptive values of coping strategies for youth with asthma depend on the family's perceived social status and on the stressor experienced.

Pharmacogenetic and pharmacogenomic considerations of asthma treatment

INTRODUCTION

Pharmacogenetic and pharmacogenomic approaches are already utilized in some areas, such as oncology and cardiovascular disease, for selecting appropriate patients and/or establishing treatment and dosing guidelines. This is not true in asthma although many patients have different responses to drug treatment due to genetic factors. Areas covered: Several genetic factors that affect the pharmacotherapeutic responses to asthma medications, such as β₂-AR agonists, corticosteroids, and leukotriene modifiers and could contribute to significant between-person variability in response are described. Expert opinion: An expanding number of genetic loci have been associated with therapeutic responses to asthma drugs but the individual effect of one single-nucleotide polymorphism is partial. In fact, epigenetic changes can modify genetic effects in time-, environment-, and tissue-specific manners, genes interact together in networks, and nongenetic components such as environmental exposures, gender, nutrients, and lifestyle can significantly interact with genetics to determine the response to therapy. Therefore, well-designed randomized controlled trials or observational studies are now mandatory to define if response to asthma medications in individual patients can be improved by using pharmacogenetic predictors of treatment response. Meanwhile, routine implementation of pharmacogenetics and pharmacogenomics into clinical practice remains a futuristic, far-off challenge for many clinical practices.