Influence of nutrition in allergic disease

The association between nutrition and allergy is complex but emerging evidence points to nutrition having an positive influence on allergic disease. This review gives an overview of the current knowledge

The incidence of allergic diseases, such as asthma, rhinitis, eczema and food allergies, is rising globally.^1–4 Allergic disorders change over time, progressing from eczema and food allergy in infancy and early childhood to asthma, rhinitis and inhalant allergy in older childhood, adolescence and adulthood. This is referred to as the ‘allergic march’ (or atopic march).⁵ 

Due to the known immune-modulatory factors of numerous nutrients, epidemiological studies that investigate factors which might affect the development of food allergy look at nutritional intake in maternal diet, infants and children. Nutrients of particular interest are polyunsaturated fatty acids (PUFAs), antioxidant vitamins (vitamins A, C, E and β-carotene), vitamin D, iron, selenium, zinc and folate.^6–9 Non-nutrient factors in the diet such as pre- and probiotics are also considered. This interest in establishing a possible link between nutrition and allergic diseases has progressed to incorporate new methodologies used in the analysis of dietary intake, which allow the whole diet to be investigated. These new methodologies also allow the link between ‘healthy’ and ‘unhealthy’ dietary factors and allergic disease to be considered.^10,11 As the aetiology of allergic disease appears to be so complex, analysis of the diet in this way might help identify nutritional/diet factors that are associated with its development.¹² 

Single nutrients

To date, PUFAs have been the most extensively studied immuno-modulatory nutrient in relation to allergic disease. There have been two Cochrane reviews looking at PUFA supplementation and allergy outcomes. The first looked at maternal supplementation with the authors concluding there was limited evidence it reduced allergic disease in children.¹³ The second looked at PUFA supplementation in infancy and found no evidence that supplementation in infancy had an effect on infant or childhood allergy.¹⁴ 

Vitamin D and its relation to allergic disease has received considerable attention in recent years; latitudinal differences in auto-injector prescriptions for food-induced anaphylaxis¹⁵ and hypoallergenic infant formula use¹⁶ suggesting a causal link with low vitamin D status. Such aassociations between vitamin D intake/status and allergic disease come from a diverse literature, including cross-sectional, case-control and cohort studies, with variable outcome definitions, analytical procedures and study quality.^17–22 However, direct evidence appears to come from an Australian study, which showed low vitamin D status increased the risk of food allergy approximately tenfold.²³

↓Article continues below this sponsored advert↓

Explore the latest advances in respiratory care at events delivered by renowned experts from CofE

AboutTickets

↑Advertisement↑

Lower intakes of antioxidants are suggested to reduce antioxidant defences and increase the risk of allergic disease.^24–28 In particular, adequate intake of vitamins A, E and C and zinc might confer some protection against allergic conditions.²⁹  

Non-nutritional factors

In recent years, there has been increasing evidence of the role the gut microbiota plays in overall health,³⁰ and this is no different for allergic disease. A number of studies have found an association between infant intestinal microbiota and the development of allergic disease.³¹ Because particular foods/dietary constituents can promote differing types of microbiota, it is hypothesised that altering the diet can affect the prevalence and severity of allergic conditions. Prebiotics and polyphenols from the diet alter the gut microbiome along with probiotics, which either confer their effect directly or via their metabolites, for example, short chain fatty acids metabolites such as butyrate.³² While there are promising signs for the use of prebiotics in the prevention and treatment of allergic conditions, as yet there are still many unanswered questions as to their role, which need answering by well-conducted research to advance our knowledge in the field.^33,34 This is a similar situation with the role of probiotics in allergic disease with the most recent Cochrane review on the subject stating that further research is needed before probiotics use can be recommended for allergy prevention,³⁵ and a World Allergy Organisation systematic review stating there was need for high quality intervention trials.³⁶ Such trials would also provide information on which strains might be the most effective for allergy prevention and treatment.

Diet patterns

The relationship between the food that we eat and any health outcome is complex and there is an emerging recognition that because nutrients and foods are not eaten in isolation, trying to find an association between single nutrients and a disease state is an unrealistic expectation. Related to this,
a number of studies have found an association between the whole diet, (including diversity), and allergic disease.^37-41 Additionally, research has reported an inverse association with processed foods and allergic outcomes. An EAACI position paper on diet diversity in allergy has been published, with the aim of understanding the role of diet diversity on allergy outcomes and to set standards for conducting research in this field.¹² While a major output of the paper is to provide a detailed narrative review of information on diet quality and diet patterns, it also summarises possible mechanisms of how a diverse diet can affect allergy outcomes due to: i) its effect on the microbiome; ii) indirectly affecting allergy outcomes by providing nutrients associated with prevention of allergic disease (for example, PUFAs and prebiotics); iii) and exposing the individual to a wider variety of dietary antigens, thus promoting immunologic tolerance. 

Conclusions

While there is a lot of ongoing work investigating the relationship between nutrition and allergic disease with some promising theories, there is, as yet, no definitive evidence regarding any such the relationship. Ongoing work will hopefully provide more robust evidence to support these theories. 

References

1. Prescott SL et al. A global survey of changing patterns of food allergy burden in children. World Allergy Org J 2013;6(1):21.
2. Lack G. Update on risk factors for food allergy. J Allergy Clin Immunol 2012;129(5):1187–97.
3. Prescott S, Allen KJ. Food allergy: riding the second wave of the allergy epidemic. Pediatr Allergy Immunol 2011;22(2):155–60.
4. Sicherer SH. Epidemiology of food allergy. J Allergy Clin Immunol 2011;127(3):594–602.
5. Wahn U. What drives the allergic march? Allergy 2000;55:591−9.
6. Calder PC et al. Inflammatory disease processes and interactions with nutrition. Br J Nutr 2009;101 Suppl 1:S1–4. 
7. Tan PH et al. Inhibition of NF-kappa B and oxidative pathways in human dendritic cells by antioxidative vitamins generates regulatory T cells. J Immunol 2005;174(12):7633–44. 
8. Vassallo MF, Camargo CA, Jr. Potential mechanisms for the hypothesized link between sunshine, vitamin D, and food allergy in children. J Allergy Clin Immunol 2010;126(2):217–22.
9. van Ruiter B et al. A specific mixture of short-chain galacto-oligosaccharides and long-chain fructo-oligosaccharides induces a beneficial immunoglobulin profile in infants at high risk for allergy. Allergy 2009;64(3):484–7.
10. Nurmatov U, Devereux G, Sheikh A. Nutrients and foods for the primary prevention of asthma and allergy: systematic review and meta-analysis. J Allergy Clin Immunol 2011;127(3):724–33.
11. West CE, D’Vaz N, Prescott SL. Dietary immunomodulatory factors in the development of immune tolerance. Curr Allergy Asthma Rep 2011;11(4):325–33.
12. Venter C et al. EAACI position paper on diet diversity in pregnancy, infancy and childhood: Novel concepts and implications for studies in allergy and asthma. Allergy 2020;75(3):497–523. 
13. Gunaratne AW, Makrides M, Collins CT. Maternal prenatal and/or postnatal n-3 long chain polyunsaturated fatty acids (LCPUFA) supplementation for preventing allergies in early childhood. Cochrane Database Syst Rev 2015;7:CD010085.
14. Schindler T, Sinn JK, Osborn DA. Polyunsaturated fatty acid supplementation in infancy for the prevention of allergy. Cochrane Database Syst Rev 2016;10:CD010112. 
15. Camargo CA Jr et al. Regional differences in EpiPen prescriptions in the United States: the potential role of vitamin D. J Allergy Clin Immunol 2007;120(1):131–6.
16. Mullins RJ, Clark S, Camargo CA Jr. Regional variation in infant hypoallergenic formula prescriptions in Australia. Pediatr Allergy Immunol 2010;21(2 Pt 2):e413–e420.
17. Van Duren-Schmidt K et al. Prenatal contact with inhalant allergens. Pediatr Res 1997;41(1):128–31.
18. Katz KA, Pocock SJ, Strachan DP. Neonatal head circumference, neonatal weight, and risk of hayfever, asthma and eczema in a large cohort of adolescents from Sheffield, England. Clin Exp Allergy 2003;33(6):737–45.
19. Baïz N et al. Cord serum 25-hydroxyvitamin D and risk of early childhood transient wheezing and atopic dermatitis. J Allergy Clin Immunol. 2014;133(1):147–53. 
20. Jones AP et al. Cord blood 25-Hydroxyvitamin D3 and allergic disease during infancy. J Am Acad Pediatr 2012;130;e1128–35.
21. Camargo CA Jr et al. Cord-blood 25-hydroxyvitamin D levels and risk of respiratory infection, wheezing, and asthma. Pediatrics. 2011;127(1):e180–7. 
22. Rothers J et al. Cord-blood 25-hydroxyvitamin D levels are associated with aeroallergen sensitization in children from Tucson Arizona. J Allergy Clin Immunol 2011;128(5):1093–9.
23. Hawrylowicz CM, Santos AF. Vitamin D: can the sun stop the atopic epidemic? Curr Opin Allergy Clin Immunol 2020;20(2):181–7. 
24. West C et al. Associations between maternal antioxidant intakes in pregnancy and infant allergic outcomes. Nutrients 2012;4(11):1747–58.
25. Hoppu U et al. Vitamin C in breast milk may reduce the risk of atopy in the infant. Eur J Clin Nutr 2005;59:123–8.
26. Sausenthaler S et al. Vitamin E intake in relation to allergic sensitisation and IgE serum concentration. Cent Eur J Public Health 2009;17(2):79–85.
27. Sato Y et al. Dietary carotenoids inhibit oral sensitization and the development of food allergy. J Agric Food Chem 2010;58:7180–6.
28. Chatzi L et al. Protective effect of fruits, vegetables and the Mediterranean diet on asthma and allergies among children in Crete. Thorax 2007;62(8):677–83.
29. Nurmatov U, Devereux G, Sheikh A. Nutrients and foods for the primary prevention of asthma and allergy: systematic review and meta-analysis. J Allergy Clin Immunol 2011;127:724–33 e1–30.
30. Cani P. Gut microbiota – at the intersection of everything? Nat Rev Gastroenterol Hepatol 2017;14;321–2. 
31. Bridgman et al. Gut microbiota and allergic disease in children. Ann Allergy Asthma Immunol 2016;116(2):99–105.  
32. Lyu Q, Hsu C-C. Can diet influence our health by altering intestinal microbiota-derived fecal metabolites. mSystems 2018;3:e00187–17.
33. Lee KH et al. The gut microbiota, environmental factors, and links to the development of food allergy Clin Mol Allergy 2020;18:5.
34. Brosseau C et al. Prebiotics: Mechanisms and preventive effects in allergy. Nutrients 2019;11(8).
35. Osborn DA, Sinn JK. Probiotics in infants for prevention of allergic disease and food hypersensitivity. Cochrane Database Syst Rev 2007;(4):CD006474.
36. Fiocchi A et al. World Allergy Organization – McMaster University Guildelines for allergic disease prevention (GLAD-P): Probiotics. World Allergy Org J 2015;8:4.
37. Grimshaw KE et al. Diet and food allergy development during infancy: birth cohort study findings using prospective food diary data. J Allergy Clin Immunol 2014;133(2):511–19.
38. Roduit C et al. Increased food diversity in the first year of life is inversely associated with allergic diseases. J Allergy Clin Immunol 2014;133(4):1056–64.
39. Ellwood P et al. Do fast foods cause asthma, rhinoconjunctivitis and eczema? Global findings from the International Study of Asthma and Allergies in Childhood (ISAAC) phase three. Thorax 2013;68(4):351–60.
40. McKeever TM et al. Patterns of dietary intake and relation to respiratory disease, forced expiratory volume in 1 s, and decline in 5-y forced expiratory volume. Am J Clin Nutr 2010;92(2):408–15.
41. Arvaniti F et al. Adherence to the Mediterranean type of diet is associated with lower prevalence of asthma symptoms, among 10–12-year old children: the PANACEA study. Pediatr Allergy Immunol 2011;22(3):283–9.