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Williams LM, Berthon BS, Stoodley IL, Williams EJ, Wood LG. Medicinal Mushroom Extracts from Hericium coralloides and Trametes versicolor Exert Differential Immunomodulatory Effects on Immune Cells from Older Adults In Vitro. Nutrients 2023; 15:2227. [PMID: 37432355 DOI: 10.3390/nu15092227] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Revised: 04/21/2023] [Accepted: 05/05/2023] [Indexed: 07/12/2023] Open
Abstract
Medicinal mushroom extracts (MMEs) exert immunomodulatory effects on innate immunity. The present study aimed to examine the effect of medicinal mushroom components on in vitro immune cell responses to inflammatory stimuli by peripheral blood mononuclear cells (PBMCs) isolated from older adults, where immune function is altered. PBMCs were treated with extracts from Hericium coralloides (HC) and Trametes versicolor (TV) prior to stimulation with rhinovirus A1 (RVA1), influenza A/H1N1pdm09 (H1N1), lipopolysaccharide (LPS), or house dust mite (HDM) for 48 h. In the presence of virus, type I and II IFN significantly (p < 0.05) decreased following treatment with at least one concentration of all extracts compared to the untreated cell controls, along with significant increases in pro-inflammatory cytokines (IL-1β, IL-6, IL-8). In the presence of LPS, extracts from TV reduced IL-1β compared to untreated cells. In the presence of HDM, the concentration of IL-5 and/or IL-13 was significantly decreased with at least one dose of all extracts. MMEs exert differential effects on the release of inflammatory and antiviral mediators in vitro. Reduced type 2 cytokine responses to HDM may be beneficial in conditions where allergic inflammation is present, including asthma, allergic rhinitis, and eczema. Further research is needed to examine extracts in vivo.
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Affiliation(s)
- Lily M Williams
- School of Biomedical Sciences and Pharmacy, College of Health, Medicine and Wellbeing, University of Newcastle, Callaghan, NSW 2308, Australia
- Immune Health Research Program, Hunter Medical Research Institute, New Lambton Heights, NSW 2305, Australia
| | - Bronwyn S Berthon
- School of Biomedical Sciences and Pharmacy, College of Health, Medicine and Wellbeing, University of Newcastle, Callaghan, NSW 2308, Australia
- Immune Health Research Program, Hunter Medical Research Institute, New Lambton Heights, NSW 2305, Australia
| | - Isobel L Stoodley
- School of Biomedical Sciences and Pharmacy, College of Health, Medicine and Wellbeing, University of Newcastle, Callaghan, NSW 2308, Australia
- Immune Health Research Program, Hunter Medical Research Institute, New Lambton Heights, NSW 2305, Australia
| | - Evan J Williams
- School of Biomedical Sciences and Pharmacy, College of Health, Medicine and Wellbeing, University of Newcastle, Callaghan, NSW 2308, Australia
- Immune Health Research Program, Hunter Medical Research Institute, New Lambton Heights, NSW 2305, Australia
| | - Lisa G Wood
- School of Biomedical Sciences and Pharmacy, College of Health, Medicine and Wellbeing, University of Newcastle, Callaghan, NSW 2308, Australia
- Immune Health Research Program, Hunter Medical Research Institute, New Lambton Heights, NSW 2305, Australia
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Hosseini B, Berthon BS, Jensen ME, McLoughlin RF, Wark PAB, Nichol K, Williams EJ, Baines KJ, Collison A, Starkey MR, Mattes J, Wood LG. The Effects of Increasing Fruit and Vegetable Intake in Children with Asthma on the Modulation of Innate Immune Responses. Nutrients 2022; 14:nu14153087. [PMID: 35956264 PMCID: PMC9370535 DOI: 10.3390/nu14153087] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Revised: 07/23/2022] [Accepted: 07/25/2022] [Indexed: 12/04/2022] Open
Abstract
Children with asthma are at risk of acute exacerbations triggered mainly by viral infections. A diet high in fruit and vegetables (F&V), a rich source of carotenoids, may improve innate immune responses in children with asthma. Children with asthma (3−11 years) with a history of exacerbations and low F&V intake (≤3 serves/d) were randomly assigned to a high F&V diet or control (usual diet) for 6 months. Outcomes included respiratory-related adverse events and in-vitro cytokine production in peripheral blood mononuclear cells (PBMCs), treated with rhinovirus-1B (RV1B), house dust mite (HDM) and lipopolysaccharide (LPS). During the trial, there were fewer subjects with ≥2 asthma exacerbations in the high F&V diet group (n = 22) compared to the control group (n = 25) (63.6% vs. 88.0%, p = 0.049). Duration and severity of exacerbations were similar between groups. LPS-induced interferon (IFN)-γ and IFN-λ production showed a small but significant increase in the high F&V group after 3 months compared to baseline (p < 0.05). Additionally, RV1B-induced IFN-λ production in PBMCs was positively associated with the change in plasma lycopene at 6 months (rs = 0.35, p = 0.015). A high F&V diet reduced asthma-related illness and modulated in vitro PBMC cytokine production in young children with asthma. Improving diet quality by increasing F&V intake could be an effective non-pharmacological strategy for preventing asthma-related illness by enhancing children’s innate immune responses.
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Affiliation(s)
- Banafsheh Hosseini
- Priority Research Centre for Healthy Lungs, Hunter Medical Research Institute, University of Newcastle, Newcastle, NSW 2305, Australia; (B.H.); (B.S.B.); (R.F.M.); (P.A.B.W.); (K.N.); (E.J.W.); (K.J.B.); (A.C.); (M.R.S.)
| | - Bronwyn S. Berthon
- Priority Research Centre for Healthy Lungs, Hunter Medical Research Institute, University of Newcastle, Newcastle, NSW 2305, Australia; (B.H.); (B.S.B.); (R.F.M.); (P.A.B.W.); (K.N.); (E.J.W.); (K.J.B.); (A.C.); (M.R.S.)
| | - Megan E. Jensen
- Priority Research Centre Grow Up Well, Hunter Medical Research Institute, University of Newcastle, Newcastle, NSW 2305, Australia; (M.E.J.); (J.M.)
| | - Rebecca F. McLoughlin
- Priority Research Centre for Healthy Lungs, Hunter Medical Research Institute, University of Newcastle, Newcastle, NSW 2305, Australia; (B.H.); (B.S.B.); (R.F.M.); (P.A.B.W.); (K.N.); (E.J.W.); (K.J.B.); (A.C.); (M.R.S.)
| | - Peter A. B. Wark
- Priority Research Centre for Healthy Lungs, Hunter Medical Research Institute, University of Newcastle, Newcastle, NSW 2305, Australia; (B.H.); (B.S.B.); (R.F.M.); (P.A.B.W.); (K.N.); (E.J.W.); (K.J.B.); (A.C.); (M.R.S.)
- Department of Respiratory and Sleep Medicine, John Hunter Hospital, Newcastle, NSW 2305, Australia
| | - Kristy Nichol
- Priority Research Centre for Healthy Lungs, Hunter Medical Research Institute, University of Newcastle, Newcastle, NSW 2305, Australia; (B.H.); (B.S.B.); (R.F.M.); (P.A.B.W.); (K.N.); (E.J.W.); (K.J.B.); (A.C.); (M.R.S.)
| | - Evan J. Williams
- Priority Research Centre for Healthy Lungs, Hunter Medical Research Institute, University of Newcastle, Newcastle, NSW 2305, Australia; (B.H.); (B.S.B.); (R.F.M.); (P.A.B.W.); (K.N.); (E.J.W.); (K.J.B.); (A.C.); (M.R.S.)
| | - Katherine J. Baines
- Priority Research Centre for Healthy Lungs, Hunter Medical Research Institute, University of Newcastle, Newcastle, NSW 2305, Australia; (B.H.); (B.S.B.); (R.F.M.); (P.A.B.W.); (K.N.); (E.J.W.); (K.J.B.); (A.C.); (M.R.S.)
| | - Adam Collison
- Priority Research Centre for Healthy Lungs, Hunter Medical Research Institute, University of Newcastle, Newcastle, NSW 2305, Australia; (B.H.); (B.S.B.); (R.F.M.); (P.A.B.W.); (K.N.); (E.J.W.); (K.J.B.); (A.C.); (M.R.S.)
- Priority Research Centre Grow Up Well, Hunter Medical Research Institute, University of Newcastle, Newcastle, NSW 2305, Australia; (M.E.J.); (J.M.)
| | - Malcolm R. Starkey
- Priority Research Centre for Healthy Lungs, Hunter Medical Research Institute, University of Newcastle, Newcastle, NSW 2305, Australia; (B.H.); (B.S.B.); (R.F.M.); (P.A.B.W.); (K.N.); (E.J.W.); (K.J.B.); (A.C.); (M.R.S.)
- Priority Research Centre Grow Up Well, Hunter Medical Research Institute, University of Newcastle, Newcastle, NSW 2305, Australia; (M.E.J.); (J.M.)
- Department of Immunology and Pathology, Central Clinical School, Sub-Faculty of Translational Medicine and Public Health, Monash University, Melbourne, VIC 3004, Australia
| | - Joerg Mattes
- Priority Research Centre Grow Up Well, Hunter Medical Research Institute, University of Newcastle, Newcastle, NSW 2305, Australia; (M.E.J.); (J.M.)
- Department of Respiratory and Sleep Medicine, John Hunter Hospital, Newcastle, NSW 2305, Australia
| | - Lisa G. Wood
- Priority Research Centre for Healthy Lungs, Hunter Medical Research Institute, University of Newcastle, Newcastle, NSW 2305, Australia; (B.H.); (B.S.B.); (R.F.M.); (P.A.B.W.); (K.N.); (E.J.W.); (K.J.B.); (A.C.); (M.R.S.)
- Priority Research Centre Grow Up Well, Hunter Medical Research Institute, University of Newcastle, Newcastle, NSW 2305, Australia; (M.E.J.); (J.M.)
- Correspondence:
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Berthon BS, Williams LM, Williams EJ, Wood LG. Effect of Lactoferrin Supplementation on Inflammation, Immune Function, and Prevention of Respiratory Tract Infections in Humans: A Systematic Review and Meta-analysis. Adv Nutr 2022; 13:1799-1819. [PMID: 35481594 PMCID: PMC9526865 DOI: 10.1093/advances/nmac047] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Revised: 02/01/2022] [Accepted: 04/21/2022] [Indexed: 01/28/2023] Open
Abstract
Lactoferrin (Lf) is a glycoprotein present in human and bovine milk with antimicrobial and immune-modulating properties. This review aimed to examine the evidence for the effect of Lf supplementation on inflammation, immune function, and respiratory tract infections (RTIs) in humans. Online databases were searched up to December 2020 to identify relevant, English-language articles that examined the effect of Lf supplementation in human subjects of all ages, on either inflammation, immune cell populations or activity, or the incidence, duration, or severity of respiratory illness or RTIs. Twenty-five studies (n = 20 studies in adults) were included, of which 8 of 13 studies (61%) in adults reported a decrease in at least 1 systemic inflammatory biomarker. Immune function improved in 6 of 8 studies (75%) in adults, with changes in immune cell populations in 2 of 6 studies (33%), and changes in immune cell activity in 2 of 5 studies (40%). RTI outcomes were reduced in 6 of 10 studies (60%) (n = 5 in adults, n = 5 in children), with decreased incidence in 3 of 9 studies (33%), and either decreased frequency (2/4, 50%) or duration (3/6, 50%) in 50% of studies. In adults, Lf reduced IL-6 [mean difference (MD): -24.9 pg/mL; 95% CI: -41.64, -8.08 pg/mL], but not C-reactive protein (CRP) [standardized mean difference: -0.09; 95% CI: -0.82, 0.65], or NK cell cytotoxicity [MD: 4.84%; 95% CI: -3.93, 13.60%]. RTI incidence was reduced in infants and children (OR: 0.78; 95% CI: 0.61, 0.98) but not in adults (OR: 1.00; 95% CI: 0.76, 1.32). Clinical studies on Lf supplementation are limited, although findings show 200 mg Lf/d reduces systemic inflammation, while formulas containing 35-833 mg Lf/d may reduce RTI incidence in infants and children, suggesting improved immune function. Future research is required to determine optimal supplementation strategies and populations most likely to benefit from Lf supplementation. This trial was registered at PROSPERO (https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42021232186) as CRD42021232186.
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Affiliation(s)
| | - Lily M Williams
- Priority Research Centre for Healthy Lungs, Hunter Medical Research Institute, The University of Newcastle, Newcastle, Australia
| | - Evan J Williams
- Priority Research Centre for Healthy Lungs, Hunter Medical Research Institute, The University of Newcastle, Newcastle, Australia
| | - Lisa G Wood
- Priority Research Centre for Healthy Lungs, Hunter Medical Research Institute, The University of Newcastle, Newcastle, Australia
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Williams EJ, Berthon BS, Stoodley I, Williams LM, Wood LG. Nutrition in Asthma. Semin Respir Crit Care Med 2022; 43:646-661. [PMID: 35272384 DOI: 10.1055/s-0042-1742385] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
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.
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Affiliation(s)
- Evan J Williams
- Hunter Medical Research Institute and School of Biomedical Science and Pharmacy, The University of Newcastle, Callaghan, Australia
| | - Bronwyn S Berthon
- Hunter Medical Research Institute and School of Biomedical Science and Pharmacy, The University of Newcastle, Callaghan, Australia
| | - Isobel Stoodley
- Hunter Medical Research Institute and School of Biomedical Science and Pharmacy, The University of Newcastle, Callaghan, Australia
| | - Lily M Williams
- Hunter Medical Research Institute and School of Biomedical Science and Pharmacy, The University of Newcastle, Callaghan, Australia
| | - Lisa G Wood
- Hunter Medical Research Institute and School of Biomedical Science and Pharmacy, The University of Newcastle, Callaghan, Australia
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Williams EJ, Guilleminault L, Berthon BS, Eslick S, Wright T, Karihaloo C, Gately M, Baines KJ, Wood LG. Sulforaphane Reduces Pro-Inflammatory Response To Palmitic Acid In Monocytes And Adipose Tissue Macrophages. J Nutr Biochem 2022; 104:108978. [DOI: 10.1016/j.jnutbio.2022.108978] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2021] [Revised: 12/03/2021] [Accepted: 02/09/2022] [Indexed: 10/18/2022]
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Williams LM, Stoodley IL, Berthon BS, Wood LG. The Effects of Prebiotics, Synbiotics, and Short-Chain Fatty Acids on Respiratory Tract Infections and Immune Function: A Systematic Review and Meta-Analysis. Adv Nutr 2021; 13:167-192. [PMID: 34543378 PMCID: PMC8803493 DOI: 10.1093/advances/nmab114] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Revised: 06/25/2021] [Accepted: 09/14/2021] [Indexed: 11/15/2022] Open
Abstract
Prebiotics, synbiotics, and SCFAs have been shown to decrease systemic inflammation and play a protective role in chronic respiratory conditions. However, their effects on infection and immune function are unclear. The objective of this systematic review was to summarize the current evidence for prebiotic, synbiotic, and SCFA supplementation on respiratory tract infections (RTIs) and immune function. The protocol for this systematic review was registered with PROSPERO (National Institute for Health Research, University of York, UK), accessed online at https://www.crd.york.ac.uk/prospero (CRD42019118786). Relevant English-language articles up to May 2021 were identified via online databases: MEDLINE, EMBASE, CINAHL, and Cochrane Library. Included studies (n = 58) examined the effect of prebiotics, synbiotics, or SCFA, delivered orally, on the incidence, severity, or duration of RTIs and/or markers of immune function (e.g., peripheral blood immunophenotyping, NK cell activity). The majority of studies were randomized controlled trials reporting on RTIs in infants and children. The meta-analysis indicated that the numbers of subjects with ≥1 RTI were reduced with prebiotic (OR, 0.73; 95% CI: 0.62-0.86; P = 0.0002; n = 17) and synbiotic (OR, 0.75; 95% CI: 0.65-0.87; P = 0.0001; n = 9) supplementation compared to placebo. Further, NK cell activity was increased with synbiotic (standardized mean difference, 0.74; 95% CI: 0.42-1.06; P < 0.0001, n = 3) supplementation. This review provides evidence that prebiotic, specifically oligosaccharide, supplementation may play a protective role in RTIs in infants and children. There is less evidence for this effect in adults. Supplementation with prebiotic and synbiotic treatment may alter immune function by increasing NK cell activity, though effects on immunophenotype were less clear.
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Affiliation(s)
| | - Isobel L Stoodley
- School of Biomedical Sciences & Pharmacy, University of Newcastle, Callaghan, Australia
| | - Bronwyn S Berthon
- School of Biomedical Sciences & Pharmacy, University of Newcastle, Callaghan, Australia,Priority Research Centre for Healthy Lungs, Hunter Medical Research Institute, New Lambton Heights, Australia
| | - Lisa G Wood
- School of Biomedical Sciences & Pharmacy, University of Newcastle, Callaghan, Australia,Priority Research Centre for Healthy Lungs, Hunter Medical Research Institute, New Lambton Heights, Australia
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Pinkerton JW, Kim RY, Brown AC, Rae BE, Donovan C, Mayall JR, Carroll OR, Khadem Ali M, Scott HA, Berthon BS, Baines KJ, Starkey MR, Kermani NZ, Guo YK, Robertson AAB, O'Neill LAJ, Adcock IM, Cooper MA, Gibson PG, Wood LG, Hansbro PM, Horvat JC. Relationship between type 2 cytokine and inflammasome responses in obesity-associated asthma. J Allergy Clin Immunol 2021; 149:1270-1280. [PMID: 34678326 DOI: 10.1016/j.jaci.2021.10.003] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Revised: 09/22/2021] [Accepted: 10/01/2021] [Indexed: 12/13/2022]
Abstract
BACKGROUND Obesity is a risk factor for asthma, and obese asthmatic individuals are more likely to have severe, steroid-insensitive disease. How obesity affects the pathogenesis and severity of asthma is poorly understood. Roles for increased inflammasome-mediated neutrophilic responses, type 2 immunity, and eosinophilic inflammation have been described. OBJECTIVE We investigated how obesity affects the pathogenesis and severity of asthma and identified effective therapies for obesity-associated disease. METHODS We assessed associations between body mass index and inflammasome responses with type 2 (T2) immune responses in the sputum of 25 subjects with asthma. Functional roles for NLR family, pyrin domain-containing (NLRP) 3 inflammasome and T2 cytokine responses in driving key features of disease were examined in experimental high-fat diet-induced obesity and asthma. RESULTS Body mass index and inflammasome responses positively correlated with increased IL-5 and IL-13 expression as well as C-C chemokine receptor type 3 expression in the sputum of subjects with asthma. High-fat diet-induced obesity resulted in steroid-insensitive airway hyperresponsiveness in both the presence and absence of experimental asthma. High-fat diet-induced obesity was also associated with increased NLRP3 inflammasome responses and eosinophilic inflammation in airway tissue, but not lumen, in experimental asthma. Inhibition of NLRP3 inflammasome responses reduced steroid-insensitive airway hyperresponsiveness but had no effect on IL-5 or IL-13 responses in experimental asthma. Depletion of IL-5 and IL-13 reduced obesity-induced NLRP3 inflammasome responses and steroid-insensitive airway hyperresponsiveness in experimental asthma. CONCLUSION We found a relationship between T2 cytokine and NLRP3 inflammasome responses in obesity-associated asthma, highlighting the potential utility of T2 cytokine-targeted biologics and inflammasome inhibitors.
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Affiliation(s)
- James W Pinkerton
- Priority Research Centre for Healthy Lungs, Hunter Medical Research Institute and University of Newcastle, Newcastle, Australia; Airway Disease Section, National Heart & Lung Institute, Imperial College London, London, United Kingdom
| | - Richard Y Kim
- Priority Research Centre for Healthy Lungs, Hunter Medical Research Institute and University of Newcastle, Newcastle, Australia; Centre for Inflammation, Centenary Institute and University of Technology Sydney, School of Life Sciences, Faculty of Science, Sydney, Australia
| | - Alexandra C Brown
- Priority Research Centre for Healthy Lungs, Hunter Medical Research Institute and University of Newcastle, Newcastle, Australia
| | - Brittany E Rae
- Priority Research Centre for Healthy Lungs, Hunter Medical Research Institute and University of Newcastle, Newcastle, Australia
| | - Chantal Donovan
- Priority Research Centre for Healthy Lungs, Hunter Medical Research Institute and University of Newcastle, Newcastle, Australia; Centre for Inflammation, Centenary Institute and University of Technology Sydney, School of Life Sciences, Faculty of Science, Sydney, Australia
| | - Jemma R Mayall
- Priority Research Centre for Healthy Lungs, Hunter Medical Research Institute and University of Newcastle, Newcastle, Australia
| | - Olivia R Carroll
- Priority Research Centre for Healthy Lungs, Hunter Medical Research Institute and University of Newcastle, Newcastle, Australia
| | - Md Khadem Ali
- Priority Research Centre for Healthy Lungs, Hunter Medical Research Institute and University of Newcastle, Newcastle, Australia; Division of Pulmonary and Critical Care Medicine, Stanford University, Stanford, Calif
| | - Hayley A Scott
- Priority Research Centre for Healthy Lungs, Hunter Medical Research Institute and University of Newcastle, Newcastle, Australia
| | - Bronwyn S Berthon
- Priority Research Centre for Healthy Lungs, Hunter Medical Research Institute and University of Newcastle, Newcastle, Australia
| | - Katherine J Baines
- Priority Research Centre for Healthy Lungs, Hunter Medical Research Institute and University of Newcastle, Newcastle, Australia
| | - Malcolm R Starkey
- Priority Research Centre for Healthy Lungs, Hunter Medical Research Institute and University of Newcastle, Newcastle, Australia; Department of Immunology and Pathology, Central Clinical School, Monash University, Melbourne, Australia; Priority Research Centre GrowUpWell, Hunter Medical Research Institute and University of Newcastle, Newcastle, Australia
| | - Nazanin Z Kermani
- Data Science Institute, Department of Computing, Imperial College London, London, United Kingdom
| | - Yi-Ke Guo
- Data Science Institute, Department of Computing, Imperial College London, London, United Kingdom
| | - Avril A B Robertson
- School of Chemistry and Molecular Biosciences, University of Queensland, Brisbane, Australia
| | - Luke A J O'Neill
- School of Biochemistry and Immunology, Trinity Biomedical Sciences Institute, Trinity College Dublin, Dublin, Ireland
| | - Ian M Adcock
- Airway Disease Section, National Heart & Lung Institute, Imperial College London, London, United Kingdom
| | - Matthew A Cooper
- Institute for Molecular Bioscience, University of Queensland, Brisbane, Australia
| | - Peter G Gibson
- Priority Research Centre for Healthy Lungs, Hunter Medical Research Institute and University of Newcastle, Newcastle, Australia
| | - Lisa G Wood
- Priority Research Centre for Healthy Lungs, Hunter Medical Research Institute and University of Newcastle, Newcastle, Australia
| | - Philip M Hansbro
- Priority Research Centre for Healthy Lungs, Hunter Medical Research Institute and University of Newcastle, Newcastle, Australia; Centre for Inflammation, Centenary Institute and University of Technology Sydney, School of Life Sciences, Faculty of Science, Sydney, Australia
| | - Jay C Horvat
- Priority Research Centre for Healthy Lungs, Hunter Medical Research Institute and University of Newcastle, Newcastle, Australia.
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Berthon BS, McLoughlin RF, Jensen ME, Hosseini B, Williams EJ, Baines KJ, Taylor SL, Rogers GB, Ivey KL, Morten M, Da Silva Sena CR, Collison AM, Starkey MR, Mattes J, Wark PAB, Wood LG. The effects of increasing fruit and vegetable intake in children with asthma: A randomized controlled trial. Clin Exp Allergy 2021; 51:1144-1156. [PMID: 34197676 DOI: 10.1111/cea.13979] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Accepted: 06/25/2021] [Indexed: 12/13/2022]
Abstract
BACKGROUND A high fruit and vegetable (F&V) diet reduces asthma exacerbations in adults; this has not been examined in children to date. OBJECTIVE To investigate the effect of a 6-month, high F&V diet on the time to first asthma exacerbation in children with asthma, in a parallel-group, randomized, controlled trial. METHODS Children (aged 3-11 years) with asthma, history of exacerbations and usual low F&V intake (≤3 serves/day) were randomized to the intervention (high F&V diet) or control group (usual diet) for 6 months. The primary outcome was time to first exacerbation requiring medical intervention. Secondary outcomes included exacerbation rate, lung function, plasma TNF-α, CRP, and IL-6, faecal microbiota and peripheral blood mononuclear cell (PBMC) histone deacetylase (HDAC) activity and G-protein coupled receptor (GPR) 41/43 and HDAC (1-11) expression. RESULTS 67 children were randomized between September 2015 and July 2018. F&V intake (difference in change (∆): 3.5 serves/day, 95% CI: [2.6, 4.4] p < 0.001) and plasma total carotenoids (∆: 0.44 µg/ml [0.19, 0.70] p = 0.001) increased after 6 months (intervention vs control). Time to first exacerbation (HR: 0.81, 95% CI: [0.38, 1.69], p = 0.569) and exacerbation rate (IRR: 0.84, [0.47, 1.49], p = 0.553) were similar between groups. In per-protocol analysis, airway reactance z-scores increased (X5 ∆: 0.76 [0.04, 1.48] p = 0.038, X20 ∆: 0.93 [0.23, 1.64] p = 0.009) and changes in faecal microbiota were observed, both in the intervention versus control group, though there was no difference between groups in systemic inflammation or molecular mechanisms. In the control group, CRP and HDAC enzyme activity increased, while GPR41 expression decreased. No adverse events attributable to the interventions were observed. CONCLUSION & CLINICAL RELEVANCE A high F&V diet did not affect asthma exacerbations over the 6-month intervention, though warrants further investigation as a strategy for improving lung function and protecting against systemic inflammation in children with asthma.
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Affiliation(s)
- Bronwyn S Berthon
- Priority Research Centre for Healthy Lungs, Hunter Medical Research Institute, University of Newcastle, Newcastle, NSW, Australia
| | - Rebecca F McLoughlin
- Priority Research Centre for Healthy Lungs, Hunter Medical Research Institute, University of Newcastle, Newcastle, NSW, Australia
| | - Megan E Jensen
- Priority Research Centre GrowUpwell, Hunter Medical Research Institute, University of Newcastle, Newcastle, NSW, Australia
| | - Banafshe Hosseini
- Priority Research Centre for Healthy Lungs, Hunter Medical Research Institute, University of Newcastle, Newcastle, NSW, Australia
| | - Evan J Williams
- Priority Research Centre for Healthy Lungs, Hunter Medical Research Institute, University of Newcastle, Newcastle, NSW, Australia
| | - Katherine J Baines
- Priority Research Centre for Healthy Lungs, Hunter Medical Research Institute, University of Newcastle, Newcastle, NSW, Australia
| | - Steven L Taylor
- Microbiome & Host Health, South Australian Health and Medical Research Institute, Adelaide, SA, Australia.,College of Medicine and Public Health, Flinders University, Adelaide, SA, Australia
| | - Geraint B Rogers
- Microbiome & Host Health, South Australian Health and Medical Research Institute, Adelaide, SA, Australia.,College of Medicine and Public Health, Flinders University, Adelaide, SA, Australia
| | - Kerry L Ivey
- Microbiome & Host Health, South Australian Health and Medical Research Institute, Adelaide, SA, Australia.,Department of Nutrition, Harvard T. H. Chan School of Public Health, Boston, MA, USA
| | - Matthew Morten
- Priority Research Centre GrowUpwell, Hunter Medical Research Institute, University of Newcastle, Newcastle, NSW, Australia
| | - Carla R Da Silva Sena
- Priority Research Centre GrowUpwell, Hunter Medical Research Institute, University of Newcastle, Newcastle, NSW, Australia
| | - Adam M Collison
- Priority Research Centre for Healthy Lungs, Hunter Medical Research Institute, University of Newcastle, Newcastle, NSW, Australia.,Priority Research Centre GrowUpwell, Hunter Medical Research Institute, University of Newcastle, Newcastle, NSW, Australia
| | - Malcolm R Starkey
- Priority Research Centre for Healthy Lungs, Hunter Medical Research Institute, University of Newcastle, Newcastle, NSW, Australia.,Priority Research Centre GrowUpwell, Hunter Medical Research Institute, University of Newcastle, Newcastle, NSW, Australia.,Department of Immunology and Pathology, Central Clinical School, Monash University, Melbourne, VIC, Australia
| | - Joerg Mattes
- Priority Research Centre GrowUpwell, Hunter Medical Research Institute, University of Newcastle, Newcastle, NSW, Australia.,Department of Respiratory and Sleep Medicine, John Hunter Hospital, Newcastle, NSW, Australia
| | - Peter A B Wark
- Priority Research Centre for Healthy Lungs, Hunter Medical Research Institute, University of Newcastle, Newcastle, NSW, Australia.,Department of Respiratory and Sleep Medicine, John Hunter Hospital, Newcastle, NSW, Australia
| | - Lisa G Wood
- Priority Research Centre for Healthy Lungs, Hunter Medical Research Institute, University of Newcastle, Newcastle, NSW, Australia.,Priority Research Centre GrowUpwell, Hunter Medical Research Institute, University of Newcastle, Newcastle, NSW, Australia
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Hosseini B, Berthon BS, Starkey MR, Collison A, McLoughlin RF, Williams EJ, Nichol K, Wark PA, Jensen ME, Da Silva Sena CR, Baines KJ, Mattes J, Wood LG. Children With Asthma Have Impaired Innate Immunity and Increased Numbers of Type 2 Innate Lymphoid Cells Compared With Healthy Controls. Front Immunol 2021; 12:664668. [PMID: 34220812 PMCID: PMC8248177 DOI: 10.3389/fimmu.2021.664668] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2021] [Accepted: 05/17/2021] [Indexed: 12/20/2022] Open
Abstract
Background Asthma is the most frequent cause of hospitalisation among children; however, little is known regarding the effects of asthma on immune responses in children. Objective The present study aimed to evaluate cytokine responses of peripheral blood mononuclear cells (PBMCs), PBMC composition and lung function in children with and without asthma. Methods Using a case-control design, we compared 48 children with asthma aged 3-11 years with 14 age-matched healthy controls. PBMC composition and cytokine production including interferon (IFN)-γ, interleukin (IL)-1β, IL-5 and lL-6 following stimulation with rhinovirus-1B (RV1B), house dust mite (HDM) and lipopolysaccharide (LPS) were measured. Lung function was assessed using impulse oscillometry and nitrogen multiple breath washout. Results The frequency of group 2 innate lymphoid cells were significantly higher in asthmatics and PBMCs from asthmatics had deficient IFN-γ production in response to both RV1B and LPS compared with controls (P<0.01). RV1B-induced IL-1β response and HDM-stimulated IL-5 production was higher in asthmatics than controls (P<0.05). In contrast, IL-1β and IL-6 were significantly reduced in response to HDM and LPS in asthmatics compared to controls (P<0.05). Children with asthma also had reduced pulmonary function, indicated by lower respiratory reactance as well as higher area of-reactance and lung clearance index values compared with controls (P<0.05). Conclusion Our study indicates that children with asthma have a reduced lung function in concert with impaired immune responses and altered immune cell subsets. Improving our understanding of immune responses to viral and bacterial infection in childhood asthma can help to tailor management of the disease.
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Affiliation(s)
- Banafshe Hosseini
- Priority Research Centre for Healthy Lungs, Hunter Medical Research Institute, University of Newcastle, Newcastle, NSW, Australia
| | - Bronwyn S Berthon
- Priority Research Centre for Healthy Lungs, Hunter Medical Research Institute, University of Newcastle, Newcastle, NSW, Australia
| | - Malcolm R Starkey
- Priority Research Centre for Healthy Lungs, Hunter Medical Research Institute, University of Newcastle, Newcastle, NSW, Australia.,Priority Research Centre GrowUpWell, Hunter Medical Research Institute, University of Newcastle, Newcastle, NSW, Australia.,Department of Immunology and Pathology, Central Clinical School, Monash University, Melbourne, VIC, Australia
| | - Adam Collison
- Priority Research Centre for Healthy Lungs, Hunter Medical Research Institute, University of Newcastle, Newcastle, NSW, Australia.,Priority Research Centre GrowUpWell, Hunter Medical Research Institute, University of Newcastle, Newcastle, NSW, Australia
| | - Rebecca F McLoughlin
- Priority Research Centre for Healthy Lungs, Hunter Medical Research Institute, University of Newcastle, Newcastle, NSW, Australia
| | - Evan J Williams
- Priority Research Centre for Healthy Lungs, Hunter Medical Research Institute, University of Newcastle, Newcastle, NSW, Australia
| | - Kristy Nichol
- Priority Research Centre for Healthy Lungs, Hunter Medical Research Institute, University of Newcastle, Newcastle, NSW, Australia
| | - Peter Ab Wark
- Priority Research Centre for Healthy Lungs, Hunter Medical Research Institute, University of Newcastle, Newcastle, NSW, Australia.,Department of Respiratory and Sleep Medicine, John Hunter Hospital, Newcastle, NSW, Australia
| | - Megan E Jensen
- Priority Research Centre GrowUpWell, Hunter Medical Research Institute, University of Newcastle, Newcastle, NSW, Australia
| | - Carla Rebeca Da Silva Sena
- Priority Research Centre for Healthy Lungs, Hunter Medical Research Institute, University of Newcastle, Newcastle, NSW, Australia
| | - Katherine J Baines
- Priority Research Centre for Healthy Lungs, Hunter Medical Research Institute, University of Newcastle, Newcastle, NSW, Australia
| | - Joerg Mattes
- Priority Research Centre GrowUpWell, Hunter Medical Research Institute, University of Newcastle, Newcastle, NSW, Australia.,Department of Respiratory and Sleep Medicine, John Hunter Hospital, Newcastle, NSW, Australia
| | - Lisa G Wood
- Priority Research Centre for Healthy Lungs, Hunter Medical Research Institute, University of Newcastle, Newcastle, NSW, Australia.,Priority Research Centre GrowUpWell, Hunter Medical Research Institute, University of Newcastle, Newcastle, NSW, Australia
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Thompson CA, Eslick SR, Berthon BS, Wood LG. Asthma medication use in obese and healthy weight asthma: systematic review/meta-analysis. Eur Respir J 2021; 57:13993003.00612-2020. [PMID: 32943399 DOI: 10.1183/13993003.00612-2020] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2020] [Accepted: 08/31/2020] [Indexed: 12/17/2022]
Abstract
BACKGROUND Obesity is a common comorbidity in asthma and associated with poorer asthma control, more frequent/severe exacerbations, and reduced response to asthma pharmacotherapy. OBJECTIVE This review aims to compare use of all classes of asthma medications in obese (body mass index (BMI) ≤30 kg·m-2) versus healthy-weight (BMI <25 kg·m-2) subjects with asthma. DESIGN Databases including CINAHL (Cumulative Index to Nursing and Allied Health Literature), Cochrane, Embase and MEDLINE were searched up to July 2019 for English-language studies that recorded medication use or dose in obese and healthy-weight adults with asthma. A critical appraisal checklist was utilised for scrutinising methodological quality of eligible studies. Meta-analysis was performed and heterogeneity was examined with the use of the Chi-squared test. This review was conducted based on a published protocol (www.crd.york.ac.uk/PROSPERO CRD42020148671). RESULTS Meta-analysis showed that obese subjects are more likely to use asthma medications, including short-acting β2-agonists (OR 1.75, 95% CI 1.17-2.60; p=0.006, I2=41%) and maintenance oral corticosteroids (OR 1.86, 95% CI 1.49-2.31; p<0.001, I2=0%) compared to healthy-weight subjects. Inhaled corticosteroid (ICS) dose (µg·day-1) was significantly higher in obese subjects (mean difference 208.14, 95% CI 107.01-309.27; p<0.001, I2=74%). Forced expiratory volume in 1 s (FEV1) % predicted was significantly lower in obese subjects (mean difference -5.32%, 95% CI -6.75--3.89; p<0.001, I2=42%); however, no significant differences were observed in FEV1/forced vital capacity (FVC) ratio between groups. CONCLUSIONS We found that obese subjects with asthma have higher use of all included asthma medication classes and higher ICS doses than healthy-weight asthma subjects, despite lower FEV1 and a similar FEV1/FVC %. A better understanding of the factors driving increased medication use is required to improve outcomes in this subgroup of asthmatics.
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Affiliation(s)
- Cherry A Thompson
- Priority Research Centre for Healthy Lungs, Hunter Medical Research Institute, School of Biomedical Sciences and Pharmacy, Faculty of Health and Medicine, University of Newcastle, Callaghan, Australia
| | - Shaun R Eslick
- Priority Research Centre for Healthy Lungs, Hunter Medical Research Institute, School of Biomedical Sciences and Pharmacy, Faculty of Health and Medicine, University of Newcastle, Callaghan, Australia
| | - Bronwyn S Berthon
- Priority Research Centre for Healthy Lungs, Hunter Medical Research Institute, School of Biomedical Sciences and Pharmacy, Faculty of Health and Medicine, University of Newcastle, Callaghan, Australia
| | - Lisa G Wood
- Priority Research Centre for Healthy Lungs, Hunter Medical Research Institute, School of Biomedical Sciences and Pharmacy, Faculty of Health and Medicine, University of Newcastle, Callaghan, Australia
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Abstract
Obesity is a significant public health problem worldwide, and it has been identified as an independent risk factor for asthma in both adults and children. Not only does obesity increase asthma risk, but it is also associated with decreased asthma-related quality of life, worsened symptoms and asthma control, increased frequency and severity of asthma exacerbations and reduced response to asthma medications. In this review we examine the epidemiology and implications of obesity in both children and adults with asthma, and how the obesogenic "western" diet contributes to asthma prevalence and progression. Finally, we summarise the current evidence on the impact of weight loss on asthma outcomes in both adults and children, highlighting the need for further research to be conducted in the paediatric population.
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Affiliation(s)
- Rebecca F McLoughlin
- Priority Research Centre for Healthy Lungs, Hunter Medical Research Institute, University of Newcastle, NSW, Australia.
| | - Bronwyn S Berthon
- Priority Research Centre for Healthy Lungs, Hunter Medical Research Institute, University of Newcastle, NSW, Australia.
| | - Lisa G Wood
- Priority Research Centre for Healthy Lungs, Hunter Medical Research Institute, University of Newcastle, NSW, Australia.
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12
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Hosseini B, Berthon BS, Saedisomeolia A, Starkey MR, Collison A, Wark PAB, Wood LG. Effects of fruit and vegetable consumption on inflammatory biomarkers and immune cell populations: a systematic literature review and meta-analysis. Am J Clin Nutr 2018; 108:136-155. [PMID: 29931038 DOI: 10.1093/ajcn/nqy082] [Citation(s) in RCA: 110] [Impact Index Per Article: 18.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2017] [Accepted: 03/28/2018] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Inflammation is associated with an increased risk of a range of chronic diseases. A diet high in fruit and vegetables may help to reduce inflammation, as fruit and vegetables are rich sources of antioxidants and other biologically active substances, which may improve immune function. OBJECTIVE To summarize the evidence, we executed a systematic review and meta-analysis examining the effects of fruit and/or vegetable intake on inflammatory biomarkers and immune cells in humans with different diseases and conditions. Design Electronic databases including PubMed, Cochrane, CINAHL, and EMBASE were systematically searched up to March 2018. RESULTS Eighty-three studies were included. Of these, 71 (86%) were clinical trials, and 12 were observational studies (n = 10 cross-sectional and n = 2 cohort). Amongst the observational research, n = 10 studies found an inverse association between intakes of fruit or vegetables and inflammatory biomarkers. Similarly, the majority of the intervention studies (68%, n = 48) reported beneficial effects of fruit or vegetable intake on ≥1 biomarker of systemic or airway inflammation. A meta-analysis of included studies showed that fruit or vegetable intake decreased circulating levels of C-reactive protein and tumor necrosis factor-α (P < 0.05) and increased the γδ-T cell population (P < 0.05). Conclusions In conclusion, this review suggests that higher intakes of fruit and vegetables lead to both a reduction in proinflammatory mediators and an enhanced immune cell profile.
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Affiliation(s)
- Banafshe Hosseini
- Grow Up Well Priority Research Centre and Priority Research Centre for Healthy Lungs and, Hunter Medical Research Institute, University of Newcastle, Newcastle, Australia
| | - Bronwyn S Berthon
- Grow Up Well Priority Research Centre and Priority Research Centre for Healthy Lungs and, Hunter Medical Research Institute, University of Newcastle, Newcastle, Australia
| | - Ahmad Saedisomeolia
- School of Medicine, Western Sydney University, Sydney, Australia.,School of Nutritional Sciences and Dietetics, Tehran University of Medical Sciences, Tehran, Iran
| | - Malcolm R Starkey
- Grow Up Well Priority Research Centre and Priority Research Centre for Healthy Lungs and, Hunter Medical Research Institute, University of Newcastle, Newcastle, Australia
| | - Adam Collison
- Grow Up Well Priority Research Centre and Priority Research Centre for Healthy Lungs and, Hunter Medical Research Institute, University of Newcastle, Newcastle, Australia
| | - Peter A B Wark
- Grow Up Well Priority Research Centre and Priority Research Centre for Healthy Lungs and, Hunter Medical Research Institute, University of Newcastle, Newcastle, Australia
| | - Lisa G Wood
- Grow Up Well Priority Research Centre and Priority Research Centre for Healthy Lungs and, Hunter Medical Research Institute, University of Newcastle, Newcastle, Australia
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13
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Wood LG, Li Q, Scott HA, Rutting S, Berthon BS, Gibson PG, Hansbro PM, Williams E, Horvat J, Simpson JL, Young P, Oliver BG, Baines KJ. Saturated fatty acids, obesity, and the nucleotide oligomerization domain-like receptor protein 3 (NLRP3) inflammasome in asthmatic patients. J Allergy Clin Immunol 2018; 143:305-315. [PMID: 29857009 DOI: 10.1016/j.jaci.2018.04.037] [Citation(s) in RCA: 73] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2017] [Revised: 03/29/2018] [Accepted: 04/30/2018] [Indexed: 01/17/2023]
Abstract
BACKGROUND Both obesity and high dietary fat intake activate the nucleotide oligomerization domain-like receptor protein 3 (NLRP3) inflammasome. OBJECTIVE We aimed to examine NLRP3 inflammasome activity in the airways of obese asthmatic patients after macronutrient overload and in immune cells challenged by inflammasome triggers. METHODS Study 1 was a cross-sectional observational study of nonobese (n = 51) and obese (n = 76) asthmatic adults. Study 2 was a randomized, crossover, acute feeding study in 23 asthmatic adults (n = 12 nonobese and n = 11 obese subjects). Subjects consumed 3 isocaloric meals on 3 separate occasions (ie, saturated fatty acid, n-6 polyunsaturated fatty acid, and carbohydrate) and were assessed at 0 and 4 hours. For Studies 1 and 2, airway inflammation was measured based on sputum differential cell counts, IL-1β protein levels (ELISA), and sputum cell gene expression (Nanostring nCounter). In Study 3 peripheral blood neutrophils and monocytes were isolated by using Ficoll density gradient and magnetic bead separation and incubated with or without palmitic acid, LPS, or TNF-α for 24 hours, and IL-1β release was measured (ELISA). RESULTS In Study 1 NLRP3 and nucleotide oligomerization domain 1 (NOD1) gene expression was upregulated, and sputum IL-1β protein levels were greater in obese versus nonobese asthmatic patients. In Study 2 the saturated fatty acid meal led to increases in sputum neutrophil percentages and sputum cell gene expression of Toll-like receptor 4 (TLR4) and NLRP3 at 4 hours in nonobese asthmatic patients. In Study 3 neutrophils and monocytes released IL-1β when challenged with a combination of palmitic acid and LPS or TNF-α. CONCLUSION The NLRP3 inflammasome is a potential therapeutic target in asthmatic patients. Behavioral interventions that reduce fatty acid exposure, such as weight loss and dietary saturated fat restriction, warrant further exploration.
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Affiliation(s)
- Lisa G Wood
- Priority Research Centre for Healthy Lungs, University of Newcastle, Newcastle, Australia.
| | - Qian Li
- Priority Research Centre for Healthy Lungs, University of Newcastle, Newcastle, Australia
| | - Hayley A Scott
- Priority Research Centre for Healthy Lungs, University of Newcastle, Newcastle, Australia
| | - Sandra Rutting
- Priority Research Centre for Healthy Lungs, University of Newcastle, Newcastle, Australia; Woolcock Institute of Medical Research, Sydney, Australia
| | - Bronwyn S Berthon
- Priority Research Centre for Healthy Lungs, University of Newcastle, Newcastle, Australia
| | - Peter G Gibson
- Priority Research Centre for Healthy Lungs, University of Newcastle, Newcastle, Australia; Department of Respiratory and Sleep Medicine, John Hunter Hospital, Newcastle, Australia
| | - Philip M Hansbro
- Priority Research Centre for Healthy Lungs, University of Newcastle, Newcastle, Australia
| | - Evan Williams
- Priority Research Centre for Healthy Lungs, University of Newcastle, Newcastle, Australia
| | - Jay Horvat
- Priority Research Centre for Healthy Lungs, University of Newcastle, Newcastle, Australia
| | - Jodie L Simpson
- Priority Research Centre for Healthy Lungs, University of Newcastle, Newcastle, Australia
| | - Paul Young
- Woolcock Institute of Medical Research, Sydney, Australia
| | - Brian G Oliver
- Woolcock Institute of Medical Research, Sydney, Australia
| | - Katherine J Baines
- Priority Research Centre for Healthy Lungs, University of Newcastle, Newcastle, Australia
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14
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Guilleminault L, Williams EJ, Scott HA, Berthon BS, Jensen M, Wood LG. Diet and Asthma: Is It Time to Adapt Our Message? Nutrients 2017; 9:E1227. [PMID: 29117118 PMCID: PMC5707699 DOI: 10.3390/nu9111227] [Citation(s) in RCA: 109] [Impact Index Per Article: 15.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2017] [Revised: 10/30/2017] [Accepted: 11/06/2017] [Indexed: 12/21/2022] Open
Abstract
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.
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Affiliation(s)
- Laurent Guilleminault
- Priority Research Centre for Healthy Lungs, Hunter Medical Research Institute, University of Newcastle, Callaghan, NSW 2308, Australia.
| | - Evan J Williams
- Priority Research Centre for Healthy Lungs, Hunter Medical Research Institute, University of Newcastle, Callaghan, NSW 2308, Australia.
| | - Hayley A Scott
- Priority Research Centre for Healthy Lungs, Hunter Medical Research Institute, University of Newcastle, Callaghan, NSW 2308, Australia.
| | - Bronwyn S Berthon
- Priority Research Centre for Healthy Lungs, Hunter Medical Research Institute, University of Newcastle, Callaghan, NSW 2308, Australia.
| | - Megan Jensen
- Priority Research Centre Grow Up Well, Hunter Medical Research Institute, University of Newcastle, Callaghan, NSW 2308, Australia.
| | - Lisa G Wood
- Priority Research Centre for Healthy Lungs, Hunter Medical Research Institute, University of Newcastle, Callaghan, NSW 2308, Australia.
- Priority Research Centre Grow Up Well, Hunter Medical Research Institute, University of Newcastle, Callaghan, NSW 2308, Australia.
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15
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McLoughlin RF, Berthon BS, Jensen ME, Baines KJ, Wood LG. Short-chain fatty acids, prebiotics, synbiotics, and systemic inflammation: a systematic review and meta-analysis. Am J Clin Nutr 2017; 106:930-945. [PMID: 28793992 DOI: 10.3945/ajcn.117.156265] [Citation(s) in RCA: 100] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2017] [Accepted: 07/10/2017] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND Prebiotic soluble fibers are fermented by beneficial bacteria in the colon to produce short-chain fatty acids (SCFAs), which are proposed to have systemic anti-inflammatory effects. OBJECTIVE This review examines the effect of SCFAs, prebiotics, and pre- and probiotic combinations (synbiotics) on systemic inflammation. DESIGN Relevant English language studies from 1947 to May 2017 were identified with the use of online databases. Studies were considered eligible if they examined the effects of SCFAs, prebiotics, or synbiotics; were delivered orally, intravenously, or per rectum; were on biomarkers of systemic inflammation in humans; and performed meta-analysis where possible. RESULTS Sixty-eight studies were included. Fourteen of 29 prebiotic studies and 13 of 26 synbiotic studies reported a significant decrease in ≥1 marker of systemic inflammation. Eight studies compared prebiotic and synbiotic supplementation, 2 of which reported a decrease in inflammation with synbiotics only, with 1 reporting a greater anti-inflammatory effect with synbiotics than with prebiotics alone. Meta-analyses indicated that prebiotics reduce C-reactive protein (CRP) [standardized mean difference (SMD): -0.60; 95% CI: -0.98, -0.23], and synbiotics reduce CRP (SMD: -0.40; 95% CI: -0.73, -0.06) and tumor necrosis factor-α (SMD -0.90; 95% CI: -1.50, -0.30). CONCLUSIONS There is significant heterogeneity of outcomes in studies examining the effect of prebiotics and synbiotics on systemic inflammation. Approximately 50% of included studies reported a decrease in ≥1 inflammatory biomarker. The inconsistency in reported outcomes may be due to heterogeneity in study design, supplement formulation, dosage, duration, and subject population. Nonetheless, meta-analyses provide evidence to support the systemic anti-inflammatory effects of prebiotic and synbiotic supplementation.
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Affiliation(s)
- Rebecca F McLoughlin
- Priority Research Centre for Healthy Lungs, Hunter Medical Research Institute, University of Newcastle, Callaghan, New South Wales, Australia
| | - Bronwyn S Berthon
- Priority Research Centre for Healthy Lungs, Hunter Medical Research Institute, University of Newcastle, Callaghan, New South Wales, Australia
| | - Megan E Jensen
- Priority Research Centre for Healthy Lungs, Hunter Medical Research Institute, University of Newcastle, Callaghan, New South Wales, Australia
| | - Katherine J Baines
- Priority Research Centre for Healthy Lungs, Hunter Medical Research Institute, University of Newcastle, Callaghan, New South Wales, Australia
| | - Lisa G Wood
- Priority Research Centre for Healthy Lungs, Hunter Medical Research Institute, University of Newcastle, Callaghan, New South Wales, Australia
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16
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Berthon BS, Gibson PG, Wood LG, MacDonald-Wicks LK, Baines KJ. A sputum gene expression signature predicts oral corticosteroid response in asthma. Eur Respir J 2017; 49:49/6/1700180. [PMID: 28663317 DOI: 10.1183/13993003.00180-2017] [Citation(s) in RCA: 46] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2017] [Accepted: 03/21/2017] [Indexed: 11/05/2022]
Abstract
Biomarkers that predict responses to oral corticosteroids (OCS) facilitate patient selection for asthma treatment. We hypothesised that asthma patients would respond differently to OCS therapy, with biomarkers and inflammometry predicting response.Adults with stable asthma underwent a randomised controlled cross-over trial of 50 mg prednisolone daily for 10 days (n=55). A six-gene expression biomarker signature (CLC, CPA3, DNASE1L3, IL1B, ALPL and CXCR2) in induced sputum, and eosinophils in blood and sputum were assessed and predictors of response were investigated (changes in forced expiratory volume in 1 s (ΔFEV1), six-item Asthma Control Questionnaire score (ΔACQ6) or exhaled nitric oxide fraction (ΔFeNO)).At baseline, responders to OCS (n=25) had upregulated mast cell CPA3 gene expression, poorer lung function, and higher sputum and blood eosinophils. Following treatment, CLC and CPA3 gene expression was reduced, whereas DNASE1L3, IL1B, ALPL and CXCR2 expression remained unchanged. Receiver operating characteristic (ROC) analysis showed the six-gene expression biomarker signature as a better predictor of clinically significant responses to OCS than blood and sputum eosinophils.The six-gene expression signature including eosinophil and Th2 related mast cell biomarkers showed greater precision in predicting OCS response in stable asthma. Thus, a novel sputum gene expression signature highlights an additional role of mast cells in asthma, and could be a useful measurement to guide OCS therapy in asthma.
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Affiliation(s)
- Bronwyn S Berthon
- Centre for Healthy Lungs, Hunter Medical Research Institute, University of Newcastle, Newcastle, NSW, Australia
| | - Peter G Gibson
- Centre for Healthy Lungs, Hunter Medical Research Institute, University of Newcastle, Newcastle, NSW, Australia
| | - Lisa G Wood
- Centre for Healthy Lungs, Hunter Medical Research Institute, University of Newcastle, Newcastle, NSW, Australia
| | - Lesley K MacDonald-Wicks
- Discipline of Nutrition and Dietetics, School of Health Sciences, University of Newcastle, Newcastle, NSW, Australia
| | - Katherine J Baines
- Centre for Healthy Lungs, Hunter Medical Research Institute, University of Newcastle, Newcastle, NSW, Australia
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17
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Hosseini B, Berthon BS, Wark P, Wood LG. Effects of Fruit and Vegetable Consumption on Risk of Asthma, Wheezing and Immune Responses: A Systematic Review and Meta-Analysis. Nutrients 2017; 9:nu9040341. [PMID: 28353635 PMCID: PMC5409680 DOI: 10.3390/nu9040341] [Citation(s) in RCA: 92] [Impact Index Per Article: 13.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2016] [Revised: 03/09/2017] [Accepted: 03/24/2017] [Indexed: 12/25/2022] Open
Abstract
Evidence suggests that reduced intake of fruit and vegetables may play a critical role in the development of asthma and allergies. The present review aimed to summarize the evidence for the association between fruit and vegetable intake, risk of asthma/wheeze and immune responses. Databases including PubMed, Cochrane, CINAHL and EMBASE were searched up to June 2016. Studies that investigated the effects of fruit and vegetable intake on risk of asthma/wheeze and immune responses were considered eligible (n = 58). Studies used cross-sectional (n = 30), cohort (n = 13), case-control (n = 8) and experimental (n = 7) designs. Most of the studies (n = 30) reported beneficial associations of fruit and vegetable consumption with risk of asthma and/or respiratory function, while eight studies found no significant relationship. Some studies (n = 20) reported mixed results, as they found a negative association between fruit only or vegetable only, and asthma. In addition, the meta-analyses in both adults and children showed inverse associations between fruit intake and risk of prevalent wheeze and asthma severity (p < 0.05). Likewise, vegetable intake was negatively associated with risk of prevalent asthma (p < 0.05). Seven studies examined immune responses in relation to fruit and vegetable intake in asthma, with n = 6 showing a protective effect against either systemic or airway inflammation. Fruit and vegetable consumption appears to be protective against asthma.
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Affiliation(s)
- Banafshe Hosseini
- School of Biomedical Sciences and Pharmacy, Faculty of Health and Medicine, University of Newcastle, Callaghan NSW 2308, Australia.
- Centre for Healthy Lungs, Hunter Medical Research Institute, Newcastle NSW 2308, Australia.
| | - Bronwyn S Berthon
- School of Biomedical Sciences and Pharmacy, Faculty of Health and Medicine, University of Newcastle, Callaghan NSW 2308, Australia.
- Centre for Healthy Lungs, Hunter Medical Research Institute, Newcastle NSW 2308, Australia.
| | - Peter Wark
- Centre for Healthy Lungs, Hunter Medical Research Institute, Newcastle NSW 2308, Australia.
| | - Lisa G Wood
- School of Biomedical Sciences and Pharmacy, Faculty of Health and Medicine, University of Newcastle, Callaghan NSW 2308, Australia.
- Centre for Healthy Lungs, Hunter Medical Research Institute, Newcastle NSW 2308, Australia.
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18
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Berthon BS, Gibson PG, McElduff P, MacDonald-Wicks LK, Wood LG. Effects of short-term oral corticosteroid intake on dietary intake, body weight and body composition in adults with asthma - a randomized controlled trial. Clin Exp Allergy 2016; 45:908-919. [PMID: 25640664 DOI: 10.1111/cea.12505] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2014] [Revised: 11/02/2014] [Accepted: 11/12/2014] [Indexed: 12/18/2022]
Abstract
BACKGROUND Oral corticosteroids (OCS) are an efficacious treatment for asthma exacerbations, yet risk of adverse effects may decrease patient adherence to therapy. In particular, changes in appetite and dietary intake, which lead to weight gain and changes in body composition, are considered undesirable. OBJECTIVE To determine whether 10-day OCS therapy in adults with asthma causes changes in leptin, appetite, dietary intake, body weight and body composition. METHODS Double-blinded, placebo-controlled randomized cross-over trial of 10 days prednisolone (50 mg) in adults with stable asthma (n = 55) (ACTRN12611000562976). Pre- and post-assessment included spirometry, body weight, body composition measured by dual-energy X-ray absorptiometry and bioelectrical impedance analysis, appetite measured using a validated visual analogue scale (VAS) and dietary intake assessed using 4-day food records. Leptin was measured as a biomarker of appetite and eosinophils as an adherence biomarker. Outcomes were analysed by generalized linear mixed models. RESULTS Subject adherence was confirmed by a significant decrease in blood eosinophils (× 10(9) /L) following prednisolone compared to placebo [Coef. -0.29, 95% CI: (-0.39, -0.19) P < 0.001]. There was no difference in serum leptin (ng/mL) [Coef. 0.13, 95% CI: (-3.47, 3.72) P = 0.945] or appetite measured by VAS (mm) [Coef. -4.93, 95% CI: (-13.64, 3.79) P = 0.267] following prednisolone vs. placebo. There was no difference in dietary intake (kJ/day) [Coef. 255, 95% CI: (-380, 891) P = 0.431], body weight (kg) [Coef. -0.38, 95% CI: (-0.81, 0.05) P = 0.083] or body fat (%) [Coef. -0.31, 95% CI: (-0.81, 0.20) P = 0.230]. Symptoms including sleep and gastrointestinal disturbance were reported significantly more often during prednisolone vs. placebo. CONCLUSIONS AND CLINICAL RELEVANCE Short-term OCS in stable asthma did not induce significant changes in appetite, dietary intake, body weight or composition, although other adverse effects may require medical management. This evidence may assist in increasing medication adherence of asthmatics prescribed OCS for exacerbations.
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Affiliation(s)
- B S Berthon
- Centre for Asthma and Respiratory Disease, Hunter Medical Research Institute, University of Newcastle, Newcastle, NSW, Australia
| | - P G Gibson
- Centre for Asthma and Respiratory Disease, Hunter Medical Research Institute, University of Newcastle, Newcastle, NSW, Australia
| | - P McElduff
- School of Medicine and Public Health, University of Newcastle, Newcastle, NSW, Australia
| | - L K MacDonald-Wicks
- School of Health Sciences, University of Newcastle, Newcastle, NSW, Australia
| | - L G Wood
- Centre for Asthma and Respiratory Disease, Hunter Medical Research Institute, University of Newcastle, Newcastle, NSW, Australia
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Wood LG, Shivappa N, Berthon BS, Gibson PG, Hebert JR. Dietary inflammatory index is related to asthma risk, lung function and systemic inflammation in asthma. Clin Exp Allergy 2015; 45:177-83. [PMID: 24708388 DOI: 10.1111/cea.12323] [Citation(s) in RCA: 195] [Impact Index Per Article: 21.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2013] [Revised: 03/06/2014] [Accepted: 03/10/2014] [Indexed: 01/22/2023]
Abstract
BACKGROUND Asthma prevalence has increased in recent years, and evidence suggests that diet may be a contributing factor. Increased use of processed foods has led to a decrease in diet quality, which may be creating a pro-inflammatory environment, thereby leading to the development and/or progression of various chronic inflammatory diseases and conditions. Recently, the dietary inflammatory index (DII) has been developed and validated to assess the inflammatory potential of individual diets. OBJECTIVE This study aimed to examine the DII in subjects with asthma compared to healthy controls and to relate the DII to asthma risk, lung function and systemic inflammation. METHODS Subjects with asthma (n = 99) and healthy controls (n = 61) were recruited. Blood was collected and spirometry was performed. The DII was calculated from food frequency questionnaires administered to study subjects. RESULTS The mean DII score for the asthmatics was higher than the mean DII score for healthy controls (- 1.40 vs. - 1.86, P = 0.04), indicating that their diets were more pro-inflammatory. For every 1 unit increase in DII score, the odds of having asthma increased by 70% (OR: 1.70, 95% CI: 1.03, 2.14; P = 0.040). FEV1 was significantly associated with DII score (β = - 3.44, 95% CI: - 6.50, - 0.39; P = 0.020), indicating that for every 1 unit increase in DII score, FEV1 decreased by 3.44 times. Furthermore, plasma IL-6 concentrations were positively associated with DII score (β = 0.13, 95% CI: 0.05, 0.21; P = 0.002). CONCLUSION AND CLINICAL RELEVANCE As assessed using the DII score, the usual diet consumed by asthmatics in this study was pro-inflammatory relative to the diet consumed by the healthy controls. The DII score was associated with increased systemic inflammation and lower lung function. Hence, consumption of pro-inflammatory foods may contribute to worse asthma status, and targeting an improvement in DII in asthmatics, as an indicator of suitable dietary intake, might be a useful strategy for improving clinical outcomes in the disease.
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Affiliation(s)
- L G Wood
- Centre for Asthma and Respiratory Diseases, Hunter Medical Research Institute, University of Newcastle, Newcastle, NSW, Australia
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Wood LG, Lagleva M, Shah S, Berthon BS, Galbraith S, Henry R, Kepreotes H, Gibson PG. Dietary changes in migrant adolescents with increasing length of stay in Australia and associated risk of wheeze--a retrospective, cross sectional study. BMC Pediatr 2015; 15:102. [PMID: 26306546 PMCID: PMC4549889 DOI: 10.1186/s12887-015-0420-x] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2014] [Accepted: 08/17/2015] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Recent studies have reported that asthma prevalence increases on migration to Australia. We hypothesised that changes in dietary intake contribute to this phenomenon. The aim of this study was to assess dietary intake in relation to migration status, length of stay in Australia and the association with self-reported wheeze. METHODS Students (n = 144) in a multicultural high school in Western Sydney completed the asthma symptoms ISAAC video questionnaire (AVQ3.0), spirometry and allergy skin prick tests. A dietitian administered a'Food Frequency' and 'Food Habits' questionnaire and a dietary history interview. RESULTS Students who spoke a language other than English, consumed a traditional or mixed dietary pattern, with lower consumption of saturated fat, compared to students who spoke English only. Saturated fat intake increased and fibre intake decreased with length of time in Australia. Intake of foods high in saturated or trans fatty acids were positively associated with length of stay in Australia. No associations between nutrient intake or whole food intake and self-reported wheeze were observed. CONCLUSION As time progressed, dietary intake of immigrant children changed. While this was not associated with the development of wheeze in the students in this cohort, these changes are likely to have negative health consequences.
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Affiliation(s)
- Lisa G Wood
- Centre for Asthma and Respiratory Diseases, Hunter Medical Research Institute, University of Newcastle, Newcastle, New South Wales, Australia.
| | - Marivic Lagleva
- Primary Health Care Education and Research Unit, Western Clinical School and School of Public Health, University of Sydney, Sydney, New South Wales, Australia.
| | - Smita Shah
- Primary Health Care Education and Research Unit, Western Clinical School and School of Public Health, University of Sydney, Sydney, New South Wales, Australia.
| | - Bronwyn S Berthon
- Centre for Asthma and Respiratory Diseases, Hunter Medical Research Institute, University of Newcastle, Newcastle, New South Wales, Australia.
| | - Sally Galbraith
- School of Mathematics and Statistics, University of New South Wales, Sydney, New South Wales, Australia.
| | - Richard Henry
- University of New South Wales, Sydney, NSW, Australia.
| | - Helen Kepreotes
- Department of Nutrition and Dietetics, Sydney Children's Hospital Network, Randwick Campus, Sydney, New South Wales, Australia.
| | - Peter G Gibson
- Centre for Asthma and Respiratory Diseases, Hunter Medical Research Institute, University of Newcastle, Newcastle, New South Wales, Australia. .,Department of Respiratory and Sleep Medicine, John Hunter Hospital, Kookaburra Circuit, New Lambton Heights, NSW, 2305, Australia.
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Abstract
Diet and nutrition may be important modifiable risk factors for the development, progression and management of obstructive lung diseases such as asthma and chronic obstructive pulmonary disease (COPD). This review examines the relationship between dietary patterns, nutrient intake and weight status in obstructive lung diseases, at different life stages, from in-utero influences through childhood and into adulthood. In vitro and animal studies suggest important roles for various nutrients, some of which are supported by epidemiological studies. However, few well-designed human intervention trials are available to definitively assess the efficacy of different approaches to nutritional management of respiratory diseases. Evidence for the impact of higher intakes of fruit and vegetables is amongst the strongest, yet other dietary nutrients and dietary patterns require evidence from human clinical studies before conclusions can be made about their effectiveness.
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Affiliation(s)
- Bronwyn S Berthon
- Centre for Asthma and Respiratory Diseases, Level 2, Hunter Medical Research Institute, University of Newcastle, Lot 1 Kookaburra Circuit, New Lambton Heights, NSW 2305, Australia.
| | - Lisa G Wood
- Centre for Asthma and Respiratory Diseases, Level 2, Hunter Medical Research Institute, University of Newcastle, Lot 1 Kookaburra Circuit, New Lambton Heights, NSW 2305, Australia.
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Berthon BS, MacDonald-Wicks LK, Wood LG. A systematic review of the effect of oral glucocorticoids on energy intake, appetite, and body weight in humans. Nutr Res 2014; 34:179-90. [DOI: 10.1016/j.nutres.2013.12.006] [Citation(s) in RCA: 54] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2013] [Revised: 12/26/2013] [Accepted: 12/30/2013] [Indexed: 11/15/2022]
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Berthon BS, Macdonald-Wicks LK, Gibson PG, Wood LG. Investigation of the association between dietary intake, disease severity and airway inflammation in asthma. Respirology 2013; 18:447-54. [DOI: 10.1111/resp.12015] [Citation(s) in RCA: 66] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2012] [Revised: 08/30/2012] [Accepted: 09/27/2012] [Indexed: 01/05/2023]
Affiliation(s)
- Bronwyn S. Berthon
- Centre for Asthma and Respiratory Disease; Hunter Medical Research Institute; Newcastle; New South Wales; Australia
| | - Lesley K. Macdonald-Wicks
- Discipline of Nutrition and Dietetics; School of Health Sciences; University of Newcastle; Newcastle; New South Wales; Australia
| | - Peter G. Gibson
- Centre for Asthma and Respiratory Disease; Hunter Medical Research Institute; Newcastle; New South Wales; Australia
| | - Lisa G. Wood
- Centre for Asthma and Respiratory Disease; Hunter Medical Research Institute; Newcastle; New South Wales; Australia
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Berthon BS. [Health education in school]. Sante Publique 1998; 10:459-71. [PMID: 10065010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/11/2023]
Affiliation(s)
- B S Berthon
- Comité français d'éducation pour la santé, Vanves
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