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Journal of Pediatric Psychology logoLink to Journal of Pediatric Psychology
. 2021 Mar 22;46(8):970–979. doi: 10.1093/jpepsy/jsab023

Asthma and Physical Activity in Urban Children

Daphne Koinis-Mitchell 1,2,✉, Sheryl J Kopel 1,2, Shira Dunsiger 3, Elizabeth L McQuaid 1,2, Luis Gonzalez Miranda 1, Patricia Mitchell 4, Nico Vehse 2, Elissa Jelalian 2,5
PMCID: PMC8634412  PMID: 33749790

Abstract

Objectives 

Asthma and obesity disproportionately affect urban minority children. Avoidance of physical activity contributes to obesity, and urban children with asthma are at risk for lower levels of physical activity. We examined associations between lung function and moderate to vigorous physical activity (MVPA) and moderators of this association in a diverse sample of children with asthma.

Methods 

Urban children (N = 142) ages 7–9 with persistent asthma and their caregivers completed a study of asthma and physical activity. Longitudinal mixed effects models examining daily-level asthma and physical activity evaluated the association between asthma and MVPA, and the moderating effect of weight, and cultural/contextual factors on this association.

Results 

Average daily MVPA was below recommended guidelines. Differences in MVPA were found by racial/ethnic group (p = .04) and weight (p = .001). Poorer asthma status was associated with lower MVPA in Latino and Black participants (p’s < .05), and in normal weight youth (p = .01). Body mass index (BMI) moderated the association between asthma and MVPA. Those with lower BMI had more optimal asthma status and higher MVPA levels, whereas associations attenuated for participants with higher BMI (p = .04). Caregivers’ perceptions of neighborhood safety and fear of asthma were marginally associated with children’s symptoms and MVPA: as perceptions of safety decreased and fear increased, associations between asthma and MVPA weakened (p’s = .09 and .07, respectively).

Conclusions 

Suboptimal asthma status is associated with less MVPA in urban children. Weight status and cultural/contextual factors play a role in the association and are worthy targets for future research and intervention.

Keywords: asthma, health disparities and inequities, obesity and weight management, school-age children

Introduction

Asthma and obesity are comorbid conditions that are disproportionately present in urban minority children (Black & Macinko, 2010; Milligan et al., 2016). Children with asthma are at increased risk for overweight/obesity (OW/OB; Chen et al., 2017), particularly those in poorer asthma control (Holderness et al., 2017; Wiesenthal et al., 2016). Urban children who have asthma and OW/OB are more likely to experience asthma symptoms (Black et al., 2013), use quick-relief medications, and frequent the emergency department for asthma more often than healthy weight children with asthma (Wiesenthal et al., 2016). Although there are pathophysiological characteristics common to both asthma and obesity, such as higher levels of inflammation (Dixon & Poynter, 2016), compromised breathing (Littleton & Tulaimat, 2017), elevated leptin levels (Mai et al., 2009), and increased airway reactivity (Sideleva et al., 2013), the asthma-obesity phenotype is understood as a complex etiology associated with a blunted response to asthma treatments (e.g., corticosteroids; Dixon & Poynter, 2016).

National PA guidelines recommend that children and adolescents engage in at least 60 min of moderate-to-vigorous physical activity (MVPA) a day (U.S. Department of Health and Human Services, 2018). Clinical guidelines for managing asthma suggest that children with asthma should participate in physical activity (PA) as long as their asthma is in control (National Asthma Education and Prevention Program [NAEPP], 2007). Children with asthma are less likely to be physically active compared with children without asthma (Glazebrook et al., 2006; Lang et al., 2004), and lower levels of PA put children at higher risk for asthma symptoms (Lochte et al., 2016). The few studies including urban children with asthma show that this group has limited opportunities for PA (Holderness et al., 2017), and few meet the recommended amounts of daily PA (Firrincieli et al., 2005; Lang et al., 2004; Reznik et al., 2018), with those who are OW/OB at greatest risk for not meeting guidelines.

Studies of factors contributing to PA avoidance or lower levels of PA in children with asthma are limited, despite PA’s importance in decreasing risk for OW/OB. Urban children are more likely to be exposed to stressors of urban poverty (e.g., violence, limited safe places to play) that can compromise asthma management and morbidity (Koinis-Mitchell et al., 2007), and these risks can also affect PA levels. Attitudes and beliefs about asthma and PA, such as caregiver fears may also play a role in determining PA levels (Piercy et al., 2018; Westergren et al., 2017). Caregivers’ misperceptions of asthma and exercise may be a target for intervention to increase PA in urban children; however, this needs to be further investigated (Eisenberg et al., 2020).

This study evaluated objective measures of asthma lung function and PA in a diverse sample of children over a 2-week period. The first goal of the study was to assess whether children’s PA levels were consistent with recommended guidelines for PA (>60 min; Piercy et al., 2018) across the monitoring period, and if there were differences by racial/ethnic group background and weight status. We expected that the sample would not meet recommended guidelines for PA, and this would be more pronounced in children from minority backgrounds and those with OW/OB and who are in poor control. Next, we examined the daily-level association between asthma and PA in the entire sample, by racial/ethnic group, and by weight status. Based on prior work (Bhagat et al., 2019), we expected this association in the entire sample, and for it to be more pronounced in minority children and in those with OW/OB. We also examined relevant multi-level moderators associated with asthma and PA, such as weight status (individual-level), fear of asthma (cultural-level), and neighborhood unsafety (community-level) in the entire sample.

Materials and Methods

The data used for this study were collected within the context of a larger 5-year observational study that assessed asthma and PA in addition to cultural and contextual factors among a sample of urban elementary school-age children with persistent asthma across a 12-month period (Eisenberg et al., 2020). Participants were recruited from both hospital-based ambulatory pediatric clinics and the four largest urban school districts in Providence, RI. Eligible participants were between 7 and 9 years old, attended public school in one of the targeted school districts, had caregiver-reported physician-diagnosed asthma or breathing problems in the previous 12 months, and had a caregiver that self-identified as Latino (Dominican or Puerto Rican), Black or African-American (AA), or Non-Latino White (NLW). We included only Dominican and Puerto Rican families as they were the most prevalent Latino ethnic subgroups in the targeted urban areas, and because a majority of families from these subgroups had similar asthma morbidity rates and income levels, and would benefit from future asthma interventions. Children were identified as having persistent asthma according to clinical guidelines (National Heart Lung and Blood Institute, 2007) using information about the child’s symptoms and medications collected during a study visit and evaluated by the study clinician.

Participants were deemed ineligible if they had moderate to severe cognitive impairment, an additional respiratory illness or other chronic health condition, were on prescription stimulants, or had a diagnosed sleep disorder. Of those screened for study eligibility (1,345), 266 met study inclusion criteria. One hundred and forty-seven families enrolled, of which 142 (children) had persistent asthma. Non-enrolling eligible families were either lost to follow-up prior to the enrollment session (N = 85) or declined to participate due to insufficient time or interest (N = 39).

The enrollment visit occurred at the family’s home where informed consent was obtained from the primary caregiver, and assent from the child, prior to completion of interview-based questionnaires including demographic information and assessment of the child’s asthma control. The second study visit occurred at our hospital-based asthma and allergy clinic at least 2 weeks later, at which a study clinician evaluated and confirmed children’s asthma diagnosis and severity, confirmed asthma medication use, and measured height and weight. Immediately after this visit, participants completed a 4-week home monitoring period, during which the child used a handheld electronic spirometer each morning and evening to assess lung function. Children and caregivers were trained to perform three forced exhalations of up to 6 s before any asthma medication was taken using our standard procedures (Fritz et al., 2010).

During the first 2 weeks of this monitoring period, children’s PA level was also assessed. Child participants were trained to use an accelerometer activity monitor, which measures levels of PA. Participants were instructed to wear the device around their waist under their clothing for 14 days, during which time they also were asked to keep a daily diary of information relevant for processing and scoring objective asthma and PA data. Children and caregivers received standardized training on the use of each device and daily diary completion (Fritz et al., 2010; Koinis-Mitchell et al., 2015). At the end of each week of the monitoring period, study staff downloaded the lung function and PA data, reviewed the device and diary data, and answered any questions that the family had regarding the devices. Periodic phone calls were also made during each monitoring week to remind children to use the devices and answer any questions families had regarding device use. An additional research visit was completed 2 weeks after the monitoring period in which caregivers reported on level of fear about their child’s asthma and about their perceptions of their neighborhood unsafety.

All assessments were administered verbally in Spanish or English by bilingual research staff. Instruments were translated from English to Spanish using standardized procedures (Canino & Bravo, 1994). Participants received monetary compensation for each completed session. The study was approved by the local Institutional Review Board.

Measures

Demographic and Descriptive Information

Primary caregivers provided demographic information including child’s age, gender, race/ethnicity, and income. Poverty threshold was determined by dividing the family’s annual income by the Federal per capita poverty threshold for a family with that many members (U.S. Department of Health and Human Services, 2005).

Physician Query

Each participant’s primary healthcare provider and (if applicable) asthma/allergy specialist were asked to complete a brief questionnaire detailing the date of the child’s last office visit, asthma diagnosis, past medical history and current asthma treatment to confirm the child’s current asthma status (Koinis-Mitchell et al., 2015).

Asthma Diagnosis and Classification of Asthma Severity

During the second study visit, the study asthma clinician collected medical history and conducted a physical examination. Child height and weight, and pulmonary function testing were also completed. Study clinicians used standard National Heart, Lung, and Blood Institute Expert Panel Report 3 (NHLBI EPR-3) Guidelines to confirm asthma diagnosis and persistent severity classification (National Asthma Education and Prevention Program [NAEPP], 2007). Caregiver reports of children’s asthma medications use, asthma control (below) and adherence were recorded. Lung function measurements (forced expiratory volume in one second [FEV1]) were obtained with the Koko incentive spirometer (nSpireHealth, Longmont, CO) before and after administration of a short-acting beta agonist (American Thoracic Society, 1999).

Asthma Control

Families completed the Asthma Control Test (Liu et al., 2007) to assess asthma control and associated impairment. Dichotomous asthma control scores (above/below a score of 19) were used to classify children as well controlled or poorly controlled. Continuous asthma control scores, in which higher scores indicate better control, were maintained for selected analyses (Koinis-Mitchell et al., 2015; Okupa et al., 2013).

Asthma Symptoms

Children and caregivers were instructed to use a paper-based diary to record daily asthma symptoms across the 4-week fall monitoring period. Data were summarized as a proportion of days with symptoms across the monitoring period (Koinis-Mitchell et al., 2015).

Lung Function

FEV 1% predicted. Using a hand-held computerized spirometer (Jaeger AM2+; VIASYS Healthcare; Yorba Linda, CA), children were asked to complete three “blows” into the device each morning and evening before using any asthma medications. Caregivers and children were trained on proper device use, including how to perform a forced, sustained expiration into the device using our standard procedures (Fritz et al., 2010). Direct observation confirmed children’s readiness to use the device and regular check ins, and home visits at the end of each monitoring week allowed for opportunities to observe device use and address any questions the child or family had regarding device use. The blow yielding the highest FEV1% predicted value was retained for each morning and evening trial. Normative values used for FEV1 taking into consideration children’s race, sex and height and details regarding data cleaning and reduction procedures have been published previously (Fritz et al., 2010; Wang et al., 1993).

Physical Activity Level

Participants wore an accelerometer activity hip monitor (Actigraph xGT3X BT) for a 14-day monitoring period. The Actigraph xGT3X BP measures 3D movement and was calibrated to store data in 1-min segments. Accelerometer data were considered valid and included in the analyses for every day in which the device was worn for ≥8 hr. An hour was considered valid if there were no more than 20 consecutive minutes with 0 activity, which would suggest the device was off. Daytime monitoring occurred between the hours of 6 a.m. and 10 p.m. to capture typical waking hours for this age group. Activity levels and minutes of PA in various intensity categories were determined using Evenson cutoffs Each device was initialized using our lab’s standard procedures in accordance with the manufacturer’s instructions. Data were collected at a sampling rate of 30 Hz, downloaded in 1-s epochs with the low frequency extension filter using the Actilife software (Actigraph, LLC, Pensacola, FL) Participants wore the accelerometer for an average of 10.7 days across the 2-week monitoring period (SD = 5). Actigraph data were available for 97 children, with an average of 8 valid days of PA data (SD = 3.7, range = 1–16). All participants with at least one valid day of PA data (N = 97) were retained for analyses, consistent with an analysis approach used in our past work (Koinis-Mitchell et al., 2017, 2019).

Caregiver Perceptions: Fear of Asthma

Using a 1–5 Likert scale, caregivers were asked to rate how often they felt afraid due to their child’s asthma, with higher scores indicating more frequent fear. Scores were dichotomized (afraid because of child’s asthma frequently or all the time vs. never, rarely, or sometimes afraid). Additionally, caregivers were asked whether they felt afraid that their child would die during an asthma exacerbation. This questionnaire has been validated in our prior work (Eisenberg et al., 2020).

Neighborhood Unsafety

Caregivers completed a questionnaire assessing their perception of neighborhood safety. Seven items addressed different elements of neighborhood safety (e.g., trusting neighbors, feeling safe while out alone at night). A Neighborhood Unsafety scale score was calculated by computing the mean across all 7 items, with higher scores representing higher levels of perceived unsafety (Canino et al., 2009; Resnick et al., 1997).

Weight Status

Children’s body mass index (BMI) was computed from height and weight measurements, and BMI percentile was calculated using normative data. Normative age and sex reference data from the Centers for Disease Control and Prevention were used to calculate child weight status (Kuczmarski et al., 2000). Children with BMI ≥ 85th percentile were classified as overweight/obese; those <85% were classified as normal weight. Participants who were classified as underweight (BMI percentile <5%, N = 1) were excluded.

Analysis Plan

Descriptive statistics of demographic characteristics and asthma-related variables for the aggregate sample, as well as separately by ethnicity were reported. Further, we compared those included in the final sample (N = 97) to those excluded (N = 45) with respect to demographics, poverty, asthma severity and lung function using a series of t-tests and chi-squared tests where appropriate. Potential confounders were identified using correlation analysis. Any variable correlated with both the predictor and outcome at a conservative p < .10 level, were adjusted in subsequent models. Potential confounders included demographics and asthma severity.

The average amount of PA per day was summarized across participants, as well as the proportion of days in which participants met PA guidelines (defined as at least 60 min of MVPA on any valid wear days). PA was summarized separately by ethnicity and compared using chi-squared analysis. Similarly, the average min/day of MVPA was also analyzed separately by race/ethnicity. A quantile regression model was used to test the association between ethnicity mean MPVA, controlling for confounders. Activity counts were converted to units of energy expenditure or METs (multiples of resting energy expenditure) using Evenson cutoff values (Trost et al., 2011; Ward et al., 2005) and subsequently, METs were converted to intensity levels, where moderate PA includes ≥ 3 and < 6 METs and vigorous PA is defined as ≥ 6 METs. As a point of reference, the mid-point of moderate activity is commonly defined by brisk walking and vigorous activity includes activities such as running or jumping rope.

Next, we examined the daily-level associations between asthma status (lung function and asthma symptoms) and PA (min/day MVPA) using longitudinal mixed effects models. Models adjusted for clustering by day (repeated observations over time within participant), and confounders. Models were run in the aggregate sample and then by ethnic group and weight status.

Finally, we examined moderators of the association between daily-level asthma status and mean min/day of MVPA using a similar modeling approach. Models included the main effect of the moderator and the interaction between the moderator and asthma status. A variable was considered a moderator if the interaction term was significantly different than zero. Moderators included weight status, neighborhood unsafety and caregiver fear.

Analysis was conducted on the enrolled sample, regardless of missing data. Coefficients were estimated using a likelihood-based approach (by maximizing a likelihood function), which makes use of all available data without directly imputing missing outcomes. This allows for consistent estimates of the regression parameters even with missing data.

Results

The study sample included 142 children with persistent asthma with an average age of 8.30 years (SD = 0.90) almost half of which identified as female (44%). Twenty four percent of participants were overweight and 26.4% were obese. As there were no differences in PA or lung function between children with overweight and obesity (p’s > .05), the categories were collapsed into overweight/obese for the purpose of analyses. Fifty-eight percent of children were Latino, 26% AA, and 16% NLW. A full description of demographic characteristics and asthma-related indicators is presented in Table I. There were no significant differences between those included in the sample (N = 97) for the analyses addressing the main study questions and those excluded (for lack of MVPA data, N = 45) with respect to demographics, poverty, asthma severity or lung function (p’s > .05).

Table I.

Demographic and Asthma-Related Descriptives of Study Sample (N = 142) and Breakdown by Ethnicity

Full sample (N = 142) Latino (N = 83) African-American (N = 37) Non-Latino White (N = 22)
Age (mean) 8.30 (0.90) 8.20 (0.95) 8.31 (0.90) 8.63 (0.68)
Gender
 % Male 56.3 63.9 51.4 36.4
 % Female 43.7 36.1 48.6 63.6
Weight status
 % Normal weight 49.2 45.2 58.3 49.2
 % Overweight/obese 50.8 54.8 41.7 50.8
At or below poverty threshold 71.7 73.0 69.7 70.0
Asthma control score 21.05 (3.74) 21.70 (3.34) 19.94 (4.44) 20.79 (3.46)
Proportion of days with asthma symptoms 0.14 (0.17) 0.13 (0.15) 0.16 (0.19) 0.13 (0.18)
FEV 1% predicted 84.13 (12.64) 81.68 (12.09) 89.16 (13.69) 85.67 (9.82)
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Proportion of Days Children Met PA Guidelines

Next, we examined the daily-level associatiIn the overall sample, participants completed an average of 50.23 min/day of MVPA (SD = 24.77) over the monitoring period (median = 46.60, range = 0.80–159.95). Latino participants completed an average of 51.28 min/day of MVPA (median = 48.91, range = 0.80–159.95) compared with 48.92 min/day among AA children (median = 46.00, range = 3.50–155.35) and 48.53 min/day (median = 43.52, range = 15.87–110.23) among NLW children, p = .045.

Participants met PA guidelines on 30.2% of days on average. There were significant differences by racial/ethnic group in proportion of days children met PA guidelines. Latino participants met PA guidelines an average of 33.2% of monitored days versus 28.7% in Black/AA participants versus 21.2% in NLW participants (chi-squared = 6.44, p = 0.04). The unadjusted proportion of children meeting PA guidelines by race/ethnicity and weight status is presented in Table I. Data indicate a difference in the percentage meeting PA guidelines by weight status (chi-squared = 10.36, p = .001) such that children of normal weight had a greater percentage of days meeting guidelines compared with children with OW/OB. A similar pattern of findings was seen when comparing average MVPA/day by weight status. The highest average min/day of MVPA was observed among children who were normal weight (53.42 min/day), followed children with obesity(46.39 min/day) and children with overweight (43.31 min/day), F = 15.58, p < .001. There were no significant differences in MPVA between children with overweight and obesity (F = 0.24, p = .63), thus we have collapsed these categories.

Daily-Level Associations Between Asthma Indicators and PA

Among the entire sample, results did not suggest an association between daily lung function and mean daily MVPA or between asthma symptoms and MVPA. Among Latino participants, there was an association between daily lung function and daily MVPA (regression coefficient b = 0.17, p = .04) with lower lung function associated with lower levels of MVPA. Among Black/AA participants there was a negative association between daily reported symptoms and MVPA (b = −23.60, p = .01). There were no significant associations between asthma indicators and MVPA amongst NLW’s. A complete description of the associations is presented in Table II.

Table II.

Association between Asthma Indicators and Physical Activity Overall and by Ethnicity

Overall Sample Latino African-American Non-Latino White
Daily Lung Function

.07(.06)

−.05 – .19

.17(.08)∗

.01 – .33

−.15(.11)

.37 – .07

.15(.16)

−.17 – .47
Asthma Symptoms

−4.16(5.72)

−15.6 – 7.28

13.49(9.79)

−6.09 – 33.07

−23.60(8.42)∗

−40.44 – −6.76

7.71(11.76)

−15.81 – 31.23
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Unstandardized regression coefficients (standard errors) and confidence intervals are presented for models predicting daily MVPA (dependent variable) from daily lung function(independent variable) (model 1) and asthma symptoms (independent variable) (model 2). Each cell corresponds to a separate model.

∗p<.05 for significant effects of asthma related variables on MVPA.

When examining associations by weight status, there was a significant negative association between reported daily symptoms and MVPA in children of the normal weight group (b = −18.83, p = .01). There was no association between lung function and MVPA or between reported symptoms and MVPA among participants with OW/OB. A full description is presented in Table III.

Table III.

Association between Asthma Indicators and Physical Activity by Weight Status

Normal Weight Overweight/Obese
Daily Lung Function

.08(.08)

−.08 – .24

.01(.09)

−.17 – .19
Asthma Symptoms

−18.83(7.46)∗

−33.75 – 3.91

6.97(9.16)

−11.35 – 25.29
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Unstandardized regression coefficients (standard errors) and confidence intervals are presented for models predicting daily MVPA from daily lung function (model 1) and asthma symptoms (model 2). Each cell corresponds to a separate model.

∗p<.05 for significant effects of asthma related variables on MVPA.

Weight Status as a Moderator of the Association Between Asthma Status and PA

BMI was a significant moderator of the association between lung function and MVPA (Interaction = −0.003, p = .04). Among participants with lower BMI, better lung function was associated with higher MVPA. This effect then gets smaller as BMI increases across the sample. Similarly, we also found that BMI was a moderator of the association between reported symptoms and MVPA (Interaction = −0.65, p = .001). Among participants with lower BMI, higher symptoms were associated with less MVPA. This effect attenuates as BMI measurements increase across the sample. A full description of effects is presented in Table IV.

Table IV.

Models Examining Moderators of the Association between Asthma Indicators and Physical Activity

Model 1.
BMI as Moderator, N=97		 Model 2. Neighborhood Unsafety as Moderator, N=97 Model 3. Caregiver Fear
as Moderator, N=97
Daily Lung Function

−.003(.002)∗

−.007 – −.001

 .63

.14(.08)+

−.03 – .30
Asthma Symptoms

−.65(.20)∗

−1.26 – −.25

8.13(4.98)+

−1.83 – 18.09

 .72
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Unstandardized interaction coefficients (standard errors) and confidence intervals are presented for models in which moderating effects were significantly different from 0 (p<.05)∗ or trending towards significance (p<.10)+. P-values of the interaction term are presented for models in which there was no significant moderator. Columns represent potential moderators and rows represent predictor (of MVPA). Each cell corresponds to a separate model.

Contextual and Cultural Moderators of the Association Between Asthma Status and PA: Neighborhood Unsafety and Caregiver Fear

In the entire sample, neighborhood unsafety did not moderate the association between lung function and MVPA but was a borderline significant moderator of the association between symptoms and MVPA (Interaction = 8.13, p = .09). Specifically, among those participants with safe neighborhood ratings (i.e., lower unsafety scores), higher symptoms were associated with lower MVPA. However, the association between asthma symptoms and MVPA became smaller the more unsafe the neighborhood ratings were, Table IV.

Caregiver fear was not a moderator of either the association between lung function and MVPA or the association between asthma symptoms and MVPA in the entire sample. However, when looking at the sample of those who did not report frequent fear because of their child’s asthma (57% of the sample), lung function had a borderline association with MVPA (b = 0.14, p = 0.07) such that better lung function was associated with greater MVPA. There was no such association among those who reported being afraid frequently or all of the time. Last, there were no associations between symptoms and MVPA in either those who were frequently afraid or those who were not (Table IV).

Discussion

This study examines the extent to which daily asthma status corresponds with daily PA using objective measurements in a carefully evaluated urban sample of children with persistent asthma and their caregivers. The asthma and obesity comorbidity in urban minority children is high; therefore, more attention is needed to identify modifiable pathways of intervention in this high-risk group, such as how to increase PA. Urban stressors related to the environment (e.g., crime, limited green space and safe places to be active; Galaviz et al., 2016; Molnar et al., 2004) as well as challenges to optimal asthma management in this group (e.g., high exposure to environmental triggers, low medication adherence; Kattan et al., 1997; McQuaid et al., 2012) can also contribute to decreased PA. This study addresses prior gaps in the literature in that it utilizes objective measurements of PA and asthma over time in a representative sample of urban children with persistent asthma, focuses on the role of PA in the asthma-obesity comorbidity, and identifies contributing factors to variations in PA patterns to inform future tailored interventions. Averaged ratings of children in the sample did not meet the recommended PA guidelines of 60 min/day, and there was a wide range in average daily PA levels. Further, Latino participants had the highest min/day of MVPA compared with Black/AA participants and NLWs. Considering average PA level alone may obscure variability over time and fail to provide context in terms of which factors or conditions may contribute to PA avoidance. Moreover, the overall sample met PA guidelines on only 30% of the days monitored, with NLW and Black/AA children meeting guidelines on fewer days than Latinos.

Additional data on children’s asthma status during the assessment period provides context to these PA findings among our sample. Although there was not a link between daily lung function and MVPA in the entire sample, racial/ethnic differences emerged in this association. Latino children’s poorer lung function corresponded to lower levels of MVPA, as did Black/AA children’s tendency to display lower levels of MVPA on days with increased frequency of asthma symptoms. These associations are expected in that urban minority children may experience more morbidity, which may affect their engagement in or avoidance of PA. Interesting patterns were observed when weight status is considered; in normal weight children greater symptoms corresponded to decreased PA. However, this association was not observed in children with overweight and obesity. Children of healthy weight in the sample may be more prone to follow recommendations to avoid engaging in PA with the presence of symptoms.

When examining whether asthma and PA differed based on children’s BMI, as demonstrated with the findings described above involving normal weight children, those with lower BMI values in the sample tended to engage in more PA and have more optimal lung function and fewer asthma symptoms. However, this effect appeared to decrease as children’s BMI values increased across the sample. This may suggest that children with OW/OB have difficulty detecting lung function compromise or perceiving their symptoms accurately as shown in our prior work (Kopel et al., 2010). Another possibility is that barriers other than asthma morbidity (e.g. victimization, self-consciousness related to appearance) may contribute to avoidance of PA in children with OW/OB, as documented in general samples (Gray et al., 2008; Zabinski et al., 2003). Our data suggest that children’s BMI played an important role in their participation in PA in relation to their lung function status. It may be that children with normal weight typically engage in PA at a higher daily average compared with their peers with OW/OB; therefore, there may be more variability in PA when they experience asthma symptoms. Likewise, children with OW/OB may experience specific risk factors related to their asthma status (poor symptom perception) which can place them at higher risk for patterns of PA and lung function that may be more dangerous to their health (e.g., engaging in PA when symptomatic).

Caregivers’ perceptions of safety in their neighborhood also appeared to contribute to lower engagement in PA in the context of asthma symptoms; as perceptions of safety decreased, the association between asthma and PA became less robust. Future work should examine which aspects of children’s neighborhood context may serve as a barrier or resource for PA participation. Finally, in caregivers who did not report frequent fear of asthma, better lung function in children corresponded with more engagement in PA and the strength of this association decreased as caregivers’ fear of asthma increased. Thus, weight status, perceptions of neighborhood safety, and fear of asthma may guide children’s daily decisions to engage in or avoid PA, particularly when children are symptomatic or experience poorer lung function. Future work should examine these multi-level processes as important moderators in the association between asthma status and PA in larger samples of children from specific ethnic groups at highest risk for the asthma-obesity comorbidity.

Several limitations of the study warrant consideration. Study questions need to be re-examined in larger samples of racially/ethnically diverse participants with asthma. Although there were statistically significant ethnic and racial differences in average daily participation in PA among children from different ethnic groups in the sample, it is unclear whether these differences are clinically meaningful. Although guidelines suggest 60 min of PA daily, it is unclear if a minimal amount or range of PA would contribute to meaningful effects from a pulmonary lung function or conditioning standpoint for children with asthma, with individual differences considered (e.g., age, weight, level of asthma severity, treatment response). Future work should also examine level of sedentary and light activity captured objectively by accelerometry as these data can also identity children who may be at risk in terms of obesity and/or poor asthma status.

Although asthma and PA monitoring was conducted on a daily level across the monitoring period, obtaining additional perceptions from children and caregivers of what may contribute to or support PA engagement in real time could inform future interventions. This may be particularly informative among children with OW/OB, for whom variables related to asthma function (e.g., presence of symptoms) appeared to have less impact on PA participation. Qualitative approaches (use of in-depth interview) are also critical for assessing barriers and facilitators of PA in children and their caregivers, to inform future interventions and tailor/validate the development of real-time assessments. Further, an item-level analysis of more global assessments of neighborhood unsafety such as the measure used in this study may shed light on important barriers that challenge activity participation across many urban children. Additionally, associations between participation in PA and asthma status were obtained over 2 weeks. Assessing these variables, including weight status, longitudinally would help to elucidate prospective relationships between these variables over time.

Moreover, additional research is needed to examine the day to day variability in PA over time to identify subgroups of children who require more careful monitoring and tailored intervention. Similarly, those with concerning patterns of PA and lung function (e.g., high levels of PA and compromised lung function) may characterize subgroups of children who are also poor symptom perceivers, and require specific intervention (e.g., asthma management training with a focus on how and when to identify symptoms with appropriate response). The addition of objective assessments of neighborhood safety via GIS, as well as other variables impacting opportunities for PA in an urban setting (e.g., access to green space) would be a significant contribution to the literature. Finally, among the sample of 142 children with persistent asthma, 97 provided at least 1 day of objectively measured MVPA (32% of participants were removed for lack of MVPA data). Although there were no differences between those included and excluded in terms of demographics, poverty, asthma severity, or lung function, the missing data may limit generalizability of the results.

Despite these limitations, this study addresses several gaps in the limited literature on PA in urban children at high risk for OW/OB, children with asthma. Participants included a diverse sample of children from an urban setting, and the study is one of the first to combine daily objective measurement of PA via accelerometry with state-of-the-art assessment of asthma. Furthermore, examination of data by ethnicity and weight status offers novel insights into potentially unique contributors to PA engagement in this urban, high-risk group and lays preliminary groundwork for intervention development. Asthma management educational interventions with urban minority children and their families should include emphasis on the importance of PA and how to engage in PA while also controlling asthma appropriately (e.g., pretreating if necessary, using a rescue inhaler when needed). Addressing caregivers’ and children’s concerns regarding PA, and offering safe opportunities for exercise in the context of their urban settings is key to enhancing PA in this group. Thus, our study findings suggest that interventions to enhance PA in this group need to address both asthma management and PA, as well as barriers and challenges to PA based on families’ neighborhood context, weight status, and ethnic background.

Funding

This work was supported by the National Heart, Lung and Blood Institute (grant number R01 HL116254-01A1).

Conflicts of interest: None declared.

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