Mediterranean diet and asthma in Spanish schoolchildren

Lifestyles and the risk of an asthma attack in adult asthma patients: a cross-sectional study using NHANES database

BACKGROUND

The influence of physical activity, diet and sleep on asthma has been well documented by recent studies respectively. However, few studies focus on the relationship between asthma attack and the overall lifestyle, which comprises interrelated lifestyle factors. This study aims to investigate the influence of lifestyles on the ratio of asthma attack. Data were extracted from the NHANES database (2017 to May 2020).

METHODS

A total of 834 asthmatic patients were enrolled and divided into non-asthma attack (N.=460) and asthma attack (N.=374) groups. The risk factors for asthma attacks were preliminarily identified by univariate logistic analysis, then multivariate logistic analysis was employed to select independent risk factors other than lifestyles and further determine the association between lifestyles and asthma attacks.

RESULTS

After multivariate logistic analysis, engagement of vigorous activity (Model 1 P=0.010, Model 2 P=0.016, Model 3 P=0.012), engagement of moderate activity (Model 1 P=0.006, Model 2 P=0.008, Model 3 P=0.003) and sleep disorder (Model1 P=0.001, Model 2 P<0.001, Model 3 P=0.008) were determined as independent risk factors of lifestyles for an asthma attack in the past year.

CONCLUSIONS

This research documented that, for asthmatic patients, engagement of vigorous activity, engagement of moderate activity, and sleep disorder will make an asthma attack more likely to happen.

The Effects of a Healthy Diet on Asthma and Wheezing in Children and Adolescents: A Systematic Review and Meta-Analysis

Background

Asthma is a public health problem requiring focused attention. This study aimed to systematically evaluate the association between dietary structure and asthma or wheezing in children.

Methods

The study protocol of this meta-analysis has been registered in the International Prospective Register of Systematic Reviews (PROSPERO) with the registration code CRD42023390191. A total of 8397 articles were retrieved, searching PubMed, Medline, Embase, Web of Science, and Scopus databases as of November 21, 2022. Two independent authors were responsible for independently conducting the literature screening process. Effect-size estimates were expressed as odds ratio (OR) in cross-sectional studies and risk ratio (RR) in cohort studies with a 95% confidence interval (CI). Summary effect estimates were evaluated with random-effect models. Meanwhile, subgroup and sensitivity analyses were performed to assess the potential sources of heterogeneity and the robustness of the pooled estimation.

Results

A total of 65 studies, including 567,426 subjects had been analyzed. Overall analyses of cross-sectional studies revealed that a healthy diet was protective against asthma (adjusted OR=0.85, 95% CI: 0.80-0.89, P <0.001, I2=69.8%, Tau2=0.026) and wheezing (adjusted OR=0.85, 95% CI: 0.81-0.89, P <0.001, I2=66.8%, Tau2=0.015) in children and adolescents. Conversely, unhealthy diets can exacerbate asthma (adjusted OR=1.28, 95% CI: 1.20-1.36, P <0.001, I2=64.9%, Tau2=0.019) and wheeze (adjusted OR=1.09, 95% CI: 1.02-1.16, P =0.006, I2=75.2%, Tau2=0.023) in children and adolescents. The same trend was found in cohort studies (adjusted RR=0.72, 95% CI: 0.58-0.90, P =0.003, I2=83.5%, Tau2=0.105). A clear trend was observed between high-frequency healthy diets (OR=0.80; 95% CI: 0.71-0.89; P <0.001) is more protective against asthma than low-frequency healthy diets (OR=0.81; 95% CI: 0.70-0.94; P =0.007).

Conclusion

Our findings highlight the protective effects of a healthy diet on asthma and wheezing in children, including fruit, seafood, cereals, and the Mediterranean diet.

Dietary patterns, lung function and asthma in childhood: a longitudinal study

BACKGROUND

Longitudinal epidemiological data are scarce examining the relationship between dietary patterns and respiratory outcomes in childhood. We investigated whether three distinct dietary patterns in mid-childhood were associated with lung function and incident asthma in adolescence.

METHODS

In the Avon Longitudinal Study of Parents and Children, 'processed', 'traditional', and 'health-conscious' dietary patterns were identified using principal components analysis from food frequency questionnaires at 7 years of age. Post-bronchodilator forced expiratory volume in 1 s (FEV1), forced vital capacity (FVC), and forced expiratory flow at 25-75% of FVC (FEF25-75) were measured at 15.5 years and were transformed to z-scores based on the Global Lung Function Initiative curves. Incident asthma was defined by new cases of doctor-diagnosed asthma at age 11 or 14 years.

RESULTS

In multivariable-adjusted models, the 'health-conscious' pattern was positively associated with FEV1 (regression coefficient comparing top versus bottom quartile of pattern score 0.16, 95% CI 0.01 to 0.31, P for trend 0.04) and FVC (0.18, 95% CI 0.04 to 0.33, P for trend 0.02), while the 'processed' pattern was negatively associated with FVC (- 0.17, 95% CI - 0.33 to - 0.01, P for trend 0.03). Associations between the 'health-conscious' and 'processed' patterns and lung function were modified by SCGB1A1 and GPX4 gene polymorphisms. We found no evidence of an association between the 'traditional' pattern and lung function, nor between any pattern and FEF25-75 or incident asthma.

CONCLUSIONS

A 'health-conscious' diet in mid-childhood was associated with higher subsequent lung function, while a diet high in processed food was associated with lower lung function.

Mediterranean Diet in Developmental Age: A Narrative Review of Current Evidences and Research Gaps

Numerous studies in recent decades have shown that Mediterranean diet (MD) can reduce the risk of developing obesity in pediatric patients. The current narrative review summarizes recent evidence regarding the impact of MD across the different stages of child development, starting from fetal development, analyzing breastfeeding and weaning, through childhood up to adolescence, highlighting the gaps in knowledge for each age group. A literature search covering evidence published between 1 January 2000 and 1 March 2022 and concerning children only was conducted using multiple keywords and standardized terminology in PubMed database. A lack of scientific evidence about MD adherence concerns the age group undergoing weaning, thus between 6 months and one year of life. In the other age groups, adherence to MD and its beneficial effects in terms of obesity prevention has been extensively investigated, however, there are still few studies that correlate this dietary style with the incidence of non-communicable diseases. Furthermore, research on multi-intervention strategy should be implemented, especially regarding the role of education of children and families in taking up this healthy dietary style.

Does Adherence to the Mediterranean Diet Have a Protective Effect against Asthma and Allergies in Children? A Systematic Review

Dietary pattern may potentially impact on the pathogenesis of asthma and allergies. The Mediterranean Diet (MD) has significant health benefits due to its antioxidant and anti-inflammatory properties. The aim of this systematic review was to investigate the effectiveness of adherence to the MD against asthma and allergies in childhood. Hence, a systematic literature search was conducted on PubMed, ESBCO (Cinahl), Scopus, and the Cochrane Library databases up to 26 January 2022. The total number of articles obtained, after the initial search on the databases was conducted, was 301. Twelve studies were included, after the removal of duplicates and screening for eligibility. Our findings indicated a protective role of the MD against childhood asthma, but they also imply that the MD probably does not affect the development of allergies. Nevertheless, the heterogeneity and limitations of the studies highlight the need for randomized controlled trials that will focus on the pediatric population and hopefully provide more robust evidence.

Time-Specific Factors Influencing the Development of Asthma in Children

Susceptibility to asthma is complex and heterogeneous, as it involves both genetic and environmental insults (pre- and post-birth) acting in a critical window of development in early life. According to the Developmental Origins of Health and Disease, several factors, both harmful and protective, such as nutrition, diseases, drugs, microbiome, and stressors, interact with genotypic variation to change the capacity of the organism to successfully adapt and grow in later life. In this review, we aim to provide the latest evidence about predictive risk and protective factors for developing asthma in different stages of life, from the fetal period to adolescence, in order to develop strategic preventive and therapeutic interventions to predict and improve health later in life. Our study shows that for some risk factors, such as exposure to cigarette smoke, environmental pollutants, and family history of asthma, the evidence in favor of a strong association of those factors with the development of asthma is solid and widely shared. Similarly, the clear benefits of some protective factors were shown, providing new insights into primary prevention. On the contrary, further longitudinal studies are required, as some points in the literature remain controversial and a source of debate.

Nutrition in Asthma

An emerging body of evidence suggests that diet plays an important role in both the development and management of asthma. The relationship between dietary intake and asthma risk has been explored in epidemiological studies, though intervention trials examining the effects of nutrient intake and dietary patterns on asthma management are scarce. Evidence for diets high in fruits and vegetables, antioxidants, omega-3 fatty acids and soluble fiber such as the Mediterranean diet is conflicting. However, some studies suggest that these diets may reduce the risk of asthma, particularly in young children, and could have positive effects on disease management. In contrast, a Westernized dietary pattern, high in saturated fatty acids, refined grains, and sugars may promote an inflammatory environment resulting in the onset of disease and worsening of asthma outcomes. This review will summarize the state of the evidence for the impact of whole dietary patterns, as well as individual nutrients on the prevalence and management of asthma.

[Diet and asthma: Better eating for better breathing?]

Inhaled therapies are the cornerstone of asthma treatment. However, according to national and international guidelines, non-pharmacological interventions should not be neglected in asthma. It has been demonstrated that a healthy diet is beneficial to general health. Recently, the effect of diet on asthma has been highlighted in many studies. Two diets have been particularly studied: the Mediterranean diet (high in fruits and vegetables and low in fat) and the Western diet (high in saturated fat and low in fruits and vegetables). A beneficial effect of the Mediterranean diet and deleterious effect of the Western diet on the development or control of asthma has been shown in some studies even after adjustment for overweight. Study findings have not been unanimous, probably related to the complexity of conducting studies on a diet that may change from day to day for any individual subject. In addition, the effect of physical exercise, which is known to be beneficial in asthma, is rarely taken into account in these studies. However, studies on diet are becoming more complex with the use of specific dietary indices, which should bring interesting data in the future.

Questioning Cause and Effect: Children with Severe Asthma Exhibit High Levels of Inflammatory Biomarkers Including Beta-Hexosaminidase, but Low Levels of Vitamin A and Immunoglobulins

Asthma affects over 8% of the pediatric population in the United States, and Memphis, Tennessee has been labeled an asthma capital. Plasma samples were analyzed for biomarker profiles from 95 children with severe asthma and 47 age-matched, hospitalized nonasthmatic controls at Le Bonheur Children's Hospital in Memphis, where over 4000 asthmatics are cared for annually. Asthmatics exhibited significantly higher levels of periostin, surfactant protein D, receptor for advanced glycation end products and β-hexosaminidase compared to controls. Children with severe asthma had lower levels of IgG1, IgG2 and IgA, and higher levels of IgE compared to controls, and approximately half of asthmatics exhibited IgG1 levels that were below age-specific norms. Vitamin A levels, measured by the surrogate retinol-binding protein, were insufficient or deficient in most asthmatic children, and correlated positively with IgG1. Which came first, asthma status or low levels of vitamin A and immunoglobulins? It is likely that inflammatory disease and immunosuppressive drugs contributed to a reduction in vitamin A and immunoglobulin levels. However, a nonmutually exclusive hypothesis is that low dietary vitamin A caused reductions in immune function and rendered children vulnerable to respiratory disease and consequent asthma pathogenesis. Continued attention to nutrition in combination with the biomarker profile is recommended to prevent and treat asthma in vulnerable children.

EAACI position paper on diet diversity in pregnancy, infancy and childhood: Novel concepts and implications for studies in allergy and asthma

To fully understand the role of diet diversity on allergy outcomes and to set standards for conducting research in this field, the European Academy of Allergy and Clinical Immunology Task Force on Diet and Immunomodulation has systematically explored the association between diet diversity and allergy outcomes. In addition, a detailed narrative review of information on diet quality and diet patterns as they pertain to allergic outcomes is presented. Overall, we recommend that infants of any risk category for allergic disease should have a diverse diet, given no evidence of harm and some potential association of benefit in the prevention of particular allergic outcomes. In order to harmonize methods for future data collection and reporting, the task force members propose relevant definitions and important factors for consideration, when measuring diet diversity in the context of allergy. Consensus was achieved on practice points through the Delphi method. It is hoped that the definitions and considerations described herein will also enable better comparison of future studies and improve mechanistic studies and pathway analysis to understand how diet diversity modulates allergic outcomes.

Obesity Does Not Increase the Risk of Asthma Readmissions

The relationship between obesity and asthma exacerbations is still under debate. The aim of our work is to analyse the relationship between obesity and hospital re-admissions in asthmatics. A review was retrospectively performed on all hospital admissions of adult patients due to asthma exacerbation occurring in our hospital for 11 years. All those cases with asthma as the first diagnosis in the discharge report were included, or those with asthma as the second diagnosis provided when the first diagnosis was respiratory infection or respiratory failure. Only the first hospital admission of each patient was included in this study. The Odds Ratios of a higher incidence of early/late readmissions due to asthma exacerbation were calculated using a binary logistic regression, using the body mass index (BMI) as independent variable, adjusted for all the variables included in the study. The study included 809 patients with a mean age of 55.6 years, and 65.2% were female. The majority (71.4%) were obese or overweight. No significant relationship was observed in the univariate or multivariate analyses between overweight or obesity and the early or late hospital readmissions due to asthma. Therefore, obesity does not seem to be a determining factor in the risk of asthma exacerbations.

The Role of Diet Diversity and Diet Indices on Allergy Outcomes

Nutrients in foods are not eaten in isolation and food intake interacts in a complex manner, affecting health and disease outcomes. For this reason, focusing on the whole "pattern" of dietary intake instead of the single nutrients or groups of nutrients when studying diseases outcomes is increasingly appealing and growing. Diet diversity refers to the variety of foods being eaten, and the terms, diversity or variety, are often used interchangeably. When the overall diet is characterized by healthy foods, diet diversity will reflect a diversity/variety of healthy foods eaten over a period of time. The introduction of solid foods in the 1st year of life is considered a measure of increased diet diversity. Consuming a diverse range of foods and food allergens in the first year of life may increase intake of important nutrients and positively affect the gut microbiome structure and function. Intake of omega-3 fatty acids and fibers/prebiotics may be particularly important but more information is required about dose and which individuals are most likely to benefit. Increased diet diversity in the first year of life is also associated with reduced food allergy outcomes. In addition to diet diversity, diet indices are considered measures of overall diet quality and can be used as a simple assessment of dietary intake. The focus of this paper is to review and critically address the current knowledge of the association between diet diversity and diet indices and allergy outcomes. Based on the current evidence, we recommend the introduction of solid foods, including common allergenic solids, during the 1st year of life, according to the infant's neuro-developmental abilities and familial or cultural habits. For infants with severe AD and/or FA, medical assessment may be advisable before introducing common food allergens into the diet. Limited evidence exist about the role of diet indices in pregnancy and allergic disease in the offspring, and the most promising results indicate a reduction in childhood wheeze and/or asthma intake.

Mediterranean diet during pregnancy and childhood for asthma in children: A systematic review and meta-analysis of observational studies

OBJECTIVES

To evaluate the relationship between high adherence to the Mediterranean diet in pregnancy and childhood and the risk of asthma and wheeze in children.

METHODS

We conducted searches of PubMed, EMBASE, and Cochrane Central Register of Controlled Trials from inception to 30 October 2018. Observational studies providing risk estimates and corresponding confidence intervals on the association of high adherence to the Mediterranean diet in pregnancy or childhood and the risk of asthma or wheeze in childhood were included. The methodological quality of all included studies was assessed. Summary odds ratios (OR) were calculated using a random-effects model.

RESULTS

Eighteen observational studies were included in this review. All studies were of moderate to high quality. The pooled data suggested high adherence to the Mediterranean diet during pregnancy was associated with a reduced incidence of wheeze in the first 12 months (OR, 0.92; 95% confidence interval [CI], 0.88-0.95; P < 0.001), and there was an inverse association between the Mediterranean diet during childhood and the incidence of wheeze in the history (OR, 0.51; 95% CI, 0.37-0.70; P = 0.001) and current wheeze (OR, 0.97; 95% CI, 0.95-0.99; P = 0.013). However, there was no significant association between high adherence of the Mediterranean diet in pregnancy and childhood and any of the other meta-analysis end points including diagnosed asthma.

CONCLUSION

High adherence to the Mediterranean diet during pregnancy and childhood may have short-term effects on wheeze in children in early life. However, these findings should be interpreted with caution owing to the heterogeneity of the studies.

Adherence to the Mediterranean diet and inflammatory markers in children with asthma

INTRODUCTION

There is accumulated evidence supporting a beneficial role of Mediterranean diet (MD) in the control of asthma symptoms. The aim of this study was to investigate the relationships between adherence to MD and serum levels of certain cytokines namely, interleukin (IL)-4, and IL-17 known to have a pathogenetic role in the airway changes associated with asthma.

METHODS

We measured serum IL-4, IL-33, and IL-17, in 44 asthmatic and 26 healthy children, 5-15 years old. Their adherence to MD was estimated with the Mediterranean Diet Quality Index for children and adolescents (KIDMED) score.

RESULTS

KIDMED score did not differ between the two groups (P=0.59) and was not correlated with any of the three measured cytokines. However, when the analysis was restricted only to asthmatic children, the KIDMED score was correlated with IL-4, IL-33, and IL-17 (Beta: -0.56, P=0.007; Beta: 0.57, P=0.010; Beta: -0.62, P=0.017, respectively).

CONCLUSION

Our results indicate that MD can modulate the production of some of the main inflammatory mediators of asthma, in asthmatic children.

Influence of the Mediterranean diet during pregnancy in the development of wheezing and eczema in infants in Pamplona, Spain

BACKGROUND

This study examined the relationship between different food groups and the adherence to a Mediterranean diet during pregnancy and the risk of wheezing and eczema in children aged 12-15 months.

METHODS

The study involves 1087 Spanish infants from the International Study of Wheezing in Infants (Estudio Internacional de Sibilancias en Lactantes, EISL). The study of the association of the different food consumption and Mediterranean diet with wheezing, recurrent wheezing and eczema was performed using different models of unconditional logistic regression to obtain adjusted prevalence odds ratios (OR) and 95% confidence intervals (95% CI).

RESULTS

No association was found between a good adherence to the Mediterranean diet during pregnancy and the development of wheezing (p=0.372), recurrent wheezing (p=0.118) and eczema (p=0.315). The consumption once or twice a week of white fish (OR: 1.95[1.01-3.75]), cooked potatoes (OR: 1.75[1.22-2.51]) and industrial pastry (OR: 1.59[1.13-2.24]), and the consumption more than three times a week of industrial pastry (OR: 1.47 [1.01-2.13]) during pregnancy increases the risk of "wheezing" at 12 months. Instead, high fruit consumption during the pregnancy has a protective effect against "wheezing" in 12-month-old infants (OR: 0.44 [0.20-0.99]). No statistically significant differences were observed between food intake during pregnancy and "recurrent wheezing". No statistically significant differences were observed between the consumption of any food during pregnancy and the presence of eczema at 12 months.

CONCLUSIONS

The present study showed that the consumption of Mediterranean diet during pregnancy did not have a protective effect for wheezing, recurrent wheezing or eczema.

Fruit intake reduces the onset of respiratory allergic symptoms in schoolchildren

BACKGROUND

Previous studies have shown that dietary pattern is associated with allergy prevention.

METHODS

We conducted a prospective cohort study on all primary schools in Omihachiman City, Shiga Prefecture, Japan. Questionnaires regarding allergic symptoms and diet were distributed to the parents of all 759 7-year-old schoolchildren for 4 consecutive years, from 2011 to 2014. Specific immunoglobulin E to inhalant allergens was measured at 10 years of age. Participants were then categorized as low, medium, or high intake during the study period for four food groups (fruits, vegetables, fish, and beans). Logistic regression analysis was performed to estimate odds ratios and 95% confidence intervals.

RESULTS

A total of 520 children (68.5%) whose parents responded to the questionnaires all 4 years were included in the analysis. The prevalence of asthma, rhinitis, and any allergic symptoms at age 10 was significantly decreased with increases in fruit intake. In addition, the onset of any allergic symptoms during the study period was significantly decreased with increases in fruit intake (33.3%, 28.3%, and 14.3% in children with low, medium, and high fruit intake, respectively; P for trend =.01). The sensitization rate to ragweed at age 10 was significantly decreased with increases in fruit intake (P for trend =.046). No significant effect was observed for the other three food groups, except for the association between fish intake and new-onset asthma symptoms.

CONCLUSIONS

These findings suggest that higher intake of fruit can help prevent respiratory allergic symptoms in schoolchildren.

Diet and Asthma: Is It Time to Adapt Our Message?

Asthma is a chronic respiratory disorder which is associated with airway inflammation. Environmental factors, in association with genetic susceptibility, play a critical role in asthma pathophysiology. Inhaled allergens, smoke exposure, indoor and outdoor air pollution are common triggers of asthma symptoms. Although the role of diet has clearly established mechanisms in diseases such as cardiovascular disease, type 2 diabetes, and cancer, it is not commonly identified as a causal factor in asthma. However, some dietary patterns, such as the Western diet, which includes a high intake of refined grains, processed and red meats, and desserts, have pro-inflammatory effects. On the contrary, the Mediterranean diet, with high intake of fruits and vegetables has anti-inflammatory properties. The influence of food on asthma outcomes is of growing interest, but dietary habits of asthma patients are not commonly investigated in clinical practice. In this review, we focus on the impact of diet on asthma risk and asthma control. We also detail the influence of diet on obese patients with asthma.

Does adherence to the Mediterranean dietary pattern reduce asthma symptoms in children? A systematic review of observational studies

OBJECTIVE

The purpose of the present systematic review was to synthesize evidence from the literature to assess efficacy of the Mediterranean dietary pattern in childhood asthma. Design/Setting A systematic search of six databases, three clinical trial registries and hand-search of peer-reviewed articles was conducted up to 29 October 2016. Inclusion criteria included exposure to a Mediterranean dietary pattern, measurement of asthma symptoms and study population of children aged <18 years. Quality assessment was conducted. Due to significant heterogeneity, meta-analysis was not feasible.

RESULTS

Of the 436 articles identified, after removal of duplicates and based on inclusion criteria, fifteen observational studies conducted in Mediterranean and non-Mediterranean countries were relevant. No randomized controlled trials were retrieved. Twelve studies reported an inverse association between adherence to a Mediterranean dietary pattern and asthma in children, two studies showed no association and one study showed an increase in asthma symptoms. In fourteen out of fifteen studies, quality assessment checks revealed good reliability and validity among study methodologies.

CONCLUSIONS

The current systematic review revealed a consistent inverse relationship (protective) between a Mediterranean dietary pattern and asthma in children. Future well-designed randomized controlled trials are needed to provide solid evidence. Nevertheless, the existing level of evidence adds to the public health message relating to the beneficial effects of a Mediterranean-type diet in children suffering with asthma.

Dietary patterns and the risk of obesity, type 2 diabetes mellitus, cardiovascular diseases, asthma, and neurodegenerative diseases

Diet and lifestyle play a significant role in the development chronic diseases; however the full complexity of this relationship is not yet understood. Dietary pattern investigation, which reflects the complexity of dietary intake, has emerged as an alternative and complementary approach for examining the association between diet and chronic diseases. Literature on this association has largely focused on individual nutrients, with conflicting outcomes, but individuals consume a combination of foods from many groups that form dietary patterns. Our objective was to systematically review the current findings on the effects of dietary patterns on chronic diseases. In this review, we describe and discuss the relationships between dietary patterns, such as the Mediterranean, the Dietary Approach to Stop Hypertension, Prudent, Seventh-day Adventists, and Western, with risk of obesity, type-2 diabetes mellitus, cardiovascular diseases, asthma, and neurodegenearive diseases. Evidence is increasing from both observational and clinical studies that plant-based dietary patterns, which are rich in fruits, vegetables, and whole grains, are valuable in preventing various chronic diseases, whereas a diet high in red and processed meat, refined grains and added sugar seems to increase said risk. Dietary pattern analysis might be especially valuable to the development and evaluation of food-based dietary guidelines.

Adherence to the Mediterranean Diet in children and adolescents: A systematic review

BACKGROUND AND AIM

A decreased adherence to the Mediterranean Diet (MD) may be related to a rise in chronic non-communicable diseases from childhood onward. The aim of this systematic review was to summarize the available literature regarding MD adherence in children and adolescents, and focusing, more specifically, on the association of MD adherence with demographic and anthropometric variables, body composition, lifestyle, and diet adequacy.

METHODS AND RESULTS

A search of scientific literature was carried out on PUBMED, SCOPUS, Clinical Trials Results, Google Scholar, and British Library Inside for studies published in the last 20 years. Fifty-eight papers were finally included according to the following criteria: MD adherence evaluated through a quantifying score or index, age 2-20 years, sample size >200 participants, observational or intervention studies regarding the general population. The KIDMED index was the most widely used scoring system. MD adherence widely varied within the Mediterranean countries for both children and adolescents, with also large differences among various European countries, while few data are available for non-Mediterranean countries. Most of the eligible studies showed that MD adherence was directly associated with physical activity (and possibly with diet adequacy) and inversely with sedentary behavior, while the results for gender, age, socioeconomic status and weight status were not consistent.

CONCLUSIONS

Further validation of MD indexes in terms of reproducibility and consistency with the MD is needed. At the same time, more prospective cohort and intervention studies may better elucidate the relationships of MD adherence with behavioral and health outcomes.

What Are the Effects of a Mediterranean Diet on Allergies and Asthma in Children?

This review updates the relationship between the adherence to Mediterranean diet (MedDiet) assessed by questionnaire and asthma, allergic rhinitis, or atopic eczema in childhood. It deals with the effect of MedDiet in children on asthma/wheeze, allergic rhinitis, and atopic dermatitis/eczema, and also with the effect of MedDiet consumption by the mother during pregnancy on the inception of asthma/wheeze and allergic diseases in the offspring. Adherence to MedDiet by children themselves seems to have a protective effect on asthma/wheezing symptoms after adjustment for confounders, although the effect is doubtful on lung function and bronchial hyperresponsiveness. By contrast, the vast majority of the studies showed no significant effect of MedDiet on preventing atopic eczema, rhinitis, or atopy. Finally, studies on adherence to MedDiet by the mother during pregnancy showed some protective effect on asthma/wheeze symptoms in the offspring only during the first year of life, but not afterward. Very few studies have shown a protective effect on wheezing, current sneeze, and atopy, and none on eczema. Randomized control trials on the effect of the adherence to MedDiet to prevent (by maternal consumption during pregnancy) or improve (by child consumption) the clinical control of asthma/wheezing, allergic rhinitis, or atopic dermatitis are needed.

Association between dietary habits and asthma severity in children

OBJECTIVE

To investigate association between dietary habits and asthma severity in children.

DESIGN

Cross-sectional study.

SETTING

Two teaching hospitals in Brazil.

PARTICIPANTS

Cases (n=268) were children (3-12yr) with persistent asthma and age-matched controls (n=126) were those with intermittent asthma.

MAIN OUTCOME MEASURES

Dietary habits were determined based on food consumption in the past 12 months classified as frequent (≥3 times per week) or infrequent (never or <3 times per week).Nutritional status was classified into two categories according to WHO Child Growth Standards: obese: >2Z-score of BMI-for-age; non-obese: ≤2Z-score of BMI-for-age.

RESULTS

After adjusting for confounding factors, maternal smoking during pregnancy, preterm birth and obesity were significantly associated with persistent asthma, with adjusted ORs (95% CI) of 2.11 (1.08- 4.13), 2.61(1.07-6.35) and 2.89 (1.49-5.61), respectively. No significant association was observed between frequency of consumption of specific foods, food groups, or dietary pattern (pro- or contra-Mediterranean diet) and the severity of asthma.

CONCLUSIONS

This study did not find a significant association between dietary habits and asthma severity in children. Maternal smoking during pregnancy, preterm birth and obesity were independent factors associated with persistent asthma.

Mediterranean diet and childhood asthma

BACKGROUND

The incidence of bronchial hyperreactivity has increased to one-third of the population in developed countries, which requires the adoption of preventive and therapeutic measures. The objective of the present study was to assess the effects of a traditional Mediterranean diet on patients diagnosed with childhood asthma and determine if there is a beneficial effect from this dietary intervention.

METHODS

Prospective before-after comparison study of 50 girls and 54 boys aged 1-5 years, who were enrolled in the 1-year programme "Learning to Eat from the Mediterranean", designed to promote the adoption of a traditional Mediterranean diet. We studied the clinical and therapeutic variables and anthropometric measurements.

RESULTS

All studied symptomatic indicators (number and intensity of asthmatic attack, infections and hospital admissions) showed a positive and statistically significant evolution of bronchial hyperreactivity from the first weeks of the intervention onwards. Throughout the treatment, 32.2% of patients remained free of crisis, 35.3% of the patients only had one attack throughout the year and 24.9% had two episodes, compared to 4.73 episodes on average in the previous year. The use of inhaled corticosteroids markedly decreased from 3.92 ± 1.61 to 1.11 ± 1.09 times per patient per year (P<0.001) and that of inhaled bronchodilators decreased from 4.14 ± 1.61 to 1.12 ± 1.40 (P<0.001). As a result, the families involved in the programme reported a high level of satisfaction.

CONCLUSIONS

The adoption of a traditional Mediterranean diet could contribute significantly to the improvement of patients diagnosed with childhood asthma.

Association Between Adherence to the Mediterranean Diet and Asthma in Peruvian Children

PURPOSE

Adherence to a Mediterranean diet pattern may be associated with lower asthma prevalence in children. We sought to corroborate these findings in Peruvian children.

METHODS

This case-control study included children of ages 9-19 years living in Lima, Peru. A food frequency questionnaire (FFQ) was completed and diet pattern was analyzed using a modified Mediterranean diet score (MDS). Primary analysis investigated the relationship between MDS and asthma status. Maternal education, age, sex, and body mass index category were included in multivariate model. Secondary outcomes included asthma control, forced expiratory volume in 1 s (FEV1), allergic rhinitis, and atopic status.

RESULTS

287 participants with asthma and 96 controls without asthma completed a FFQ. Mean age was 13.5 years. According to the asthma control test (ACT), 86 % of those with asthma were controlled (score >19). MDS scores ranged 6-18 (median 15). In adjusted analysis, being above the median MDS scores was associated with decreased odds of asthma [OR = 0.55, 95 % CI (0.33, 0.92), p = 0.02]. Among children whose mothers completed secondary education, being above the median MDS significantly decreased the odds of asthma [OR = 0.31, 95 % CI (0.14, 0.71), p < 0.01], whereas among those whose mothers did not complete secondary education there was no protective effect [OR = 0.86, 95 % CI (0.43, 1.7), p = 0.66]. There was no association between MDS scores and asthma control, FEV1, allergic rhinitis, or atopic status.

CONCLUSION

Adherence to the Mediterranean diet was inversely associated with having asthma among children in Lima, Peru. This effect was strongest among children with better educated mothers.

Adiposity, fractional exhaled nitric oxide, and asthma in U.S. children

RATIONALE

Whether allergic airway inflammation mediates the association between overweight or obesity and childhood asthma is unknown.

OBJECTIVES

To examine adiposity, asthma, and fractional exhaled nitric oxide (FeNO) in U.S. children.

METHODS

Cross-sectional study of indicators of adiposity or obesity, FeNO (a biomarker of eosinophilic airway inflammation), and asthma in 2,681 children aged 6-17 years in the 2007-2010 National Health and Nutrition Examination Survey. Adiposity measures included body mass index (BMI), percent body fat (PBF), and waist circumference (WC).

MEASUREMENTS AND MAIN RESULTS

BMI, PBF, and WC were associated with asthma among children with low FeNO (odds ratio, 1.54-1.68; P < 0.01), but not among children with increased FeNO. Among children without asthma, BMI, PBF, and WC were associated with higher FEV1 and FVC, and lower FEV1/FVC. Among children with asthma and a high FeNO, all adiposity indicators were associated with decreased FEV1/FVC (β = -1.5% to -1.7% per z score) but not with FEV1 or FVC. Higher BMI or PBF was associated with worse asthma severity or control in children with asthma and increased FeNO, but not in children with asthma and low FeNO. Similar results were obtained in a secondary multivariate analysis of overweight or obesity (defined as BMI ≥85th percentile) and asthma or indicators of asthma severity or control, stratified by FeNO level.

CONCLUSIONS

Adiposity indicators are associated with asthma in children with low FeNO. Among children with asthma, adiposity indicators are associated with worse asthma severity or control in those with high FeNO.

Risk factors affecting asthma prevalence in adolescents living in Istanbul, Turkey

BACKGROUND

Asthma is one of the most important diseases of childhood. The aim of this study was to evaluate the prevalence of asthma symptoms and risk factors affecting asthma.

METHODS

In a cross-sectional study design, 9991 children, aged 13-14 years in 61 primary schools in 32 districts of Istanbul were evaluated. Asthma prevalence among the children was assessed using the ISAAC protocol.

RESULTS

In our study, a total of 10,894 questionnaires were distributed to 13-14 years old children, and of these 9991 questionnaires were suitable for analysis with an overall response rate of 91.7%. The rates of wheeze ever, wheezing in last 12 months and lifetime doctor diagnosed asthma prevalence were 17.4%, 9.0%, and 11.8%, respectively. There were 4746 boys (47.9%) and 5166 girls (52.1%) with M/F ratio of 0.92. Atopic family history, fewer than three siblings living at home, tonsillectomy or adenoidectomy history, consumption of fermented foods, mixed pickles, margarine and meat were found to be associated with an increased asthma risk. Use of paracetamol in the last 12 months, consumption of fruit and animal fats acted as a protective factor against asthma. The Mediterranean-style diet was not associated with the prevalence of asthma.

CONCLUSIONS

Lifetime doctor diagnosed asthma prevalence was found to be 11.8% in 13-14 year olds. History of tonsillectomy and/or adenoidectomy and consumption of fermented foods, mixed pickles, margarine and meat may increase the symptoms of asthma. Usage of paracetamol and consumption of animal fats may be investigated as a protective factor against asthma.

Dietary pattern and asthma: a systematic review and meta-analysis

Background

The literature on the relationship between diet and asthma has largely focused on individual nutrients, with conflicting results. People consume a combination of foods from various groups that form a dietary pattern. Studying the role of dietary patterns in asthma is an emerging area of research. The purpose of this study was to systematically review dietary patterns and asthma outcomes in adults and children, to review maternal diet and child asthma, and to conduct a meta-analysis on the association between asthma prevalence and dietary patterns in adults.

Methods

We searched Medline, Scopus, and ISI Web of Knowledge up to January 2014. Two researchers independently reviewed studies meeting the inclusion criteria using the American Dietetic Association quality criteria. A linear mixed model was used to derive the pooled effect size (95% confidence interval) for each of three dietary pattern categories (healthy, unhealthy, and neutral).

Results

Thirty-one studies were identified (16 cross-sectional, one case-control, 13 cohort, and one randomized controlled trial), including 12 in adults, 13 in children, five in pregnant woman–child pairs, and one in both children and pregnant woman–child pairs. Six of the 12 adult studies reported significant associations between dietary patterns and asthma outcomes (eg, ever asthma and forced expiratory volume in one second). Seven of ten studies examining the Mediterranean diet showed protective effects on child asthma and/or wheeze. Four of the six studies in mother-child pairs showed that maternal dietary patterns during pregnancy were not associated with child asthma or wheeze. The meta-analysis including six adult studies, the primary outcome of which was the prevalence of current or ever asthma, showed no association with healthy, unhealthy, or neutral dietary patterns.

Conclusion

The evidence suggests no association of dietary patterns with asthma prevalence in adults or of maternal diet with child asthma or wheeze. The Mediterranean diet in children may prevent asthma or wheeze, but randomized controlled trials are lacking.

Adolescents in southern regions of Italy adhere to the Mediterranean diet more than those in the northern regions

There is a large amount of literature regarding the benefits of the Mediterranean diet in the adult population; however, there is growing curiosity about the individuals who naturally adhere to those principles early in life. The "Evaluation of Dietary Habits in Adolescents," carried out by the National Research Council of Italy in 2009, is a survey that aimed to assess the dietary habits and lifestyles of Italian adolescents and their adherence to the Mediterranean diet. We hypothesized that there would be differences across regions, with a higher adherence in Southern Italy compared with Northern Italy based on geography. The survey was conducted in 3 different geographic locations in Italy and included a convenience sample of adolescents who attended either a middle or high school. The participants were asked to fill out a questionnaire concerning demographic data, lifestyle factors, and eating patterns, and scores were assigned according to adherence to the Mediterranean diet, as calculated using Trichopoulou's Mediterranean diet scale. The final sample included 565 adolescents, between 12 and 19 years old, who attended school in the northeastern, northwestern, or southern regions of Italy in 2009. According to the findings, 38.6% of the respondents had scores indicating a low adherence to the Mediterranean diet, whereas only 14% had scores showing a high adherence. Teenagers from the Southern region showed the highest adherence. Those with a high adherence to the Mediterranean diet consumed higher quantities of fiber, iron, vitamin B6, vitamin C, folic acid, vitamin A, vitamin D, and monounsaturated fats.

Obesity in asthma: approaches to treatment

There is mounting evidence that obesity is associated with asthma, both of which are seeing a dramatic increase in prevalence. Not only is obesity a risk factor for the development of asthma but it is also associated with poor asthma control. Asthma phenotypes associated with obesity include early-onset allergic asthma and late-onset non-allergic asthma. The pathogenesis of the linkage is complex; obesity causes a variety of mechanical, metabolic, and immunological changes that can affect the airways. The treatment of asthma in obesity can be challenging, as obesity is associated with poor response to standard controller medications. A tailored approach that involves combining pharmacologic and non-pharmacologic therapies including weight loss, dietary interventions, and exercise, along with identification and treatment of obstructive sleep apnea, should therefore be considered in this population.

Diet and allergic diseases among population aged 0 to 18 years: myth or reality?

Allergic diseases are an important health problem. However, epidemiological studies concerning childhood diet-related allergic diseases are scarce. This review examines published articles dealing with diet, dietary patterns and nutrition in relation with allergic diseases among population aged 0 to 18 years. Studies and trials were identified using MEDLINE/PubMed and Cochrane Database of Systematic Reviews and were limited to those published in English or French from 1992 until 2012. This manuscript also reviews the evidence for maternal diet during pregnancy and diet during early childhood and their association with childhood atopic diseases, taking into account the methodology used to evaluate dietary patterns. The evidence reviewed is derived from large epidemiological studies exploring the effects of different food categories on asthma, atopic dermatitis, and allergic rhinitis in children. Overall, maternal diet during pregnancy and a childhood diet rich in antioxidants and omega-3 fatty acids are considered as healthy diets that could be protective for allergic diseases in childhood.

DASH for asthma: a pilot study of the DASH diet in not-well-controlled adult asthma

This pilot study aims to provide effect size confidence intervals, clinical trial and intervention feasibility data, and procedural materials for a full-scale randomized controlled trial that will determine the efficacy of Dietary Approaches to Stop Hypertension (DASH) as adjunct therapy to standard care for adults with uncontrolled asthma. The DASH diet encompasses foods (e.g., fresh fruit, vegetables, and nuts) and antioxidant nutrients (e.g., vitamins A, C, E, and zinc) with potential benefits for persons with asthma, but it is unknown whether the whole diet is beneficial. Participants (n = 90) will be randomized to receive usual care alone or combined with a DASH intervention consisting of 8 group and 3 individual sessions during the first 3 months, followed by at least monthly phone consultations for another 3 months. Follow-up assessments will occur at 3 and 6 months. The primary outcome measure is the 7-item Juniper Asthma Control Questionnaire, a validated composite measure of daytime and nocturnal symptoms, activity limitations, rescue medication use, and percentage predicted forced expiratory volume in 1 second. We will explore changes in inflammatory markers important to asthma pathophysiology (e.g., fractional exhaled nitric oxide) and their potential to mediate the intervention effect on disease control. We will also conduct pre-specified subgroup analyses by genotype (e.g., polymorphisms on the glutathione S transferase gene) and phenotype (e.g., atopy, obesity). By evaluating a dietary pattern approach to improving asthma control, this study could advance the evidence base for refining clinical guidelines and public health recommendations regarding the role of dietary modifications in asthma management.

Influence of Mediterranean diet on asthma in children: a systematic review and meta-analysis

BACKGROUND

There is epidemiological evidence that Mediterranean diet exposure is associated with lower asthma prevalence in children. We aimed to summarize the available data and to know whether the Mediterranean setting modifies this association.

METHODS

The literature search, up to May 2012, was on epidemiological studies in the general population of children assessing whether adherence to Mediterranean diet (measured as a score) was associated with the prevalence of 'current wheeze'; 'current severe wheeze'; or 'asthma ever'. Odds ratios (OR) of the eight included studies compared the highest tertile of the score with the lowest. Random-effects meta-analyses for the whole group of studies and stratified by Mediterranean setting (centers <100 Km from the Mediterranean coast) were performed. Differences between strata were assessed using the Q test.

RESULTS

For 'current wheeze', there was a negative significant association with the highest tertile of Mediterranean diet score (OR 0.85, 95% CI 0.75-0.98; p = 0.02), driven by Mediterranean centers (0.79, 0.66-0.94, p = 0.009), although the difference with the non-Mediterranean centers (0.91, 0.78-1.05, p = 0.18) was not significant. The results for 'current severe wheeze' were as follows: 0.82, 0.55-1.22, p = 0.330 (all); 0.66, 0.48-0.90, p = 0.008 (Mediterranean); and 0.99, 0.79-1.25, p = 0.95 (non-Mediterranean); with the difference between regions being significant. For 'asthma ever', the associations were as follows: 0.86, 0.78-0.95, p = 0.004 (all); 0.86, 0.74-1.01, p = 0.06 (Mediterranean); 0.86, 0.75-0.98; p = 0.027 (non-Mediterranean); with the difference between regions being negligible.

CONCLUSIONS

Adherence to the Mediterranean diet tended to be associated with lower occurrence of the three respiratory outcomes. For current and current severe wheeze, the association was mainly driven by the results in Mediterranean populations.

Nutrition and asthma

Over the past four decades, the prevalence of asthma has markedly increased in Westernized countries and countries transitioning to this lifestyle. It has been hypothesized that these increases are a consequence of changing environmental and/or behavioral factors. The modification of dietary habits (ie, decreased intake of fruits/vegetables and increased intake of "Westernized" processed foods) and a decrease in sun exposure have led to decreased intake of antioxidant vitamins and fatty acids and to decreased circulating levels of vitamin D, and have been proposed to explain the rise in asthma prevalence. This article summarizes the main findings on foods and nutrients connected to asthma based on several exhaustive recent reviews on the topic, and examines the evidence for an effect of dietary patterns on asthma. Overall, findings underscore the importance of conducting prospective studies and clinical trials to better understand the role of diet in the etiology of asthma.

Dietary Patterns and Wheezing in the Midst of Nutritional Transition: A Study in Brazil

To assess the influence of dietary patterns on the prevalence of wheezing in the child and adolescent population in Northeastern Brazil. This is a cross-sectional study of male and female students, 6-12 years old, from the public elementary schools of São Francisco do Conde, Bahia, Northeastern Brazil. The report of wheezing in the past 12 months was collected using a questionnaire from the International Study of Asthma and Allergies in Childhood Program phase III, adapted to Portuguese. Consumption patterns were derived from principal component analysis based on the frequency of consumption of 97 food items by the food frequency questionnaire. We also obtained the anthropometric status, level of physical activity, pubertal development, and socioeconomic information, for each participant. Multivariate logistic regression analyses were used to assess the associations of interest. Of the children surveyed, 10.6% reported having wheezing. We identified 2 dietary patterns named Western and Prudent. We found a positive statistically significant association of the Western pattern with wheeze (odds ratio=1.77, 95% confidence interval: 1.10-2.84) after adjustment for total energy intake and controlling for potential confounders. The results showed that the Western dietary pattern was associated with wheezing. Our result is according with previous findings reported in several other studies.

Allergic airway diseases in childhood - marching from epidemiology to novel concepts of prevention

In the past years, a wide range of epidemiological, clinical, and experimental studies have produced remarkable advances in the field of respiratory allergies in childhood. By the recent investigations on epidemiological trends, risk factors, and prevention of asthma and allergic rhinitis, various exiting concepts have been challenged, and novel innovative approaches have been developed. Pediatric Allergy and Immunology (PAI), with a number of highly relevant contributions between 2010 and 2012, has become an important forum in this area. The prevalence of asthma in some developed countries may have reached a plateau, while in developing countries, where the prevalence was previously low, allergic diseases are still on the increase. A wide array of risk and protective factors, including hygiene, infections, outdoor and indoor air pollution, allergen exposure, breast-feeding practices, nutrition, and obesity, play a multifaceted role in shaping the observed worldwide trends of respiratory allergies. Under the guidance of recent research, prediction and prevention strategies in the clinical practice are progressively changing, the focus moving away from avoidance of allergen exposure and toward tolerance induction.

Dietary factors associated with lifetime asthma or hayfever diagnosis in Australian middle-aged and older adults: a cross-sectional study

BACKGROUND

There is abundant research relevant to genetic and environmental influences on asthma and hayfever, but little is known about dietary risk factors in Australian adults. This study's purpose was to identify dietary factors associated with lifetime asthma (AS) and asthma or hayfever (AS/HF) diagnosis in Australian middle-aged and older adults.

METHODS

From The 45 and Up Study baseline self-report data, this study included 156,035 adult men and women. Participants were sampled from the general population of New South Wales, Australia in 2006-2009. About 12% of participants reported ever receiving an AS diagnosis (men 10%; women 14%) and 23% reported AS/HF diagnosis (men 19%; women 26%). Following principle components factor analysis, dietary items loaded onto one of four factors for men (meats/cheese; fruits/vegetables; poultry/seafood; grains/alcohol) or five factors for women (meats; fruits/vegetables; poultry/seafood; cereal/alcohol; brown bread/cheese). Logistic regression was used to analyze the associations between dietary factors and AS or AS/HF diagnosis.

RESULTS

For men, the meats/cheese factor was positively associated with AS (AOR = adjusted odds ratio for highest versus lowest quintile = 1.18, 95%CI = 1.08, 1.28; P(trend) = 0.001) and AS/HF (AOR for highest versus lowest quintile = 1.22, 95%CI = 1.14, 1.29; P(trend) < 0.001). Poultry/seafood was also associated with AS/HF in men (AOR for highest versus lowest quintile = 1.11, 95%CI = 1.04, 1.17; P(trend) = 0.002). For women, significant risk factors for AS/HF included meats (AOR for highest versus lowest quintile = 1.25, 95%CI = 1.19, 1.31; P(trend) = 0.001), poultry/seafood (AOR for highest versus lowest quintile = 1.06, 95%CI = 1.01, 1.12; P(trend) = 0.016), and fruits/vegetables (AOR for highest versus lowest quintile = 1.07, 95%CI = 1.02, 1.12; P(trend) = 0.011). In contrast, the cheese/brown bread dietary factor was protective against AS in women (AOR for highest versus lowest quintile = 0.88, 95%CI = 0.82, 0.94; P(trend) < 0.001).

CONCLUSIONS

Generally, diets marked by greater intakes of meats, poultry, and seafood were associated with diagnosed AS and AS/HF. Taken together, these findings suggest that adherence to a more meat-based diet may pose risk for AS and AS/HF in Australian adults.

Early life exposures: impact on asthma and allergic disease

PURPOSE OF REVIEW

To identify and discuss recent studies relating prenatal and early-life environmental exposures to the development of asthma and allergic disease.

RECENT FINDINGS

New studies show that prenatal and early-life stress can alter infant immune profiles, increasing risk for asthma and allergy. Mounting evidence implicates indoor and outdoor air pollution in the origins of allergic disease, while Vitamin D intake and a Mediterranean diet may be protective. The role of early-life fever and infection remain controversial, with recent studies yielding conflicting results and new evidence indicating that previous studies may have been confounded. New studies are increasingly focused on environmental 'imprinting' of the infant gut microbiota, which is a critical determinant of immune system development. Early exposures impacting the intestinal microbiota include mode of delivery, infant diet, and use of antibiotics - factors that are also associated with childhood asthma and allergic disease.

SUMMARY

This overview highlights environmental exposures during the in-utero and ex-utero time periods that are potential stimuli for the early programming of asthma and allergy. Special consideration is given for the potential role of intestinal microbiota. Future studies in this field promise to inform health policy and intervention strategies for the prevention of asthma and allergic disease.

Use of dietary indexes among children in developed countries

In this article, we review studies that have used dietary indexes to assess different aspects of diet in relation to health outcomes and sociodemographic factors in childhood populations of developed countries. Eighty-four papers published from 1980 to mid-2010 including 90 unique dietary indexes were reviewed. Seventy-two indexes were developed (or have been adapted) specifically for childhood populations; 38 of these were used to assess diet-disease associations, mostly of diet and obesity. In the majority of these studies, small inverse associations between dietary indexes and obesity indexes were shown. Children who were younger, female, and from high-income families had better dietary quality scores. Forty-nine indexes (of 90) were compared with other aspects of dietary intakes or behaviors, with correlations ranging from very low to modest (∼r = 0.05-0.50). Only 2 validation studies compared an index with nutritional biomarkers, and correlations were quite weak for most plasma nutrients (P < 0.10). Overall, a large number of indexes have been created and used, but the majority of studies are descriptive. Fewer analytic studies on index-health associations have been performed, and most analyses insufficiently adjusted for confounders. Thus, prospective and intervention research in diverse populations is needed to further test these tools. In conclusion, indexes are potentially useful methods for dietary assessment, because they offer valuable information on overall dietary patterns in children. However, understanding the advantages and limitations when applying them in research and public health settings is important, and more research is needed to further develop their utility.