ARTICLE

Quality of Life and Health Outcomes in Overweight and Non-Overweight Children With Asthma Amy Becker Manion, PhD, RN, CPNP, & Barbara Velsor-Friedrich, PhD, RN, FAAN

ABSTRACT Background: During the past two decades, the number of children and adolescents who are obese has more than doubled. Following this trend in childhood obesity, there has been an alarming increase in the number of children with asthma who are overweight. Objective: The aim of this study was to examine the differences in quality of life (QOL) and health outcomes of obese and overweight children with asthma compared with normal-weight children with asthma using a descriptive comparative survey design. Methods: This comparative study consisted of 90 overweight and normal-weight 9- to 14-year-olds with asthma. Health outcomes examined included asthma-related missed number of school days, emergency department (ED) visits, hospitalizations, number of days wheezing, and number of night awakenings. QOL was measured using the Pediatric Asthma Quality of Life Questionnaire.

Amy Becker Manion, Assistant Professor, College of Nursing, Rush University, Chicago, IL. Barbara Velsor-Friedrich, Professor and Director of PhD Program, College of Nursing, Loyola University, Chicago, IL. Supported by a National Association of Pediatric Nurse Practitioners Foundation Research Grant to A.B.M. Conflicts of interest: None to report. Correspondence: Amy Becker Manion, PhD, RN, CPNP, College of Nursing, Rush University, 600 S Paulina St, Suite 1080, Chicago, IL 60612; e-mail: [email protected]. 0891-5245/$36.00 Copyright Q 2016 by the National Association of Pediatric Nurse Practitioners. Published by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.pedhc.2016.01.005

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Results: The obese group reported the highest percentage of ED visits, hospitalizations, and number of days wheezing compared with the normal-weight group. A risk ratio analysis showed that the obese group had an overall 2.73 (95% confidence interval [CI] 2.15, 3.63) times higher likelihood of going to the ED and a 2.46 (95% CI 1.97, 3.19) times higher likelihood of hospitalization than the overweight and normal-weight groups. Asthma severity was a significant predictor of overall QOL (b = 23.737, p = .002). Conclusions: The study results are consistent with other investigations that demonstrate that obese persons are at higher risk of experiencing severe asthma symptoms and support obesity as a potentially modifiable risk factor for asthma mitigation and prevention. J Pediatr Health Care. (2016) -, ---.

KEY WORDS Asthma, obesity, quality of life

Asthma is the most common chronic childhood illness in the United States, affecting an estimated 6.8 million children and adolescents (Bloom, Jones, & Freeman, 2013). During the period of 1980 through 1996, the prevalence of asthma in the United States increased dramatically by 4.6% per year, with rates eventually stabilizing at the current historically elevated plateau level of 9.3% for U.S. children (Akinbami, Moorman, Garbe, & Sondik, 2009; Akinbami, Moorman, & Liu, 2011; Bloom et al., 2013). Asthma affects an estimated 1 of out every 10 school-aged children, leading to a total of 10.5 million missed school days per year as a result of asthma (Mooreman et al., 2012). Despite the apparent stabilization of asthma prevalence rates during the past decade, enormous racial -/- 2016

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and economic disparities remain (Centers for Disease Control and Prevention [CDC], 2013; McDaniel, Paxson, & Waldfogel, 2006). Children in families below the federal poverty level are more likely to have been diagnosed with asthma than are children in families at higher income levels (Akinbami et al., 2011; Bloom, Cohen, & Freeman, 2010). In addition, the rate of asthma mortality is highest among minorities. Non-Hispanic Black children with asthma are twice as likely to visit the emergency department (ED), three times more likely to be hospitalized, and four times more likely to die from asthma compared with non-Hispanic White children (Akinbami et al., 2009; McDaniel et al., 2006). Similarly, the same rates for Hispanic children fall between these two groups, with Hispanic children 1.7 times more likely to be hospitalized and 1.4 times more likely to die from asthma compared with non-Hispanic White children (CDC, 2013; National Healthcare Quality Report, 2011). In fact, the CDC (2012) reports that Puerto Rican children residing in the United States have the highest asthma prevalence, with a 2.4 times higher rate of having asthma compared with non-Hispanic Whites. Regardless of the advances in therapeutic management, the economic burden of asthma in the United States has been increasing at an alarming rate during the past two decades. In 1990, total costs due to asthma were estimated to be $6.2 billion (Weiss & Sullivan, 2001). The current total cost due to asthma is estimated to be $56 billion per year (Zahran, Bailey, & Garbe, 2011). A large portion of the overall cost of asthma can be attributed to ED visits and hospitalizations, with more than 1.8 million ED visits and 439,000 hospitalizations due to asthma (Mooreman et al., 2012). In children, asthma accounts for 640,000 ED visits per year and is the third leading cause of hospitalization (Mooreman et al., 2012). The high prevalence of asthma and its continued drain on health resources makes it a major cause for concern. Moreover, children and adolescents with asthma often have comorbid conditions that can worsen health outcomes. One such condition is obesity. The number of children who are overweight has more than doubled during the past two decades (Dietz & Robinson, 2005; Ogden, Carroll, Kit, & Flegal, 2014). Currently, nearly 16.9% of children and adolescents in the United States are obese (Ogden, Caroll, Brian, & Flegal, 2012). This trend may be due in part to the fact that children’s diets have changed to include high-calorie foods with little nutritional value, while mandatory exercise has been removed from educational curriculums. For children living in impoverished urban setting, even physical activity at home is often limited because of neighborhood safety issues (Covington, et al, 2001; Datar, Nicosia, & Shier, 2013). Unless this obesity trend is reversed, it has been predicted that today’s children 2

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may be the first generation to live less healthy and even shorter lives than their parents (Olshansky et al., 2005). Another disquieting trend is emerging: child health studies report an increased prevalence of asthma in children who are obese (Castro-Rodriguez, Holberg, Morgan, Wright & Martinez, 2001; Chen, Kim, Houtrow, & Newacheck, 2009). Recent studies suggest that the marked increase in obesity observed during the past 20 years may in part be contributing to the increase in asthma prevalence that has concomitantly been observed (Ali & Ulrik, 2013; Castro-Rodriguez et al., 2001; Mannino et al., 2006). A study by Magnusson, Kull, Mai, Wickman, and Bergstrom (2012) found that children who were overweight at age 7 years were up to twice as likely to be diagnosed with asthma by age 8 years than were normal-weight children. In addition, other investigations have demonstrated that obese persons are at a higher risk of experiencing severe asthma symptoms (Akerman, Calacanis, & Madsen, 2004; Ford & Mannino, 2005). Further prospective, longitudinal studies on the outcomes of children in whom either asthma or obesity develops in the first 5 years of life suggest that asthma and obesity have interactional effects (Mannino et al., 2006; Scholtens et al., 2009). However, whether this relationship is a direct or indirect one has yet to be fully determined. One theory that has been proposed, which supports the view that asthma causes obesity, is that parents of children with asthma may restrict their child’s activity level for fear of inducing an asthma exacerbation, which would put them at increased risk for obesity because of a more sedentary lifestyle (FigueroaMunoz, Chinn, & Rona, 2001). The reverse association, that obesity causes asthma, has also been examined. Proposed theories include dietary, genetic, hormonal, and mechanical factors (Chin, 2003; Davis, Lipsett, Milet, Etherton, & Kreutzer, 2007; Silva et al., 2012). One main theory is that cytokines generated from adipose tissue, such as leptin, can cause chronic inflammation, which creates asthma symptoms (Davis et al., 2007; Silva et al., 2012). Still other researchers have suggested that obese children with asthma may just be experiencing obesity-related chest symptoms that mimic asthma (Bibi et al., 2004). Regardless of the direction of the relationship, a link appears to exist between asthma and obesity. Because of this connection and the increase in prevalence of asthma and obesity, research has begun to focus on how asthma and obesity affect not only each other but quality of life (QOL) as well. QUALITY OF LIFE In asthma research examining QOL in both adults and children, minimal to moderate impairment has been found except in subjects recently hospitalized for Journal of Pediatric Health Care

an acute exacerbation (Annett, Bender, Lapidus, Duhamel, & Lincoln, 2001; Luskin et al., 2014; Okelo et al., 2004). Yet asthma severity has been found to be strongly associated with QOL, with studies finding a lower QOL associated with poor symptom control and higher asthma severity classification (Everhart & Fiese, 2009). In addition, childhood obesity has been found to have a profound negative influence on QOL (Friedlander, Larkin, Rosen, Palermo, & Redline, 2003; Schwimmer, Burwinkle, & Varni, 2003; Williams, Wake, Hesketh, Maher, & Waters, 2005). One disquieting study by Schwimmer and associates (2003) revealed that the obese children studied were five times more likely to have an ‘‘impaired’’ QOL compared with the healthy control subjects (p < .001), and the likelihood of an obese child having impaired QOL was similar to that of a child or adolescent diagnosed as having cancer. Despite high asthma and obesity prevalence, knowledge regarding the influence of co-existing asthma and obesity on a child’s QOL is sparse. The limited pediatric QOL research examining both obesity and asthma have found lower QOL scores in children with both asthma and obesity compared with children who have either asthma alone or obesity alone (Blandon Vijil, Del Rio Navarro, Berber Eslava, & Sienra Monge, 2004; Van Gent et al., 2007). In light of the negative impact that obesity exerts on QOL and the prevalence of asthma, further research is warranted to assess how these health conditions are jointly affecting the QOL of children. The aim of this study was to examine the influence of obesity on QOL in children with asthma. QOL for each subject was measured using the Pediatric Asthma Quality of Life Questionnaire (PAQLQ).

METHODS Design A descriptive, comparative survey design guided this study of 90 children with asthma, of whom 36 were overweight. A comparative analysis of the QOL scores and health outcome measurements was conducted to determine the differences that existed between the two groups of subjects.

Setting Participants were recruited through a pediatric asthma clinic affiliated with a large, freestanding pediatric hospital in Chicago. The geographic area where this study took place has a high asthma mortality rate and higher childhood obesity prevalence than the national average (City of Chicago Department of Health, 2013; Respiratory Health Association of Metropolitan Chicago, 2011). Both overweight and obese children were included in the study. www.jpedhc.org

Sample Institutional Review Board (IRB) approval was obtained from the IRBs at the participating children’s hospital and the authors’ university prior to the start of the study. Informed consent was obtained from the child’s legal guardian. Children 12 years and older were given a written assent form to sign. For children younger than 12 years, verbal assent was obtained. Confidentiality was maintained throughout the study. In addition, all Health Insurance Portability and Accountability Act (HIPAA) regulations were followed. Convenience sampling was used to select participants. Inclusion criteria included the following parameters: (a) children between the ages of 9 to 14 years, (b) children who had a diagnosis of mild, moderate, or severe asthma (intermittent diagnoses were excluded), and (c) the family understood written and spoken English. The overweight inclusion criteria used for this study were defined using CDC guidelines (2015). Childhood overweight status was defined as a body mass index (BMI) between the 85th and 94th percentile for age and gender, and obese status was defined as having a BMI at or above the 95th percentile. Exclusion criteria included (a) children with severe developmental or motor delay and (b) children with chronic illnesses other than asthma. Study sampling took place over a 13-month period. The sample was separated into two groups, overweight/obese and non-overweight children with asthma. The final sample consisted of a total of 90 subjects: 54 normal weight and 36 overweight/obese children ages 9 to 14 years (see the Figure). A power analysis was calculated for a = 0.05 based on the achieved study sample (N1 = 54, N2 = 36). The results showed that the study sample had a power of 0.63 with the ability to detect a difference of 0.50 effect size and a power of 0.95 to detect a difference of 0.80 in effect size (Faul & Erdfelder, 1992). Study Variables Outcome: Quality of life and health outcomes The investigator-designed, parent-completed socioeconomic questionnaire measured the following health outcomes: asthma-related school absences, ED visits, hospitalizations, and unscheduled outpatient clinic visits due to asthma during the preceding 6 months. Further, health outcomes occurring during the 2 weeks prior to their participation in the study included the number of days the child wheezed and how many nights he or she woke up coughing. QOL was measured using the PAQLQ. The PAQLQ was designed to measure asthma-specific QOL in children ages 7 to 17 years and includes problems identified by children with asthma as being most important and troublesome to them in their everyday lives (Juniper, 2005). The PAQLQ is a 23-item, 7-point Likert scale -/- 2016

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FIGURE. Body mass index distribution of study participants.

This figure appears in color online at www.jpedhc. org. covering three domains: symptoms, emotional function, and activity limitation. The 7-point response scale ranges from 1 = extremely bothered/all of the time to 7 = not bothered/none of the time; the lower the score, the greater the level of impairment. Each item is equally weighted. The results were calculated as the mean score for each domain, as well as the overall QOL, which was calculated as the mean score for all the items. The PAQLQ has been translated into more than 20 languages (Roncada, Mattiello, Pitrez, & Sarria, 2013; Sousa, West, Moser, Harris, & Cook, 2012). The selfadministered English version of the PAQLQ was used for this study. A Cronbach a reliability coefficient of 0.84 has been reported for this tool (Juniper, 2005). Predictors: Asthma and overweight The child’s BMI was calculated from the height and weight measurements obtained on the day of the clinic visit. BMI percentiles for age and gender established by the CDC were used to identify overweight and obese children for this study (CDC, 2015). Asthma severity classifications were based on previous clinician diagnostic identification in this clinic setting. Children with mild to severe persistent asthma classifications, as defined by the National Asthma Education and Prevention Program Guidelines (2007), qualified for the study. Mild persistent asthma was defined as having day symptoms less than 2 days a week requiring the use of a b2-agonist and night symptoms, such as cough or wheezing fewer than three to four times a month. Moderate persistent asthma was defined as having day symptoms requiring daily use of a b2-agonist and night 4

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symptoms once a week or more often but not nightly. Severe persistent asthma was defined as having continual symptoms, as well as frequent night symptoms. Procedure for Data Collection Recruitment of subjects took place at the asthma clinic. Flyers about the study were posted in the clinic waiting room. Potential subjects who met the study criteria were asked if they were interested in participating in the study by the clinic nurse. Subjects who expressed interest in the study were then approached by the study principal investigator, who explained the study further and obtained consent/assent. The demographic questionnaire was given to the parent/guardian to complete. The PAQLQ was given to the child to complete. The child’s age, gender, height, and weight values were obtained as per clinic protocol with all identifiers removed. For their participation in the study, the children were allowed to pick an item from an assortment of stickers and pencils. Data Analysis Statistical analyses were completed using Statistical Package for the Social Sciences (SPSS) version 19.0 software (IBM Corp., Armonk, NY). Descriptive statistics were used to describe and summarize overall data. The key variables for this study were asthma, overweight, QOL, and health outcomes. QOL was the primary outcome analyzed. For continuous dependent outcomes, a one-way analysis of variance (ANOVA) assessed for differences between groups. For nominal dependent outcomes, a nonparametric, Pearson two-way v2 analysis was conducted. For ordinal and non-normally distributed dependent outcomes, a Kruskal-Wallis, one-way ANOVA was used. In addition, a multiple regression analysis was conducted to identify factors that were most predictive of QOL. Pearson v2 analyses of the six health outcomes were obtained to determine any difference among the three weight categories: normal weight, overweight, and obese. RESULTS Demographics of the Sample A total of 90 children were recruited for the study. All 90 children and their parent/legal guardian completed the study instruments. Key sample characteristics for the 90 children are displayed in Table 1. The mean for the entire sample was 11.37 years (range, 9-14 years). The majority of the children (43.3%; n = 39) were White, compared with those who were black or African American (26.7%; n = 24), Hispanic or Latino (23.3%; n = 21), Asian (5.6%; n = 5), and ‘‘other’’ (1.1%; n = 1). No significant differences by ethnicity among the sociodemographic variable were evident. Journal of Pediatric Health Care

TABLE 1. Age, gender, and ethnicity characteristics for subjects Characteristic Age, year 9 10 11 12 13 14 Gender Male Female Ethnicity White Black Hispanic or Latino Asian Other

N

%

22 12 12 14 15 15

24.4 13.3 13.3 15.6 16.7 16.7

62 28

68.9 31.1

39 24 21 5 1

43.3 26.7 23.3 5.6 1.1

Weight and Asthma Severity Table 2 presents BMI characteristics by gender. A total of 36 of the children (40%) were overweight (n = 19, 21.1%) or obese (n = 17, 18.9%); 69.4% (n = 25) were male, and 30.6% (n = 11) were female. The Figure illustrates the BMI distribution of the study participants. Table 3 presents the asthma classification characteristics of the participants. The obese children demonstrated the highest levels of asthma severity, with 76.4% of the obese children having moderate or severe asthma classifications compared with the children classified as overweight (42.1%) and normal weight (53.7%). Moreover, 23.5% of the obese children were ranked as having the highest level of asthma classification: severe persistent. These findings, nevertheless, did not reach statistical significance (p = .190).

TABLE 2. Body mass index characteristics for children by gender Child body mass index Normal weight Male Female Total sample Overweight Male Female Total sample Obese Male Female Total sample Overweight/obese Male Female Total sample

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Frequency

%

37 17 54

68.5 31.5 60.0

15 4 19

78.9 21.1 21.1

10 7 17

58.8 41.2 18.9

25 11 36

69.4 30.6 40.0

Quality of Life The PAQLQ symptom domain mean scores ranged from 1.7 to 7.0 (M = 5.76, SD = 1.29, N = 90). The symptom domain mean score was 5.774 (SD = 1.30, n = 54) for the normal-weight group, 5.621 (SD = 1.46, n = 19) for the overweight group, and 5.865 (SD = 1.10, n = 17) for the obese group. A one-way ANOVA was calculated for the children’s symptom mean scores on the PAQLQ. However, no significant difference in PAQLQ symptom scores was found by weight status (F = 0.166, df = 2, p = .847). The scores from the three domains were added together to calculate an overall QOL score for the PAQLQ. The overall QOL mean scores ranged from 1.47 to 7.0 (M = 5.86, SD = 1.26, N = 90). For the normal-weight group, the reported overall QOL mean score was 5.87 (SD = 1.27, n = 54); for the overweight group, the overall QOL mean score was 5.79 (SD = 1.34, n = 19); and for the obese group, the overall QOL mean score was 5.88 (SD = 1.14, n = 17). A one-way ANOVA was calculated on the children’s overall response mean scores to the QOL questions. The analysis was not significant: F(2, 87) = 0.034, p = .966. A regression analysis comparing the normal weight and obese groups was performed to examine whether child size (BMI) and child asthma severity classification could be used to predict overall QOL using the QOL scores from the PAQLQ. The results indicated that asthma severity was a significant predictor of overall QOL (b = 23.737, p = .002). Neither child size (b = 7.160, p = .619) nor the interaction between child size and asthma severity (b = 1.879, p = .912) were significant predictors of overall QOL. Regression analysis results are shown in Table 4. Health Outcomes The obese group accounted for the highest percentage of ED visits, 41.2% (7/17), compared with the overweight group (15.8%; 3/19) and normal-weight group (14.9%; 8/54). A Pearson v2 analysis of the normalweight and overweight/obese groups did not show significance, v2 (1) 2.269, p = .132, N = 90. Using Fisher’s exact test, a significant difference in ED visits between the normal-weight and obese children, p = .037, was calculated. When divided into three groups, the obese children reported the highest hospitalization rate, 17.7% (3/17), compared with the overweight group (5.3%, 1/19) and normal-weight group (9.3%, 5/54). A risk ratio analysis showed that the obese group had an overall 2.73 (95% confidence interval [CI] 2.15, 3.63) times higher likelihood of going to the ED and a 2.46 (95% CI 1.97, 3.19) times higher likelihood of hospitalization compared with the overweight and normal weight groups. A Pearson v2 analysis showed no significance among normal weight and overweight/obese on the variable of hospitalization, -/- 2016

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TABLE 3. Asthma classification characteristics Asthma classification Mild persistent No. (%) Moderate persistent No. (%) Severe persistent No. (%) Total No. (%)

Normal weight

Overweight

Obese

Total

25 (46.3)

11 (57.9)

4 (23.5)

40 (44.4)

24 (44.4)

7 (36.8)

9 (52.9)

40 (44.4)

5 (9.3)

1 (5.3)

4 (23.5)

10 (11.1)

54 (100)

19 (100)

17 (100)

90 (100)

v2 (1) = .082, p = .774, N = 90. Fisher’s exact test also showed no significance (p = .387). The obese children reported a higher percentage of days wheezing (47.1%; 8/17) compared with the overweight children (21%, 4/19) and normal-weight children (38.9%, 21/54). Still, this difference was not statistically significant: v2 (2) = 1.302, p = .522, N = 90. A risk ratio analysis documented a 1.38 (95% CI 0.45, 2.73) times higher likelihood of wheezing prior to the clinic visit for the obese group compared with the normal-weight and overweight group. No significant statistical difference was found between Although this study groups for the remainsupports the ing health outcomes: association missed schooldays, unscheduled doctor between visits, and episodes of overweight/obesity night waking.

and asthma severity, no significant association was found between child BMI, asthma severity, and QOL.

DISCUSSION Three asthma classifications were examined in this study: mild persistent, moderate persistent, and severe persistent. The obese children demonstrated the highest levels of asthma severity, which is consistent with larger scale studies indicating that obese persons are at higher risk of experiencing severe asthma symptoms (Akerman et al., 2004; Ford & Mannino, 2005). Importantly, in

accordance with research discovery of a doseresponse relation between asthma and obesity, these findings support obesity as a potentially modifiable risk factor for asthma mitigation and prevention (Akerman et al., 2004; Beuther & Sutherland, 2007; Shore, 2007; Shore & Johnson, 2006). Although this study supports the association between overweight/ obesity and asthma severity, no significant association was found between child BMI, asthma severity, and QOL. Quality of Life Although the obese children in this study had the highest proportion of asthma severity, the interaction between child weight status and asthma severity was found not to be a significant indicator of QOL. Therefore, based on these findings, obesity, when combined with a chronic illness such as asthma, does not affect QOL unless severity is considered and does not appear to place an additional burden on a child’s QOL. Nonetheless, the study findings bolster the link between asthma severity and QOL and support previous studies showing that children with severe persistent asthma have lower QOL (Everhart & Fiese, 2009). Furthermore, the study results validate the use of the PAQLQ tool in assessing how asthma severity affects a child’s QOL. Health Outcomes The obese children had a higher percentage of days wheezing and were more than twice as likely to visit the ED or be hospitalized for asthma symptoms. The increased ED visits and hospitalizations reported coincide with the concurrent higher asthma severity

TABLE 4. Regression analysis results for normal-weight and obese groups Unstandardized coefficients Model % BMI child normal weight or obese Asthma severity Size and asthma severity

B 7.160 23.737 1.879

Standardized coefficients

Standard error

b

t

14.319 7.257 16.847

0.108 0.412 0.026

0.500 3.271 0.112

Significance .619 .002 .912

Note. BMI, body mass index.

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classifications. Together, these findings support the fact that health outcomes such as days wheezing, ED visits, and hospitalizations are reliable indicators of asthma severity. It would seem logical that if a child wheezed more then he or she would need to frequent the ED more, which would lead to increased hospitalization risk. Overall, hospitalization rates for asthma have been on the decline since 1995, with the majority of exacerbations being managed at home (American Lung Association, 2014). Unfortunately, the often worsening progression of symptoms seen in obese children experiencing an asthma exacerbation is evident in the results of this study, which indicated a higher risk for ED visits, hospitalizations, and asthma severity, further supporting weight management as a consideration in overall asthma treatment and prevention protocols. LIMITATIONS Several study limitations require discussion. One significant limitation of this study was sample size. The study results (i.e., the data showing a higher percentage of days wheezing in the obese children) suggest that a larger sample size would probably generate a statistically significant result in this area. Because of time constraints, a larger sample size was not possible for this study. Further research is needed to investigate the strength of the association between weight status and hospitalization rate and number of days wheezing uncovered in the data. Another subsequent limitation of the study was the obesity severity. Only 17 of the 90 subjects, approximately 18%, were obese. Although this percentage is equal to the obesity prevalence percentage currently seen among children in the United States, a larger number of obese children to compare with the normal-weight children may have produced more significant results. In addition, the average BMI of the obese children in the study sample was 29.8, which is a lower level than what has been reported in the literature to affect QOL (Schwimmer et al., 2003). A larger number of morbidly obese or severely obese children would assist in determining if higher levels of obesity severity would eventually have an impact on the QOL of children with asthma. CLINICAL PRACTICE AND RESEARCH IMPLICATIONS Even though the results of this study show that weight did not affect overall QOL in the obese children with asthma, the true beginnings of the future impact of obesity on an individual’s health are evident in the higher percentages of hospitalizations, days wheezing, ED visits, and asthma severity classifications seen in the obese group. The multitude of health problems associated with obesity in adults is well known and include cardiovascular disease, hypertension, stroke, type 2 diabetes, and certain forms of cancer (National Heart, www.jpedhc.org

Lung, & Blood Institute, 2012). However, it is difficult for parents, caregivers, and even the children themselves to perceive and anticipate the impact the child’s weight will have on their future health when it seems so unaffected at the time. Obesity can be difficult to treat. The central cause of childhood obesity is eating too much and exercising too little (Mayo Clinic, 2015). The simple solution is to eat healthier foods and increase physical activity, but this can be difficult for a child to implement and maintain (Mayo Clinic, 2015). To be successful, establishing healthy habits should involve the entire family. Health care providers are in the best position to work with families to establish healthy goals to prevent and treat childhood obesity. Parents and children should be educated about ways to adopt healthy lifestyle changes by incorporating exercise into their everyday activities by walking to school, limiting television and computer time to 2 hours or less a day, and encouraging five servings of fruits and vegetables a day (Evans, Christoffel, Necheles, Becker, & Snider, 2011). Weight reduction programs targeting adults that combine asthma education with lifestyle interventions using pedometers, frequent weight checks, nutrition counseling sessions, and dietary restrictions have demonstrated positive results (Ma et al., 2015; Scott, et al., 2013; Sivapalan, Diamant, & Ulrik, 2015). However, there is a lack of similar weight reduction programs directed toward children despite the increasing presence of both obesity and asthma seen in the clinical setting (Willeboordse et al., 2013). One weight reduction intervention program targeting obese children with asthma currently being conducted by Willeboordse and Health care associates (2013) is incorporating sports acproviders can tivities and dietary, incorporate healthy parental, and individbehaviors into their ual counseling sessions to encourage weight everyday reduction and improve discussions about asthma symptoms. well-being with Although treating obesity is important, their patients and prevention is the key. families and include The best way to weight decrease the prevalence of obesity in chilmanagement as dren is to prevent it part of the standard from occurring in the asthma treatment first place. The healthy habits already disprotocol. cussed are best taught before the issue of obesity develops. The majority of overweight adults were not overweight children, but the unhealthy habits that led to their adult weight issues developed in childhood. Health care providers can incorporate healthy -/- 2016

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behaviors into their everyday discussions about wellbeing with their patients and families and include weight management as part of the standard asthma treatment protocol. Further research is needed to better understand the relationship between obesity, asthma, and QOL. Although this study found that weight has a limited affect on the QOL of children with asthma, QOL is still an important factor to consider when managing and treating asthma (National Asthma Education and Prevention Program, 2007). Understanding the resilience of obese children, especially those with chronic illnesses such as asthma, may assist in the management of childhood obesity (Pinhas-Hamiel et al., 2006) Additional research directed at the development of effective interventions for treating and preventing obesity and asthma in children is needed to improve overall QOL. CONCLUSION The obesity epidemic and its negative consequences on asthma is an emerging major health threat for children globally (Chu et al., 2009; Sithole, Douwes, Burstyn, & Veugelers, 2008). This study demonstrates the complexity of the interaction between child obesity and asthma. With asthma and obesity now the most prevalent chronic illnesses among children, and given warnings that the obesity escalation of the past decades are expected to continue, future research is warranted to broaden the results of this study and to develop evidence-based interventions to prevent and effectively treat comorbid childhood obesity and asthma. We thank Chandice Covington, PhD, RN, FAAN, for her expert guidance. REFERENCES Akerman, M. J., Calacanis, C. M., & Madsen, M. K. (2004). Relationship between asthma severity and obesity. Journal of Asthma, 41(5), 521-526. Akinbami, L. J., Moorman, J. E., Garbe, P. L., & Sondik, E. J. (2009). Status of childhood asthma in the United States, 1980-2007. Pediatrics, 123(Suppl. 3), S131-S145. Akinbami, L. J., Moorman, J. E., & Liu, X. (2011). Asthma prevalence, health care use, and mortality: United States, 2005-2009. National Health Statistics Reports, 32, 1-14. Ali, Z., & Ulrik, C. S. (2013). Obesity and asthma: A coincidence or a causal relationship? A systematic review. Respiratory Medicine, 107(9), 1287-1300. American Lung Association. (2014). Asthma & children fact sheet. Retrieved from http://www.lung.org/lung-health-and-diseases/ lung-disease-lookup/asthma/learn-about-asthma/asthmachildren-facts-sheet.html Annett, R., Bender, B. G., Lapidus, J., Duhamel, T. R., & Lincoln, A. (2001). Predicting children’s quality of life in an asthma clinical trial: What do children’s reports tell us? Journal of Pediatrics, 139(6), 854-861. Beuther, D. A., & Sutherland, E. R. (2007). Overweight, obesity, and incident of asthma: A meta-analysis of prospective epidemiologic studies. American Journal of Respiratory and Critical Care Medicine, 175(7), 661-666.

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Bibi, H., Shoseyov, D., Feigenbaum, D., Genis, M., Friger, M., Peled, R., & Sharff, S. (2004). The relationship between asthma and obesity in children: Is it real or a case of over diagnosis? Journal of Asthma, 41(4), 403-410. Blandon Vijil, V., Del Rio Navarro, B., Berber Eslava, A., & Sienra Monge, J. J. (2004). Quality of life in pediatric patients with asthma with or without obesity: A pilot study. Allergologia et Immunopathologia, 32(5), 259-264. Bloom, B., Cohen, R. A., & Freeman, G. (2010). Summary health statistics for U.S. children: National health interview survey, 2009. Vital & Health Statistics, Series 10, Data from the National Health Survey, 247, 1-82. Bloom, B., Jones, L., & Freeman, G. (2013). Summary of health statistics for U.S. children: National Health Interview Survey, 2012. Vital & Health Statistics, Series 10, Data from the National Health Survey, 258, 1-82. Castro-Rodriguez, J. A., Holberg, C. J., Morgan, W. J., Wright, A. L., & Martinez, F. D. (2001). Increased incidence of asthmalike symptoms in girls who become overweight or obese during the school years. American Journal of Respiratory & Critical Care Medicine, 163(6), 1344-1349. Centers for Disease Control and Prevention. (2015). Defining childhood obesity. Retrieved from http://www.cdc.gov/obesity/ childhood/defining.html Centers for Disease Control and Prevention. (2013). Most recent asthma data. Retrieved from http://cdc.gov/asthma/most_ recent_data.htm Centers for Disease Control and Prevention. (2012). Summary Health Statistics for the U.S. Population: National Health Interview Survey, 2012. Retrieved from http://www.cdc.gov/nchs/ data/series/sr_10/sr10_259.pdf Chen, A. Y., Kim, S. E., Houtrow, A. J., & Newacheck, P. W. (2009). Prevalence of obesity among children with chronic conditions. Obesity, 17(6), 1-4. Chin, S. (2003). Obesity and asthma: Evidence for and against a causal relation. Journal of Asthma, 40(1), 1-16. Chu, Y. T., Chen, W. Y., Wang, T. N., Tseng, H. I., Wu, J. R., & Ko, Y. C. (2009). Extreme BMI predicts higher asthma prevalence and is associated with lung function impairment in schoolaged children. Pediatric Pulmonology, 44(5), 472-479. City of Chicago Department of Health. (2013). Healthy Chicago: Transforming the health of our city: Overweight and obesity among Chicago Public Schools students, 2010-2011. Retrieved from http://www.cityofchicago.org/content/dam/city/ depts/cdph/CDPH/OverweightObesityReportFeb272013.pdf Covington, C. Y., Cybulski, M. J., Davis, T. L., Duca, G. E., Farrell, E. B., Kasgorgis, M. L., . Sell, T. L. (2001). Kids on the move: Preventing obesity among urban children. American Journal of Nursing, 101(3), 73-77, 79, 81–82. Datar, A., Nicosia, N., & Shier, V. (2013). Parent perceptions of neighborhood safety and children’s physical activity, sedentary behavior, and obesity: Evidence from a national longitudinal study. American Journal of Epidemiology, 177(10), 1065-1073. Davis, A., Lipsett, M., Milet, M., Etherton, M., & Kreutzer, R. (2007). An association between asthma and BMI in adolescents: Results from the California Healthy Kids Survey. Journal of Asthma, 44(10), 873-879. Dietz, W. H., & Robinson, T. N. (2005). Overweight children and adolescents. New England Journal of Medicine, 352(20), 2100-2109. Evans, W. D., Christoffel, K. K., Necheles, J., Becker, A. B., & Snider, J. (2011). Outcomes of the 5-4-3-2-1 Go! Childhood obesity community trial. American Journal of Health Behavior, 35(2), 189-198. Everhart, R. S., & Fiese, B. H. (2009). Asthma severity and child quality of life in pediatric asthma: A systematic review. Patient Education and Counseling, 75(2), 162-168.

Journal of Pediatric Health Care

Faul, F., & Erdfelder, E. (1992). G Power: A priori, post-hoc, and compromise power analyses for MS-DOS (Version 2) [Computer Program]. Bonn, Federal Republic of Germany: Bonn University. Figueroa-Munoz, J., Chinn, S., & Rona, R. J. (2001). Association between obesity and asthma in 4-11 year old children in the U.K. Thorax, 56, 133-137. Ford, E. S., & Mannino, D. M. (2005). Time trends in obesity among adults with asthma in the United States: Findings from three national surveys. Journal of Asthma, 42(2), 91-95. Friedlander, S. L., Larkin, E. K., Rosen, C. L., Palermo, T. M., & Redline, S. (2003). Decreased quality of life associated with obesity in school-aged children. Archives of Pediatrics and Adolescent Medicine, 157, 1206-1211. Juniper, E. F. (2005). Measurement of health-related quality of life. Retrieved from http://www.qoltech.co.uk/index.htm Luskin, A. T., Chipps, B. E., Rasouliyan, L., Miller, D. P., Haselkorn, T., & Dorenbaum, A. (2014). Impact of asthma exacerbations and asthma triggers on asthma-related quality of life in patients with severe or difficult-to-treat asthma. The Journal of Allergy & Clinical Immunology in Practice, 2(5), 544-552. Ma, J., Strub, P., Xiao, L., Lavori, P. W., Camargo, C. A., Wilson, S. R., . Lv, N. (2015). Behavioral weight loss and physical activity intervention in obese adults with asthma. A randomized trial. Annals of the American Thoracic Society, 12(1), 1-11. Magnusson, J. O., Kull, I., Mai, X., Wickman, M., & Bergstrom, A. (2012). Early childhood overweight and asthma and allergic sensitization at 8 years of age. Pediatrics, 129(1), 70-76. Mannino, D. M., Mott, J., Ferdinands, J. M., Camargo, C. A., Friedman, M., Greves, H. M., & Redd, S. C. (2006). Boys with high body masses have an increased risk of developing asthma: Findings from the National Longitudinal Survey of Youth (NLSY). International Journal of Obesity, 30(1), 6-13. Mayo Clinic. (2015). Diseases and conditions: Childhood obesity. Retrieved from http://www.mayoclinic.org/diseases-conditions/ childhood-obesity/basics/definition/con-20027428 McDaniel, M., Paxson, C., & Waldfogel, J. (2006). Racial disparities in childhood asthma in the United States: Evidence from the national health interview survey, 1997 to 2003. Pediatrics, 117(5), e868-e877. Mooreman, J. E., Akinbami, L. J., Bailey, C. M., Zahran, H. S., King, M. E., Johnson, C. A., & Liu, X. (2012). National Surveillance of Asthma: United States, 2001-2010. National Center for Health Statistics. Vital & Health Statistics, 3(35), 1-58. National Asthma Education and Prevention Program. (2007). Expert Panel Report 3: Guidelines for the diagnosis and management of asthma (NIH publication No. 07-4051). Bethesda, MD: National Heart Lung and Blood Institute. National Healthcare Quality Report. (2011). Table 6_4_14.1_1: Children ages 1-19 with hospital emergency department visit for asthma per 10,000 population, United States, 2005-2007. Retrieved from http://archive.ahrq.gov/research/findings/ nhqrdr/nhqrdr11/6_maternalchildhealth/T6_4_14_1_1.html National Heart, Lung, and Blood Institute. (2012). What are the health risks of overweight and obesity?. Retrieved from http://www. nhlbi.nih.gov/health/health-topics/topics/obe/risks Ogden, C. L., Carroll, M. D., Brian, K. K., & Flegal, K. M. (2012). Prevalence of obesity and trends in body mass index among U.S. children and adolescents, 1999-2010. Journal of the American Medical Association, 307(5), 483-490. Ogden, C. L., Carroll, M. D., Kit, B. K., & Flegal, K. M. (2014). Prevalence of childhood and adult obesity in the United States, 2011-2012. Journal of the American Medical Association, 311(8), 806-814. Okelo, S. O., Wu, A. W., Krishnan, J. A., Rand, C. S., Skinner, E. A., & Diette, G. B. (2004). Emotional quality-of-life and outcomes in adolescents with asthma. Journal of Pediatrics, 145(4), 523-529.

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Olshansky, S. J., Passaro, D. J., Hershow, R. C., Layden, J., Carnes, B. A., Brody, J., . Ludwig, D. S. (2005). A potential decline in life expectancy in the United States in the 21st century [see comment]. New England Journal of Medicine, 352(11), 11381145. Pinhas-Hamiel, O., Singer, S., Pilpel, N., Fradkin, A., Modan, D., & Reichman, B. (2006). Health-related quality of life among children and adolescents: Associations with obesity. International Journal of Obesity, 30(2), 267-272. Respiratory Health Association of Metropolitan Chicago. (2011). Asthma in Chicago: Disparities, perspectives and interventions: 2011 Report. Retrieved from http://www.lungchicago.org/ asthma-in-chicago/ Roncada, C., Mattiello, R., Pitrez, P. M., & Sarria, E. E. (2013). Specific instruments to assess quality of life in children and adolescents with asthma. Jornal de Pediatria, 89(3), 217-225. Scholtens, S., Wijga, A. H., Seidell, J. C., Brunekreef, B., de Jongste, J. C., Gehring, U., . Smit, H. A. (2009). Overweight and changes in weight status during childhood in relation to asthma symptoms at 8 years of age. Journal of Allergy and Clinical Immunology, 123(6), 1312-1318. Schwimmer, J. B., Burwinkle, T. M., & Varni, J. W. (2003). Healthrelated quality of life of severely obese children and adolescents [see comment]. Journal of the American Medical Association, 289(14), 1813-1819. Scott, H. A., Gibson, P. G., Garg, M. L., Pretto, J. J., Morgan, P. J., Callister, R., & Wood, L. G. (2013). Dietary restriction and exercise improve airway inflammation and clinical outcomes in overweight and obese asthma: A randomized trial. Clinical and Experimental Allergy, 43(1), 36-49. Shore, S. A. (2007). Obesity and asthma: Implications for treatment. Current Opinion in Pulmonary Medicine, 13(1), 56-62. Shore, S. A., & Johnson, R. A. (2006). Obesity and asthma. Pharmacology & Therapeutics, 110, 83-102. Silva, P. L., Mello, M. T., Cheik, N. C., Sanches, P. L., Piano, A., Corgosinho, F. C., . Damaso, A. R. (2012). The role of pro-inflammatory and anti-inflammatory adipokines on exercise-induced bronchospasm in obese adolescents undergoing treatment. Respiratory Care, 57(4), 572-582. Sithole, F., Douwes, J., Burstyn, I., & Veugelers, P. (2008). Body mass index and childhood asthma: A linear association? Journal of Asthma, 45(6), 473-477. Sivapalan, P., Diamant, Z., & Ulrik, C. S. (2015). Obesity and asthma: Current knowledge and future needs. Current Opinion in Pulmonary Medicine, 21(1), 80-85. Sousa, K. H., West, S. G., Moser, S. E., Harris, J. A., & Cook, S. W. (2012). Establishing measurement invariance: English and Spanish Paediatric Asthma Quality of Life Questionnaire. Nursing Research, 61(3), 171-180. Van Gent, R., van der Ent, C. K., Rovers, M. M., Kimpen, J. L., van Essen-Zandvliet, L., & de Meer, G. (2007). Excessive body weight is associated with additional loss of quality of life in children with asthma. Journal of Clinical Immunology, 119(3), 591-596. Weiss, K. B., & Sullivan, S. D. (2001). The health economics of asthma and rhinitis. I. Assessing the economic impact. Journal of Allergy and Clinical Immunology, 107, 3-8. Willeboordse, M., van de Kant, K., de Laat, M. N., van Schayck, O., Mulkens, S., & Dompeling, E. (2013). Multifactoral intervention for children with asthma and overweight (Mikado): Study design of a randomized controlled trial. BMC Public Health, 13, 494. Williams, J., Wake, M., Hesketh, K., Maher, E., & Waters, E. (2005). Health-related quality of life of overweight and obese children. JAMA, 293(1), 70-76. Zahran, H. S., Bailey, C., & Garbe, P. (2011). Vital signs: Asthma prevalence, disease characteristics, and self-management education—United States, 2001-2009. Morbidity and Mortality Weekly Report, 60(17), 547-552.

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