Effects of Weight Loss on Peak Flow

Variability, Airways Obstruction, and

Lung Volumes in Obese Patients With
Asthma*
Katri Hakala, MD; Brita Stenius-Aarniala, MD, PhD; and
Anssi Sovijärvi, MD, PhD

Study objectives: To clarify the pathophysiologic features of the relation between asthma and
obesity, we measured the effects of weight reduction on peak expiratory flow (PEF) variability
and airways obstruction, compared to simultaneous changes in lung volumes and ventilatory
mechanics in obese patients with stable asthma.
Methods: Fourteen obese asthma patients (11 women and 3 men; aged 25 to 62 years) were
studied before and after a very-low-calorie-diet period of 8 weeks. PEF variability was deter-
mined as diurnal and day-to-day variations. FEV1 and maximal expiratory flow values were
measured with a flow-volume spirometer. Lung volumes, airways resistance (Raw), and specific
airways conductance were measured using a constant-volume body plethysmograph. Minute
ventilation was monitored in patients in supine and standing positions.
Results: As patients decreased their body mass index (SD) from 37.2 (3.7) to 32.1(4.2) kg/m2
(p < 0.001), diurnal PEF variation declined from 5.5% (2.4) to 4.5% (1.5) (p ⴝ 0.01), and
day-to-day variation declined from 5.3% (2.6) to 3.1% (1.3) (p < 0.005). The mean morning PEF,
FEV1, and FVC increased after weight loss (p ⴝ 0.001, p < 0.005, and p < 0.05, respectively).
Flow rate at the middle part of FVC (FEF25–75) increased even when related to lung volumes
(FEF25–75/FVC; p < 0.05). Functional residual capacity and expiratory reserve volume were
significantly higher after weight loss (p < 0.05 and p < 0.005, respectively). A significant
reduction in Raw was found (p < 0.01). Resting minute ventilation decreased after weight loss
(p ⴝ 0.01).
Conclusion: Weight loss reduces airways obstruction as well as PEF variability in obese patients
with asthma. The results suggest that obese patients benefit from weight loss by improved
pulmonary mechanics and a better control of airways obstruction.
(CHEST 2000; 118:1315–1321)

Key words: airways obstruction; asthma; obesity; peak expiratory flow variation; pulmonary function; weight loss

Abbreviations: AFV ⫽ area under the expiratory flow volume curve; BHR ⫽ bronchial hyperresponsiveness;
BMI ⫽ body mass index; Dlco ⫽ diffusing capacity of the lung for carbon monoxide; ERV ⫽ expiratory reserve
volume; FEF25–75 ⫽ flow rate at the middle part of FVC; FRC ⫽ functional residual capacity; NS ⫽ not statistically
significant; PD15 ⫽ provocative dose causing a 15% fall in FEV1; PEF ⫽ peak expiratory flow; Raw ⫽ airways resistance;
RR ⫽ respiratory rate; RV ⫽ residual volume; SGaw ⫽ airways conductance; TLC ⫽ total lung capacity; TLC-B ⫽ TLC
measured using body plethysmograph; TLC-He ⫽ TLC measured using the single-breath helium dilution method;
VAS ⫽ visual analogue scale; V̇e ⫽ minute ventilation; VLCD ⫽ very-low-calorie-diet; Vt ⫽ tidal volume

T heincreasing
prevalence of asthma and obesity has been
worldwide in recent years. Sev- 1,2
risk of developing asthma is uncertain.7 Luder et al8
studied the relationship between asthma symptoms
eral studies have reported the association between and overweight in children. They found that a higher
body mass index (BMI) and asthma prevalence.3– 6 BMI was associated with more severe asthma symp-
Whether asthma patients gain weight as a result of toms. In adult obese asthmatics, improvement in
activity limitations or whether obesity increases the asthma severity after weight loss has been reported.9,10

*From the Department of Medicine (Drs. Hakala and Stenius- This study was supported by the Finnish Cultural Foundation.
Aarniala), Division of Pulmonary Medicine, and the Labora- Manuscript received December 29, 1999; revision accepted May
tory Department (Dr. Sovijärvi), Division of Clinical Physiology 3, 2000.
and Nuclear Medicine, Helsinki University Hospital, Helsinki, Correspondence to: Katri Hakala, MD, Kallenkaarre 9, FIN -
Finland. 14200 Turenki, Finland

CHEST / 118 / 5 / NOVEMBER, 2000 1315

 It could be assumed that impairment in pulmo- Study Protocol
nary mechanics related to obesity, such as reduction All patients participated in a weight reduction program starting
in lung volumes, increased airways resistance (Raw), with a very-low-calorie-diet (VLCD) period of 8 weeks. The
and impairments in small airways function,11 may VLCD preparation used was Nutrilett (Nycomed Pharma AS;
contribute to an increase in asthma severity. Al- Oslo, Norway). The daily dose gives 1,760 kJ/d, and contains daily
though there is evidence that weight loss may im- allowances of all essential nutrients. The principles of this weight
reduction program are described by Pekkarinen et al.13
prove lung function and oxygenation in obesity,12 Before weight loss and after the VLCD period, PEF measure-
very little is known about the effects of weight loss on ments for 2 weeks, pulmonary function tests (see below), and
the severity of asthma in terms of variability of arterial blood gas analyses were evaluated. The symptoms (ie,
airways obstruction. dyspnea and cough) were recorded on a 100-mm visual analogue
To clarify pathophysiologic features of the relation scale (VAS), where 0 mm represented best possible and 100 mm
represented worst possible. The use of rescue medication was
between asthma and obesity, we measured the ef- recorded. Patients had been advised not to change their antiasth-
fects of weight loss on peak expiratory flow (PEF) matic treatment other than short-acting ␤2-agonists during the
variability and airways obstruction, compared to study if the stability of asthma was clinically acceptable. Patients
simultaneous changes in lung volumes and ventila- with allergy to pollen were studied out of season. The dose and
tory mechanics in obese patients with stable asthma. timing of long-acting ␤2-agonists and sustained-release theoph-
ylline compounds were identical at study visits before and after
weight loss. Patients did not consume any caffeinated beverages or
short-acting bronchodilators for 4 h before pulmonary function tests.
Materials and Methods
Pulmonary Function and Arterial Blood Gas Measurements
Fourteen patients (11 women and 3 men; aged 25 to 62 years)
with a clinical diagnosis of asthma and moderate to morbid Flow-volume spirometry was performed using a rolling seal
obesity BMI (range, 32.5 to 42.5 kg/m2) were recruited for the spirometer (CPI 220; Cardio Pulmonary Instruments; Houston,
study. Characteristics of the patients and antiasthmatic medica- TX) connected to a microcomputer system (Medikro 202;
tions are presented in Table 1. Prior to our study, all patients Medikro Oy; Kuopio, Finland) according to European recom-
participated as a control group in another study.10 Their spiro- mendations.14 The results from the envelope curve of at least
metric and serial PEF values were carefully followed up every 2 three superimposed forced expiratory flow-volume curves were
months for 1 year before starting in our study. Because they were recorded. FEV1, FVC, flow rate at the middle part of FVC
control patients, they underwent no interventions other than (FEF25–75), and area under the expiratory flow volume curve
education concerning asthma and allergy.10 Medical therapy (AFV) were determined with the patient in the sitting position.
included regular use of inhaled corticosteroids in all 14 patients, Vital capacity (VC), total lung capacity (TLC), residual volume
sustained-release theophylline compounds in 2 patients, and (RV), functional residual capacity (FRC), Raw, and specific
regular long-acting inhaled ␤2-agonists in 3 patients. All patients airways conductance (SGaw) were measured using a constant-
were nonsmokers or ex-smokers who had stopped smoking for volume body plethysmograph (Bodyscreen; Erich Jaeger;
ⱖ 2 years (Table 1). Patients gave informed consent to participate Wurtzburg, Germany) during tidal breathing timed with a met-
in the study, which was approved by the Ethical Committee of ronome (30/min). The mean value of 3 to 5 determinations was
the Department of Pulmonary Medicine of Helsinki University recorded for analysis. A single-breath diffusing capacity test
Hospital. (Master Lab; Erich Jaeger) was used for measuring diffusing

Table 1—Baseline Characteristics of the Patients*

Age, Weight, BMI, FEV1, % Smoking History, Asthma Allergy to

Patient No. yr Sex kg kg/m2 Predicted Pack-yr Duration, yr Pollen Medications, ␮g

1 25 F 120 42.5 105 0 15 Yes Bud 200 bid

2 53 F 105 39.5 73 0 12 Yes Bud 400 bid, SRT, salm
3 62 F 98 40.3 77 6.5† 3 No Bud 400 bid
4 56 F 87 34.4 50 0 7 No Becl 500 bid, salm
5 54 F 90 33.1 85 0 17 No Bud 400 tid
6 49 M 115 33.6 66 0 1 No Becl 500 bid, salm
7 49 F 97 37.0 83 0 5 No Bud 400 bid
8 48 M 109 32.5 89 23† 18 Yes Becl 500 bid
9 57 F 94 41.2 81 8.5† 11 Yes Bud 400 bid
10 53 F 86 36.3 83 0 19 Yes Bud 400 bid, SRT
11 40 F 117 42.5 65 0 16 Yes Bud 200 bid
12 58 M 113 35.7 55 10† 27 No Becl 500 bid
13 61 F 110 39.4 84 0 14 Yes Bud 200 bid
14 60 F 74 32.5 75 0 14 No Becl 500 bid
Mean 51.8 F/M 101 37.2 77 Ex-smokers 12.7 Total
SD 9.1 11/3 14 3.7 14 4/14 4.9 7/14
*M ⫽ male; F ⫽ female; Bud ⫽ budesonide; Becl ⫽ beclomethasone; salm ⫽ salmeterol; SRT ⫽ sustained-release theophylline.
†Ex-smoker.

1316 Clinical Investigations

capacity of the lung for carbon monoxide (Dlco). TLC was also between two variables were calculated with Spearman’s correla-
measured using the single-breath helium dilution method (TLC- tion test. A p value ⬍ 0.05 was considered to indicate statistical
He). The value of nonventilated lung compartment was calcu- significance.
lated as the TLC measured using body plethysmograph (TLC-B)
minus the TLC-He.
Minute ventilation (V̇e), tidal volume (Vt), and respiratory rate Results
(RR) were continuously monitored and recorded over a 30-s
interval in patients in supine and standing positions. A face mask The effects of weight reduction on BMI and
(Rudolph series 7910; Hans Rudolph; Kansas City, MO) was symptom scores as well as use of rescue medication
tightly attached and connected to an automatic gas exchange
are shown in Table 2. The mean weight loss was 13.7
analyzer with a mixing chamber (Ergo-Oxyscreen; Erich Jaeger).
The mask and the valve system had a dead space of 185 mL. The kg (range, 8 to 18 kg). The mean BMI decreased by
mean values of 10 consecutive measurements of 30 s in both body 5.1 kg/m2 (range, 3.0 to 7.4 kg/m2). Symptoms were
positions were calculated for further analyses. recorded on a VAS scale from 0 to 100 mm. A
Arterial blood samples for blood gas analysis were taken from significant reduction in dyspnea was demonstrated;
a brachial artery after a rest of 10 min with the patients in supine
the change in cough score was not statistically sig-
position.
nificant (NS). The use of rescue sympathomimetics
was ⬍ 1 dose per day at baseline, and it did not
Histamine Challenge
change by the end of the weight reduction period.
A rapid dosimetric method with controlled tidal breathing was A significant improvement in the mean morning
used for histamine challenge of the airways.15 Patients with an and evening PEF values with weight loss was found.
FEV1 of ⱕ 70% predicted were excluded from histamine prov-
The difference between the daily highest and lowest
ocation testing. If FEV1 decreased from the baseline by ⱖ 15%
after any dose, further administration of histamine was discon- PEF did not change. Before weight loss, it was 24
tinued. The provocative dose causing a 15% fall in FEV1 (PD15) L/min (range, 10 to 59 L/min), and after weight loss,
was calculated from logarithmically transformed histamine doses. it was 20 L/min (range, 8 to 41 L/min). Diurnal PEF
variation declined from 5.5% (2.4) to 4.5% (1.5)
PEF Variability (p ⫽ 0.01). PEF indexes over a follow-up period of
14 days are presented in Table 2. Calculated from
The highest of three measurements of PEF by mini-Wright
peak flowmeter was recorded by the patients themselves every the serial morning PEF values over 2 weeks, the
morning and evening during 14 successive days before and after mean difference between the highest and lowest
the weight loss period. If patients were receiving bronchodilator, morning PEF values fell by 38% with weight reduc-
PEF values were measured before its use. PEF variability was tion (Table 2). Day-to-day PEF variation decreased
expressed in three ways: as the diurnal PEF variation (highest
from 5.3% (2.6) to 3.1% (1.3) (p ⬍ 0.005). Individual
PEF ⫺ lowest PEF/mean value of the two, ⫻ 100%), the mean
difference between the highest and lowest morning PEF values changes in diurnal and day-to-day PEF variations are
measured over a follow-up period of 14 days, and the day-to-day shown in Figure 1.
PEF variation (SD percent mean morning PEF). Seven patients met the inclusion criteria for the
histamine challenge test. The mean PD15 was 0.20
Statistical Analysis mg (range, 0.015 to 1.6 mg) before weight loss and
0.30 mg (range, 0.043 to 1.6 mg) after weight loss.
Pulmonary function data are expressed as mean (SD). PD15
values were analyzed after log10 conversion. Wilcoxon signed- The change was NS.
rank test was used in statistical comparisons of lung function Pulmonary function data are shown in Table 3.
variables between baseline and after treatment. The relations The mean FEV1 was low before weight loss (77% of

Table 2—Weight, BMI, Asthma Symptoms, and PEF Indexes Before and After VLCD Period of 8 Weeks in Obese
Patients With Asthma*

Variables Before Weight Loss After Weight Loss p Value

Weight, kg 101 (14) 87 (15) p ⬍ 0.001

BMI, kg/m2 37.2 (3.7) 32.1 (4.2) p ⬍ 0.001
Dyspnea VAS,† mm 14.6 (1.2–34.9) 8.1 (1.0–24.5) p ⬍ 0.001
Cough VAS,† mm 8.8 (1.8–22.4) 8.6 (1.0–21.4) NS
Rescue medication, doses/d 0.6 (0–3.0) 0.4 (0–1.8) NS
Morning PEF, L/min 399 (80) 418 (85) p ⬍ 0.001
Evening PEF, L/min 406 (86) 426 (88) p ⬍ 0.005
Lowest morning PEF L/min 368 (66) 404 (84) p ⬍ 0.001
Highest morning PEF, L/min 437 (92) 452 (93) NS
Highest ⫺ lowest morning PEF, L/min 63 (35) 39 (10) p ⬍ 0.005
*Data are presented as means (SD) or means (range). NS ⫽ not significant.
†0 mm ⫽ best possible; 100 mm ⫽ worst possible.

CHEST / 118 / 5 / NOVEMBER, 2000 1317

 volume (ERV) from 0.43 L (0.22) to 0.72 L (0.50).
The rise in ERV also mainly accounts for the in-
crease in FRC, because RV did not change. TLC-He
and TLC-B are presented in Table 3. Nonventilated
gas compartment (TLC-B ⫺ TLC-He) was 0.43 L
before and 0.61 L after weight loss; the change was
NS. The mean Raw was high before weight loss
(329% predicted; range, 161 to 579% predicted;
Table 3). In response to weight reduction, Raw
decreased toward the normal level (p ⬍ 0.05), but
the mean value was still after weight reduction 252%
of predicted (range, 67 to 473% predicted). The
change in BMI expressed as a percent baseline value
correlated with the increase in SGaw (1/Raw;
r ⫽ 0.59; p ⬍ 0.05).
The mean baseline arterial oxygen tension
(Pao2 ⫽ 11.4 [0.9] kPa) and the mean carbon dioxide
tension (Paco2 ⫽ 5.2 [0.3] kPa) were within normal
range. Weight loss did not alter the values. The
effects of weight loss on V̇e are shown in Table 4. V̇e
measured in patients in supine and standing posi-
tions fell after weight loss by 16% (p ⬍ 0.01) and by
14% (p ⫽ 0.01), respectively. Vt also showed slight
decrease (p ⫽ 0.07 supine; p ⬍ 0.05 standing) while
RR did not change.

Discussion
The results of our study indicate improved pulmo-
Figure 1. The individual changes in (top, a) diurnal and (bottom, nary function after weight reduction in obese pa-
b) day-to-day PEF variations before and after weight loss in obese tients with asthma, suggesting that these patients
patients with asthma (n ⫽ 14). The bars present the mean values. benefit from even modest weight loss. The increase
The p values refer to Wilcoxon signed rank test.
in FEV1 with no change in FEV1/FVC ratio may
rather reflect improvement in lung volumes, a well-
known effect of weight loss in obesity,12,16,17 than
predicted; range, 50 to 105%), while the mean FVC decrease in airways obstruction. However, increased
was within normal range (93% of predicted; range, FEF25–75 even when related to volume (FEF25–75/
71 to 114%). Weight reduction induced a significant FVC) may suggest a relief in peripheral airways
increase in FEV1 (percent predicted; p ⬍ 0.01) and obstruction. Furthermore, increased FVC and VC
FVC (percent predicted; p ⬍ 0.05). Also, AFV in- may indicate improvement in small airways obstruc-
creased with weight loss (p ⬍ 0.005). FEV1/FVC tion. However, the decrease in PEF variability after
ratio did not change. Flow rates at low lung volumes weight loss found in the present study refers to an
(FEF25–75) were slightly reduced and showed a attenuated variability of bronchial obstruction in
significant rise after weight loss (percent predicted; larger airways. Also the decline in Raw may reflect
p ⫽ 0.01) also when related to FVC (FEF25–75/FVC the decrease in airways obstruction more in large
percent; p ⬍ 0.05; Table 3). Dlco was within nor- than in small airways.
mal range in all patients before and after weight loss. In obesity, increased volumes after weight loss,
The mean baseline Dlco was 102.5% of predicted especially ERV or FRC, have been reported in
(range, 84 to 121% of predicted). several studies.12,16,17 RV usually remains un-
The mean values of FRC, VC, and TLC were changed.12 In chronic asthma, RV and FRC can be
within normal range before weight loss, but still a elevated because of hyperinflation.18 In obese asth-
significant increase in lung volumes was demon- matics, weight reduction and a decrease in asthma
strated with weight reduction. RV or RV/TLC did severity with lessened hyperinflation may change
not change. The most significant improvement in FRC values to opposite directions. The results of the
lung volumes was the increase in expiratory reserve present study demonstrated a significant increase in

1318 Clinical Investigations

 Table 3—Pulmonary Function Data

Before Weight Loss After Weight Loss

Percent Percent
Variables Mean (SD) Predicted (SD)* Mean (SD) Predicted (SD)*

FEV1, L 2.4 (0.8) 77 (14) 2.6 (0.8)§ 83 (13)‡

FVC, L 3.3 (1.0) 88 (13) 3.5 (1.1)† 93 (13)‡
FEF25–75, L/s 1.61 (0.76) 45 (18) 1.95 (0.87)‡ 54 (22)‡
FEV1/FVC, % 71.3 (9.3) 88 (11) 72.5 (8.2) 90 (10)
FEF25–75/FVC, % 48.8 (17.3) 55.6 (20.4)†
AFV, L2/s 8.7 (5.1) 9.9 (5.6)§
Raw, kPa 䡠 s 䡠 L⫺1 0.59 (0.28) 329 (166) 0.45 (0.19)‡ 252 (112)†
SGaw, kPa⫺1 䡠 s⫺1 0.98 (0.57) 52 (31) 1.12 (0.69) 61 (40)
Dlco, mmol/min/kPa 7.9 (1.7) 103 (11) 7.9 (1.7) 103 (13)
FRC㛳 2.4 (0.6) 86 (21) 2.8 (1.0)† 90 (19)
ERV㛳 0.43 (0.22) 0.72 (0.50)§
TLC-He 4.9 (1.3) 86 (11) 5.0 (1.2) 87 (11)
TLC-B 5.3 (1.2) 93 (12) 5.6 (1.4)‡ 96 (13)†
VC㛳 3.3 (1.0) 86 (11) 3.5 (1.1)§ 91 (13)§
RV㛳 2.0 (0.5) 116 (26) 2.1 (0.6) 113 (25)
*According to Viljanen et al.31
†p ⬍ 0.05.
‡p ⱕ 0.01.
§p ⱕ 0.005.
㛳Measured using body plethysmograph.

the mean FRC after weight reduction, although the sized that in this respect, low FRC could be unfa-
individual changes in FRC varied within a wide vorable in obese asthmatics. Thirdly, low FRC with
range. The increase in ERV was more constant. In further decrease in FRC in supine position and
this respect, changes in ERV may better than FRC concomitant increase in Raw may worsen nocturnal
reflect the effects of obesity or weight loss on lung airways obstruction and increase diurnal variation of
volumes in this study. obstruction in asthma.21
Mechanisms how higher lung volumes affect pul- Both obesity and asthma can cause an excessive
monary mechanics and work of breathing in asthma small airway closure and increase in gas trap-
are not clear. Based on previous data concerning ping.11,12,22 Of parameters that reflect small airways
pulmonary function in asthma or obesity, several obstruction, our data showed reduced FEF25–75 that
mechanisms could be postulated. Firstly, increase in increased after weight loss as well as FEF25–75/FVC.
FRC may contribute to a decrease in Raw that
Also, an increase in FVC and VC may reflect de-
further reduces work of breathing.19 Secondly, in
creased small airway obstruction. However, only
acute asthma with bronchoconstriction, a certain
slight, if any, gas trapping was observed based on our
degree of hyperinflation with increased FRC may
TLC-B ⫺ TLC-He data.
decrease work of breathing.20 It could be hypothe-
Rapid shallow breathing pattern with low Vt has
been reported in morbid obesity.11 However, our
data showed higher V̇e and Vt before than after
Table 4 —The Effects of Weight Loss on V̇E, VT, and weight loss. Tobin et al23 have suggested that symp-
RR Measured with Patients in Supine and Standing
Positions* tomatic patients with chronic asthma may display
increased V̇e in association with an elevated respira-
Before After tory center drive. They have reported increased Vt
Variables Weight Loss Weight Loss p Value in patients with asthma while breathing frequency
V̇e, L/min may be normal. Our findings are in keeping with this,
Supine 8.6 (1.5) 7.2 (1.5) p ⬍ 0.01 suggesting that tendency to increase Vt in asthma
Standing 11.1 (4.1) 9.6 (3.8) p ⫽ 0.01 patients may counteract the effects of obesity on
Vt, L
Supine 0.53 (0.1) 0.47 (0.1) p ⫽ 0.07
breathing pattern.
Standing 0.74 (0.3) 0.64 (0.2) p ⬍ 0.05 There are increasing data available on the relation
RR, breaths/min between obesity and bronchial hyperresponsiveness
Supine 16 (2) 15 (3) NS (BHR). It has been postulated that the lower Vt of
Standing 15 (3) 15 (3) NS obese patients results in less tidal stretching of
*Data are presented as mean (SD).
CHEST / 118 / 5 / NOVEMBER, 2000 1319
airways smooth muscle and could promote airway ventilatory mechanics. Our results also indicate de-
narrowing and possibly airway hyperreactivity.24 creased airways obstruction as well as lower PEF
Kaplan and Montana25 have studied exercise-in- variability after weight loss, suggesting that obesity
duced bronchospasm in obese nonasthmatic chil- may increase the degree and variability of airways
dren. They demonstrated that the frequency and obstruction in asthmatics. Yet, further studies with
degree of exercise-induced bronchospasm was larger patient groups will be necessary to clarify the
higher in obese children. Huang and colleagues26 relationship between obesity and asthma.
have studied the relation between BMI and BHR in
adolescents in Taiwan. They found that BMI was a
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1320 Clinical Investigations

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