Why HAVE asthma deaths risen by a quarter in 10 years?
Amid fears London’s choking pollution lies behind the death of a nine-year-old girl...
THE tragic death of little Ella Kissi-Debrah from an asthma attack will have sent shivers down the spines of thousands of British parents. If her doctors’ suspicions are confirmed by the courts, she will become the first asthmatic child in Britain – if not the world – to be officially recognised as having been killed by toxic air.
Nine-year-old Ella and her family lived just 80ft from London’s South Circular road, a notorious pollution hot spot.
The original inquest concluded she died from acute respiratory failure, but an expert who has examined the case believes it was the filthy air she was forced to breathe that caused her eventually fatal asthma attacks, and a second inquest into Ella’s death is to be opened. The verdict remains to be seen.
But one thing is sure: if one child had suffered such a fate, there are undoubtedly many more. Today more than one million Britons are living with asthma. To non-sufferers, it may seem like this common chronic condition is merely a minor breathing complication, that it only affects children, and that most ‘grow out of it’.
But this is a gross misunderstanding. For thousands of sufferers, asthma is deadly, debilitating and can be as serious as diabetes or cancer. And the number of those afflicted are climbing fast. There are now three times as many asthma sufferers as there were 50 years ago, and it kills three Britons every day.
There is one asthma attack every three seconds, according to a recent report from research-funding charity Asthma UK.
Asthma most commonly starts in childhood, from two to five years old, but can also develop in adulthood when symptoms are often triggered by allergies, smoke, pollution or exercise. The chronic condition affects the bronchial airways – the tubes that carry air in and out of the lungs – causing them to narrow, resulting in attacks of breathlessness and wheezing.
While many children’s symptoms do disappear with age, for a third of patients asthma remains a debilitating life sentence involving constant medical care and, sometimes, potentially fatal attacks.
In only a decade, asthma fatalities have risen by 25 per cent, with the condition now responsible for 67,000 visits a year to A&E, costing the NHS almost £1billion. So what is behind this terrifying rise? There’s no one answer, according to world experts. Some blame obesity, while others pin it on global warming.
The likelihood is that it is not one factor, but a perfect storm of many elements. Here, with the help of the UK’s leading asthma authorities, we reveal the scientific theories about what is fuelling this growing epidemic...
THE TRUTH ABOUT ASTHMA AND BRITAIN’S POISONOUS AIR
POLLUTION is a hot topic, blamed for everything from cancer to obesity. But with regards to asthma and other lung conditions, the link is said to be far more obvious. In just three years, the number of British deaths thought to be attributable to pollution have risen from 29,000 to 36,000. And now, following the widely publicised case of Ella, who died in 2013, the direct links between asthma and air pollution are finally being taken seriously.
An analysis by Professor Stephen Holgate, an asthma researcher at University Hospital Southampton, found a ‘striking association’ between Ella’s emergency hospitalisations and local spikes in traffic pollution.
And Dominick Shaw, professor of Respiratory Medicine at the Nottingham University says: ‘Motor vehicles release carbon fuels which contain compounds called particulate matter. When there’s lots of these in the air, they flow into the delicate lining of the lung, irritating the airway.’
Last year, a team of international scientists studied the city of Bradford in West Yorkshire and concluded that air pollution may be causing nearly 40 per cent of its childhood asthma cases.
Intriguingly, levels of pollution in cities decreased by 12 per cent from 2012 to 2016, according to Government statistics. So the toll of asthma continues to rise despite our air getting less, not more, polluted.
According to experts, pollution is not causing more people to develop asthma, but rather making sufferers more vulnerable to lethal attacks. ‘Those with asthma already have highly inflamed airways,’ says Prof Shaw. ‘The toxic particles come into contact with this tissue and irritate it further, worsening breathing difficulties.
‘But for people without asthma, who have non-inflamed airways, breathing in pollutants is unlikely to increase the risk of developing the condition.’
A 2018 study by researchers at The George Washington University in Washington estimated that one in three asthma attacks is directly related to air pollution.
For those with severe asthma, Prof Shaw’s advice is to ‘avoid exercising when and where it’s polluted, and avoid walking and driving along the busiest roads.’
He adds: ‘The Department for Environment, Food and Rural Affairs (DEFRA) have a useful map on their website, detailing pollutant levels in any given area.’
IS OBESITY A CAUSE… OR A RESULT?
BRITAIN’S obesity epidemic is undoubtedly linked to the surge in asthma cases, and being overweight exacerbates symptoms. But is fat to blame?
According to US research published this month, being obese as a child increases the risk of developing asthma by a third. Researchers studied more than half a million children for four years and found that the more overweight the child, the greater their risk.
Government statistics show that nearly a quarter of British four to five-year-olds are overweight, as are a third of ten to 11-year-olds.
Studies indicate that the link between asthma and obesity relates to excess body fat putting pressure on the lungs and the chest wall, compressing and irritating the tissues.
In children and adults this can cause shortness of breath, wheeziness and airways that are oversensitive to substances such as pollen and pollution.
However, experts caution against concluding that obesity causes asthma. The link, they say, may not run in one direction.
Last year, a European study suggested that being asthmatic in childhood may in fact cause youngsters to become obese by discouraging them from participating in sporting activities.
Another theory relates to steroid medication, which works to reduce inflammation in the lungs, and can cause weight gain. ‘It’s often a vicious cycle,’ says Prof Shaw. ‘People with breathing problems are prescribed oral steroids which can potentially make you lose muscle and increase hunger, so patients gain weight which then increases asthma symptoms.’
THE RISE OF THE JUNK FOOD HYPOTHESIS
HISTORICALLY, experts believed in ‘the hygiene hypothesis’ as an explanation for rising allergy cases, including asthma.
The idea was that modern obsessions with cleanliness had eradicated so many germs that children’s immune systems
had ‘nothing to do’ so turned inward and began to attack the body or otherwise harmless environmental substances we come into contact with.
However, this has never been proved, and experts have moved away from this way of thinking.
But a modern-day ‘evil’ has given rise to a new theory: the junk food.
Obesity and poor diets often go hand in hand, but some research suggests that certain foods alone may trigger the development of asthma.
An emerging area of research regards the microbiome, the healthy bacteria that live inside the gut and are important for a healthy immune system.
Dr Samantha Walker, of Asthma UK, says that poor diets may upset the healthy balance of bacteria in the gut and spark a cascade of inflammatory responses in the immune system.
It is thought that the disruption of the microbiome triggers signals instructing the immune system to ‘attack’ its own tissues – including the lungs. This increases inflammation and swelling, constricting breathing.
But this is just one of several routes by which food influences asthma risk.
A wealth of studies have linked ultra-processed foods with raised risks of developing asthma and other allergies. For example, a survey of more than 300,000 adolescents and children by Nottingham University researchers found a 40 per cent increased risk of asthma in teenagers who ate burgers and other fast food more than three times a week.
Fast food is typically high in sugar and ultra-refined carbohydrates, known to lead to frequent spikes in blood sugar after eating, triggering an inflammatory response throughout the body – making lungs wheezy and oversensitive.
The answer? Last year, a trial led by Australia’s La Trobe University in Melbourne showed eating oily fish such as salmon and sardines as part of a healthy diet can reduce children’s asthma symptoms. Maria Papamichael, the dietician who led the study, says: ‘Fatty fish is high in omega-3 fatty acids which have anti-inflammatory properties. Eating it just twice a week can significantly decrease asthmatic children’s lung inflammation.’ Other research last year, by the European Lung Foundation, says that diets high in fruits, vegetables and wholegrain cereals cut by a third the risk of asthma in adults, and reduce symptoms in people who have the condition by a fifth. And it is important to note that the junk food hypothesis is just that. Critics have pointed out that those who habitually eat junk food tend to come from poor backgrounds and that low-income families are more likely to live near polluted roads, and be overweight for myriad reasons.
A REVOLUTION IN DRUGS IS ON THE WAY
FOR centuries asthma was believed to be a single condition. But in recent years scientists have made the breakthrough realisation that asthma is an umbrella term for different lung conditions, which all may need to be treated differently.
Crucially, effective new drug therapies are emerging for a previously hard-to-treat form of asthma, called T2 inflammatory asthma.
Up to ten per cent of UK asthma patients have the severe form of this, which does not respond to conventional steroid inhalers and leaves them prone to multiple attacks, visits to A&E and hospitalisations.
T2 inflammatory asthma usually emerges in adulthood. It is also called eosinophilic asthma, as it is caused by immune cells called eosinophils sparking inflammation in the lungs.
This month the National Institute for Health and Care Excellency (NICE) approved the injectable drug benralizumab to treat the condition. The drug targets inflammatory proteins released by eosinophil cells.
It is the third drug of its type to be approved for NHS use, following mepolizumab in December 2016 and reslizumab in October 2017.
‘The next few years will see a revolution in treatment for people with severe asthma,’ says Prof Shaw. ‘Drug companies are racing to develop targeted treatments and get them to the right patients.’
Such drugs are currently very expensive. In the US, the price for these new types of drugs is around $30,000 a year but Prof Shaw expects this to drop rapidly, enabling the drugs to be given to people with less severe forms of inflammatory asthma as well.
PATIENTS NEED TO BE PART OF THE ANSWER
WHILE these drugs may vastly improve the quality of life of people with severe T2 asthma, they will not significantly reduce the UK’s appalling death rate, says Prof Shaw.
This is because the majority of deaths occur in people with asthma that responds to conventional steroid inhalers – but who do not use their inhalers properly and succumb to fatal attacks.
This is why practising simple everyday prevention is the most vital step of all. It starts with taking asthma seriously, says Dr Walker. The best way for people to stay well year-round is to take their preventer inhaler (usually brown) every day, she explains.
Dr Walker explains that this builds up protection in the airways over time, preventing them becoming inflamed and susceptible to an asthma attack. Furthermore, many asthmatics should act much faster to see their GPs rather than waiting for a serious attack.
‘They should do this if they need to use their reliever inhaler three or more times a week, are waking up at night because of their asthma and are wheezing or have a cough that is worsening,’ says Dr Walker.
‘Two-thirds of asthma deaths are preventable, but often people still don’t think the condition can be fatal,’ warns Dr Walker. ‘The stark fact is that every asthma attack is potentially life-threatening.’