As hma and Medi e anean Die
Asma e Alimen ação Medi e ânica
Ana Isabel Mo ais Dua e
O ien ação: D a. Pa ícia Pad ão
Co-o ien ação: D . Fe nando Pichel
T abalho de Re isão
1.º Ciclo em Ciências da Nu ição
Faculdade de Ciências da Nu ição e Alimen ação da Uni e sidade do Po o
Po o, 2012
i
Abs ac
As hma is one o he mos common ch onic disease in childhood, imposing a huge
bu den on he pa ien , hei amily and socie y. The e is e idence ha i s
p e alence has inc eased o e he las decades and is s ill inc easing, despi e
he e being some indica ions ha he inc ease in p e alence may ha e pla eaued
in some coun ies in he las ew yea s. I has been hypo hesized ha his inc ease
is a consequence o changes in en i onmen al and/o beha io al ac o s, namely
he modi ica ion in die a y habi s. A ecen numbe o in es iga ions ag ee ha
adhe ence o a Medi e anean die a y pa e n can be associa ed wi h a dec eased
isk o cu en as hma symp oms. Al hough his e idence is p omising, u he
esea ch is needed.
Key wo ds: As hma, Medi e anean die , die a y pa e ns, p e alence
ii
Resumo
A Asma é uma das doenças c ónicas mais comuns na in ância, aca e ando
consigo um eno me ónus an o pa a o pacien e, como pa a a sua amília e
sociedade. Há es udos que mos am que a p e alência des a pa ologia em indo
a aumen a nas úl imas décadas, apesa de ha e algumas indicações no sen ido
des a es a a es abiliza em alguns países. Algumas hipó eses suge em que es e
aumen o é consequência de mudanças ambien ais e compo amen ais,
nomeadamen e na modi icação dos hábi os alimen a es. In es igações ecen es
assumem que a adesão ao pad ão medi e ânico pode es a associada a uma
diminuição dos sin omas da asma. Embo a es a conclusão seja p omisso a, é
necessá ia uma in es igação mais ap o undada.
Pala as-Cha e: Asma, Die a Medi e ânica, Pad ões Alimen a es, P e alência
iii
Index
Abs ac i
Key wo ds i
Resumo ii
Pala as-cha e ii
1. In oduc ion 1
2. As hma 1
2.1. The p e alence o As hma 1
2.2. Social and Economic Bu den 3
2.3. Fac o s in luencing he De elopmen and Exp ession o As hma 4
2.3.1. An ioxidan Hypo hesis 5
2.3.2. Lipid Hypo hesis 6
2.3.3. Vi amin D Hypo hesis 6
3. Die a y Pa e ns e sus Single Nu ien s 7
4. Medi e anean Die 8
5. Medi e anean Die and As hma 9
6. Conclusions 14
7. Acknowledgemen s 15
8. Re e ences 16
1
1. In oduc ion
As hma is a mul i ac o ial and o dina y ch onic in lamma o y diso de o he
ai ways, wi h a high p e alence in all age g oups, bu mos ly in child en and young
adul s, and i is a se ious public heal h p oblem in se e al coun ies h oughou he
wo ld(1-3).
This e iew conside s he cu en scien i ic e idence o he associa ion be ween
Medi e anean die a y and as hma.
2. As hma
Al hough he e is no s anda d as hma de ini ion, a desc ip ion has been p oposed
by he Global Ini ia i e o As hma (GINA) based on he unc ional consequences
o he ai ways in lamma ion: As hma is a ch onic in lamma o y diso de o he
ai ways in which many cells and cellula elemen s play a ole. The ch onic
in lamma ion is associa ed wi h ai way hype esponsi eness ha leads o
ecu en episodes o wheezing, b ea hlessness, ches igh ness, and coughing,
pa icula ly a nigh o in he ea ly mo ning. These episodes a e usually associa ed
wi h widesp ead, bu a iable ai low obs uc ion wi hin he lung and is o en
e e sible ei he spon aneously o wi h ea men (4).
2.1. The P e alence o As hma
The p e alence o as hma has ma kedly inc eased in he las decades, especially
in child en in he wes e n wo ld, o igina ing wha has been e e ed o as an
2
‘‘alle gy epidemic”(5-9). Nowadays, i is es ima ed ha his disease a ec s
app oxima ely 300 million people and ha is causes 250 housand annual dea hs
(4, 10). I is es ima ed ha by 2025 he e could be an addi ional 100 million people
a ec ed by his disease(1, 11). The a eas o he wo ld's highes p e alence o
as hma a e in No h Ame ica, La in Ame ica and Aus alia (Figu e 1).
Ne e heless, ecen e idence om epidemiological s udies sugges s ha he
p e alence o as hma eached a pla eau in mos indus ialized coun ies, and may
now be declining due o ea lie de ec ion and imp o ed ea men (3, 12-14). In
Eu ope, he p e alence o his disease anges om 18.4% (Sco land) o 1.3%
(Albania) (Table1).
In pa icula , s udies indica e ha he p e alence o as hma in Po ugal is 11.0% in
child en (6-7 yea s), 11.8% in adolescen s (13-14 yea s) and 5.2% in adul s (20-44
yea s)(15, 16).
Figu e 1 - Wo ldwide p e alence o clinical as hma(11)
3
2.2. Social and Economic Bu den
As hma ep esen s a se ious economic and social impac in heal h ca e sys ems,
on pa ien s’ quali y o li e and on socie y as a whole(4, 12, 17, 18).
In he economic analysis o as hma bo h di ec medical cos s as well as indi ec
non-medical cos s need o be accoun ed o (4). On he one hand, hospi al
admissions and medica ions en ail high cos s o people and o heal h ca e
sys ems(19). On he o he hand, his disease is one o he mos common causes o
3
Table 1 - P e alence o Clinical As hma in Eu ope (adap ed om Masoli e al.)(11)
Coun y
P e alence %
Sco land
18.4
Wales
16.8
England
15.3
Republic o I eland
14.6
Mal a
8.0
Belgium
6.0
Aus ia
5.8
Spain
5.7
Es onia
5.4
Po ugal
4.8
I aly
4.5
Poland
4.1
Denma k
3.0
G eece
1.9
Albania
1.3
10
Table 3 - Summa y o s udies and hei indings ega ding die a y ac o s and lung unc ion
Au ho
Design
Sample
Coun y
Main Findings
De Ba le e al.(13)
C oss-sec ional
1476 Child en, 6-7
yea s
Mexicali egion,
Mexico
Medi e anean Die (MD) o e s a p o ec i e e ec
agains as hma and alle gic hini is
Ba os R., e
al.(23)
C oss-sec ional
174 Adul s
Po ugal
High adhe ence o adi ional MD inc eased likelihood
o as hma con ol
Cha zi e al.(47)
C oss-sec ional
690 Child en, 7-18
yea s
C e e, G eece
Consump ion o ui s, ege ables, nu s and a high
adhe ence o a adi ional MD ha e bene icial e ec s
on as hma and hini is
Gonzalez e
al.(48)
C oss-sec ional
14700 Child en and
Adolescen s
Galicia, Spain
G ea e adhe ence o MD is associa ed wi h highe
isk o se e e as hma
Ga cia-Ma cos e
al.(49)
C oss-sec ional
20106 Child en, 6-7
yea s
Spain
A Medi e anean die has a po en ially p o ec i e
e ec in gi ls aged 6-7 yea s
A an ini e al.(29)
C oss-sec ional
700 Child en, 10-12
yea s
A hens, G eece
In e se ela ionship be ween le el o adhe ence o
Medi e anean die and p e alence o as hma
Cha zi e al.(50)
Re iew o he
li e a u e
-
-
High le el o adhe ence o he Medi e anean die
ea ly in li e p o ec s agains he de elopmen o
as hma and a opy in child en
Cas o-
Rod iguez(43)
C oss-sec ional
1784 Child en, 4
yea s
Mu cia, Spain
The MD is an independen p o ec i e ac o o
cu en wheezing in p e-schoole s, i espec i e o
obesi y and physical ac i i y
Tabak e al.(32)
C oss-sec ional
598 Child en, 8-13
yea s
The
Ne he lands
High in ake o whole g ain p oduc s and ish may
ha e a p o ec i e e ec agains as hma in child en.
No clea associa ion o ci us ui , ege ables, and
dai y p oduc s in ake and as hma
Cook e al.(51)
C oss-sec ional
2650 child en, 8 -11
yea s
England
F esh ui consump ion appea s o ha e a bene icial
e ec on lung unc ion in child en.
Ellwood e al.(35)
C oss-sec ional
721 601 Child en
56 di e en
coun ies
Nega i e associa ion be ween ege able
consump ion and as hma
Fa chi e al.(33)
C oss-sec ional
5257 Child en, 6-7
yea s
I aly
High consump ion o ui s and ege ables may
educe wheezing symp oms
11
con ol in adul s(23). In u al a eas o C e e, a p o ec i e e ec o ui s, ege ables
and nu s on sel - epo ed wheezing in child en and adolescen s was obse ed(47).
Ano he s udy in Mexican child en showed ha a g ea e adhe ence o a
Medi e anean die a y pa e ns was associa ed wi h ha ing less as hma, wheezing
alle gic hini is and cu en sneezing(13). In a Spanish mul icen e s udy,
Medi e anean Die dec eased he isk o se e e as hma in school aged gi ls(49).
A an ini e al. shows ha he e is an in e se ela ionship be ween he le el o
adhe ence o Medi e anean die and p e alence o as hma in school-aged
child en(29). Medi e anean die has key elemen s ha ha e been sugges ed o be
esponsible o he bene icial e ec o die on human heal h in gene al and
po en ially p o ec i e o as hma in pa icula .
Wi h ega ds o he Medi e anean die du ing p egnancy and i s impac on
as hma, he e a e some ecen s udies sugges ing ha a high le el o adhe ence
o he Medi e anean die in ma e nal and ea ly li e play a ole in he child’s
immune sys em de elopmen and p o ec s agains he de elopmen o as hma and
a opy in child en(50, 52). Mo e speci ically, consump ion o ege ables mo e han
eigh imes pe week was in e sely associa ed wi h pe sis en wheeze and a opy.
Fish in ake mo e han wo o h ee imes pe week and legumes in ake mo e han
once pe week we e in e sely associa ed wi h pe sis en wheeze. In con as , an
inc eased in ake o ed mea (mo e han h ee o ou imes pe week) showed a
end owa ds posi i e associa ions wi h pe sis en wheeze and a opic wheeze in
o sp ing (50, 52). I was also epo ed ha oli e oil (componen o he Medi e anean
die ), used as he main sou ce o oil o cooking o d essing salads du ing
p egnancy, is associa ed wi h less wheezing o he child en du ing hei i s yea
o li e(53). The main ac i e componen s o oli e oil include oleic acid, phenolic
12
de i a i es (hyd oxy y osol, y osol, oleu opein, and ligs oside) and squelene, all
o which ha e been ound o exhibi a ma ked an ioxidan ac i i y; oleu opein and
i s hyd olysis p oduc (hyd oxy y osol) being he mos po en an ioxidan s(53).
Se e al s udies epo ed ha a g ea e in ake o esh ui and ege ables is
ela ed o a lowe p e alence o espi a o y symp oms(23, 51, 54, 55). In ac , hese
oods may p o ide ib e and an ioxidan s, which may educe endogenous oxida i e
s ess ela ed o in lamma o y diseases(13, 23). Fu he mo e, ui s and ege ables
a e ex emely ich in i amins C, E, ẞ-ca o ene, magnesium, and selenium which
a e associa ed wi h educ ion in as hma p e alence and may p e en o limi an
in lamma o y esponse in he ai ways by educing eac i e oxygen species and
inhibi ing lipid pe oxida ion(29, 47, 56). In addi ion, la onoids, an ioxidan s equen ly
ound in ui s and ed wine, may ha e an i-alle gic and an i-in lamma o y
e ec s(28). These a e associa ed wi h educ ion in as hma p e alence and may
p e en o limi an in lamma o y esponse in he ai ways by educing eac i e
oxygen species and inhibi ing lipid pe oxida ion(29, 47).
On he o he hand, he Medi e anean die encou ages he consump ion o nu s,
including almonds, hazelnu s, walnu s, peanu s, pine nu s, pis achios and
cashews, which con ain a high p opo ion o monounsa u a ed (MUFA) and α-
linolenic acid, ib es, i amins ( ola e, i amins E and B6), mine als (coppe ,
magnesium, zinc and selenium) and many bioac i e compounds, including a
a ie y o polyphenols ha may modula e edox s a us, in lamma o y and immune
esponse(23).
Addi ionally, he ela i ely high consump ion o a y ish (e.g. sa dine, una,
salmon), sou ce o n-3 a y acids, combined wi h low n-6 consump ion om
die a y a s is ypical in a Medi e anean die . This high n-3/ n-6 a y acid a io
13
educes he le els o p o-in lamma o y cy okines ( ha a e inc eased in as hma ic
subjec s) and in luences he di e en ia ion o T-helpe lymphocy es(13, 54).
Fu he mo e, long-chain n-3 PUFA dec eases he p oduc ion o in lamma o y
media o s, compe i i ely inhibi ing he me abolism o a achidonic acid (gene a ing
less ac i e p os enoids and leuko ienes), supp essing IgE p oduc ion, and he eby
po en ially ac ing o educe ai way in lamma ion and b onchocons ic ion in
as hma(27).
Ce eals (pa icula ly wholeg ain) a e ich in i amin D, phenolic acids, and phy ic
acid which a e an ioxidan s and an i-in lamma o y helping in he ea men o
as hma (29, 53).
Respec ing eligious and social belie s, a mode a e consump ion o wine and o he
e men ed be e ages du ing meals (one glass pe day o women and wo glasses
pe day o men, as a gene ic e e ence) is ecommended in his die a y pa e n(45).
Howe e , he Medi e anean Die Sco e conside s o al e hanol in ake, i espec i e
o he di e en alcoholic be e ages(41). On he opposi e, e hanol in ake was
associa ed wi h inc eased isk o non-con olled as hma. Indeed, some s udies
show ha alcohol consump ion has been associa ed wi h hay e e symp oms,
alle gic sensi iza ion and se um IgE(23, 57). Hence, he associa ion be ween speci ic
be e ages and as hma needs mo e in es iga ion.
Fo all he s a ed easons, high adhe ence o Medi e anean die and o some o
hei ypical componen s such as esh ui s, ege ables, nu s, oli e oil, and
o he s, may ha e a p o ec i e ole in as hma con ol.
14
6. Conclusions
As hma is a mul i ac o ial disease, and he e is a gene al consis ency in he
e idence ha a wes e nized die seems o be associa ed wi h an inc eased isk o
incidence and p e alence o his pa hology.
Epidemiologic s udies in es iga ing he associa ion be ween he in ake o single
nu ien s and oods and as hma a e e y limi ed. Howe e , die a y pa e ns,
especially he Medi e anean, seem o ha e po en ial bene icial e ec s ha should
be aken in o accoun . The e o e, heal h p o essionals should implemen nu i ional
educa ion as a means o imp o e heal hy ea ing.
Because as hma and alle gic diseases usually ha e hei beginnings in ea ly li e,
p ospec i e bi h s udies a e needed o in es iga e he ole o die du ing e al and
ea ly li e. Resea ch on po en ial isk ac o s o as hma and espi a o y alle gies
can enhance ou unde s anding o geog aphic di e ences and suppo decisions
on p e en i e s a egies. In addi ion, mul idisciplina y s udies a e equi ed o
in es iga e he complexi y o die a y ac o s and unde s and he mechanisms o
his p o ec i e e ec , o e alua e he mos ele an window o exposu e, and o
add ess speci ic componen s o die in ela ion o as hma.
15
7. Acknowledgemen s
I would like o hank my supe iso , D a. Pa ícia Pad ão, o he a ec ion,
comp ehension and suppo h oughou he esea ch, planning and w i ing p ocess
o his pape .
A special hanks o D a. Rena a Ba os, who ound he ime and ene gy o gi e
some guidance on he ield o expe ise.
A huge hanks o my amily, iends and boy iend, who always suppo ed me and
ga e me he s eng h and pe se e ance needed o o e come unexpec ed ba ie s.
To my Sis e Susana, o all he ime she in es ed in me and o he inc edible
suppo she ga e me. Thanks o being my Sis e wi h an "S".
To FCNAUP – he place whe e I lea n ha good is no good enough; being pa o
his Facul y s imula es us o be he bes .
16
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