Introduction

This is the third article in a series covering health promotion for non-communicable diseases, looking at:

This article focuses on chronic respiratory diseases, such as asthma, chronic obstructive pulmonary disease and occupational lung conditions. Risk factors for chronic respiratory diseases include: 

• air pollution
• allergens
• tobacco smoking
• exposure to second-hand smoke (World Health Organization, 2024a)

There are also more complex issues associated with respiratory diseases that are linked to lifestyle behaviours and poverty. Health outcomes for people with chronic respiratory disease have seen little improvement in the last 10 years, particularly when compared to cardiovascular disease and cancer (Public Health England, 2022).

Asthma is a chronic respiratory disease caused by airway inflammation and hyper-responsiveness. Asthma affects more than 300 million people across the world, 8 million (12%) of which are in the UK (National Institute of Health and Care Excellence, 2024). Asthma risk is multifactorial and more likely to occur in people or families with atopy. However, there are also preventable risks linked to: 

• environmental pollution
• tobacco exposure (both intrauterine and from birth)
• poor housing
• overweight or obesity (World Health Organization, 2024b)

Chronic obstructive pulmonary disease is caused by restricted airflow and is the third leading contributor to global mortality, causing 3.23 million deaths in 2019 (World Health Organization, 2024c). Smoking is linked to 70% of chronic obstructive pulmonary disease cases in high-income countries and around 30–40% of cases in low- to middle-income countries, with air pollution being a further significant risk factor (World Health Organization, 2024c). Air pollution is the most serious environmental health risk factor globally (Whyand et al, 2018). 

Occupational lung diseases are caused and exacerbated by exposure to harmful materials in the workplace. The most common condition is occupational asthma, but other conditions, such as hypersensitivity pneumonitis, pneumoconiosis, chronic obstructive pulmonary disease, pulmonary fibrosis and malignancies such as mesothelioma and lung cancer, can also occur (Vlahovich and Sood, 2021). The causes include: 

• dust from coal and silica
• vapours
• fumes
• gases
• vitreous fibres
• metals
• chemicals
• second-hand smoke
• infectious materials (Vlahovich and Sood, 2021)

For further reading on person-centred health promotion and lifestyle approaches, see Webster and Morris (2024), where the authors explore why people participate (or do not) in certain lifestyle behaviours and choices.

Modifiable risk factors

The risk factors of asthma and chronic obstructive pulmonary disease are less modifiable compared with the other conditions explored in this series. The American Lung Association (2024a; 2024b) only list smoking or second-hand smoke, occupational exposure and air pollution as modifiable risk factors for chronic obstructive pulmonary disease and asthma. However, Reddel et al (2022) recommended that comorbidities such as rhinosinusitis, obesity and gastro-oesophageal reflux disease are identified and managed, as these can lead to poor symptom control or exacerbations, and ultimately an impaired quality of life. Nurses should also encourage patients to take up the offer of routine vaccinations, such as influenza (National Institute for Health and Care Excellence, 2024). Additionally, triggers such as specific allergens, pollution, non-steroidal anti-inflammatory drugs and beta-blockers should be avoided (National Institute for Health and Care Excellence, 2024). Specialist referral is required for suspected occupational lung diseases. 

Health nutrition

Asthma and chronic obstructive pulmonary disease do not have cures, but are treatable and manageable, therefore prevention of progression and onset are crucial. Nutrition can play a key role in this, as a poor diet can lead to obesity, which can cause symptoms of respiratory conditions to worsen. van Iersel et al (2022) linked the western diet to a decline in lung function and higher chronic obstructive pulmonary disease risk. The systematic review found that a Mediterranean diet (which focuses on plant-based foods and healthy fats, such as seafood, nuts and legumes) was linked to a decrease in the risk of chronic obstructive pulmonary disease development, given the higher consumption of nutrients such as vitamins E and C, fibre and polyphenols (van Iersel et al, 2022).

The American Lung Association (2018) highlighted the positive effects of vitamin E and vitamin D on asthma symptoms, as these are linked to a reduction in respiratory inflammation. They also emphasised the importance of nutrition, as different nutrients can require different amounts of oxygen and generate different amounts of carbon dioxide. For example, carbohydrates use more oxygen and generate more carbon dioxide, while fats produce the same amount of oxygen while generating less carbon dioxide (American Lung Association, 2018). Certain foods can exacerbate symptoms, such as salicylates found in tea and coffee, sulphites found in bananas, and foods that cause gas, such as fried foods (American Lung Association, 2018).

Alwarith et al (2020) demonstrated how the pathophysiology of asthma and the correlation between inflammation and food can either have positive or negative effects on asthma depending on the person’s dietary habits. This is mirrored in the review by van Iersel et al (2022) regarding chronic obstructive pulmonary disease, with both articles highlighting the importance of avoiding the western diet and adopting a Mediterranean or plant-based diet, as supported by the wider literature (Ambrosino and Bertella, 2018: Stoodley et al, 2018; Born et al, 2024).

Physical activity

Physical activity is the most influential lifestyle behaviour on organ function and reducing mortality (Thompson et al, 2020). However, exercise may be more challenging in patients who experience breathlessness. Reduced physical activity in patients with chronic obstructive pulmonary disease, for example, can increase the risk of poorer outcomes and premature mortality (Elonheimo et al, 2022). However, there are various ways to improve outcomes for patients with respiratory conditions. Resistance training can increase exercise tolerance, muscle strength and arm function, while aerobic exercise can increase patients’ oxygen consumption, neurological control of heart rate and quality of life (Xiang et al, 2022). Nurses should also be aware of local referral pathways for physiotherapy and pulmonary rehabilitation. 

Regular exercise has been shown to improve innate immune response, reducing the risk of infection and, in turn, reducing potential hospital admission and exposure to antibiotic treatment (Xiang et al, 2022). Thompson et al (2022) advocated for the inclusion of questions to assess levels of physical activity during routine patient assessment in the same way that vital signs might be measured. This would allow nurses to make suggestions on how to reduce sedentary time by encouraging mild to moderation intervals of activity, such as taking the stairs, walking and intermittently standing during tasks undertaken while seated. These are small but effective means of increasing physical activity that most patients would be able to implement. 

Harmful substances

The harmful effects of smoking and the link to lung disease has been widely studied, but the effects of other materials, such as cannabis and e-cigarettes, as less understood (Elicker et al, 2019). Nurses must identify where there is potential for reduction in harm through smoking cessation and signpost appropriately. Nurses are well placed to deliver interventions, as they can offer effective strategies and constructive advice, particularly to people with chronic diseases who may have little intention to stop the use of harmful substances, such as smoking (Ho et al, 2021).

It is difficult to establish an epidemiological link between environmental chemical exposure and occupational chronic lung disease, because most studies analyse the health impacts of only one chemical at a time, so little is known about how exposure to a combination of chemicals impacts on health (Elonheimo et al, 2022). Differentiating between non-occupational and occupational disease is challenging and leads to frequent misdiagnosis (Vlahovich and Sood, 2021). Therefore, occupational history must be considered when assessing patients’ social history. Identifying potential high-risk occupations is critical for the implementation of preventative strategies to address the mortality and morbidity associated with lung disease (De Matteis et al, 2019). Prevention of occupational lung disease requires a collaborative approach from employers, employees and government, and is underpinned by a legislative framework. While nurses may feel they have little influence in relation to prevention of occupational lung disease, they can offer advice about risk reduction and signpost workers to compensation programmes where appropriate (Jumat et al, 2021). 

Conclusions

The third article in this series highlighting lifestyle interventions linked to asthma, chronic obstructive pulmonary disease and occupational lung disease. Although these conditions are arguably less modifiable through lifestyle modification, there remains a link between behaviours and disease outcomes. Nurses are in an ideal position to address certain lifestyle behaviours in a supportive way to not only manage the conditions, but also reduce symptoms, side effects and even onset.