Conquer Your Weight

Dr. Sarah Stombaugh: This is Dr. Sarah Stombaugh, and you are listening to the Conquer Your Weight Podcast, episode number 68. Announcer: Welcome to the Conquer Your Weight Podcast, where you will learn to understand your mind and body so you can achieve long-term weight loss. Here's your host, obesity medicine physician and life coach, Dr. Sarah Stombaugh. Dr. Sarah Stombaugh: Hello everyone, and thank you for joining me today. I'm so excited because we have a special guest with us, Dr. Gina Dapul. She is a allergist and immunologist, and today we are going to be talking about asthma. But before we do, I would love to hear from you. Thank you so much, Dr. Dapul for being with us. Tell us a little bit about yourself. Dr. Gina Dapul: Yes, thank you so much, Dr. Stombaugh for having me here. So yes, I'm a board certified pediatric and adult allergist immunologist. I'm based out of the Washington DC area, and right now I'm practicing in Montgomery County, Maryland, specifically Rockville and Gaithersburg for those familiar to the DC area. And yes, I am the CEO and founder of Family Center for Allergy and Asthma, where I take care of infants all the way up to adults regarding their allergies, their asthma, and anything allergic related conditions. So I'm here to serve my local community and help those who suffer from these conditions. Dr. Sarah Stombaugh: And certainly in this springtime, I know those are starting to flare up, so I'm sure you are busy. Dr. Gina Dapul: Yes, yes. Dr. Sarah Stombaugh: So tell me, we all know that asthma is a thing, but I don't know, tell us a little bit more. What is the definition of asthma? How does it impact people? Let's just set some of the groundwork so that as we're talking about the role of asthma and weight, we have this really good understanding. So tell me a bit about asthma itself. Dr. Gina Dapul: Okay, great question and great way to start. So really what asthma is, it's this chronic disease that involves inflammation of the airways in your lungs. So what that means is that the airways get swollen, the muscles around there get tight, and then when you have a trigger, then you get the symptoms that make it difficult for you to breathe. So for example, certain triggers can be exercise, getting sick with a cold. We get sick with a cold, and then it ends up in our chest different allergens. So for now we have pollen coming out. There are some who are also allergic to year-round things like indoor dust mites or pets. Cold air can also be a trigger as well as cigarette smoke. So anything that can cause these airways to kind of clamp down and cause your breathing to have a problem are the reasons that we have this asthma. Dr. Sarah Stombaugh: Okay, thank you. That I think as a foundation for us, because we know that obesity or having excess weight can impact asthma. Tell us a little bit about how that can be the case. Dr. Gina Dapul: Yes. So there's many interplay of biologic factors, physiologic factors and environmental factors that can put these two together. And what we found is that the greater the BMI for patients, actually the greater risk of asthma, and I did forget to mention that the main symptoms that you could have with this condition are coughing, wheezing, shortness of breath, as well as feeling like your chest is tight. So any of those, or a combination of them can be asthma related. So what happens clinically for our patients who have obesity with asthma is that you actually are found to have more symptoms. They are more severe, there's more frequent exacerbations or meaning, asthma attacks, and then you're also less likely to respond to the medications that we use to treat asthma. And then there's also this impaired quality of life. So those are the factors that kind of go together when we talk about asthma and obesity. Dr. Sarah Stombaugh: And do we know why that's the case? Dr. Gina Dapul: Oh, there's so many different theories and a lot of the mechanisms are that certain adipokines like IL-6 and we're getting into the mechanism of things, but certain chemicals are released that then make it so that the asthma is affected by obesity and the different chemicals that are released. So that's how they kind of work together. Dr. Sarah Stombaugh: Okay. And I think it's really common inflammation is this buzzword that we hear used very often. Is it fair to say that inflammation is playing a role between obesity and asthma, or do you think it's a little bit more than that? Dr. Gina Dapul: So that is a role, but there's also genetics, right? So if there's some predisposition in the family to having asthma and related conditions as well as environmental factors. So as I mentioned before, if you're living in an area where there's a lot of allergens that can trigger it. If you're growing up around secondary smoke exposure, that can trigger it many, many different factors. And it's hard to say that just one thing is contributing to the underlying inflammation. Dr. Sarah Stombaugh: Yeah, absolutely. And so tell me both maybe just in general and then also sort of moving into for patients who have obesity, what do we do to treat and n asthma? Dr. Gina Dapul: Oh, so great question because this is the important part of knowing that while it's a chronic condition, meaning that it comes in, it's something that will be with us for a while, it is definitely something that we can control. So there's different things that we use to help control the asthma. And so for those who may not be familiar, there's different medications. One of the sets of medications are called quick relief or rescue medicines. You might've seen this, where patients will reach for an inhaler and that will help open up their airways right away. Those again, are rescue medicines. Then we have controller medications. And what those do are things that you take on a daily basis to really prevent the symptoms from happening. These can be tablets, these can be inhalers, combination inhalers, and that's really the mainstay for a lot of asthma control. If it's allergy-induced asthma, then we actually can go in the route of allergy shops or something called allergen immunotherapy. So that can be helpful, especially if it's outdoor triggers or indoor triggers like your pets or dust mites for those who have asthma flares. So this is when there's an attack that happens. We do end up going to oral steroids or IV steroids, but we definitely want to be mindful of those because the side effects can be weight gain when we do use them for long periods of time. And finally, really in the past two decades, we now have what we call biologics, which are injectable asthma medicines. So these are for those patients who have severe or difficult to control asthma. So we do have newer therapies that can help patients depending on how severe the asthma is. Dr. Sarah Stombaugh: Yeah, absolutely. Well, I'm curious, do people, I think a lot of people may, if they're experiencing shortness of breath or having really audible wheezing, it may be obvious to them, but tell me, are there patients who don't even realize that they have asthma? How do patients present as they're coming into your clinic? I'd love to hear a little bit about if someone's listening and they're like, oh gosh, do I have asthma when my allergies are flaring up or when I have an illness, maybe that's what's going on. What are the things that someone should be looking for and that you might be seeing patients in your clinic with? Dr. Gina Dapul: Yes, and we see this quite frequently because not everybody realizes that they have asthma, but that's why the question is, oh, if you had any of these, this is a reason to definitely bring up to your physician. Oh, is this something I should look into? So a lot of the shortness of breath that we talked about, some wheezing, coughing, feeling like your chest is tight, and when patients present in an asthma attack, sometimes it can be to the point where we're not even able to speak in complete sentences. So we're taking a breath after every couple of words because you're not able to catch your breath. That's when it depends on how severe that is. But yes, definitely being able to speak in complete sentences. What we see sometimes is the use of accessory muscles. So that's where you're using your shoulders and your chest to really help you breathe. So that's when it can be more severe, which at that point, if we are those types of symptoms, I suggest and recommend going to the urgent care or ER first. But if you're able to drive yourself, if you're able to speak in complete sentences, then it's definitely worth seeing your physician for a follow-up care. Dr. Sarah Stombaugh: Yeah, I can imagine someone listening to this podcast, even if they're thinking back like, oh gosh, when I do get sick, I might notice that I have these symptoms, for example. And that might be a good thing to make sure that if you haven't been seeing your physician during those times, you certainly should and then potentially to be referred to someone like yourself. So tell me, so especially for patients who have obesity, we know that it can be more challenging to manage. There may be less response to treatment and other aspects that make it more challenging as a patient is losing weight. Do we see changes in their asthma or and improvement? Dr. Gina Dapul: Yes. Yes. And this is where it's so important to bring this up so that everyone's able to realize where the benefits are if we're able to lose some weight. So they have done studies in both pediatric and adult patients showing that if with lifestyle interventions, so whether this is diet alone, exercise alone, or diet and exercise, that this has actually been shown to have a significant improvement in asthma control. So not only are your symptoms better, but then your parameters that we measure on breathing tests that those also improve. So there's a great benefit to being able to lose the weight and then have these really good benefits for your asthma. And what it did show in adults is that a weight loss of at least 5% is what's required to produce a significant improvement in asthma control. And so if we can do 5% that, that's really helpful. Long-term wise, what we see too is that not only do the symptoms improve, but we have a decreased risk of exacerbations. The treatment is able to be more responsive and more importantly, which is where what we do for everybody is to help improve quality of life. Once you're able to lose some weight, the quality of life improves and everything gets better from there. Dr. Sarah Stombaugh: Absolutely. And I feel like sometimes it's chicken and the egg too. Dr. Gina Dapul: Yes. Dr. Sarah Stombaugh: If you're noticing it's challenging to exercise because of breathing problems, for example, then you can't exercise and then you're gaining weight because you don't have that ability to move. And so often as we're treating some of these underlying conditions, then you're moving more, then you can have more weight loss, which improves the asthma, which could be obviously the great the way we want that to play out. Dr. Gina Dapul: Yes, yes. And actually that was one of the things I definitely wanted to bring up by the end of our discussion, Dr. Stombaugh, is that I have patients coming to me saying, I don't exercise because I can't breathe exactly what you said. And then our job as asthma specialists, as primary care physicians, as pulmonologists, our goal is to be able to turn that around and say, in spite of your asthma, you can. And so what we need to do is better control the symptoms so that patients can exercise whatever form that is, whether it's walking or riding a bike or using something stationary at home. The idea is we need to help control those coughing, breathing, wheezing issues on a daily basis so that when you feel like you can breathe, you can say, oh, I'm able to go outside and do what I need to get that physical activity in. And so great, great, great point. Because we don't want the mindset to think, oh, I can't exercise because I can't breathe. Instead, we need to find a specialist to really work with us to say, well, what are your goals and how can we get you to being able to accomplish those goals? Whether it's controlling your asthma or figuring out, okay, what do you like to do? Are you a walker? Do you walk your dog? Do you like yoga? Are you a runner? Really trying to encourage patients to find what their passion and physical exercises and supporting them through that. Dr. Sarah Stombaugh: I love that. One of the things that you pointed out, you said a patient needs to lose usually about 5% of weight before we start seeing an improvement. And I really want to emphasize that because sometimes when someone is looking at their weight loss journey, and let's say they're in a body that weighs 200 pounds, for example, they may, especially if they're a petite female, that may be a really significant weight for their body. And they may be looking at, oh gosh, I wish I weighed 140 pounds. And they're thinking about the 60 pound weight loss rate, which is 30% of their body weight. It's really a pretty significant number. And while that can still potentially be the overall goal, and there may be other ways that we're moving towards that, recognizing that even losing 10 pounds for example, may be a really significant move in the direction of their symptom management, whether it is asthma or a number of other health conditions, really at the 5% mark is where we start seeing improvement in blood pressure and sometimes cholesterol and blood sugar control. And so it's like we start to move the needle at 10 pounds weight loss for someone who weighs 200 pounds, which is really feels a lot more attainable sometimes than like, oh my gosh, I need to lose 60 pounds, for example. Dr. Gina Dapul: Yes. And so looking at it from the thing of a journey, so we're not trying to run a sprint, but this is a marathon. And then kind of giving yourself that grace and compassion to say, okay, look, I can do that little bit. And once you do that little bit, then you actually can do more. And you just keep increasing that and recognizing, wow, if I did 10 pounds, okay, there's 15, that's the next one, or even 20. And so yes, starting really small so that we don't get overwhelmed feeling like, oh, that's impossible. Right? But 10 pounds is something that is doable, and once your mind starts to believe that and you can see it, then it really does keep that habit going and you're able to progress to your goals. Dr. Sarah Stombaugh: Yeah, absolutely. One of the things I want to mention as well is that certainly in my world, I'm always thinking about what is the impact of weight with medications that we're using? And I am always scrutinizing someone's medication list, and it is common that we find medications on their list that may be weight promoting, but there's always this risk versus benefit there. Right. And so you mentioned that when we're taking oral steroids for sure, that can cause and create weight gain for us. We know that across the board. My understanding is though, even some of the inhaled corticosteroids when given for a long time or at high dose may create some slight increase in BMI. Can you tell me about that a little bit? Dr. Gina Dapul: Yes, yes and no, for sure. So inhaled steroids are the inhalers that we were talking about earlier that are used as controller medications. So these are things that we probably typically take on a daily basis, or if we're not, we should be, and that you need to talk to your doctors about. But the idea behind it, as you said, I have this conversation multiple times a day with my patients that the benefits should outweigh the risk, right? And so if we need to breathe, then the risk of side effects from some of these medications are on the lower side because we do need to breathe. And then at some point, if we're able to wean it off, meaning, whoa, maybe we don't need it two puffs twice a day, maybe we can go to two puffs once a day that the risks are less, but we're still maintaining control of the asthma symptoms. So yes, inhaled steroids can cause some weight gain, but again, we always want to weigh out the benefits of being on it versus the risk because we do need to breathe. And then when you speak with your physician who does prescribe these medicines, we really do try to monitor every three months or six months to say, oh, do you still need this? And then do we wean off appropriately? Meaning, okay, maybe during certain times of the year you don't need to be on this. So for some asthma patients, we can wean this off in the summer and we're not on anything, but then comes flu and virus season, all the stuff in mold in the spring, kids coming home sick, then we need to maybe restart it then and then we can weed it off in the spring and summer. So to answer your question, yes, there is that concern of medications causing weight gain, but we always want to make sure that we look at alternatives, which there could be in this case, there are some tablets that can be used for asthma, as we mentioned before, allergy shots, which have been out for over a hundred years. And that's something that really helps improve your allergy symptoms and your asthma symptoms. Sometimes to the point of my patients being able to be off of their controller medicines, so every patient responds differently, but there are ways to really try to control the asthma without having all the side effects of the meds. Dr. Sarah Stombaugh: Yeah, absolutely. And I appreciate you going into that really in depth explanation because certainly as I'm doing an intake with someone and we're reviewing that medication list, and as I'm seeing these things, I'm always thinking, okay, do I need to be having a conversation with a specialist to see are there other options that are here? But the inhaled corticosteroids, we hear steroids sometimes that gives us this big fear. The weight gain from those is so, so much less compared to the oral steroids, right? Dr. Gina Dapul: For sure. Yes. Dr. Sarah Stombaugh: If being on the inhaled steroids means that then we don't have to be on the oral steroids, we're not having the flare up, we've also prevented this much worser of the evils. And so I think that's an important thing to recognize as well. And so Dr. Gina Dapul: Yes, those are exactly the conversations I have with my patients. I said, these are microgram doses that we are inhaling or we're asking you to take on a daily basis. Whereas if you had an asthma attack and a flare and you're going to get treatment to your local er, urgent care, what we give are milligrams of these over periods of days. And so really this little amount of inhaled steroid to decrease where the inflammation is, which is in your lungs, is a much better option than having to have these bursts of oral steroids when possible. Dr. Sarah Stombaugh: Yeah, absolutely. And so I wanted to make sure to highlight that because we still, even as an obesity medicine physician, I'm not just slashing these medications off list. They still, if you're having the condition, we can't just remove those medications. And so I certainly wouldn't be recommending that. I don't think any other person in my position would be, and for patients to recognize that, again, it's that risk versus benefits. If it's helping you to breathe, helping you to exercise, preventing those flareups, you're really going to feel so much better. And that small risk, the increase is often really insignificant when we're talking about the inhaled steroids, and it's not a reason that I would ever recommend stopping them. Dr. Gina Dapul: Very true. Dr. Sarah Stombaugh: Excellent. Well, let me ask you, is there anything else before we wrap up today that you want to make sure that we share with our listeners? Dr. Gina Dapul: So I had a patient just the other day, and I thought about, oh, this is a perfect example to talk about. And so she came in for her follow-up of asthma just on Monday and said to me, I lost 10 pounds since January. So I'm like, oh my goodness, this is two months. And really encouraged her. I said, what have you been doing? And so she said, yes, I'm using a bike at home. I'm walking. And I said, how has this impacted your breathing? And she goes, not only do I feel better, but my symptoms are much better controlled. And she hasn't had to use her rescue inhaler as often as she did when I saw her last in October. So I say this to share that even though asthma is a chronic condition with the right treatment, the right team of doctors taking care of you and helping you, it's really something that we can live with, but also be able to still accomplish the goals that you want to. And if my patient said, I'm able to walk multiple miles per week and spend time with her grandchildren and do all these things, that's where for me as a allergy and asthma specialist, I have so much pride to say, look, I'm taking a part of that. I'm a part of being able to help treat her asthma so that she can live this fulfilling life that she enjoys with whatever activities she wants to do. And so I say this to encourage everyone to think, well, what is it that I want to do? How can I be active and what steps do I need to be able to achieve those goals? And who do I need on my team to be able to help support me in this journey? Dr. Sarah Stombaugh: I love that. Thank you for sharing that example with us. And Dr. Dapul, thank you so much for joining us today. It was really a pleasure to talk about asthma, its role with obesity and weight, and thank you. This was great.