Mediterranean diet and childhood asthma | Allergologia et Immunopathologia

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Garcia-Marcos" "autores" => array:1 [ 0 => array:2 [ "nombre" => "L." "apellidos" => "Garcia-Marcos" ] ] ] ] ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0301054616300015?idApp=UINPBA00004N" "url" => "/03010546/0000004400000002/v1_201603070011/S0301054616300015/v1_201603070011/en/main.assets" ] "en" => array:18 [ "idiomaDefecto" => true "cabecera" => "Original Article" "titulo" => "Mediterranean diet and childhood asthma" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "99" "paginaFinal" => "105" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "F.M. Calatayud-Sáez, B. Calatayud Moscoso del Prado, J.G. Gallego Fernández-Pacheco, C. González-Martín, L.F. Alguacil Merino" "autores" => array:5 [ 0 => array:4 [ "nombre" => "F.M." 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Error bars." ] ] ] "textoCompleto" => "IntroductionThe incidence of childhood asthma and bronchial hyperreactivity (BHR) has been progressively increasing in developed countries, reaching nearly one-third of the population.<a class="elsevierStyleCrossRef" href="#bib0205">1</a> This disease causes educational, economic and health problems for patients, their families, and society, which requires the adoption of preventive and therapeutic measures. The degree of asthma varies from patients who experience only a few episodes of wheezing, coughing with mild bronchospasm to patients with repeated episodes and persistent symptoms. The diagnosis of BHR in children is primarily clinical and can be complicated due to the subjective symptoms, which are sometimes difficult for their parents to assess.<a class="elsevierStyleCrossRef" href="#bib0210">2</a> There is no universal test to determine the exact diagnosis. It has been demonstrated that the fundamental pathophysiological basis is bronchial inflammation, which triggers hypersensitivity to a variety of stimuli such as upper respiratory tract infections, air pollution, tobacco, smoke, exercise, central heating, seasonal pollination and obesity.Current treatment is based on the use of bronchodilator β2-agonists (which reduce bronchial muscle spasticity), anti-inflammatory corticosteroids and anti-leukotrienes (which reduce BHR and clinical symptoms). All are effective upon acute application, but prolonged use is more questionable due to the limited evidence supporting efficacy and the emergence of adverse effects such as abnormal growth in children.<a class="elsevierStyleCrossRef" href="#bib0215">3</a> It has been suggested that dietary interventions could be of potential use based on a number of publications that have linked the disease with the loss of traditional dietary patterns. Some of these results, however, are controversial.<a class="elsevierStyleCrossRefs" href="#bib0220">4–7</a> One of our recent studies on overweight and obese children supports this idea because patients with BHR improved considerably after controlling the quality of their diet.<a class="elsevierStyleCrossRef" href="#bib0240">8</a> We therefore hypothesise that restoring traditional, healthy diets such as the Mediterranean diet could help decrease bronchial hyperreactivity significantly. In accordance with this idea, a meta-analysis has recently been published supporting the positive influence of Mediterranean diets on respiratory outcomes in children.<a class="elsevierStyleCrossRef" href="#bib0245">9</a> The present study aims to extend knowledge in this direction by studying the effects of a traditional Mediterranean diet (TMD), on patients diagnosed with childhood asthma through a food re-education programme developed in the family sphere. The study diet was based on the Decalogue proposed by the Mediterranean Diet Foundation.<a class="elsevierStyleCrossRef" href="#bib0250">10</a> The Mediterranean diet was proclaimed an Intangible Cultural Heritage of Humanity by UNESCO in 2010 and is characterised by a high intake of unrefined plant-based foods such as fruits and fresh vegetables, whole grains, legumes, olive oil and nuts; low to moderate consumption of foods of animal origin such as fermented milk, fish, eggs and lean meats; and by a low intake of sugar, refined flour and fast food.MethodsStudy designThe study was approved by the Research and Ethics Committees of the General University Hospital of Ciudad Real, Spain. The research design was an analytical, before–after comparison study, which consecutively enrolled patients 1–5 years of age who met childhood asthma criteria<a class="elsevierStyleCrossRef" href="#bib0255">11</a> and who attended a consultation at a primary care practice between May 2009 and September 2013. It was considered necessary to include the medical history of at least 1 year prior to the study and informed consent signed by their parents or guardians. The intervention focused on dietary re-education based on the TMD by a nutritional education programme named “Learning to Eat from the Mediterranean”. This programme is based on a series of visits to the nutritionist and paediatrician that are designed to assist the entire family. The visits were monthly during the first 4 months and bimonthly the rest of the year. To start the programme a 7-day recall questionnaire was required. On the first visit, we evaluated the food choices of each child and family. Based on the problems identified, we proposed dietary changes by providing dietary patterns, recipes, sample menus, etc. An anthropometric assessment was also performed and key health issues were explained, such as the importance of a good breakfast, variability in menus, the balance between food consumption and energy expenditure, the quality of fats, proteins and carbohydrates, understanding labels and creating a healthy shopping list. The patients were followed-up for 1 year to evaluate growth, clinical evolution, treatment needs, adherence to the TMD and the degree of family satisfaction. The conventional treatment remained initially unchanged and the drugs were reduced only when clinical improvements were observed.Study variablesClinical parameters and treatmentPrimary end point: The number of BHR episodes and childhood asthma attacks per person per year (relapses or exacerbations). The Third International Pediatric Consensus has defined childhood asthma as a condition in which there are three or more episodes of wheezing and/or coughing in a clinical setting in which the diagnosis of asthma is the most likely after excluding other less common conditions. This conceptually strategic definition is still in use (2008 PRACTALL consensus) because it includes the expression of the disease (wheezing, coughing), recurrent episodes (three or more) and the absence of other conditions (wheezing and coughing unrelated to asthma).<a class="elsevierStyleCrossRef" href="#bib0260">12</a>Secondary end points: Intensity of attacks, evaluated according to the protocols of the Spanish Pediatrics Association (1 – mild, 2 – moderate, 3 – severe),<a class="elsevierStyleCrossRef" href="#bib0265">13</a> upper respiratory tract infections (URTIs), bacterial complications, emergency room visits, hospital admissions, drugs administered (inhaled corticosteroids, oral corticosteroids, short-acting bronchodilators, antibiotics and symptomatic treatment).Clinical and therapeutic evaluation indexTo evaluate the patients’ clinical outcome, in addition to clinical assessment made by the paediatrician, we have developed a questionnaire given to the parents or guardians that assessed symptoms related to childhood asthma. Ten questions concerning the past 4 weeks were evaluated and scored from a minimum of 0 (poor control) to a maximum of 30 (asymptomatic). It was considered that the patient was well controlled when the sum of the 10 items was greater than 20.Weight and height evolution parametersTaking into account that the intervention performed involved a limitation of certain types of high-energy food, it was considered necessary to carefully evaluate the patients’ anthropometric development. Thus, we collected anthropometric data such as weight, height, skin folds and circumferences of the arm, abdomen and waist to calculate the body mass index (BMI), lean mass and fat mass following the procedures routinely used by our group.<a class="elsevierStyleCrossRef" href="#bib0240">8</a>Parameters of adherence to the TMDAll participants received identical nutritional information intended for the whole family and whose characteristics are condensed in the Decalogue of the Mediterranean diet.<a class="elsevierStyleCrossRef" href="#bib0250">10</a> To evaluate the new habits acquired by the patients and their families, we used the KIDMED test, which assesses the degree of adherence to the Mediterranean dietary pattern among children and adolescents.<a class="elsevierStyleCrossRef" href="#bib0270">14</a>The 10 basic Mediterranean diet recommendations are: (1) use olive oil as your main source of added fat. (2) Eat plenty of fruits and vegetables; fruits, vegetables, legumes and nuts. (3) Bread and other grain products (pasta, rice, and whole grains) should be a part of your everyday diet. (4) Foods that have undergone minimal processing, that is fresh and locally produced are best. (5) Consume dairy products on a daily basis, mainly yoghourt and cheese. (6) Red meat should be consumed in moderation and if possible as a part of stews and other recipes. (7) Consume fish abundantly and eggs in moderation. (8) Fresh fruit should be your everyday dessert and, sweets, cakes and dairy desserts should be consumed only on occasion. (9) Water is the beverage par excellence in the Mediterranean diet. (10) Be physically active every day, since it is just as important as eating well.For the sample size calculation, a significance level of 0.05 and a power of 85% were used, assuming a decrease in the mean number of childhood asthma attacks of one unit per patient per year, with a standard deviation of four units, adjusted for a 25% loss. The resulting sample size was 115 patients. For the analysis of the results, SPSS 15.0 was employed. We performed a descriptive statistical analysis of central tendency and dispersion for quantitative variables and absolute and relative frequencies for qualitative variables. After checking for normality with the Shapiro–Wilk test, the results of the different variables before and after treatment intervention were compared with Student's t-test for paired data, when the variables followed a normal distribution, and Wilcoxon's test otherwise.ResultsAccording to the sample size calculation, the families of the 137 patients who met the inclusion criteria were invited to participate in the programme “Learning to Eat from the Mediterranean”, of whom 24 families refused to participate. Of the 113 patients initially enrolled in the programme, 6 gave up the project after the first session and 3 after the fifth session. Five of these patients left due to social or personal difficulties in implementing the diet and four due to disagreement with the limitation of certain foods. Therefore, a total of 104 patients completed the study, of whom 50 were girls and 54 were boys, with a mean age of 2.74 years (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>). The results were similar for both sexes and are therefore presented together. <a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a> shows the evolution of the indicators studied in symptomatic patients (number and severity of attacks, respiratory infections, emergency and hospital admissions). All of them showed a positive and statistically significant change in the BHR from the first weeks of the intervention onwards. This clinical improvement was maintained until the end of the treatment year. There were no episodes of BHR in 32.2% of children during the year of treatment, 35.3% had only one attack during the year and 24.9% had two episodes, compared to 4.73 episodes on average in the previous year. The intensity of the crisis was assessed by the paediatrician and decreased from mild-moderate to low-mild. This positive evolution of symptoms was accompanied by a significant decrease in the URTIs, bacterial complications, ER admissions and emergency assistance. Moreover, the need for anti-asthma therapy, antibiotic use and other symptomatic medications was also dramatically reduced (<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>). In the year of study, none of the patients required treatment with anti-leukotrienes, or oral corticosteroids. The degree of family satisfaction was very high, as seen in the questionnaire regarding the improvement observed (<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>). Air pollution and smoke snuff was not object of study, so we interpret that the results are mainly due to nutritional changes. The anthropometric variables measured before the intervention, at 4 months, and after 1 year revealed an adequate evolution of parameters related to growth and development, with a significant increase of lean mass (<a class="elsevierStyleCrossRef" href="#tbl0020">Table 4</a>). The patient's dietary habits had also improved in the entire sample by the end of the programme (<a class="elsevierStyleCrossRef" href="#tbl0025">Table 5</a>). As a result, there were an increased number of patients who had breakfast and consumed fruits, vegetables, fish, whole grains and fermented milk, while the proportion of those who ate sweets daily and bakery products for breakfast decreased. According to these data, the KIDMED index positively evolved from an upper-middle score at the beginning of the programme to a good-optimal value by the end.<elsevierMultimedia ident="tbl0005"></elsevierMultimedia><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><elsevierMultimedia ident="tbl0020"></elsevierMultimedia><elsevierMultimedia ident="tbl0025"></elsevierMultimedia>DiscussionThe overall results reflect a fast and positive evolution of patients enrolled in the programme, as shown by the various study variables. Thus, the number of attacks had notably decreased by the conclusion of the study, as had their intensity and associated complications. There was a very favourable start within weeks of dietary treatment, even in younger children and in those with more intense involvement response. Of particular importance is the marked decrease observed in the need for bronchodilators and inhaled corticosteroids, given that one of the main goals of the treatment according to the Global Initiative for Asthma is the prevention of exacerbations and the avoidance of adverse effects of antiasthma medication.<a class="elsevierStyleCrossRefs" href="#bib0275">15–17</a> There was a significant decrease in symptomatic drugs as a result of fewer illnesses and their lesser intensity degree. It is important to note that the use of anti-leukotrienes, and oral corticosteroids was not necessary during the study period. Significant improvements with respect to the previous year's situation were observed within the first 4 months of the intervention, which led to a high adherence to the programme and greatly enhanced monitoring. There was good tolerance of the proposed diet, with an easy adaptation and a lack of relevant culinary difficulties. The evolution of the height and weight of the patients was also satisfactory. There was a slight decrease in BMI and fat mass, and a significant increase in lean mass which happened in a similar way in our previous study of childhood obesity.<a class="elsevierStyleCrossRef" href="#bib0240">8</a> The clinical outcome was assessed by a paediatrician when there was disease and by periodic inspections. The lack of a control group is the major weakness in our study and prevents us from categorically affirming that the dietary intervention was the direct cause of the observed improvements. However, the clinical history of the patients included in the study did not permit to expect a spontaneous favourable evolution of the symptoms<a class="elsevierStyleCrossRef" href="#bib0290">18</a> and therefore the therapeutic efficacy of the diet seems obvious. Furthermore, our results agree with those of other studies that tend to show the beneficial effects of adherence to the TMD and the increased consumption of fruits, vegetables, legumes, oily fish and whole grains.<a class="elsevierStyleCrossRefs" href="#bib0220">4,6,19,20</a> In contrast, the consumption of fast food and sugar has been associated with childhood asthma and counteracts the protective effect of breastfeeding. Junk food<a class="elsevierStyleCrossRef" href="#bib0305">21</a> and excessive salt consumption<a class="elsevierStyleCrossRef" href="#bib0310">22</a> have also been linked with asthma. Despite these findings, a number of other studies do not support the idea that healthy food intake and/or avoidance of certain foods can play an important role in the control of childhood asthma.<a class="elsevierStyleCrossRef" href="#bib0315">23</a> Thus, a recent review and meta-analysis concluded that nutritional factors responsible for the increase in these diseases are unclear.<a class="elsevierStyleCrossRefs" href="#bib0320">24,25</a> Of note is the cross-sectional study of 14,700 Spanish children that found no protective effect of the TMD on the prevalence and severity of asthma.<a class="elsevierStyleCrossRef" href="#bib0225">5</a> Among the possible causes that could explain the lack of effectiveness of these studies related to the dietary intervention, we highlight the lack of an exhaustive follow up and inadequate diet control. We consider that the beneficial effect of our intervention is due to the implementation of a very specific and well-controlled TDM. The positive results of interventions such as ours on childhood asthma could depend on the effects of the TMD; we highlight the implementation of a very specific and well-controlled TMD on inflammation and the immune processes underlying the disease. This was previously proposed after a prospective study of children with asthma in Mexico City in which the strict adherence to the TMD appeared to have a beneficial effect on airway inflammation and lung function.<a class="elsevierStyleCrossRef" href="#bib0235">7</a> In a recent clinical trial in adults with asthma, consistent improvements were seen in the clinic and spirometry in those who adhered to the TMD.<a class="elsevierStyleCrossRef" href="#bib0330">26</a> In patients with mild asthma, it has been shown that inflammation remains asymptomatic for long periods from the start of the disease.<a class="elsevierStyleCrossRef" href="#bib0335">27</a> The bronchial mucus inflammation will condition bronchial hyperresponse to stimuli, causing a major airflow limitation due to smooth muscle contraction, mucous oedema and mucus hypersecretion. The putative anti-inflammatory properties of the TMD could be partially attributed to a proper intake of carbohydrates. By limiting the intake of white bread, refined flour, sugar and bakery products, our dietary intervention decreases the amount of carbohydrates with a high glycaemic index and glycaemic load, which could prevent an excess of circulating insulin from interfering with the proper formation of eicosanoids. It is known that hyperinsulinaemia stimulates the delta-6-desaturase enzyme, which favours the formation of arachidonic acid and type II eicosanoids, which are strongly proinflammatory.<a class="elsevierStyleCrossRef" href="#bib0340">28</a>In addition to limiting simple carbohydrates, reducing the intake of unhealthy fats appears to be a highly beneficial aspect of the TMD and could significantly contribute to limiting inflammation. Before participating in the study, most of our patients ate little in the way of vegetable fats and consumed significant amounts of animal or industrial fats. By limiting the intake of meat and animal derivatives, fatty and unfermented dairy, butter, margarine, bakery products and precooked meals, patients can reduce their intake of saturated fats, trans-fats and arachidonic acid, as well as reduce certain sensitising proteins<a class="elsevierStyleCrossRef" href="#bib0345">29</a> that could interfere with the proper function of cell membranes that are more hyperreactive to triggers. The TMD also provides a correct balance of omega-3 and omega-6 fatty acids, which can decrease the levels of inflammatory cytokines (already high in patients with asthma)<a class="elsevierStyleCrossRef" href="#bib0350">30</a> and affect the differentiation of T helper cells.<a class="elsevierStyleCrossRef" href="#bib0220">4</a>Fresh and seasonal foods contain numerous vitamins, minerals, enzymes, yeasts and antioxidants, and many of these are important co-factors in the formation of the eicosanoids involved in bronchial inflammation.<a class="elsevierStyleCrossRef" href="#bib0355">31</a> We have encouraged the use of raw and steamed foods and foods heated at low temperatures so as to avoid modification by excess heat. By promoting fresh, seasonal foods, many of the additives in processed foods have been eliminated, additives that might be involved in the enzymatic block of bronchial inflammatory mediators. The TMD is rich in antioxidants that can counteract the reduced intake of these substances, which have been associated with increased asthma prevalence.<a class="elsevierStyleCrossRefs" href="#bib0355">31,32</a> Additionally, plant foods, acting as symbiotic, favour intestinal flora fermentation, which has co-evolved with the human race since ancient times.<a class="elsevierStyleCrossRef" href="#bib0365">33</a> Intestinal microbiota depends on the food we eat and have a critical role in modulating the immune system. The immune response also depends on the consumption of significant amounts of fibre,<a class="elsevierStyleCrossRef" href="#bib0370">34</a> which is present in the TMD. The significant decrease of URTIs and their complications are remarkable in our study, which suggests a protective immune effect. Intestinal microbiota is essential for initiating individual IgA production in children younger than 1 year and influence the development of the entire IgA system.<a class="elsevierStyleCrossRef" href="#bib0375">35</a> IgA is abundant in most mucous membranes, where harmless antigens are neutralised and prevented from entering the epithelium.<a class="elsevierStyleCrossRef" href="#bib0380">36</a> Therefore, low levels of IgA in infancy might be the cause of the lack of a significant response to innocuous antigens, namely the induction of oral tolerance. This could be important in the prevention of allergic diseases. Microbiota have a symbiotic relationship with the host, and if this relationship is not adequate, it can cause immune dysregulation and pathological response to environmental antigens (atopy).<a class="elsevierStyleCrossRef" href="#bib0385">37</a>It is noteworthy that the patients in our study showed a high score in the KIDMED test at the beginning of the intervention, before they had started undergoing dietary changes. In our opinion, the KIDMED test, which measures the quality of the Mediterranean diet, is not sensitive to all the nutritional factors proposed in the Decalogue of the Mediterranean diet.<a class="elsevierStyleCrossRefs" href="#bib0390">38,39</a> Thus, it does not take into account whether the cereals are whole grain or refined grain, the percentage of fresh or processed food, the kind of dairy products or the proportion of meat and sausages. A reformulation of this tool could be useful. In addition to the lack of a randomised control group, our study has a number of other limitations that should be mentioned. In the course of the study, it was impossible to make a clinical classification as proposed by the GEMA<a class="elsevierStyleCrossRef" href="#bib0400">40</a> because the intervention began from the third crisis of BHR, and therefore the possible evolution of the patients could not be known. No additional systematic tests were conducted, which is why we have no asthma predictive index values. We did not use the Asthma Control Questionnaire (ACQ) in children proposed by the Spanish consensus because it does not include nutritional questions.In conclusion, our study supports the hypothesis that a diet of high nutritional quality such as the Traditional Mediterranean Diet can contribute to a better control of asthma in children, possibly impacting the underlying immune and inflammatory pathophysiology. The study protocol presented here is easily reproducible in any primary care clinic and can significantly contribute to a better understanding of the therapeutic effects of diet on respiratory diseases, being thus complementary to the use of modern technologies in cross-sectional studies and clinical trials that also address childhood asthma but require much larger budgets.Ethical disclosuresProtection of human subjects and animalsThe authors state that the procedures followed were in accordance with the regulations of the Ethics Committee for Clinical Research responsibly and in accordance with the World Medical Association and the Declaration of Helsinki.Confidentiality of dataThe authors declare that they have followed the protocol of the workplace in the publication of patient data and all patients included in the study have received sufficient information and gave written informed consent to participate in this study.Right to privacy and informed consentThe authors declare that there is no patient data displayed on this article.Conflict of interestThe authors have no conflict of interest to declare." "textoCompletoSecciones" => array:1 [ "secciones" => array:10 [ 0 => array:3 [ "identificador" => "xres612849" "titulo" => "Abstract" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Background" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec626642" "titulo" => "Keywords" ] 2 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 3 => array:3 [ "identificador" => "sec0010" "titulo" => "Methods" "secciones" => array:1 [ 0 => array:2 [ "identificador" => "sec0015" "titulo" => "Study design" ] ] ] 4 => array:3 [ "identificador" => "sec0020" "titulo" => "Study variables" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "sec0025" "titulo" => "Clinical parameters and treatment" ] 1 => array:2 [ "identificador" => "sec0030" "titulo" => "Clinical and therapeutic evaluation index" ] 2 => array:2 [ "identificador" => "sec0035" "titulo" => "Weight and height evolution parameters" ] 3 => array:2 [ "identificador" => "sec0040" "titulo" => "Parameters of adherence to the TMD" ] ] ] 5 => array:2 [ "identificador" => "sec0045" "titulo" => "Results" ] 6 => array:2 [ "identificador" => "sec0050" "titulo" => "Discussion" ] 7 => array:3 [ "identificador" => "sec0055" "titulo" => "Ethical disclosures" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0060" "titulo" => "Protection of human subjects and animals" ] 1 => array:2 [ "identificador" => "sec0065" "titulo" => "Confidentiality of data" ] 2 => array:2 [ "identificador" => "sec0070" "titulo" => "Right to privacy and informed consent" ] ] ] 8 => array:2 [ "identificador" => "sec0075" "titulo" => "Conflict of interest" ] 9 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2014-11-19" "fechaAceptado" => "2015-04-02" "PalabrasClave" => array:1 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec626642" "palabras" => array:6 [ 0 => "Bronchial hyperreactivity" 1 => "Childhood asthma" 2 => "Dietary pattern" 3 => "Dietary programme" 4 => "Mediterranean diet" 5 => "Nutritional assessment" ] ] ] ] "tieneResumen" => true "resumen" => array:1 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "BackgroundThe incidence of bronchial hyperreactivity has increased to one-third of the population in developed countries, which requires the adoption of preventive and therapeutic measures. The objective of the present study was to assess the effects of a traditional Mediterranean diet on patients diagnosed with childhood asthma and determine if there is a beneficial effect from this dietary intervention. MethodsProspective before–after comparison study of 50 girls and 54 boys aged 1–5 years, who were enrolled in the 1-year programme “Learning to Eat from the Mediterranean”, designed to promote the adoption of a traditional Mediterranean diet. We studied the clinical and therapeutic variables and anthropometric measurements. ResultsAll studied symptomatic indicators (number and intensity of asthmatic attack, infections and hospital admissions) showed a positive and statistically significant evolution of bronchial hyperreactivity from the first weeks of the intervention onwards. Throughout the treatment, 32.2% of patients remained free of crisis, 35.3% of the patients only had one attack throughout the year and 24.9% had two episodes, compared to 4.73 episodes on average in the previous year. The use of inhaled corticosteroids markedly decreased from 3.92±1.61 to 1.11±1.09 times per patient per year (P<0.001) and that of inhaled bronchodilators decreased from 4.14±1.61 to 1.12±1.40 (P<0.001). As a result, the families involved in the programme reported a high level of satisfaction. ConclusionsThe adoption of a traditional Mediterranean diet could contribute significantly to the improvement of patients diagnosed with childhood asthma." "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Background" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] ] "multimedia" => array:6 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 907 "Ancho" => 1650 "Tamanyo" => 69395 ] ] "descripcion" => array:1 [ "en" => "Evolution of parameters indicative of BHR symptomatology in the year before intervention (baseline) and during the year of intervention (1 year). Error bars." ] ] 1 => array:7 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Boys (n=54) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Girls (n=50) \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Weight (kg) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">14.06±3.32 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">13.58±3.77 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Height (m) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.92±0.11 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.91±0.10 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">BMI (kg/m2) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">16.50±1.50 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">15.13±1.39 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Fat mass (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">14.11±3.13 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">15.67±3.49 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Lean mass (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">12.08±2.96 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">11.38±2.87 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1003993.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Characteristics of the sample." ] ] 2 => array:7 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Year before intervention \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Year of intervention \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">P \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Treatment with inhaled corticosteroids \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3.92±1.61 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.11±1.09 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.001 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Treatment with short acting bronchodilators \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4.14±1.61 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.11±1.11 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.001 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Treatment with leukotrienes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.20±0.42 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.01±0.09 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.001 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Symptomatic treatment \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">7.50±2.88 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3.40±1.24 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.001 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1003995.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Evolution of drug treatments." ] ] 3 => array:7 [ "identificador" => "tbl0015" "etiqueta" => "Table 3" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">4 Months of intervention \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">1 Year of intervention \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Did asthma recurrence decrease? \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2.31 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2.41 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Have you noticed lower intensity of asthma attacks? \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2.58 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2.95 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">In your opinion, did emergency room and hospitalisation need decrease? \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2.84 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2.95 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Have you noticed cough improvements? \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2.80 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2.95 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Have you noticed a decline in respiratory distress (whistles, catcalls, fatigue, shortness of breath)? \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2.31 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2.95 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Have you noticed a greater recovery of normal state? \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2.42 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2.95 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Have you noticed less use of inhaled corticosteroids and bronchodilators? \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2.97 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2.95 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Have you found the diet well tolerated and linked to reduced asthma symptoms? \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2.95 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2.95 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Have culinary changes been simple or easy? \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2.35 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2.5 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Are you satisfied with the results? \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2.58 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2.95 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Total score \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">26.11 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">28.96 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1003991.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Questionnaire answers from parents or guardians about improvements in bronchial hyperreactivity. (3) A lot; (2) considerably; (1), a bit; (0) nothing." ] ] 4 => array:7 [ "identificador" => "tbl0020" "etiqueta" => "Table 4" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Before intervention \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">4 Months of intervention \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">1 Year of intervention \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">P \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">BMI (kg/m2) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">16.15±1.45 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">15.67±2.28 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">15.35±2.47 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.14 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Fat mass (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">15.12±3.04 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">14.95±3.10 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">14.81±2.95 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.24 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Lean mass (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">11.60±3.38 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">12.27±3.46 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">13.54±3.50 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.01 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1003994.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Anthropometric assessments." ] ] 5 => array:7 [ "identificador" => "tbl0025" "etiqueta" => "Table 5" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:2 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">At the beginning \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">After 4 months \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">After 1 year \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Eat 1 fruit per day? \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">81 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">99 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">100 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Eat more than 1 fruit per day? \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">24 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">71 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">88 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Eat 1 vegetable per day? \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">88 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">98 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">100 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Eat more than 1 vegetable per day? \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">15 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">38 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">67 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Eat fresh fish regularly (2–3 times/week)? \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">84 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">96 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">96 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Attend fast food centres once a week or more? \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">30 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Eat legumes regularly (1–2 times/week)? \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">88 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">98 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">98 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Eat pasta and rice weekly? \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">96 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">98 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">98 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Breakfast cereals or derivates? \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">92 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">99 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">99 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Eat raw nuts regularly?<a class="elsevierStyleCrossRef" href="#tblfn0005">a</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">21 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">38 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">48 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Use olive oil at home? \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">100 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">100 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">100 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">No breakfast \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">12 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">One dairy breakfast? \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">98 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">98 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">100 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Consume bakery at breakfast? \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">33 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">13 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">9 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Eat two yoghourts or 40g cheese daily? \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">98 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">98 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">97 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Eat sweets frequently? \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">22 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1003992.png" ] ] ] "notaPie" => array:1 [ 0 => array:3 [ "identificador" => "tblfn0005" "etiqueta" => "a" "nota" => "Not recommended for children under 3 years." ] ] ] "descripcion" => array:1 [ "en" => "KIDMED test (percentage)." ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:40 [ 0 => array:3 [ "identificador" => "bib0205" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Worldwide trends in the prevalence of asthma symptoms: phase three of the International Study of Asthma and Allergies in Childhood (ISAAC)" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "N. 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Original Article

Mediterranean diet and childhood asthma

F.M. Calatayud-Sáeza,

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altayud@gmail.com

Corresponding author.

, B. Calatayud Moscoso del Pradoa, J.G. Gallego Fernández-Pachecob, C. González-Martínc, L.F. Alguacil Merinoc,d

a Clínica “La Palma”, Ciudad Real, Spain

b Centro de Salud de Atención Primaria # 1, Ciudad Real, Spain

c Unidad de Investigación Traslacional, Hospital General Universitario, Ciudad Real, Spain

d Universidad San Pablo CEU, Madrid, Spain

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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">The incidence of childhood asthma and bronchial hyperreactivity &#40;BHR&#41; has been progressively increasing in developed countries&#44; reaching nearly one-third of the population&#46;<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">1</span></a> This disease causes educational&#44; economic and health problems for patients&#44; their families&#44; and society&#44; which requires the adoption of preventive and therapeutic measures&#46; The degree of asthma varies from patients who experience only a few episodes of wheezing&#44; coughing with mild bronchospasm to patients with repeated episodes and persistent symptoms&#46; The diagnosis of BHR in children is primarily clinical and can be complicated due to the subjective symptoms&#44; which are sometimes difficult for their parents to assess&#46;<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">2</span></a> There is no universal test to determine the exact diagnosis&#46; It has been demonstrated that the fundamental pathophysiological basis is bronchial inflammation&#44; which triggers hypersensitivity to a variety of stimuli such as upper respiratory tract infections&#44; air pollution&#44; tobacco&#44; smoke&#44; exercise&#44; central heating&#44; seasonal pollination and obesity&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">Current treatment is based on the use of bronchodilator &#946;<span class="elsevierStyleInf">2</span>-agonists &#40;which reduce bronchial muscle spasticity&#41;&#44; anti-inflammatory corticosteroids and anti-leukotrienes &#40;which reduce BHR and clinical symptoms&#41;&#46; All are effective upon acute application&#44; but prolonged use is more questionable due to the limited evidence supporting efficacy and the emergence of adverse effects such as abnormal growth in children&#46;<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">3</span></a> It has been suggested that dietary interventions could be of potential use based on a number of publications that have linked the disease with the loss of traditional dietary patterns&#46; Some of these results&#44; however&#44; are controversial&#46;<a class="elsevierStyleCrossRefs" href="#bib0220"><span class="elsevierStyleSup">4&#8211;7</span></a> One of our recent studies on overweight and obese children supports this idea because patients with BHR improved considerably after controlling the quality of their diet&#46;<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">8</span></a> We therefore hypothesise that restoring traditional&#44; healthy diets such as the Mediterranean diet could help decrease bronchial hyperreactivity significantly&#46; In accordance with this idea&#44; a meta-analysis has recently been published supporting the positive influence of Mediterranean diets on respiratory outcomes in children&#46;<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">9</span></a> The present study aims to extend knowledge in this direction by studying the effects of a traditional Mediterranean diet &#40;TMD&#41;&#44; on patients diagnosed with childhood asthma through a food re-education programme developed in the family sphere&#46; The study diet was based on the Decalogue proposed by the Mediterranean Diet Foundation&#46;<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">10</span></a> The Mediterranean diet was proclaimed an Intangible Cultural Heritage of Humanity by UNESCO in 2010 and is characterised by a high intake of unrefined plant-based foods such as fruits and fresh vegetables&#44; whole grains&#44; legumes&#44; olive oil and nuts&#59; low to moderate consumption of foods of animal origin such as fermented milk&#44; fish&#44; eggs and lean meats&#59; and by a low intake of sugar&#44; refined flour and fast food&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Methods</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Study design</span><p id="par0015" class="elsevierStylePara elsevierViewall">The study was approved by the Research and Ethics Committees of the General University Hospital of Ciudad Real&#44; Spain&#46; The research design was an analytical&#44; before&#8211;after comparison study&#44; which consecutively enrolled patients 1&#8211;5 years of age who met childhood asthma criteria<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">11</span></a> and who attended a consultation at a primary care practice between May 2009 and September 2013&#46; It was considered necessary to include the medical history of at least 1 year prior to the study and informed consent signed by their parents or guardians&#46; The intervention focused on dietary re-education based on the TMD by a nutritional education programme named &#8220;Learning to Eat from the Mediterranean&#8221;&#46; This programme is based on a series of visits to the nutritionist and paediatrician that are designed to assist the entire family&#46; The visits were monthly during the first 4 months and bimonthly the rest of the year&#46; To start the programme a 7-day recall questionnaire was required&#46; On the first visit&#44; we evaluated the food choices of each child and family&#46; Based on the problems identified&#44; we proposed dietary changes by providing dietary patterns&#44; recipes&#44; sample menus&#44; etc&#46; An anthropometric assessment was also performed and key health issues were explained&#44; such as the importance of a good breakfast&#44; variability in menus&#44; the balance between food consumption and energy expenditure&#44; the quality of fats&#44; proteins and carbohydrates&#44; understanding labels and creating a healthy shopping list&#46; The patients were followed-up for 1 year to evaluate growth&#44; clinical evolution&#44; treatment needs&#44; adherence to the TMD and the degree of family satisfaction&#46; The conventional treatment remained initially unchanged and the drugs were reduced only when clinical improvements were observed&#46;</p></span></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Study variables</span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Clinical parameters and treatment</span><p id="par0020" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Primary end point&#58;</span> The number of BHR episodes and childhood asthma attacks per person per year &#40;relapses or exacerbations&#41;&#46; 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bacterial complications&#44; emergency room visits&#44; hospital admissions&#44; drugs administered &#40;inhaled corticosteroids&#44; oral corticosteroids&#44; short-acting bronchodilators&#44; antibiotics and symptomatic treatment&#41;&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Clinical and therapeutic evaluation index</span><p id="par0030" class="elsevierStylePara elsevierViewall">To evaluate the patients&#8217; clinical outcome&#44; in addition to clinical assessment made by the paediatrician&#44; we have developed a questionnaire given to the parents or guardians that assessed symptoms related to childhood asthma&#46; Ten questions concerning the past 4 weeks were evaluated and scored from a minimum of 0 &#40;poor control&#41; to a maximum of 30 &#40;asymptomatic&#41;&#46; It was considered that the patient was well controlled when the sum of the 10 items was greater than 20&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Weight and height evolution parameters</span><p id="par0035" class="elsevierStylePara elsevierViewall">Taking into account that the intervention performed involved a limitation of certain types of high-energy food&#44; it was considered necessary to carefully evaluate the patients&#8217; anthropometric development&#46; Thus&#44; we collected anthropometric data such as weight&#44; height&#44; skin folds and circumferences of the arm&#44; abdomen and waist to calculate the body mass index &#40;BMI&#41;&#44; lean mass and fat mass following the procedures routinely used by our group&#46;<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">8</span></a></p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Parameters of adherence to the TMD</span><p id="par0040" class="elsevierStylePara elsevierViewall">All participants received identical nutritional information intended for the whole family and whose characteristics are condensed in the Decalogue of the Mediterranean diet&#46;<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">10</span></a> To evaluate the new habits acquired by the patients and their families&#44; we used the KIDMED test&#44; which assesses the degree of adherence to the Mediterranean dietary pattern among children and adolescents&#46;<a class="elsevierStyleCrossRef" href="#bib0270"><span class="elsevierStyleSup">14</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">The 10 basic Mediterranean diet recommendations are&#58;</span> &#40;1&#41; use olive oil as your main source of added fat&#46; &#40;2&#41; Eat plenty of fruits and vegetables&#59; fruits&#44; vegetables&#44; legumes and nuts&#46; &#40;3&#41; Bread and other grain products &#40;pasta&#44; rice&#44; and whole grains&#41; should be a part of your everyday diet&#46; &#40;4&#41; Foods that have undergone minimal processing&#44; that is fresh and locally produced are best&#46; &#40;5&#41; Consume dairy products on a daily basis&#44; mainly yoghourt and cheese&#46; &#40;6&#41; Red meat should be consumed in moderation and if possible as a part of stews and other recipes&#46; &#40;7&#41; Consume fish abundantly and eggs in moderation&#46; &#40;8&#41; Fresh fruit should be your everyday dessert and&#44; sweets&#44; cakes and dairy desserts should be consumed only on occasion&#46; &#40;9&#41; Water is the beverage par excellence in the Mediterranean diet&#46; &#40;10&#41; Be physically active every day&#44; since it is just as important as eating well&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">For the sample size calculation&#44; a significance level of 0&#46;05 and a power of 85&#37; were used&#44; assuming a decrease in the mean number of childhood asthma attacks of one unit per patient per year&#44; with a standard deviation of four units&#44; adjusted for a 25&#37; loss&#46; The resulting sample size was 115 patients&#46; For the analysis of the results&#44; SPSS 15&#46;0 was employed&#46; We performed a descriptive statistical analysis of central tendency and dispersion for quantitative variables and absolute and relative frequencies for qualitative variables&#46; After checking for normality with the Shapiro&#8211;Wilk test&#44; the results of the different variables before and after treatment intervention were compared with Student&#39;s <span class="elsevierStyleItalic">t</span>-test for paired data&#44; when the variables followed a normal distribution&#44; and Wilcoxon&#39;s test otherwise&#46;</p></span></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Results</span><p id="par0055" class="elsevierStylePara elsevierViewall">According to the sample size calculation&#44; the families of the 137 patients who met the inclusion criteria were invited to participate in the programme &#8220;Learning to Eat from the Mediterranean&#8221;&#44; of whom 24 families refused to participate&#46; Of the 113 patients initially enrolled in the programme&#44; 6 gave up the project after the first session and 3 after the fifth session&#46; Five of these patients left due to social or personal difficulties in implementing the diet and four due to disagreement with the limitation of certain foods&#46; Therefore&#44; a total of 104 patients completed the study&#44; of whom 50 were girls and 54 were boys&#44; with a mean age of 2&#46;74 years &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46; The results were similar for both sexes and are therefore presented together&#46; <a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a> shows the evolution of the indicators studied in symptomatic patients &#40;number and severity of attacks&#44; respiratory infections&#44; emergency and hospital admissions&#41;&#46; All of them showed a positive and statistically significant change in the BHR from the first weeks of the intervention onwards&#46; This clinical improvement was maintained until the end of the treatment year&#46; There were no episodes of BHR in 32&#46;2&#37; of children during the year of treatment&#44; 35&#46;3&#37; had only one attack during the year and 24&#46;9&#37; had two episodes&#44; compared to 4&#46;73 episodes on average in the previous year&#46; The intensity of the crisis was assessed by the paediatrician and decreased from mild-moderate to low-mild&#46; This positive evolution of symptoms was accompanied by a significant decrease in the URTIs&#44; bacterial complications&#44; ER admissions and emergency assistance&#46; Moreover&#44; the need for anti-asthma therapy&#44; antibiotic use and other symptomatic medications was also dramatically reduced &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46; In the year of study&#44; none of the patients required treatment with anti-leukotrienes&#44; or oral corticosteroids&#46; The degree of family satisfaction was very high&#44; as seen in the questionnaire regarding the improvement observed &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#41;&#46; Air pollution and smoke snuff was not object of study&#44; so we interpret that the results are mainly due to nutritional changes&#46; The anthropometric variables measured before the intervention&#44; at 4 months&#44; and after 1 year revealed an adequate evolution of parameters related to growth and development&#44; with a significant increase of lean mass &#40;<a class="elsevierStyleCrossRef" href="#tbl0020">Table 4</a>&#41;&#46; The patient&#39;s dietary habits had also improved in the entire sample by the end of the programme &#40;<a class="elsevierStyleCrossRef" href="#tbl0025">Table 5</a>&#41;&#46; As a result&#44; there were an increased number of patients who had breakfast and consumed fruits&#44; vegetables&#44; fish&#44; whole grains and fermented milk&#44; while the proportion of those who ate sweets daily and bakery products for breakfast decreased&#46; According to these data&#44; the KIDMED index positively evolved from an upper-middle score at the beginning of the programme to a good-optimal value by the end&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><elsevierMultimedia ident="tbl0020"></elsevierMultimedia><elsevierMultimedia ident="tbl0025"></elsevierMultimedia></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Discussion</span><p id="par0060" class="elsevierStylePara elsevierViewall">The overall results reflect a fast and positive evolution of patients enrolled in the programme&#44; as shown by the various study variables&#46; Thus&#44; the number of attacks had notably decreased by the conclusion of the study&#44; as had their intensity and associated complications&#46; There was a very favourable start within weeks of dietary treatment&#44; even in younger children and in those with more intense involvement response&#46; Of particular importance is the marked decrease observed in the need for bronchodilators and inhaled corticosteroids&#44; given that one of the main goals of the treatment according to the Global Initiative for Asthma is the prevention of exacerbations and the avoidance of adverse effects of antiasthma medication&#46;<a class="elsevierStyleCrossRefs" href="#bib0275"><span class="elsevierStyleSup">15&#8211;17</span></a> There was a significant decrease in symptomatic drugs as a result of fewer illnesses and their lesser intensity degree&#46; It is important to note that the use of anti-leukotrienes&#44; and oral corticosteroids was not necessary during the study period&#46; Significant improvements with respect to the previous year&#39;s situation were observed within the first 4 months of the intervention&#44; which led to a high adherence to the programme and greatly enhanced monitoring&#46; There was good tolerance of the proposed diet&#44; with an easy adaptation and a lack of relevant culinary difficulties&#46; The evolution of the height and weight of the patients was also satisfactory&#46; There was a slight decrease in BMI and fat mass&#44; and a significant increase in lean mass which happened in a similar way in our previous study of childhood obesity&#46;<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">8</span></a> The clinical outcome was assessed by a paediatrician when there was disease and by periodic inspections&#46; The lack of a control group is the major weakness in our study and prevents us from categorically affirming that the dietary intervention was the direct cause of the observed improvements&#46; However&#44; the clinical history of the patients included in the study did not permit to expect a spontaneous favourable evolution of the symptoms<a class="elsevierStyleCrossRef" href="#bib0290"><span class="elsevierStyleSup">18</span></a> and therefore the therapeutic efficacy of the diet seems obvious&#46; Furthermore&#44; our results agree with those of other studies that tend to show the beneficial effects of adherence to the TMD and the increased consumption of fruits&#44; vegetables&#44; legumes&#44; oily fish and whole grains&#46;<a class="elsevierStyleCrossRefs" href="#bib0220"><span class="elsevierStyleSup">4&#44;6&#44;19&#44;20</span></a> In contrast&#44; the consumption of fast food and sugar has been associated with childhood asthma and counteracts the protective effect of breastfeeding&#46; Junk food<a class="elsevierStyleCrossRef" href="#bib0305"><span class="elsevierStyleSup">21</span></a> and excessive salt consumption<a class="elsevierStyleCrossRef" href="#bib0310"><span class="elsevierStyleSup">22</span></a> have also been linked with asthma&#46; Despite these findings&#44; a number of other studies do not support the idea that healthy food intake and&#47;or avoidance of certain foods can play an important role in the control of childhood asthma&#46;<a class="elsevierStyleCrossRef" href="#bib0315"><span class="elsevierStyleSup">23</span></a> Thus&#44; a recent review and meta-analysis concluded that nutritional factors responsible for the increase in these diseases are unclear&#46;<a class="elsevierStyleCrossRefs" href="#bib0320"><span class="elsevierStyleSup">24&#44;25</span></a> Of note is the cross-sectional study of 14&#44;700 Spanish children that found no protective effect of the TMD on the prevalence and severity of asthma&#46;<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">5</span></a> Among the possible causes that could explain the lack of effectiveness of these studies related to the dietary intervention&#44; we highlight the lack of an exhaustive follow up and inadequate diet control&#46; We consider that the beneficial effect of our intervention is due to the implementation of a very specific and well-controlled TDM&#46; The positive results of interventions such as ours on childhood asthma could depend on the effects of the TMD&#59; we highlight the implementation of a very specific and well-controlled TMD on inflammation and the immune processes underlying the disease&#46; This was previously proposed after a prospective study of children with asthma in Mexico City in which the strict adherence to the TMD appeared to have a beneficial effect on airway inflammation and lung function&#46;<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">7</span></a> In a recent clinical trial in adults with asthma&#44; consistent improvements were seen in the clinic and spirometry in those who adhered to the TMD&#46;<a class="elsevierStyleCrossRef" href="#bib0330"><span class="elsevierStyleSup">26</span></a> In patients with mild asthma&#44; it has been shown that inflammation remains asymptomatic for long periods from the start of the disease&#46;<a class="elsevierStyleCrossRef" href="#bib0335"><span class="elsevierStyleSup">27</span></a> The bronchial mucus inflammation will condition bronchial hyperresponse to stimuli&#44; causing a major airflow limitation due to smooth muscle contraction&#44; mucous oedema and mucus hypersecretion&#46; The putative anti-inflammatory properties of the TMD could be partially attributed to a proper intake of carbohydrates&#46; By limiting the intake of white bread&#44; refined flour&#44; sugar and bakery products&#44; our dietary intervention decreases the amount of carbohydrates with a high glycaemic index and glycaemic load&#44; which could prevent an excess of circulating insulin from interfering with the proper formation of eicosanoids&#46; It is known that hyperinsulinaemia stimulates the delta-6-desaturase enzyme&#44; which favours the formation of arachidonic acid and type II eicosanoids&#44; which are strongly proinflammatory&#46;<a class="elsevierStyleCrossRef" href="#bib0340"><span class="elsevierStyleSup">28</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall">In addition to limiting simple carbohydrates&#44; reducing the intake of unhealthy fats appears to be a highly beneficial aspect of the TMD and could significantly contribute to limiting inflammation&#46; Before participating in the study&#44; most of our patients ate little in the way of vegetable fats and consumed significant amounts of animal or industrial fats&#46; By limiting the intake of meat and animal derivatives&#44; fatty and unfermented dairy&#44; butter&#44; margarine&#44; bakery products and precooked meals&#44; patients can reduce their intake of saturated fats&#44; trans-fats and arachidonic acid&#44; as well as reduce certain sensitising proteins<a class="elsevierStyleCrossRef" href="#bib0345"><span class="elsevierStyleSup">29</span></a> that could interfere with the proper function of cell membranes that are more hyperreactive to triggers&#46; The TMD also provides a correct balance of omega-3 and omega-6 fatty acids&#44; which can decrease the levels of inflammatory cytokines &#40;already high in patients with asthma&#41;<a class="elsevierStyleCrossRef" href="#bib0350"><span class="elsevierStyleSup">30</span></a> and affect the differentiation of T helper cells&#46;<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">4</span></a></p><p id="par0070" class="elsevierStylePara elsevierViewall">Fresh and seasonal foods contain numerous vitamins&#44; minerals&#44; enzymes&#44; yeasts and antioxidants&#44; and many of these are important co-factors in the formation of the eicosanoids involved in bronchial inflammation&#46;<a class="elsevierStyleCrossRef" href="#bib0355"><span class="elsevierStyleSup">31</span></a> We have encouraged the use of raw and steamed foods and foods heated at low temperatures so as to avoid modification by excess heat&#46; By promoting fresh&#44; seasonal foods&#44; many of the additives in processed foods have been eliminated&#44; additives that might be involved in the enzymatic block of bronchial inflammatory mediators&#46; The TMD is rich in antioxidants that can counteract the reduced intake of these substances&#44; which have been associated with increased asthma prevalence&#46;<a class="elsevierStyleCrossRefs" href="#bib0355"><span class="elsevierStyleSup">31&#44;32</span></a> Additionally&#44; plant foods&#44; acting as symbiotic&#44; favour intestinal flora fermentation&#44; which has co-evolved with the human race since ancient times&#46;<a class="elsevierStyleCrossRef" href="#bib0365"><span class="elsevierStyleSup">33</span></a> Intestinal microbiota depends on the food we eat and have a critical role in modulating the immune system&#46; The immune response also depends on the consumption of significant amounts of fibre&#44;<a class="elsevierStyleCrossRef" href="#bib0370"><span class="elsevierStyleSup">34</span></a> which is present in the TMD&#46; The significant decrease of URTIs and their complications are remarkable in our study&#44; which suggests a protective immune effect&#46; Intestinal microbiota is essential for initiating individual IgA production in children younger than 1 year and influence the development of the entire IgA system&#46;<a class="elsevierStyleCrossRef" href="#bib0375"><span class="elsevierStyleSup">35</span></a> IgA is abundant in most mucous membranes&#44; where harmless antigens are neutralised and prevented from entering the epithelium&#46;<a class="elsevierStyleCrossRef" href="#bib0380"><span class="elsevierStyleSup">36</span></a> Therefore&#44; low levels of IgA in infancy might be the cause of the lack of a significant response to innocuous antigens&#44; namely the induction of oral tolerance&#46; This could be important in the prevention of allergic diseases&#46; Microbiota have a symbiotic relationship with the host&#44; and if this relationship is not adequate&#44; it can cause immune dysregulation and pathological response to environmental antigens &#40;atopy&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0385"><span class="elsevierStyleSup">37</span></a></p><p id="par0075" class="elsevierStylePara elsevierViewall">It is noteworthy that the patients in our study showed a high score in the KIDMED test at the beginning of the intervention&#44; before they had started undergoing dietary changes&#46; In our opinion&#44; the KIDMED test&#44; which measures the quality of the Mediterranean diet&#44; is not sensitive to all the nutritional factors proposed in the Decalogue of the Mediterranean diet&#46;<a class="elsevierStyleCrossRefs" href="#bib0390"><span class="elsevierStyleSup">38&#44;39</span></a> Thus&#44; it does not take into account whether the cereals are whole grain or refined grain&#44; the percentage of fresh or processed food&#44; the kind of dairy products or the proportion of meat and sausages&#46; A reformulation of this tool could be useful&#46; In addition to the lack of a randomised control group&#44; our study has a number of other limitations that should be mentioned&#46; In the course of the study&#44; it was impossible to make a clinical classification as proposed by the GEMA<a class="elsevierStyleCrossRef" href="#bib0400"><span class="elsevierStyleSup">40</span></a> because the intervention began from the third crisis of BHR&#44; and therefore the possible evolution of the patients could not be known&#46; No additional systematic tests were conducted&#44; which is why we have no asthma predictive index values&#46; We did not use the Asthma Control Questionnaire &#40;ACQ&#41; in children proposed by the Spanish consensus because it does not include nutritional questions&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">In conclusion&#44; our study supports the hypothesis that a diet of high nutritional quality such as the Traditional Mediterranean Diet can contribute to a better control of asthma in children&#44; possibly impacting the underlying immune and inflammatory pathophysiology&#46; The study protocol presented here is easily reproducible in any primary care clinic and can significantly contribute to a better understanding of the therapeutic effects of diet on respiratory diseases&#44; being thus complementary to the use of modern technologies in cross-sectional studies and clinical trials that also address childhood asthma but require much larger budgets&#46;</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Ethical disclosures</span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Protection of human subjects and animals</span><p id="par0085" class="elsevierStylePara elsevierViewall">The authors state that the procedures followed were in accordance with the regulations of the Ethics Committee for Clinical Research responsibly and in accordance with the World Medical Association and the Declaration of Helsinki&#46;</p></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Confidentiality of data</span><p id="par0090" class="elsevierStylePara elsevierViewall">The authors declare that they have followed the protocol of the workplace in the publication of patient data and all patients included in the study have received sufficient information and gave written informed consent to participate in this study&#46;</p></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Right to privacy and informed consent</span><p id="par0095" class="elsevierStylePara elsevierViewall">The authors declare that there is no patient data displayed on this article&#46;</p></span></span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Conflict of interest</span><p id="par0100" class="elsevierStylePara elsevierViewall">The authors have no conflict of interest to declare&#46;</p></span></span>"
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    "fechaRecibido" => "2014-11-19"
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            0 => "Bronchial hyperreactivity"
            1 => "Childhood asthma"
            2 => "Dietary pattern"
            3 => "Dietary programme"
            4 => "Mediterranean diet"
            5 => "Nutritional assessment"
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        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Background</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">The incidence of bronchial hyperreactivity has increased to one-third of the population in developed countries&#44; which requires the adoption of preventive and therapeutic measures&#46; The objective of the present study was to assess the effects of a traditional Mediterranean diet on patients diagnosed with childhood asthma and determine if there is a beneficial effect from this dietary intervention&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Prospective before&#8211;after comparison study of 50 girls and 54 boys aged 1&#8211;5 years&#44; who were enrolled in the 1-year programme &#8220;Learning to Eat from the Mediterranean&#8221;&#44; designed to promote the adoption of a traditional Mediterranean diet&#46; We studied the clinical and therapeutic variables and anthropometric measurements&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">All studied symptomatic indicators &#40;number and intensity of asthmatic attack&#44; infections and hospital admissions&#41; showed a positive and statistically significant evolution of bronchial hyperreactivity from the first weeks of the intervention onwards&#46; Throughout the treatment&#44; 32&#46;2&#37; of patients remained free of crisis&#44; 35&#46;3&#37; of the patients only had one attack throughout the year and 24&#46;9&#37; had two episodes&#44; compared to 4&#46;73 episodes on average in the previous year&#46; The use of inhaled corticosteroids markedly decreased from 3&#46;92<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#46;61 to 1&#46;11<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#46;09 times per patient per year &#40;<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#41; and that of inhaled bronchodilators decreased from 4&#46;14<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#46;61 to 1&#46;12<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#46;40 &#40;<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#41;&#46; As a result&#44; the families involved in the programme reported a high level of satisfaction&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">The adoption of a traditional Mediterranean diet could contribute significantly to the improvement of patients diagnosed with childhood asthma&#46;</p></span>"
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                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Boys &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>54&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Girls &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>50&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Weight &#40;kg&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">14&#46;06<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>3&#46;32&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">13&#46;58<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>3&#46;77&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Height &#40;m&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;92<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;11&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;91<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;10&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">BMI &#40;kg&#47;m<span class="elsevierStyleSup">2</span>&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">16&#46;50<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#46;50&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">15&#46;13<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#46;39&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Fat mass &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">14&#46;11<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>3&#46;13&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">15&#46;67<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>3&#46;49&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Lean mass &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">12&#46;08<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>2&#46;96&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">11&#46;38<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>2&#46;87&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
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                0 => "xTab1003993.png"
              ]
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          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Characteristics of the sample&#46;</p>"
        ]
      ]
      2 => array:7 [
        "identificador" => "tbl0010"
        "etiqueta" => "Table 2"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "tabla" => array:1 [
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Year before intervention&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Year of intervention&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">P</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Treatment with inhaled corticosteroids&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">3&#46;92<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#46;61&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&#46;11<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#46;09&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Treatment with short acting bronchodilators&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4&#46;14<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#46;61&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&#46;11<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#46;11&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Treatment with leukotrienes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;20<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;42&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;01<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;09&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Symptomatic treatment&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">7&#46;50<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>2&#46;88&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">3&#46;40<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#46;24&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
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                0 => "xTab1003995.png"
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          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Evolution of drug treatments&#46;</p>"
        ]
      ]
      3 => array:7 [
        "identificador" => "tbl0015"
        "etiqueta" => "Table 3"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "tabla" => array:1 [
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">4 Months of intervention&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">1 Year of intervention&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Did asthma recurrence decrease&#63;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2&#46;31&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2&#46;41&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Have you noticed lower intensity of asthma attacks&#63;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2&#46;58&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2&#46;95&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">In your opinion&#44; did emergency room and hospitalisation need decrease&#63;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2&#46;84&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2&#46;95&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Have you noticed cough improvements&#63;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2&#46;80&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2&#46;95&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Have you noticed a decline in respiratory distress &#40;whistles&#44; catcalls&#44; fatigue&#44; shortness of breath&#41;&#63;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2&#46;31&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2&#46;95&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Have you noticed a greater recovery of normal state&#63;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2&#46;42&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2&#46;95&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Have you noticed less use of inhaled corticosteroids and bronchodilators&#63;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2&#46;97&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2&#46;95&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Have you found the diet well tolerated and linked to reduced asthma symptoms&#63;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2&#46;95&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2&#46;95&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Have culinary changes been simple or easy&#63;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2&#46;35&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2&#46;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Are you satisfied with the results&#63;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2&#46;58&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2&#46;95&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Total score&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">26&#46;11&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">28&#46;96&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
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                0 => "xTab1003991.png"
              ]
            ]
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Questionnaire answers from parents or guardians about improvements in bronchial hyperreactivity&#46; &#40;3&#41; A lot&#59; &#40;2&#41; considerably&#59; &#40;1&#41;&#44; a bit&#59; &#40;0&#41; nothing&#46;</p>"
        ]
      ]
      4 => array:7 [
        "identificador" => "tbl0020"
        "etiqueta" => "Table 4"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "tabla" => array:1 [
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Before intervention&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">4 Months of intervention&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">1 Year of intervention&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">P</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">BMI &#40;kg&#47;m<span class="elsevierStyleSup">2</span>&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">16&#46;15<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#46;45&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">15&#46;67<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>2&#46;28&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">15&#46;35<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>2&#46;47&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;14&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Fat mass &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">15&#46;12<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>3&#46;04&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">14&#46;95<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>3&#46;10&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">14&#46;81<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>2&#46;95&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;24&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Lean mass &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">11&#46;60<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>3&#46;38&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">12&#46;27<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>3&#46;46&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">13&#46;54<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>3&#46;50&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;01&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
              "imagenFichero" => array:1 [
                0 => "xTab1003994.png"
              ]
            ]
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Anthropometric assessments&#46;</p>"
        ]
      ]
      5 => array:7 [
        "identificador" => "tbl0025"
        "etiqueta" => "Table 5"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "tabla" => array:2 [
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">At the beginning&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">After 4 months&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">After 1 year&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Eat 1 fruit per day&#63;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">81&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">99&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">100&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Eat more than 1 fruit per day&#63;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">24&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">71&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">88&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Eat 1 vegetable per day&#63;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">88&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">98&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">100&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Eat more than 1 vegetable per day&#63;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">15&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">38&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">67&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Eat fresh fish regularly &#40;2&#8211;3 times&#47;week&#41;&#63;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">84&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">96&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">96&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Attend fast food centres once a week or more&#63;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">30&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Eat legumes regularly &#40;1&#8211;2 times&#47;week&#41;&#63;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">88&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">98&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">98&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Eat pasta and rice weekly&#63;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">96&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">98&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">98&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Breakfast cereals or derivates&#63;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">92&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">99&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">99&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Eat raw nuts regularly&#63;<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">21&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">38&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">48&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Use olive oil at home&#63;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">100&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">100&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">100&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">No breakfast&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">12&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">One dairy breakfast&#63;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">98&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">98&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">100&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Consume bakery at breakfast&#63;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">33&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">13&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Eat two yoghourts or 40<span class="elsevierStyleHsp" style=""></span>g cheese daily&#63;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">98&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">98&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">97&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Eat sweets frequently&#63;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">22&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
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                0 => "xTab1003992.png"
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              "identificador" => "tblfn0005"
              "etiqueta" => "a"
              "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Not recommended for children under 3 years&#46;</p>"
            ]
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">KIDMED test &#40;percentage&#41;&#46;</p>"
        ]
      ]
    ]
    "bibliografia" => array:2 [
      "titulo" => "References"
      "seccion" => array:1 [
        0 => array:2 [
          "identificador" => "bibs0005"
          "bibliografiaReferencia" => array:40 [
            0 => array:3 [
              "identificador" => "bib0205"
              "etiqueta" => "1"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Worldwide trends in the prevalence of asthma symptoms&#58; phase three of the International Study of Asthma and Allergies in Childhood &#40;ISAAC&#41;"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "N&#46; Pearce"
                            1 => "N&#46; A&#239;t-Khaled"
                            2 => "R&#46; Beasley"
                            3 => "J&#46; Mallol"
                            4 => "U&#46; Keil"
                            5 => "E&#46; Mitchell"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1136/thx.2006.070169"
                      "Revista" => array:6 [
                        "tituloSerie" => "Thorax"
                        "fecha" => "2007"
                        "volumen" => "62"
                        "paginaInicial" => "758"
                        "paginaFinal" => "766"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/17504817"
                            "web" => "Medline"
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                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            1 => array:3 [
              "identificador" => "bib0210"
              "etiqueta" => "2"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Tratamiento pr&#225;ctico del asma basado en el control de la enfermedad&#58; actualizaci&#243;n de gu&#237;as GINA"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:1 [
                            0 => "M&#46;E&#46; Soto-Quir&#243;s"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "An Pediatr &#40;Barc&#41;"
                        "fecha" => "2008"
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                ]
              ]
            ]
            2 => array:3 [
              "identificador" => "bib0215"
              "etiqueta" => "3"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Effect of inhaled glucocorticoids in childhood on adult height"
                      "autores" => array:1 [
                        0 => array:3 [
                          "colaboracion" => "CAMP Research Group"
                          "etal" => true
                          "autores" => array:6 [
                            0 => "H&#46;W&#46; Kelly"
                            1 => "A&#46;L&#46; Sternberg"
                            2 => "R&#46;S&#46; Zeiger"
                            3 => "A&#46;L&#46; Fuhlbrigge"
                            4 => "P&#46; Williams"
                            5 => "R&#46;S&#46; Zeiger"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1056/NEJMoa1203229"
                      "Revista" => array:6 [
                        "tituloSerie" => "N Engl J Med"
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                        "volumen" => "367"
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                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/22938716"
                            "web" => "Medline"
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                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            3 => array:3 [
              "identificador" => "bib0220"
              "etiqueta" => "4"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Mediterranean diet is associated with reduced asthma and rhinitis in Mexican children"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:5 [
                            0 => "J&#46; Batlle"
                            1 => "J&#46; Garcia-Aymerich"
                            2 => "A&#46; Barraza-Villarreal"
                            3 => "J&#46;M&#46; Ant&#243;"
                            4 => "I&#46; Romieu"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1111/j.1398-9995.2008.01722.x"
                      "Revista" => array:6 [
                        "tituloSerie" => "Allergy"
                        "fecha" => "2008"
                        "volumen" => "63"
                        "paginaInicial" => "1310"
                        "paginaFinal" => "1316"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/18782109"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            4 => array:3 [
              "identificador" => "bib0225"
              "etiqueta" => "5"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Mediterranean diet and asthma in Spanish school children"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "F&#46;J&#46; Gonz&#225;lez Barcala"
                            1 => "S&#46; Pertega"
                            2 => "L&#46; Bamonde"
                            3 => "L&#46; Garnelo"
                            4 => "T&#46; Perez Castro"
                            5 => "M&#46; Sampedro"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:4 [
                        "tituloSerie" => "Pediatr Allergy Immunol"
                        "fecha" => "2010"
                        "paginaInicial" => "1021"
                        "paginaFinal" => "1027"
                      ]
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                  ]
                ]
              ]
            ]
            5 => array:3 [
              "identificador" => "bib0230"
              "etiqueta" => "6"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Effect of diet on asthma and allergic sensitisation in the International Study on Allergies and Asthma in Childhood &#40;ISAAC&#41; phase two"
                      "autores" => array:1 [
                        0 => array:3 [
                          "colaboracion" => "ISAAC Phase Two Study Group"
                          "etal" => false
                          "autores" => array:5 [
                            0 => "G&#46; Nagel"
                            1 => "G&#46; Weinmayr"
                            2 => "A&#46; Kleiner"
                            3 => "L&#46; Garcia-Marcos"
                            4 => "D&#46;P&#46; Strachan"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1136/thx.2009.128256"
                      "Revista" => array:6 [
                        "tituloSerie" => "Thorax"
                        "fecha" => "2010"
                        "volumen" => "65"
                        "paginaInicial" => "516"
                        "paginaFinal" => "522"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/20522849"
                            "web" => "Medline"
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                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            6 => array:3 [
              "identificador" => "bib0235"
              "etiqueta" => "7"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Dietary intake&#44; lung function and airway inflammation in Mexico City school children exposed to air pollutants"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "I&#46; Romieu"
                            1 => "A&#46; Barraza-Villarreal"
                            2 => "C&#46; Escamilla-N&#250;&#241;ez"
                            3 => "J&#46;L&#46; Texcalac-Sangrador"
                            4 => "L&#46; Hernandez-Cadena"
                            5 => "D&#46; D&#237;az-S&#225;nchez"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1186/1465-9921-10-122"
                      "Revista" => array:5 [
                        "tituloSerie" => "Respir Res"
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                        "volumen" => "10"
                        "paginaInicial" => "122"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/20003306"
                            "web" => "Medline"
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                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            7 => array:3 [
              "identificador" => "bib0240"
              "etiqueta" => "8"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Efectos de una dieta mediterr&#225;nea tradicional en ni&#241;os con sobrepeso y obesidad tras un a&#241;o de intervenci&#243;n"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [
                            0 => "F&#46; Calatayud"
                            1 => "B&#46; Calatayud"
                            2 => "J&#46;G&#46; Gallego"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "Rev Pediatr Aten Primaria"
                        "fecha" => "2011"
                        "volumen" => "13"
                        "paginaInicial" => "553"
                        "paginaFinal" => "569"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            8 => array:3 [
              "identificador" => "bib0245"
              "etiqueta" => "9"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Influence of Mediterranean diet on asthma in children&#58; a systematic review and meta-analysis"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:6 [
                            0 => "L&#46; Garcia-Marcos"
                            1 => "J&#46;A&#46; Castro-Rodriguez"
                            2 => "G&#46; Weinmayr"
                            3 => "D&#46;B&#46; Panagiotakos"
                            4 => "K&#46;N&#46; Priftis"
                            5 => "G&#46; Nagel"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1111/pai.12071"
                      "Revista" => array:6 [
                        "tituloSerie" => "Pediatr Allergy Immunol"
                        "fecha" => "2013"
                        "volumen" => "24"
                        "paginaInicial" => "330"
                        "paginaFinal" => "338"
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Article information

ISSN: 03010546
Original language: English

DOI:10.1016/j.aller.2015.04.007

The statistics are updated each day

Year/Month	Html	Pdf	Total

2024 November	2	0	2
2024 October	25	9	34
2024 September	60	15	75
2024 August	38	7	45
2024 July	43	11	54
2024 June	33	16	49
2024 May	19	12	31
2024 April	21	21	42
2024 March	29	9	38
2024 February	25	10	35
2024 January	26	10	36
2023 December	48	16	64
2023 November	27	16	43
2023 October	32	27	59
2023 September	24	3	27
2023 August	33	15	48
2023 July	23	10	33
2023 June	58	10	68
2023 May	78	14	92
2023 April	84	8	92
2023 March	53	7	60
2023 February	33	4	37
2023 January	29	23	52
2022 December	19	12	31
2022 November	35	9	44
2022 October	29	14	43
2022 September	26	25	51
2022 August	35	7	42
2022 July	19	15	34
2022 June	30	16	46
2022 May	32	10	42
2022 April	32	10	42
2022 March	17	9	26
2022 February	27	10	37
2022 January	30	19	49
2021 December	22	12	34
2021 November	60	21	81
2021 October	43	19	62
2021 September	36	15	51
2021 August	59	10	69
2021 July	24	23	47
2021 June	30	10	40
2021 May	40	21	61
2021 April	59	23	82
2021 March	48	22	70
2021 February	29	16	45
2021 January	22	21	43
2020 December	3	3	6
2020 November	0	1	1
2020 October	1	2	3
2020 August	0	2	2
2020 July	0	2	2
2020 June	0	1	1
2020 May	0	2	2
2020 April	0	1	1
2020 March	0	1	1
2020 February	0	1	1
2019 December	0	10	10
2019 November	0	4	4
2019 October	0	4	4
2019 September	0	5	5
2019 August	0	1	1
2019 July	0	5	5
2019 June	0	3	3
2019 May	0	12	12
2019 April	0	12	12
2018 March	0	2	2
2018 February	31	8	39
2018 January	22	3	25
2017 December	26	1	27
2017 November	75	9	84
2017 October	26	6	32
2017 September	21	20	41
2017 August	18	16	34
2017 July	42	6	48
2017 June	62	22	84
2017 May	43	20	63
2017 April	38	19	57
2017 March	27	29	56
2017 February	24	16	40
2017 January	21	11	32
2016 December	2	1	3
2016 July	1	1	2
2016 May	1	2	3
2016 April	0	1	1
2016 March	16	14	30

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Allergologia et Immunopathologia is no longer published on Elsevier since the 2021 year.Transferred to Codon Publications

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Allergologia et Immunopathologia is no longer published on Elsevier since the 2021 year.Transferred to Codon Publications

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