ASTHMA and NUTRITION

1. ASTHMA and NUTRITION DR. İLKNUR BAŞYİĞİT KOCAELI UNIVERSITY FACULTY OF MEDICINE DEPARTMENT OF PULMONARY DISEASE

2. DIET

3. Plan • Breastfeeding, hipoallergenic formula, probiotics • Antioxidants • Vitamin C, E and A • Selenium • Lipids • n-3/n-6 polyunsaturated fatty acids (PUFA) • Electrolytes • Sodium • Magnesium

4. Observational studies Cross-sectional Cohort Intervention studies Case-control Randomized-controlled Evaluation of diet Food frequency questionnaires 24-h dietary recall Measurement of biomarkers Methodological issues in the nutrition studies

5. Breastfeeding Friedman NJ, Zieger ZS. J Allergy Clin Immunol 2005

6. Gdalevich M etal. J Pediatr 2001

7. Cohort, Finland 6 years of follow-up between the years of 1991-1997 1933 children Fredriksson P etal. BMC Pediatrics 2007

8. Conclusion • Exclusive breast feeding at least 4 months seems to protect against atopic dermatitis and early childhood wheezing • Maternal history of atopy and duration of breastfeeding may affect the results • Breast feeding should be recommended for infants irrespective of maternal history of asthma Friedman NJ, Zieger ZS. J Allergy Clin Immunol 2005

9. Hipoallergenic formula • There is no evidence to support feeding with a hydrolysed formula for the prevention of allergy compared to exclusive breast feeding • In high risk infants who are unable to be completely breast fed, there is limited evidence that prolonged feeding with a hydrolysed formula compared to a cow's milk formula reduces infant and childhood allergy Osborn DA, Sin J. Cochrane Database Syst Rev. 2006

10. Probiotics • There is insufficient evidence to determine the role of prebiotic supplementation of infant formula for prevention of allergic disease and food hypersensitivity Osborn DA, Sin JK. Cochrane Database Syst Rev. 2007

11. Antioxidants • Increased fetal oxidative stress may be associated with reduced lung function and asthma (smoking during pregnancy…) • It seems that antioxidants supplementation during pregnancy and early childhood period might be protective from asthma Devereux G, Seaton A. J Allergy Clin Immunol 2005

12. The levels of antioxidant vitamins were found to be lower in asthmatics • Observational studies suggested that maternal consumption of vitamin E, C, A, D, zinc and selenium was negatively associated with the development of eczema, wheezing and asthma • It is also suggested that besides their antioxidant properties, these nutrients also have effects on fetal airway development, and/or the first interaction between allergen and the immune system Kalayci O et al. Turkish J Pediatr 2000 Devereux G. Pediatr Pulmonol 2007 Devereux G et al. Am J Clin Nutr 2007 Martindale et al. Am J Respir Crit Care Med 2005 Litonjua A et al. Am J Clin Nutr 2006

13. 4 093 children aged 6-17 yrs (278 asthma) Evaluation included questionnaires, physical exam, pulmonary function and measurement of serum vitamin levels Harik-Khan RI et al. NHANES III data Am J Epidemiol 2004

14. Rubin RN et al. Am J Respir Crit Care Med 2004

15. NHANES III • 6 153 children aged 4-16 yrs (415 asthma) • Increase in the levels of vitamin C, selenium and beta-carotene was associated with a 10-20% reduction in asthma prevalence. • Minimal association with vitamin E • The selenium-asthma association was stronger especially in smoke-exposed youth Rubin RN et al. Am J Respir Crit Care Med 2004

16. ISAAC study • 156 centers in 53 countries • Nutrient database was estimated per capita as a percentage of total energy consumption (%TEC) • Questionnaires on asthma, allergic rhinitis and eczema symptoms were used • 721. 601 children of 6-7 and 13-14 years age group Ellwood P et al. Eur Respir J 2001

17. There was a negative association between vitamin A and E consumption with wheezing however no association was observed with vitamin C • An increase of vegetable consumption by 100g was associated with a decrease of current wheeze by 2% • Consumption of fish and fish oil was negatively associated with current wheeze • Olive oil showed a negative association with current wheeze Ellwood P et al. Eur Respir J 2001

18. Chatzi L et al. Thorax 2008

19. 64 asthmatics (30 in experiment, 34 in control groups) 500 mg/day vitamin E supplemented for 6 weeks Pearson PJK et al. Thorax 2004

20. Evidence is insufficient to recommend antioxidants in the treatment of asthma. Further methodologically strong, long-term studies are needed. Allam MF, Lucane RA. Cochrane Database Syst Rev. 2004 Ram FS, Rowe BH, Kaur B. Cochrane Database Syst Rev. 2004

21. Lipids • Observational studies suggested that increased consumption of n-6 PUFA and decreased consumption of n-3 PUFA in pregnancy was associated with the development of asthma in child • Dietary intakes of margarine and vegetable oil (n-6 PUFA) increased, intake of oily fish (n-3 PUFA) decreased in recent years Devereux G. Pediatr Pulmonol 2007

23. Children Health Study (CHS); 279 children with asthma diagnosis by age 5 years + 412 controls Fish consumption during pregnancy was evaluated retrospectively Salam MT et al. J Asthma 2005

24. Cohort of 462 pregnant women whose offspring were followed up to 6 years Romieu I et al. Clin Exp Allergy 2007

25. Chatzi L et al. Thorax 2008

26. Childhood Asthma Prevention Study (CAPS) • 616 high-risk children, RCT • 500 mg/day fish oil vs. placebo • Plasma fatty acid levels were measured, symptom assessment and skin prick test were performed at 18 months, 3 and 5 years of ages • Fish oil supplementation was associated with a 9.8% reduction in the prevalence of any wheeze • Beneficial effect was minimal at 3 and 5 years Mihrshahi S et al. J Allergy Clin Immunol 2003 Almqvist C et al. J Allergy Clin Immunol 2007

27. Why there is conflicting results between observational and interventional studies? • Antioxidants may be effective when there is an antioxidant deficiency • Supplementation studies have too short duration • The results in observational studies may be affected from other environmental factors (socioeconomic status, lifestyle etc) besides diet • Dietary changes may be effective in pregnancy and infancy rather than adulthood

28. 83 atopic pregnant women, 40 of them received 4 g/day fish oil capsules after the 20. gestational week. Cord blood cytokine levels were measured Dunstan JA et al. J Allergy Clin Immunol 2003

29. Sodium • There are some studies suggested that dietary salt intake was associated with airway hyper reactivity and wheezing • Mostly cross-sectional in design • Low-salt diet was found to be beneficial in exercise-induced asthma • There is no sufficient evidence of high salt intake on the increase in asthma prevalence Romieu I, Trenga C. Epidemiol Rev 2001

30. Gotshall RW et al. Med Sci Sports Exerc 2000

31. Magnesium • IV magnesium is beneficial in severe asthma attack • Long-term oral magnesium supplementation does not lead to improved control in adult asthma • No relation was shown between magnesium deficiency and asthma incidence Beasley R, Aldington S. Curr Opin Allergy Clin Immunol 2007

32. Conclusion • Decreased consumption of antioxidants and n-3 fatty acids may be associated with the increase of asthma prevalence • Low-salt diet may be beneficial in exercise-induced asthma • In order to determine the role of dietary interventions in prevention and treatment of asthma, better designed studies are needed in pregnancy and infancy

34. Thanks