Dietary Factors Associated with Asthma Development: A Narrative Review and Summary of Current Guidelines and Recommendations

Figures & data

Figure 1 Mechanisms of dietary interventions on asthma.

Note: This figure was created using BioRender.com.

Abbreviations: APC, antigen-presenting cell; COX, cyclooxygenase; HMO, human milk oligosaccharides; IgA, immunoglobulin A; LOX, lipoxygenase; MHC, major histocompatibility complex; SCFAs, short-chain fatty acids; Th2, T helper 2 cell; Treg, regulatory T cell; 12,13-diHOME, 12,13-dihydroxy-9-octadecenoic acid.

Figure 2 Dietary interventions from current evidence on prenatal intake in pregnant mothers and postnatal intake in children for asthma primary prevention.

Notes: Most guideline recommendations were based on limited evidence and could not make a firm conclusion. Created with BioRender.com.

Table 1 Summary of Recommendations on Breastfeeding Practice^†

Year	Guideline/Society	Statement
2021	CPS/CSACI^Citation124	Promote and support breastfeeding for up to 2 years and beyond.
2020	Dietary Guidelines for Americans (2020–2025)^Citation125	Feed human milk for the first 6 months of life. Exclusive breastfeeding is encouraged.
2020	AAIAT^Citation126	Breastfeeding for at least 4 months
2019	ESCNH^Citation127	Early nutrition, preferably using human milk Exclusive feeding with human milk during the hospital stay Encourage mothers to give exclusive breastfeeding after discharge.
2019	ASCIA^Citation128	Breastfeeding for at least 6 months and for as long as mother and infant wish to continue No consistent evidence of the effect of breastfeeding on allergy prevention. However, breastfeeding is recommended for other benefits it provides to mother and infant.
2019	AAP^Citation129	Any breastfeeding beyond 3–4 months duration protects against wheezing in the first 2 years. A longer duration of any breastfeeding may protect against asthma beyond age 5 years.
2017	WHO^Citation130	Initiate breastfeeding within the first hour of birth. Exclusive breastfeeding for the first 6 months of life No other foods or liquids to be provided, including water No bottles, teats, or pacifiers should be used.
2013	AAAAI^Citation131,Citation132	Exclusive breastfeeding for at least 4 months and up to 6 months to reduce early wheezing before 4 years of age, but not necessarily to reduce asthma
2012	Finnish Allergy Programme 2008–2018^Citation133,Citation134	Exclusive breastfeeding for 4–6 months

Notes: ^†These recommendations are for preventing allergic diseases by dietary factors and are not specific to asthma. They typically consider the costs, benefits, and level of evidence.

Abbreviations: AAAAI, American Academy of Allergy, Asthma & Immunology; AAIAT, the Allergy, Asthma and Immunology Association of Thailand; AAP, American Academy of Pediatrics; ASCIA, Australasian Society of Clinical Immunology and Allergy; CPS, Canadian Paediatric Society; CSACI, Canadian Society of Allergy and Clinical Immunology; ESCNH, European Standards of Care for Newborn Health; WHO, World Health Organization.

Table 2 Summary of Recommendations on Intake of Probiotics and Prebiotics^†

Year	Guideline/Society	Statement
2022	GINA^Citation135	Evidence is insufficient to recommend probiotics for the prevention of allergic diseases (ie, asthma, rhinitis, eczema, and food allergy)
2016	WAO^Citation136	For not-exclusively breastfed infants: suggests prebiotic supplementation. For exclusively breastfed infants: do not use prebiotic supplementation. (Conditional recommendations and a very low certainty of the evidence)
2015	WAO^Citation137	For pregnant mothers at high risk for allergy in their children: suggests use of probiotics due to the net benefit for eczema prevention. However, there is a lack of evidence to prevent allergies other than eczema. (High risk for allergy in a child is defined as a biological parent or sibling with allergic rhinitis, asthma, eczema, or food allergy)
2020	ESPGHAN^Citation138	Focuses on probiotics and preterm infants. No recommendations on allergy prevention were made.
2011	ESPGHAN^Citation139	Does not recommend routine administration of prebiotics for the prevention of allergies

Notes: ^†These recommendations are for preventing allergic diseases by dietary factors and are not specific to asthma. They typically consider the costs, benefits, and level of evidence.

Abbreviations: ESPGHAN, Nutrition Committee of the European Society of Pediatric Gastroenterology, Hepatology and Nutrition; GINA, Global Initiative for Asthma; WAO, World Allergy Organization.

Table 3 Summary of Recommendations on Fatty Acid-Rich Food and the Dietary Pattern^†

Year	Guideline/Society	Statement
2021	The Finnish Allergy Program 2008–2018^Citation133,Citation134,Citation140	Primary prevention: Follow a healthy diet (eg, the Mediterranean or Baltic diets) including fresh fruits, berries, vegetables, and less meat. Secondary prevention: A healthy, anti-inflammatory diet (the Mediterranean or Baltic diets) may improve asthma control.
2022	GINA^Citation135	Pregnant mothers: Maternal dietary intake of fish or LC-PUFA showed no consistent effects on the risks of wheeze, asthma, or atopy in children. Dietary changes during pregnancy are not recommended.
2019	ASCIA^Citation128	Pregnant and lactating mothers: Eat a healthy balanced diet rich in fiber, vegetables and fruits. Eat up to 3 servings of oily fish containing omega-3 fatty acids per week
2019	EAACI^Citation50	Public recommendations: Fatty acids are essential components of a healthy diet and deficiencies should be avoided. At risk of LC-PUFAs deficiency (eg, allergic children on elimination diets): Dietary assessment of LC-PUFAs intake is advised, and safe dietary expansion to include LC-PUFA-rich foods or PUFA supplementation may be required. Pregnant and lactating women: Supplementation studies demonstrated more consistent result of asthma risk reduction when mothers had low preexisting levels of EPA and DHA

Notes: ^†These recommendations are for preventing allergic diseases by dietary factors and are not specific to asthma. They typically consider the costs, benefits, and level of evidence.

Abbreviations: ASCIA, Australasian Society of Clinical Immunology and Allergy; DHA, docosahexaenoic acid; EAACI, The European Academy of Allergy and Clinical Immunology; EPA, eicosapentaenoic acid; GINA, The Global Initiative for Asthma; LC-PUFA, Long‐chain polyunsaturated fatty acid; PUFA, polyunsaturated fatty acid; US FDA, The United States Food and Drug Administration.

Table 4 Summary of Recommendations on Vitamin D Intake^†

Year	Guideline/Society	Statement
2022	GINA^Citation135	Pregnant mothers or women planning pregnancy: Identifying and correcting vitamin D insufficiency may reduce the risk of early life wheezing episodes in children.
2015	WAO^Citation137	Pregnant mothers and breastfeeding mothers: Do not use vitamin D supplementation to prevent the development of allergic diseases in their children (conditional recommendation, very low certainty of evidence). Infants: Do not use vitamin D supplementation to prevent the development of allergic diseases (conditional recommendation, very low certainty evidence).

Notes: ^†These recommendations are for preventing allergic diseases by dietary factors and are not specific to asthma. They typically consider the costs, benefits, and level of evidence.

Abbreviations: GINA, The Global Initiative for Asthma; WAO, World Allergy Organization.

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