02. Asma

Sathvik Namburar, William Checkley, Oscar Flores-Flores, Karina M. Romero, Katherine Tomaino Fraser, Nadia N. Hansel, and Suzanne L. Pollard, GASP Study Investigators.

Journal of Physical Activity and Health, 2020, 17, 816-822

Background: The authors sought to examine physical activity patterns among children with and without asthma in 2 peri-urban communities in Lima, Peru, to identify socioeconomic and demographic risk factors for physical inactivity and examine the relationship between asthma and physical activity. Methods: The authors measured mean steps per day in 114 children (49 with
asthma and 65 without) using pedometers worn over a 1-week period. They also used the 3-day physical activity recall to determine the most common activities carried out by children. Results: The authors found that 84.2% of the children did not meet the daily international physical activity recommendations. Girls took significantly fewer mean steps per day as compared with boys (2258
fewer steps, 95% confidence interval, 1042–3474), but no other factors, including asthma status, showed significant differences in the mean daily steps. Mean daily steps were positively associated with higher socioeconomic status among girls, and current asthma had a larger inverse effect on daily steps in boys when compared with girls. Conclusion: Physical activity levels were below recommended guidelines in all children. There is a need for policy and neighborhood-level interventions to address low physical activity levels among Peruvian youth. Special focus should be given to increasing the physical activity levels in girls.

Josiah L. Kephart, Magdalena Fandino-Del-Rio, Kendra N. Williams, Gary Malpartida, Alexander Lee, Kyle Steenland, Luke P. Naeher, Gustavo F. Gonzalesi, Marilu Chiang, William Checkley, Kirsten Koehler, CHAP trial Investigators.

Environment International 146 (2021) 106196

Background: Liquefied petroleum gas (LPG) stoves have been promoted in low- and middle-income countries (LMICs) as a clean energy alternative to biomass burning cookstoves.
Objective: We sought to characterize kitchen area concentrations and personal exposures to nitrogen dioxide (NO2) within a randomized controlled trial in the Peruvian Andes. The intervention included the provision of an LPG stove and continuous fuel distribution with behavioral messaging to maximize compliance.

Methods: We measured 48-hour kitchen area NO2 concentrations at high temporal resolution in homes of 50 intervention participants and 50 control participants longitudinally within a biomass-to-LPG intervention trial. We also collected 48-hour mean personal exposures to NO2 among a ubsample of 16 intervention and 9 control participants. We monitored LPG and biomass stove use continuously throughout the trial.

Results: In 367 post-intervention 24-hour kitchen area samples of 96 participants’ homes, geometric mean (GM) highest hourly NO2 concentration was 138 ppb (geometric standard deviation [GSD] 2.1) in the LPG intervention group and 450 ppb (GSD 3.1) in the biomass control group. Post-intervention 24-hour mean NO2 concentrations were a GM of 43 ppb (GSD 1.7) in the intervention group and 77 ppb (GSD 2.0) in the control group. Kitchen area NO2 concentrations exceeded the WHO indoor hourly guideline an average of 1.3 h per day among LPG intervention participants. GM 48-hour personal exposure to NO2 was 5 ppb (GSD 2.4) among 35 48-hour samples of 16 participants in the intervention group and 16 ppb (GSD 2.3) among 21 samples of 9 participants in the control group.

Discussion: In a biomass-to-LPG intervention trial in Peru, kitchen area NO2 concentrations were substantially lower within the LPG intervention group compared to the biomass-using control group. However, within the LPG intervention group, 69% of 24-hour kitchen area samples exceeded WHO indoor annual guidelines and 47% of samples exceeded WHO indoor hourly guidelines. Forty-eight-hour NO2 personal exposure was below WHO indoor annual guidelines for most participants in the LPG intervention group, and we did not measure personal exposure at high temporal resolution to assess exposure to cooking-related indoor concentration peaks. Further research is warranted to understand the potential health risks of LPG-related NO2 emissions and inform current campaigns which promote LPG as a clean-cooking option.

Elisa D. Romani, Trishul Siddharthan, Nair Lovatón, Carol C. Alvítez-Luna, Oscar Flores-Flores and Suzanne L. Pollard.

Romani et al. Trials (2020) 21:377

Introduction:
Asthma is the most common chronic disease among children worldwide, with 80% of asthmarelated deaths occurring in low- and middle-income countries (LMICs). While evidence-based guidelines exist for asthma treatment and management, adoption of guideline-based practices is low in high-income country and LMIC settings alike. While asthma prevalence among children and adolescents in Lima, Peru is in the range of 13%–19.6%, our data suggest that < 5% of children in low-resource communities are currently taking guideline-based therapies. There is an urgent need for effective, locally tailored solutions to address the asthma treatment gap in low-income communities in Peru.

Methods:
This study aims to develop and test a locally adapted intervention package to improve adoption of selfmanagement practices and utilization of preventive health services for asthma among children in Lima Norte. The intervention package was designed using a systematic, theory-based framework (Capability, Opportunity, Motivation – Behavior Framework) and is rooted in a multi-phased formative research approach. The main study design is an individually randomized implementation-effectiveness hybrid trial enrolling 110 children aged 5–17 years with asthma and their caregivers. Families allocated to the treatment group receive the supported self-management intervention package, while families allocated to the control group receive the standard of care plus asthma
education. We will follow participants monthly for six months and evaluate asthma control (Asthma Control Test), healthcare utilization, and medication adherence (Adherence to Refills and Medications Scale). Disease-specific quality of life for children (Pediatric Asthma Quality of Life Questionnaire) and caregivers (Pediatric Asthma Caregiver’s Quality of Life Questionnaire) will be evaluated at baseline, 3 months, and 6 months. We will also evaluate acceptability, feasibility, and fidelity of the intervention using mixed methods approaches.

Discussion:
The long-term goal of this study is to disseminate locally appropriate asthma management strategies in LMIC settings. This study will contribute to the body of knowledge surrounding approaches for developing and evaluating intervention strategies for asthma using systematic, theory-based approaches grounded in local context. Such strategies have the potential to inform the development and adaptation of appropriate and scalable solutions for asthma management in LMIC settings.

William Checkley, Kendra N. Williams, Josiah L. Kephart, Magdalena Fandino-Del-Rio, N. Kyle Steenland, Gustavo F. Gonzales, Luke P. Naeher, Steven A. Harvey, Lawrence H. Moulton, Victor G. Davila-Roman, Dina Goodman, Carla Tarazona-Meza, Catherine H. Miele, Suzanne Simkovich, Marilu Chiang, Ryan T. Chartier, Kirsten Koehler, and the CHAP Trial Investigators.

Rationale:
Approximately 40% of people worldwide are exposed to household air pollution (HAP) from the burning of biomass fuels. Previous efforts to document health benefits of HAP mitigation have been stymied by an inability to lower emissions to target levels.

Objectives:
We sought to determine if a household air pollution intervention with liquefied petroleum gas (LPG) improved cardiopulmonary health outcomes in adult women living in a resource-poor setting in Peru.

Methods: We conducted a randomized controlled field trial in 180 women aged 25–64 years living in rural Puno, Peru. Intervention women received an LPG stove, continuous fuel delivery for 1 year, education, and behavioral messaging, whereas control women were asked to continue their usual cooking practices. We assessed for stove use adherence using temperature loggers installed in both LPG and biomass stoves of intervention households.

Measurements and Main Results:
We measured blood pressure, peak expiratory flow (PEF), and respiratory symptoms using the St. George’s Respiratory Questionnaire at baseline and at 3–4 visits after randomization. Intervention women used their LPG stove exclusively for 98% of days. We did not find differences in average
postrandomization systolic blood pressure (intervention – control 0.7 mm Hg; 95% confidence interval, 22.1 to 3.4), diastolic blood pressure (0.3 mm Hg; 21.5 to 2.0), prebronchodilator peak
expiratory flow/height2 (0.14 L/s/m2; 20.02 to 0.29), postbronchodilator peak expiratory flow/height2 (0.11 L/s/m2; 20.05 to 0.27), or St. George’s Respiratory Questionnaire total score (21.4;
23.9 to 1.2) over 1 year in intention-to-treat analysis. There were no reported harms related to the intervention.

Conclusions:
We did not find evidence of a difference in blood pressure, lung function, or respiratory symptoms during the year-long intervention with LPG

Carla E. Tarazona-Meza, Corrine Hanson, Suzanne L. Pollard, Karina M. Romero Rivero, Rocio M. Galvez Davila, Sameera Talegawkar, Carlos Rojas, Jessica L. Rice, William Checkley and Nadia N. Hansel.

Tarazona-Meza et al. BMC Pulmonary Medicine (2020) 20:63

Background:
Asthma is one of the conditions that contributes to the global burden of respiratory diseases and has been previously associated with diet intake. The goal of this study was to determine the relationship between diet, assessed by a developed score, and asthma in Peruvian children.

Methods: This study was a cross sectional analysis nested within an unmatched case-control study of children in two peri-urban communities of Lima, Peru. We evaluated 767 children and adolescents (573 with asthma, 194 controls) between 9 and 19 years. Diet was assessed using a food frequency questionnaire (FFQ), with food groups classified as “healthy” or “unhealthy”. Asthma control, Lung function and atopy were assessed by Asthma Control Test, Spirometry and InmunoCAP 250 test, respectively.

Results:
Mean age of participants was 13.8 years (SD 2.6). Mean diet score was 5 (SD 1.23; range 2–8). Healthy Diet Score was associated with asthma status [OR 0.83, 95% CI (0.72, 0.95), p = 0.009] in adjusted analysis. Thus, participants with higher HDS, had lower odds of asthma. In sensitivity analyses, when adjusting for atopy, results did not change significantly. [OR 0.85, 95% CI (0.72, 0.99); p = 0.04]. No association between the HDS and asthma control, FEV1, nor FeNO were observed. Atopy did not modify the association between diet and asthma outcomes.

Conclusions: In our study cohort, better diet quality was associated with lower odds of asthma, but was not associated with asthma control. Diet modification may be a potential intervention to impact the increasing prevalence of this disease.

Andrew Nicholson, Suzanne L Pollard, John J Lima, Pharm, Karina Romero, Carla Tarazona-Meza, Gary Malpartida-Guzmán, Edward Mougey, Nadia N Hansel, William Checkley, and GASP Study Investigators.

Respir Med. 2017 Dec;133:29-35.

The relationship between folate status and asthma-related outcomes has not been carefully examined in low- and middle-income countries where folate deficiency is common.

Ancillary analysis of an unmatched case-control study in which we analyzed serum folate concentrations in 412 children with asthma and 342 controls living in peri-urban communities in Lima, Peru. We examined baseline associations between folate and asthma, atopy, total serum IgE, pulmonary function, and fractional exhaled nitric oxide. We then followed children with asthma longitudinally for 6-9 months and assessed associations between folate and odds of uncontrolled asthma (defined as Asthma Control Test score ≤ 19) and of ≥1 emergency visits during follow-up.

Serum folate concentrations were inversely associated with asthma, but this effect was stronger in children without atopy. Among children with asthma, lower serum folate concentrations were associated with higher risk of uncontrolled asthma.