Linking COPD epidemiology with pediatric asthma care: Implications for the patient and the physician

Lung-function trajectories: relevance and implementation in clinical practice

Lung development starts in utero and continues during childhood through to adolescence, reaching its peak in early adulthood. This growth is followed by gradual decline due to physiological lung ageing. Lung-function development can be altered by several host and environmental factors during the life course. As a result, a range of lung-function trajectories exist in the population. Below average trajectories are associated with respiratory, cardiovascular, metabolic, and mental health comorbidities, as well as with premature death. This Review presents progressive research into lung-function trajectories and assists the implementation of this knowledge in clinical practice as an innovative approach to detect poor lung health early, monitor respiratory disease progression, and promote lung health. Specifically, we propose that, similar to paediatric height and weight charts used globally to monitor children's growth, lung-function charts could be used for both children and adults to monitor lung health status across the life course. To achieve this proposal, we introduce our free online Lung Function Tracker tool. Finally, we discuss challenges and opportunities for effective implementation of the trajectory concept at population level and outline an agenda for crucial research needed to support such implementation.

A systematic review and meta-analysis of the prevalence and epidemiology of asthma in people over 14 years of age in China

OBJECTIVE

Asthma is a common chronic respiratory disease that seriously affects the health of adults and children. The risk factors for asthma are constantly changing; thus, it is necessary to study the prevalence of asthma and risk factors in different populations. Currently, there have been no epidemiological studies on the prevalence and risk factors of asthma in people over 14 years in mainland China. Therefore, we performed a meta-analysis of the prevalence and risk factors for asthma in mainland China.

METHODS

A literature search was conducted for studies on the epidemiology of asthma in China between 2000 and 2020 using English and Chinese databases. Prevalence and epidemiological information on asthma in people aged >14 years were extracted. Meta-analysis was performed using a random-effects model (If I2>50%) with 95% confidence intervals for forest plots.

RESULTS

Nineteen studies (including data from 345,950 samples) met our evaluation criteria. The overall prevalence of asthma in Chinese adults is 2%, without differences between Northern and Southern China. The prevalence increased after 2010 compared with that before 2010. The prevalence of asthma also increased with age, with people aged 55-64 years being the most affected. The prevalence of asthma was independent of sex and residence area. In conclusion, the prevalence of asthma among adolescents (age >14 years) and adult population in China has increased since 2010.

CONCLUSION

Further studies are necessary to monitor the prevalence of asthma in mainland China. The elderly population also has a high prevalence of asthma, which should be focused on more in the future.

Early Origins of Chronic Obstructive Pulmonary Disease: Prenatal and Early Life Risk Factors

The main risk factor for chronic obstructive pulmonary disease (COPD) is active smoking. However, a considerable amount of people with COPD never smoked, and increasing evidence suggests that adult lung disease can have its origins in prenatal and early life. This article reviews some of the factors that can potentially affect lung development and lung function trajectories throughout the lifespan from genetics and prematurity to respiratory tract infections and childhood asthma. Maternal smoking and air pollution exposure were also analyzed among the environmental factors. The adoption of preventive strategies to avoid these risk factors since the prenatal period may be crucial to prevent, delay the onset or modify the progression of COPD lung disease throughout life.

Air pollution, metabolites and respiratory health across the life-course

Previous studies have explored the relationships of air pollution and metabolic profiles with lung function. However, the metabolites linking air pollution and lung function and the associated mechanisms have not been reviewed from a life-course perspective. Here, we provide a narrative review summarising recent evidence on the associations of metabolic profiles with air pollution exposure and lung function in children and adults. Twenty-six studies identified through a systematic PubMed search were included with 10 studies analysing air pollution-related metabolic profiles and 16 studies analysing lung function-related metabolic profiles. A wide range of metabolites were associated with short- and long-term exposure, partly overlapping with those linked to lung function in the general population and with respiratory diseases such as asthma and COPD. The existing studies show that metabolomics offers the potential to identify biomarkers linked to both environmental exposures and respiratory outcomes, but many studies suffer from small sample sizes, cross-sectional designs, a preponderance on adult lung function, heterogeneity in exposure assessment, lack of confounding control and omics integration. The ongoing EXposome Powered tools for healthy living in urbAN Settings (EXPANSE) project aims to address some of these shortcomings by combining biospecimens from large European cohorts and harmonised air pollution exposure and exposome data.

Pathogenesis of chronic obstructive pulmonary disease: understanding the contributions of gene-environment interactions across the lifespan

The traditional view of chronic obstructive pulmonary disease (COPD) as a self-inflicted disease caused by tobacco smoking in genetically susceptible individuals has been challenged by recent research findings. COPD can instead be understood as the potential end result of the accumulation of gene-environment interactions encountered by an individual over the life course. Integration of a time axis in pathogenic models of COPD is necessary because the biological responses to and clinical consequences of different exposures might vary according to both the age of an individual at which a given gene-environment interaction occurs and the cumulative history of previous gene-environment interactions. Future research should aim to understand the effects of dynamic interactions between genes (G) and the environment (E) by integrating information from basic omics (eg, genomics, epigenomics, proteomics) and clinical omics (eg, phenomics, physiomics, radiomics) with exposures (the exposome) over time (T)-an approach that we refer to as GETomics. In the context of this approach, we argue that COPD should be viewed not as a single disease, but as a clinical syndrome characterised by a recognisable pattern of chronic symptoms and structural or functional impairments due to gene-environment interactions across the lifespan that influence normal lung development and ageing.

Predicting the course of asthma from childhood until early adulthood

PURPOSE OF REVIEW

To communicate recent insights about the natural history of childhood asthma, with a focus on prediction of persistence and remission of childhood asthma, up to early adulthood.

RECENT FINDINGS

Lung function around the age of 8-9 years is the strongest predictor: obstructive lung function predicts asthma persistence up to early adulthood, whereas normal lung function predicts remission. The ability to predict asthma remission improves when lung function is combined with blood eosinophil levels and degree of bronchial hyperresponsiveness. Interventions, such as inhaled corticosteroids and immunotherapy do not appear to alter the course of asthma. Epigenetic studies have revealed potential novel biomarkers of asthma remission, such as micro-RNA patterns in blood. Specifically, lower serum levels of mi-R221-5p, which is associated with lower IL-6 release and eosinophilic inflammation, predict remission. Higher levels of blood DNA-methylation of a CpG site in Peroxisomal Biogenesis Factor 11 Beta were associated with asthma remission.

SUMMARY

Lung function, allergic comorbidity and polysensitization in childhood predict the course of asthma. Recent epigenetic studies have provided a better understanding of underlying pathological processes in asthma remission, which may be used to improve prediction or develop novel treatments aimed at altering the course of asthma.

Holy Grail: the journey towards disease modification in asthma

At present, there is no cure for asthma, and treatment typically involves therapies that prevent or reduce asthma symptoms, without modifying the underlying disease. A “disease-modifying” treatment can be classed as able to address the pathogenesis of a disease, preventing progression or leading to a long-term reduction in symptoms. Such therapies have been investigated and approved in other indications, e.g. rheumatoid arthritis and immunoglobulin E-mediated allergic disease. Asthma's heterogeneous nature has made the discovery of similar therapies in asthma more difficult, although novel therapies (e.g. biologics) may have the potential to exhibit disease-modifying properties. To investigate the disease-modifying potential of a treatment, study design considerations can be made, including: appropriate end-point selection, length of trial, age of study population (key differences between adults/children in physiology, pathology and drug metabolism) and comorbidities in the patient population. Potential future focus areas for disease-modifying treatments in asthma include early assessments (e.g. to detect patterns of remodelling) and interventions for patients genetically susceptible to asthma, interventions to prevent virally induced asthma and therapies to promote a healthy microbiome. This review explores the pathophysiology of asthma, the disease-modifying potential of current asthma therapies and the direction future research may take to achieve full disease remission or prevention.

Asthma is a complex, heterogeneous disease, which currently has no cure; this review explores the disease-modifying potential of asthma therapies and the direction future research may take to achieve disease remission or prevention.https://bit.ly/31AxYou

COPD is Associated with Epigenome-wide Differential Methylation in BAL Lung Cells

DNA methylation patterns in chronic pulmonary obstructive disease (COPD) might offer new insights into disease pathogenesis. To assess methylation profiles in the main COPD target organ, we performed an epigenome-wide association study on bronchoalveolar lavage (BAL) cells. Bronchoscopies were performed in 18 COPD subjects and 15 controls (ex- and current smokers). DNA methylation was measured with Illumina MethylationEPIC BeadChip covering >850,000 CpGs. Differentially methylated positions (DMPs) were examined for 1) enrichment in pathways and functional gene relationships using Kyoto Encyclopedia of Genes and Genomes and Gene Ontology; 2) accelerated aging using Horvath's epigenetic clock; 3) correlation with gene expression; and 4) co-localization with genetic variation. We found 1,155 Bonferroni significant (P < 6.74 × 10^-8) DMPs associated with COPD, many with large effect sizes. Functional analysis identified biologically plausible pathways and gene relationships, including enrichment for transcription factor activity. Strong correlation was found between COPD and chronological age, but not with accelerated epigenetic aging. For 79 unique DMPs, DNA methylation correlated significantly with gene expression in BAL cells. Thirty-nine percent of DMPs were co-localized with COPD-associated SNPs. To the best of our knowledge, this is the first EWAS of COPD on BAL cells, and our analyses revealed many differential methylation sites. Integration with mRNA data showed a strong functional readout for relevant genes, identifying sites where DNA methylation might directly impact expression. Almost half of DMPs were co-located with SNPs identified in previous GWAS of COPD, suggesting joint genetic and epigenetic pathways related to disease.

Increased cytotoxic T-cells in the airways of adults with former bronchopulmonary dysplasia

Rationale

Bronchopulmonary dysplasia (BPD) in preterm-born infants is a risk factor for chronic airway obstruction in adulthood. Cytotoxic T-cells are implicated in COPD, but their involvement in BPD is not known.

Objectives

To characterise the distribution of airway T-cell subsets in adults with a history of BPD.

Methods

Young adults with former BPD (n=22; median age 19.6 years), age-matched adults born preterm (n=22), patients with allergic asthma born at term (n=22) and healthy control subjects born at term (n=24) underwent bronchoalveolar lavage (BAL). T-cell subsets in BAL were analysed using flow cytometry.

Results

The total number of cells and the differential cell counts in BAL were similar among the study groups. The percentage of CD3⁺CD8⁺ T-cells was higher (p=0.005) and the proportion of CD3⁺CD4⁺ T-cells was reduced (p=0.01) in the BPD group, resulting in a lower CD4/CD8 ratio (p=0.007) compared to the healthy controls (median 2.2 versus 5.3). In BPD and preterm-born study subjects, both CD3⁺CD4⁺ T-cells (r_s=0.38, p=0.03) and CD4/CD8 ratio (r_s=0.44, p=0.01) correlated positively with forced expiratory volume in 1 s (FEV₁). Furthermore, CD3⁺CD8⁺ T-cells were negatively correlated with both FEV₁ and FEV₁/forced vital capacity (r_s= −0.44, p=0.09 and r_s= −0.41, p=0.01, respectively).

Conclusions

Young adults with former BPD have a T-cell subset pattern in the airways resembling features of COPD. Our findings are compatible with the hypothesis that CD3⁺CD8⁺ T-cells are involved in mechanisms behind chronic airway obstruction in these patients.

Young adults with former BPD display more cytotoxic T-cells in the airways than healthy subjects. These T-cells correlate with FEV₁. Thus, cytotoxic T-cells may contribute to the pathology behind chronic airway obstruction in adults with former BPD.https://bit.ly/3soI4lK

Spirometric phenotypes from early childhood to young adulthood: a Chronic Airway Disease Early Stratification study

Background

The prevalences of obstructive and restrictive spirometric phenotypes, and their relation to early-life risk factors from childhood to young adulthood remain poorly understood. The aim was to explore these phenotypes and associations with well-known respiratory risk factors across ages and populations in European cohorts.

Methods

We studied 49 334 participants from 14 population-based cohorts in different age groups (≤10, >10–15, >15–20, >20–25 years, and overall, 5–25 years). The obstructive phenotype was defined as forced expiratory volume in 1 s (FEV₁)/forced vital capacity (FVC) z-score less than the lower limit of normal (LLN), whereas the restrictive phenotype was defined as FEV₁/FVC z-score ≥LLN, and FVC z-score <LLN.

Results

The prevalence of obstructive and restrictive phenotypes varied from 3.2–10.9% and 1.8–7.7%, respectively, without clear age trends. A diagnosis of asthma (adjusted odds ratio (aOR=2.55, 95% CI 2.14–3.04), preterm birth (aOR=1.84, 1.27–2.66), maternal smoking during pregnancy (aOR=1.16, 95% CI 1.01–1.35) and family history of asthma (aOR=1.44, 95% CI 1.25–1.66) were associated with a higher prevalence of obstructive, but not restrictive, phenotype across ages (5–25 years). A higher current body mass index (BMI was more often observed in those with the obstructive phenotype but less in those with the restrictive phenotype (aOR=1.05, 95% CI 1.03–1.06 and aOR=0.81, 95% CI 0.78–0.85, per kg·m⁻² increase in BMI, respectively). Current smoking was associated with the obstructive phenotype in participants older than 10 years (aOR=1.24, 95% CI 1.05–1.46).

Conclusion

Obstructive and restrictive phenotypes were found to be relatively prevalent during childhood, which supports the early origins concept. Several well-known respiratory risk factors were associated with the obstructive phenotype, whereas only low BMI was associated with the restrictive phenotype, suggesting different underlying pathobiology of these two phenotypes.

Obstructive and restrictive phenotypes are present from childhood to adulthood but without age trends. Established risk factors for airway disease are associated with the obstructive phenotype, whereas low BMI is associated with the restrictive.https://bit.ly/3BMoMtI

Expert meeting report: towards a joint European roadmap to address the unmet needs and priorities of paediatric asthma patients on biologic therapy

A digital multidisciplinary European expert meeting took place on the 9 July 2020 to identify the unmet needs of paediatric severe asthma patients, and set the priorities for clinical and research activities ahead https://bit.ly/3CeLBHB.

Dietary Fibre Intake in Relation to Asthma, Rhinitis and Lung Function Impairment-A Systematic Review of Observational Studies

A high intake of dietary fibre has been associated with a reduced risk of several chronic diseases. This study aimed to review the current evidence on dietary fibre in relation to asthma, rhinitis and lung function impairment. Electronic databases were searched in June 2021 for studies on the association between dietary fibre and asthma, rhinitis, chronic obstructive pulmonary disease (COPD) and lung function. Observational studies with cross-sectional, case–control or prospective designs were included. Studies on animals, case studies and intervention studies were excluded. The quality of the evidence from individual studies was evaluated using the RoB-NObs tool. The World Cancer Research Fund criteria were used to grade the strength of the evidence. Twenty studies were included in this systematic review, of which ten were cohort studies, eight cross-sectional and two case–control studies. Fibre intake during pregnancy or childhood was examined in three studies, while seventeen studies examined the intake during adulthood. There was probable evidence for an inverse association between dietary fibre and COPD and suggestive evidence for a positive association with lung function. However, the evidence regarding asthma and rhinitis was limited and inconsistent. Further research is needed on dietary fibre intake and asthma, rhinitis and lung function among adults and children.

Stevens-Johnson Syndrome in Children: Consider Monitoring for Bronchiolitis Obliterans

We reviewed patients with Stevens-Johnson syndrome (SJS) evaluated at Children's Hospital Colorado and investigated the occurrence of bronchiolitis obliterans (BO). Approximately 9% of patients with SJS developed BO. Pediatricians should consider monitoring patients with SJS for BO, especially those with recurrent SJS and patients treated with mechanical ventilation.

Technological readiness and implementation of genomic-driven precision medicine for complex diseases

The fields of human genetics and genomics have generated considerable knowledge about the mechanistic basis of many diseases. Genomic approaches to diagnosis, prognostication, prevention and treatment - genomic-driven precision medicine (GDPM) - may help optimize medical practice. Here, we provide a comprehensive review of GDPM of complex diseases across major medical specialties. We focus on technological readiness: how rapidly a test can be implemented into health care. Although these areas of medicine are diverse, key similarities exist across almost all areas. Many medical areas have, within their standards of care, at least one GDPM test for a genetic variant of strong effect that aids the identification/diagnosis of a more homogeneous subset within a larger disease group or identifies a subset with different therapeutic requirements. However, for almost all complex diseases, the majority of patients do not carry established single-gene mutations with large effects. Thus, research is underway that seeks to determine the polygenic basis of many complex diseases. Nevertheless, most complex diseases are caused by the interplay of genetic, behavioural and environmental risk factors, which will likely necessitate models for prediction and diagnosis that incorporate genetic and non-genetic data.

Asthma, bronchial hyperresponsiveness, allergy and lung function development until early adulthood: A systematic literature review

BACKGROUND

It is unclear in which periods of life lung function deficits develop, and whether these are affected by risk factors such as asthma, bronchial hyper-responsiveness (BHR) and allergic comorbidity. The goal of this systematic review was to identify temporal associations of asthma, BHR and allergic comorbidity with large and small lung function development from birth until peak function in early adulthood.

METHODS

We searched MEDLINE, EMBASE, Web of Science and CINAHL for papers published before 01.01.2020 on risk factors and lung function measurements of large and small airways. Studies were required to report lung function at any time point or interval from birth until peak lung function (age 21-26) and include at least one candidate risk factor.

RESULTS

Of the 45 papers identified, 44 investigated cohorts and one was a clinical trial with follow-up. Asthma, wheezing, BHR and allergic sensitization early in life and to multiple allergens were associated with a lower lung function growth of large and small airways during early childhood compared with the control populations. Lung function development after childhood in subjects with asthma or persistent wheeze, although continuing to grow at a lower level, largely tracked parallel to non-affected individuals until peak function was attained.

CLINICAL IMPLICATIONS AND FUTURE RESEARCH

Deficits in lung function growth develop in early childhood, and children with asthma, BHR and early-life IgE (poly)sensitization are at risk. This period is possibly a critical window of opportunity to identify at-risk subjects and provide treatment aimed at preventing long-term sequelae of lung function.

Spirometry: A practical lifespan predictor of global health and chronic respiratory and non-respiratory diseases

OBJECTIVES

1. To review and discuss available evidence supporting that spirometry is an overlooked global health marker, that could be used regularly through the lifespan to monitor human health and predict risk of chronic respiratory and other chronic non-communicable diseases (NCDs). 2. To discuss the challenges and opportunities that this proposal faces.Summary of key data. First, spirometry is essential to assess and monitor respiratory health. Second, spirometry adds prognostic value to other well-accepted health markers used in clinical practice, such as blood pressure, body mass index, glucose and blood lipids, by identifying individuals at risk, not only of respiratory diseases, but also of other NCDs, particularly cardiovascular and metabolic disorders.

CONCLUSION

Although we acknowledge that research gaps still exist, we propose that spirometry assessed during childhood, adolescence and early and late adulthood can be a reproducible, non-invasive, safe and affordable global health marker to identify individuals in the general population at risk of respiratory and non-respiratory NCDs. In this context, spirometry may act as the caged canaries that miners used to carry into mines to alert them of dangerous accumulations of gases, thus providing an early warning and save lives.

Characterization of Asthma Trajectories from Infancy to Young Adulthood

BACKGROUND

Development of asthma is complicated by the multidimensional nature of the disease.

OBJECTIVE

To identify and characterize trajectories of asthma from infancy to young adulthood, and their associations with lung function and inflammatory and respiratory markers in adolescence and young adulthood.

METHODS

A latent class analysis was performed in a population-based cohort (N = 4089). Parental and self-reported symptoms of asthma were used to investigate asthma development. We characterized background factors, allergic comorbidity, and IgE sensitization and investigated associations with asthma markers.

RESULTS

A 4-class solution of asthma trajectories was identified: never/infrequent (n = 3291 [80.4%]), early-onset transient (n = 307 [7.5%]), adolescent-onset (n = 261 [6.4%]), and persistent asthma (n = 230 [5.6%]). Uncontrolled asthma was equally prevalent in the adolescent-onset and persistent asthma trajectory groups, at both age 16 (41.7% vs 42.4%; P = .90) and 24 years (53.7% vs 52.4%; P = .81). The persistent asthma trajectory group had a higher proportion of eosinophil counts greater than or equal to 0.3 (10⁹ cells/L) at age 24 years compared with the adolescent-onset trajectory group (31.0% vs 18.5%; P < .01).

CONCLUSIONS

The adolescent-onset and persistent asthma trajectory groups had equal burdens of asthma control in adolescence and young adulthood. However, the persistent asthma trajectory group showed more signs of type 2 inflammation than the adolescent-onset trajectory group. This unbiased approach highlights the need of identifying patients with adolescent asthma to optimize care, because they suffer the same lack of asthma control as those with persistent asthma.

Early-life risk factors for reversible and irreversible airflow limitation in young adults: findings from the BAMSE birth cohort

We aimed to determine prevalence and early-life risk factors for reversible and irreversible airflow limitation in young adults from the general population. Among young adults in their 20s, the prevalence was 5.3% for reversible airflow limitation and 2.0% for irreversible airflow limitation. While parental asthma was the only risk factor for development of reversible airflow limitation, the risk factors for development of irreversible airflow limitation were current asthma, childhood respiratory tract infections and asthma, and exposure to air pollution.

Agreement between spirometry and impulse oscillometry for lung function assessment in 6-year-old children born extremely preterm and at term

BACKGROUND

Extremely preterm birth is a risk factor for reduced lung function later in life, and clinical follow-up from early childhood is recommended. Dynamic spirometry is the most widely used method to assess airway obstruction, but impulse oscillometry (IOS) may be an alternative method that is easier to perform in young children. The feasibility and agreement between spirometry and IOS outcome variables has not been investigated in children born extremely preterm.

AIM

To determine the feasibility of and correlation between spirometry and IOS in pre-school children born extremely preterm.

METHODS

Spirometry and IOS were performed in 6-year-old children born extremely preterm (n = 88) and age-matched term controls (n = 84) in Stockholm, Sweden. Correlations between spirometry and IOS outcome variables were analyzed using Pearson's partial correlation, adjusting for height.

RESULTS

Success rate for spirometry (60%) was lower than for IOS (93%) but did not differ significantly between the preterm and term groups (56% and 64% for spirometry, P = .25; and 92% and 94% for IOS, P = .61). Correlations between spirometry and IOS outcomes were at best moderate (Spearman's r = -0.31 to -0.56). Normal IOS identified 69% to 90% of those with normal spirometry. A negative predictive value of 90% was found for R5-R20 versus FEV_0.75 /FVC, suggesting that IOS may be used to exclude obstructive airway disease as measured by spirometry.

CONCLUSION

IOS is a more feasible method than spirometry to assess lung function in young children irrespective of gestational age at birth and could be considered an alternative in children who cannot perform spirometry.

Addressing the risk domain in the long-term management of pediatric asthma

There is growing concern regarding the long-term outcomes of early and poorly controlled childhood asthma, either of which can potentially lead to the development of severe asthma in adults and irrecoverable loss of lung function leading to chronic obstructive pulmonary disease. These outcomes of inadequately controlled asthma should prompt a change in practice to better and/or earlier identify children at risk of adverse respiratory outcomes of asthma, to monitor disease progression, and to design intervention strategies that could either prevent or reverse asthma progression in children. The careful follow-up of spirometry over time-in the form of lung function trajectories, the application of biomarkers to assist in the diagnosis of early asthma and medication selection for these patients, as well as methods to identify patients at risk of asthma attacks-can be used to develop individualized management strategies for children with asthma. It is now time for asthma specialists to communicate this information to patients, parents, and primary care physicians and to incorporate them into routine clinical assessments of children with asthma. In time, these concepts of risk management and prevention can be refined to provide a more comprehensive approach to asthma care so as to prevent adverse respiratory outcomes from poorly controlled childhood asthma.

Dietary antioxidant intake in school age and lung function development up to adolescence

Dietary antioxidant intake has been hypothesised to influence lung function. The association between total antioxidant capacity (TAC) of the diet at age 8 years and lung function development up to 16 years in 2307 participants from the Swedish population-based birth cohort BAMSE (Children, Allergy, Milieu, Stockholm, Epidemiology) was investigated.

Information on TAC was obtained from a food frequency questionnaire at 8 years. Lung function was measured by spirometry at 8 and 16 years, impulse oscillometry (IOS) and exhaled nitric oxide fraction (F_eNO) at 16 years. Low lung function was defined as forced expiratory volume in 1 s (FEV₁) z-score below the 25th percentile. Longitudinal associations between TAC and lung function were analysed by mixed effect models adjusted for potential confounders. Stratification by asthma at 8 years was performed to examine effect modification.

The median TAC intake was 10 067 μmol Trolox equivalents (TE)·g⁻¹, with males having a lower mean compared to females (9963 versus 10 819 μmol TE·g⁻¹). In analyses of lung function change between 8 and 16 years, there were no statistically significant associations between TAC in tertiles and spirometry results for the total study population. Among children with asthma at 8 years (prevalence 7%), higher TAC was associated with higher mean FEV₁ (0.46 sd, 95% CI 0.11–0.80) and decreased odds of low lung function at 16 years (OR 0.28, 95% CI 0.12–0.65). There were no associations between TAC and forced vital capacity or IOS/F_eNO results.

High dietary antioxidant intake in school age may be associated with improved lung function development from school age to adolescence among children with asthma.

Dietary antioxidant intake at school age may influence lung function development as measured by FEV₁ up to adolescence among children with asthma. In contrast, no association was observed among children without asthma.http://bit.ly/2CzEZ8W