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Wednesday, February 27, 2019

The tricky thing about asthma

Can we make humans healthier by growing healthier places? A 2016 analysis found that women living in areas with higher levels of green vegetation had lower rates of mortality. Researchers at the Harvard School of Public Health conducted a nationwide study of approximately 100,000 women from the Nurses’ Health Study. Those women that had homes in areas with the highest level of greenness in the surrounding 250 meters (roughly 820 feet, or a little over 1/10 of a mile) had a 12% lower rate of death compared to the women whose homes had the lowest level of greenness. Specifically, there was a 13% lower rate for cancer mortality, 35% lower respiratory disease-related mortality, and 41% lower rate for kidney disease mortality in the women living in the areas with the highest levels of green vegetation.
Just how does being in green spaces increase longevity?

When trying to figure out just how the greenness was protecting women against death, researchers found a combination of factors that came into play. These included lower levels of depression, increased social engagement, higher levels of physical activity, and lower levels of pollution. There are probably many reasons why being in green spaces might decrease depression. Perhaps people who live in greener areas are more likely to go outside. Exposure to sunlight helps people to make vitamin D, and low levels of vitamin D are associated with depression. Spending time with friends and participating in social activities were also associated with greener areas, and these things can decrease feelings of loneliness and depression. Being outside and experiencing nature has been known to increase feelings of well-being. In fact, some research suggests that even images of nature can lead to increased positive mood.

Exercise is medicine, and the more physically active a person is, the more fit they will be and the healthier they will be. Green spaces invite people to enjoy the outdoors and encourage people to walk, bicycle, or jog for physical activity. When the space around a home is green and full of vegetation, there are likely paths or trails that are in safe and beautiful places. In this study, those women that lived in greener spaces were more physically active.

Living among trees, plants, grass, and flowers provides an environment with less pollution than one with low levels of vegetation. The plants can reduce levels of nitrogen dioxide and particulate matter, which lowers the level of pollution. In this study, death from respiratory disease was reduced by about one third in those women who lived in the homes with the highest amount of vegetation. Breathing clean air matters, and plants help to clean the air.
Take advantage of green spaces

If you live in an area with heavy vegetation, this is good news for you. Take the opportunity to improve your health. Get outside and breathe the clean air, walk around the neighborhood, find some friends to walk with you, and enjoy the great, green outdoors. If you do not live in an area with a lot of greenery around you, consider planting some trees, plants, or shrubs. If you live in a highly urban area, you can get involved with local policy to work to encourage your community to increase green spaces. Spend time with friends who live in areas with lots of trees and greenery, consciously seek out green areas as often as you can, and consider vacationing in areas with lots of vegetation. When people feel that their lives have meaning, they perceive their lives as significant, purposeful, and valuable. This is critical for psychological well-being. People who feel that their lives have meaning feel less depressed and even have better outcomes in psychotherapy. Feeling that one’s life has meaning can also ease the psychological burden of medical illnesses. For example, people who have medical conditions such as a spinal cord injury cope better when they feel that their lives have meaning, and having a sense of meaning can improve the quality of life in cancer patients.
What to do when your sense of meaning slips away

Anything that makes you feel less safe — the death of a loved one, an illness, sudden financial burdens — can create a kind of anxiety that obscures all meaning. That’s when you may start to ask, “Why am I working so hard?” or “Why do I actually care about anything?” You may start to search for meaning frantically. While meaning is the “primary motivational force in man,” searching for meaning does not guarantee that you will find it. When you feel psychologically adrift and disconnected from meaning, how can you increase the chances that you will find it?

You might be surprised to learn that reconnecting with meaning may not involve a set of techniques, but a set of spontaneous actions removed from the humdrum of life’s everyday routines. As helpful as “psychological techniques” such as reframing or positive thinking can be, they often miss the mark in the search for meaning. Stanford psychiatrist Irvin Yalom explained that it is the intangibles and “off the beaten track” thoughts and activities that can make the greatest difference, much like the cook who spontaneously throws in a handful of spices into a dish without thinking much. When we examine the psychological elements that underlie the cook’s instinctive “throw-ins,” we find clues as to how we can jump-start meaning in our lives. Here are three ways to open yourself to rediscovering meaning.
Be curious

Seasoned cooks are capable of these precise “throw-ins” without much thinking because they are willing to be curious and follow their instincts. As much as the cook may follow a recipe, it is curiosity that drives the exceptional touch and activates the intangible taste that results from it. As Samuel Johnson said, “The gratification of curiosity rather frees us from uneasiness than confers pleasure; we are more pained by ignorance than delighted by instruction.” Curiosity, defined as the desire to know, see, or experience new things, can activate a sense of purpose and meaning. Adding this vital ingredient to your life by literally walking a safe path you’ve never walked before or tasting a brand-new dish may get you back to the road of meaning. It is this “unfocus” from learned daily habits that is necessary to activate meaning.
Understand that we want to be independent and connected all at the same time

Underlying the cook’s “dare” are two well-known psychological attributes that shape how we relate to the world: agency (a feeling of independence) as well as communion (a feeling of connection to others). These are contrasting, yet important aspects of who we are, and having enough of both in our lives can also help to activate meaning. By doing so, we acknowledge our two-sided selves. Too much independence can lead to isolation. Too much communion can lead to loss of a sense of self. Living life fully requires switching between the two and organizing your day so that you have enough of both. In the cook’s dare, she is independent, but she is motivated by feeding and tantalizing the palates of others too. Learning to accept your contradictions is central to experiencing a sense of meaning and more rewarding that choosing to be “one” or “the other” thing.
Notice when “meaning” appears

When you feel that sense of meaning, it is like a taste that “hits the spot” with the first mouthful. What you are tasting is not just a carefully crafted combination of ingredients, though you can be sure that that is part of the picture. In addition, you are the beneficiary of the cook’s spontaneous insight — an important factor in meaning-making. When you make time for spontaneous insights in your day, you can jump-start the flow of experience, which is characteristic of meaning-driven activities. You can’t have such insights if your day is run like clockwork or if it is jam-packed or if your calendar dictates your meaning (unless, of course, your calendar leaves room for spontaneous whims and fancies — these moments can require space too). Setting aside time for doing something with no particular goal in mind adds a vital ingredient to your life that can bring back the very meaning for which you were searching.

In essence then, when you are psychologically adrift, you may be tempted to try to ground yourself with rational approaches to life. In fact, what you may need is to also find your “psychological wings” so that you may catch the breeze of life and enjoy gliding into it before you land. In mid-January, health headlines announced that nearly one-third of adults diagnosed with asthma don’t actually have this respiratory condition at all. This announcement appeared everywhere from Fox News Health to the Chicago Tribune.

As a primary care doc, a medical writer, and an asthma sufferer, I was very skeptical of these dramatic announcements, and with good reason. An editorial that accompanied this study provides important perspective that suggests the news headlines were exaggerated and misleading.
Taking a closer look at the study

Let’s talk about the study, which is a good one, and has merit. Canadian researchers recruited 615 random people who had been given a diagnosis of asthma, and performed formal testing to see if they still had it. And in fact, 33% of those tested did not meet criteria for the diagnosis of asthma at the time of testing. The lead author of this study is then quoted as suggesting that doctors diagnosed these patients with asthma without doing the necessary tests.

Okay. As a physician who diagnoses and treats asthma (and its many variants), a medical writer and researcher who dissects these articles, and someone who is currently experiencing an awful asthma flare (or exacerbation), I take major issue with these headlines and the lead author’s press statements.
Looking a little deeper

The data tell the story. Of the one-third of patients who tested negative for asthma in the study, 24 (or 12% of them) actually did have appropriate testing (that confirmed asthma) when they were first diagnosed. What’s more, 22 of the participants who tested negative for asthma at the time of the study, tested positive months later (again using appropriate testing).

What this really tells us is that asthma has many forms and, like many chronic disease, symptoms may come and go. This is consistent with what I know from professional — and personal — experience.

The study authors themselves recognize at the start of the study how tricky asthma can be, pointing out that there are many types of asthma that can look a little different, and have different triggers. They go on to say (as mentioned in the editorial) that symptoms of asthma can relapse (come back) and remit (go away).
Let’s get real about asthma

When I see a patient with wheezing and/or coughing spasms, and especially whose symptoms improve after a breathing (nebulizer or neb) treatment in the office, I will tell them that they at the very least have reactive airways syndrome. This is not exactly asthma. It just means that something triggered them to wheeze — maybe an allergic reaction, or a virus. They may never wheeze again. But in my office, right then, because they are wheezing at that moment, they will probably benefit from an inhaler. If an inhaler has been helpful in the past or the neb provided immediate relief, I’m not going to say, oh wait, we need to have formal testing first, before we treat you. Nope.

But, if symptoms continue and we are worried that this is more than a one-time or occasional thing, then we may want to pursue a formal, official diagnosis of asthma.
How do you know for sure if it’s asthma?

A diagnosis of asthma requires two things: a history of respiratory symptoms consistent with asthma (chest tightness, wheezing, coughing spasms, particularly nighttime cough), along with proof of “variable expiratory airflow obstruction.” What the heck is that?

Lung function tests can show whether inflammation and narrowing of the airways is impeding your ability to breathe out. A key piece of equipment for doing this is called a spirometer, and it’s not something that you will generally find in any primary care office (it is not the same as a peak flow meter you can buy at the drug store). We refer patients to a pulmonary function lab for this sort of testing. The person breathes into the spirometer while the machine measures total lung capacity, as well as various measures of exhalation speed. They may also receive inhaled medications that can help to make the diagnosis of asthma. Sometimes medications (bronchodilators like albuterol) may be used to see if they relieve symptoms (or a different medication called methacholine can be used to carefully provoke an asthma attack). If the albuterol helps or the methacholine triggers an asthma attack — diagnosis made.

For some patients, the formal testing may be too expensive. Or maybe they can’t get it scheduled in a timely manner. If their history is as clear as mine, it may make sense to simply give them the asthma diagnosis, so that things like a nebulizer machine can be covered by insurance. Even if formal testing confirms asthma, it can resolve on its own, and repeat testing may be negative later on. Was this a misdiagnosis? No, this was just asthma.
Asthma in real life

Me? I was in my doctor’s office today with wheezing. I had the flu last week (more on that in another post) which triggered a prolonged wheezing/coughing episode. My doctor saw that I was struggling to breathe, measured my oxygen levels, which were low, and heard wheezing when listening to my lungs. She also tested my peak flow, which improved with a nebulized albuterol treatment in her office. This all supports a diagnosis of asthma, but for now, I’m labeled as having reactive airways, because I haven’t had any formal evaluation with a pulmonologist and I have never had spirometry.

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