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1
TO CHANGE ASTHMA NATURAL HISTORY A MITH?

• Introduction
• Genetic Factors
• Environmental Factors
• Conclusions

Attilio Boner
University of Verona, Italy
2
TUCSON CHILDRENS RESPIRATORY STUDY 1980 TO
PRESENT Taussig JACI 2003 111661
Lung Development and Physiology
ALB
3
TUCSON CHILDRENS RESPIRATORY STUDY 1980 TO
PRESENT Taussig JACI 2003 111661
Lung Development and Physiology
Immunology
ALB
4
FAMILY HISTORY OF ASTHMA AND ATOPY IN DEPTH
ANALYSES OF THE IMPACT ON ASTHMA AND WHEEZE IN 7-
TO 8- YEAR-OLD CHILDREN. Bjerg Pediatrics
2007 120 741
Prevalence () of current asthma in relation to
parental asthma, parental atopy, SPT result, and
combinations of these categories.

• A cohort of 3420 7- to 8- year-old children
• SPTs
• Questionnaires

5
FAMILY HISTORY OF ASTHMA AND ATOPY IN DEPTH
ANALYSES OF THE IMPACT ON ASTHMA AND WHEEZE IN 7-
TO 8- YEAR-OLD CHILDREN. Bjerg Pediatrics
2007 120 741
FH of asthma and atopy and OR for
current asthma in the previous 12
months
15 14 13 12 11 10
13.6
OR for parental asthma is multiplicative.
OR for parental atopy is additive
9 8 7 6 5 4 3 2 1 0
3.6
3.2
2.8
1.6
1.2
1
1
NONE M only F only FM
NONE M only F only FM
PARENTAL
6
TO CHANGE ASTHMA NATURAL HISTORY A MITH?

• Introduction
• Genetic Factors - lung development
  - immunology
• Environmental Factors
• Conclusions

Attilio Boner
University of Verona, Italy
7
OUTCOME OF ASTHMA AND WHEEZING IN THE FIRST 6
YEARS OF LIFE Morgan AJRCCM 2005 172 1253
0.4 0.2 0.0 -0.2 -0.4 -0.6 -0.8 -1.0 -1.2

• A population-based birth cohort in Tucson
• Maximal expiratory
• flows at ages
• 2.4 mo and 6, 11,
• and 16 yr
• for the preschool wheeze phenotypes

Z-Scores of Height Adjusted Flow (/-se)

Never Wheeze Transient Early Late Onset Persistent



0 2 4 6 8 10 12 14 16 18
Age, years
8
REDUCED LUNG FUNCTION BOTH BEFORE BRONCHIOLITIS
AND AT 11 YRS Turner Arch Dis Child 2002 87
417
.
VmaxFRC
3 2 1 0
p0.02

• 253 cohort members
• VmaxFRC at 1 month of age
• Individuals with bronchiolitis were prospectively
  identified
• At 11 years of age lung function was repeated

.
z score
-1 -2 -3
Confirmed bronchiolitis (n 16)
Control (n 162)
Box and whisker plot for z scores for
VmaxFRC at 1 month
9
REDUCED LUNG FUNCTION AT BIRTH AND THE RISK OF
ASTHMA AT 10 YEARS OF AGE Haland , Carlsen N
Engl J Med 2006 355 1682
children with a history of asthma at age 10 year
children with current asthma at age 10 year
30 20 10 0
30 20 10 0
p0.01
24.3
p0.005
16.2
14.6
7.5
Above the median
At-below the median
Above the median
At-below the median
tPTEF/tE at age 3 days
tPTEF/tE at age 3 days
10
ASTHMA ORIGINS

• Lung Development

• Reduced lung development is a
• premorbid predisposing factor for
• Transient wheezing,
• Bronchiolitis,
• Persistent atopic wheezing,
• Loss of lung function is characteristic of
  asthma.

Attilio Boner
University of Verona, Italy
11
ASTHMA ORIGINS

• Lung Development

• Reduced lung development is a
• premorbid predisposing factor for
• Transient wheezing,
• Bronchiolitis,
• Persistent atopic wheezing,
• Loss of lung function is characteristic of
  asthma.

Good care of pregnancy is essential to allow a
normal development of the lungs.
Attilio Boner
University of Verona, Italy
12
TO CHANGE ASTHMA NATURAL HISTORY A MITH?

• Introduction
• Genetic Factors - lung development
  - immunology
• Environmental Factors
• Conclusions

Attilio Boner
University of Verona, Italy
13
MATERNO-PLACENTO-FETAL INTERACTIONS Warner Arch
Dis Child 20048997
One of the explanations for maintenance of a
successful pregnancy is that both Th-2 (IL-4 and
IL-13) and T regulatory (IL-10 and TGF-ß)
cytokines are generated by the conceptus to
down-regulate maternal Th-1 immune responses to
feto-paternal antigens which might otherwise
lead to fetal rejection.
22wk
14wk
14
Functional maturation of CD4CD25CTLA4CD45RA T
regulatory cells in human neonatal T cell
responses to environmental antigens/allergens.
Thorton J Immunol
20041733084

1. In contrast to allergen-responsive adult CD4() T
   cell cultures, responding neonatal T cell
   cultures displays a high level of apoptosis.
2. In these cultures CD4CD25CTLA4 T regulatory
   cells appears and exert a suppressive activity.

Neonatal T cell responses to allergens differ
markedly from those occurring in later life
15
PRENATAL VERSUS POSTNATAL SENSITIZATION
TO ENVIRONMENTAL ALLERGENS IN A
HIGH-RISK BIRTH COHORT Rowe JACI
20071191164

• Prospectively studied HDM (house dust mite)
  specific sIgE and IgG4 and T-cell immunity in a
  cohort of 200 high-risk infants

0.35
Age (months)
Tracking antibody titers in individuals who are
HDM SPT-negative at age 24 months
16
PRENATAL VERSUS POSTNATAL SENSITIZATION
TO ENVIRONMENTAL ALLERGENS IN A
HIGH-RISK BIRTH COHORT Rowe JACI
20071191164

• Prospectively studied HDM (house dust mite)
  specific sIgE and IgG4 and T-cell immunity in a
  cohort of 200 high-risk infants

0.35
Age (months)
Tracking antibody titers in individuals who are
HDM SPT-positive at age 24 months
17
SKIN BARRIER FUNCTION AND ALLERGIC RISK Hudson
Nature Genetics 2006 38 399
Skin barrier function and allergic risk. An
intact epithelial barrier (a) prevents allergens
from reaching antigen presenting cells (APCs) in
subepithelial tissues. Damage to this barrier (b)
allow allergens to penetrate into the
subepidermal layer and interact with APCs,
leading to allergic sensitization and,
secondarily, to allergic manifestations in the
host.
18
FILLAGRIN LOSS-OF-FUNCTION MUTATIONS PREDISPOSE
TO PHENOTYPES INVOLVED IN THE ATOPIC MARCH
Marenholz JACI 2006 118 866
OR ratio for concomitant eczema and asthma
OR ratio for concomitant eczema and allergic
rhinitis
7 6 5 4 3 2 1 0
OR for non atopic eczema
OR for atopic eczema
6.21
4.79
3.94
3.84
p0.0006
p0.00001
p0.00001
p0.00065
IN CHILDREN WITH FILAGGRIN LOSS-OF-FUNCTION
MUTATION
19
ASTHMA ORIGINS

• Lung Development
• Immunologic Maturation

The fetal life and the newborn period are prone
to atopy. Sensitization starts early but
postnataly. Defective skin barrier fuction
predispose to allergy development.
Attilio Boner
University of Verona, Italy
20
ASTHMA ORIGINS

• Lung Development
• Immunologic Maturation

• Good care of pregnancy
• Allergen avoidance thereafter.
• Immunomodulating natural factors?
• Good care of the skin is probably important.

The fetal life and the newborn period are prone
to atopy. Sensitization starts early but
postnataly. Defective skin barrier fuction
predispose to allergy development.
Attilio Boner
University of Verona, Italy
21
TO CHANGE ASTHMA NATURAL HISTORY A MITH?

• Introduction
• Genetic Factors
• Environmental Factors - allergens
  - tobacco smoke -
  pollutants - diet
  - life-style
  - psychology - treatment
• Conclusions

Attilio Boner
University of Verona, Italy
22
PULMONARY FUNCTION IN THREE YEAR OLD CHILDREN
EFFECT OF EXPOSURE AND SENSITIZATION TO INDOOR
ALLERGENS Lowe JACI 2002 109 521Ab
mean difference in sRaw in mite sensitive vs
non-sensitive
10 8 6 4 2 0

• Manchester Asthma and Allergy Study (birth
  cohort 276 children)
• specific airway resistance (sRaw) at 3 yrs of
  age

9.2
p0.020
23
PERENNIAL ALLERGEN SENSITISATION EARLY IN LIFE
AND CHRONIC ASTHMA IN CHILDREN A BIRTH COHORT
STUDY Illi Lancet 2006 368 763
OR for BHR at school age
8.3

• 1314 children from birth to 13 years of age (MAS
  study)
• Allergen exposure at age 6 months, 18 months,
  and at 3, 4, and 5 yrs
• Lung function at 7, 10, and 13 yrs

3.29
Early Current sensitization
sensitisation
(age lt3)
24
RISK FACTORS FOR ASTHMA AT 3.5 AND 7 YEARS OF AGE
Mitchell Clin Exp Allergy 2007371747
OR for asthma both at age 3.5 and 7 years
2.0 1.5 1.0 0.5 0
2.1

• 871 children of European mothers enrolled at
  birth
• Data collected at birth, 12 months, 3.5
  years of age and 7 years.

1.8
Contact with dog
Sleeping in a previously used mattress in the
first year
25
PREVENTION OF ALLERGIC DISEASE DURING CHILDHOOD
BY ALLERGEN AVOIDANCE THE ISLE OF WIGHT
PREVENTION STUDY Arshad JACI 2007119307

• Infants at higher risk because of family
  predisposition.
• Randomized to prophylactic (n58) and control
  (n62) groups.
• Prophylactic group breast-fed or extensively
  hydrolyzed formula, acaricide and mattress
  covers.
• Development of allergic disease at age 1,2,4 and
  8 years.

OR in the prophylactic group at age 8 years
1 0,5 0
0,24
0,23
0,14
0,13
p0.005
plt0.005
p0.0003
asthma
Atopic dermatitis
atopy
Allergic rhinitis
26
EARLY LIFE ENVIROMENTAL CONTROL EFFECT ON
SYMPTOMS, SENSITIZATION AND LUNG FUNCTION AT AGE
3 YEARS Woodcock AJRCCM 2004170433
1.0 0.8 0.6 0.4 0.2 0.0
Ln VmaxFRC GM 95 CI at age 4 weeks

• Manchester cohort
• 128 active group
• 111 control group
• Allergen level, symptoms, sensitization and lung
  function at 3 years of age

p0.49
27
EARLY LIFE ENVIROMENTAL CONTROL EFFECT ON
SYMPTOMS, SENSITIZATION AND LUNG FUNCTION AT AGE
3 YEARS Woodcock AJRCCM 2004170433
Ln sRaw GM 95 CI at age 3 years

• Manchester cohort
• 128 active group
• 111 control group
• Allergen level, symptoms, sensitization and lung
  function at 3 years of age

0.4 0.3 0.2 0.1 0.0 -.1

p0.003
28
PERENNIAL ALLERGEN SENSITISATION EARLY IN LIFE
AND CHRONIC ASTHMA IN CHILDREN A BIRTH COHORT
STUDY Illi Lancet 2006 368 763












NS S/LE SHE
NS S/LE SHE
NS S/LE SHE
NS S/LE SHE
NS S/LE SHE
NS S/LE SHE
FEV1 ( predicted)
MEF50 ( predicted)
MEF25 ( predicted)
FVC ( predicted)
FEV1/FVC
MEF75 ( predicted)
Effect of allergen sensitisation and exposure at
lt 3 years on lung function at age 7 years. NS
Not sensitised to dust mites or cat dander. S/LE
sensitised to dust mites cat dander and low
exposure to these allergens. S/HE Sensitised to
dust mites or cat dander and high exposure to
these allergen.
29
IMPAIRED GROWTH OF PULMONARY FUNCTION IN
CHILDREN SENSITIVE TO HOUSE DUST MITE ULRIK
AJRCCM 1999 160 40
408 children (7-17 years of age at enrollment)
reevaluated after 5 years subjects with either
persistent or new atopy to HDM had lower FEV1
compared with those who had persistent (-) SPT
to HDM
ATOPY TO HDM
PERSISTENT NEW
F E V1 P R E D I C T E D
- 1 - 2 - 3 - 4 - 5 - 6
- 4.3
- 5.5
30
PREVENTION OF SENSITIZATION TO HOUSE DUST MITE
BY ALLERGEN AVOIDANCE IN SCHOOL AGE CHILDREN A
RANDOMIZED CONTROLLED STUDY Arshad Clin. Exp.
All. 2002 32 843
ch. developing SPT () to mites in the 12 mo
follow-up

• Study of prevention of
• Allergy in children of
• Europe, U.K., Greece
• and Lithuania
• () FH of atopy and
• SPT() to an aeroallergen
• but not to house dust mite
• Ch.(5-7 yrs)
• - Cover mattress (n117) ?
• - Control group (n96) ?

10 - 9 - 8 - 7 - 6 - 5 - 4 - 3 - 2 - 1
- 0
9.38
plt0.05
2.56
9/96
3/117
CONTROL ACTIVE
31
A LONGITUDINAL, POPULATION-BASED, COHORT STUDY OF
CHILDHOOD ASTHMA FOLLOWED TO ADULTHOOD.Sears NEJM
20033491414
OR FOR WHEEZING AT AGE 26 YEARS
5 - 4 - 3 2 1 0
plt0.001 for trend
4.17 FOR RELAPSE
3.38 FOR PERSISTANCE
() SPT FOR MITES AT AGE 13 YEARS
32
ARE ATOPY AND SPECIFIC IgE TO MITES AND MOLDS
IMPORTANT FOR ADULT ASTHMA? Jaakkola JACI 2006
117 642
OR for new onset asthma
5 - 4 - 3 2 1 0

• Specific IgE
• to mites and molds
• All new diagnosed cases of asthma
• 21-63 years
• of age
• (1997-2000)
• A random sample
• of control
• 485 cases and
• 665 controls.

4.69
2.73
2.30
sIgE
MITE
ASPERGILLUS
CLADOSPORIUM
33
ASTHMA ORIGINS

• Lung Development
• Immunologic Maturation
• Allergens

• Early sensitization to allergens is a risk factor
  for more severe asthma and reduced lung function,
• Sensitization can occur through the skin,
• Sesitization can occur also later in life and is
  always a risk factor for asthma

Attilio Boner
University of Verona, Italy
34
ASTHMA ORIGINS

• Lung Development
• Immunologic Maturation
• Allergens

• Early sensitization to allergens is a risk factor
  for more severe asthma and reduced lung function,
• Sensitization can occur through the skin,
• Sesitization can occur also later in life and is
  always a risk factor for asthma

• Environmental strategies
• to delay sensitization might be helpful.
• Early contact with cat and dog is not protective.

Attilio Boner
University of Verona, Italy
35
TO CHANGE ASTHMA NATURAL HISTORY A MITH?

• Introduction
• Genetic Factors
• Environmental Factors - allergens
  - tobacco smoke -
  pollutants - diet
  - life-style
  - psychology - treatment
• Conclusions

Attilio Boner
University of Verona, Italy
36
AIRWAY ALVEOLAR ATTACHMENT POINTS AND EXPOSURE
TO CIGARETTE SMOKE IN UTERO Elliot AIRCCM
2003 167 45

• 32 infants who died from sudden infant
  death syndrome
• Compared with those without any exposure
  to cigarette smoke, the distance
  between alveolar attachments on airways
  was greater (plt 0.001) in infants
  exposed to cigarette smoke in utero

37
THE EFFECT OF MATERNAL SMOKING DURING PREGNANCY
ON EARLY INFANT LUNG FUNCTION Hanrahan Am. Rev.
Respir. Dis. 1992 145 1129
Flow at functional residual capacity (ml/s)
200 150 100 50 0

• 80 healthy infants tested shortly
  after birth (mean, 4.2/-1.9 wk)
• Urine cotinine
• Expiratory flow-volume curves

150.4
p 0.0007
74.3
YES NO
38
PARENTAL SMOKING AND LUNG FUNCTION IN CHILDREN
Moshammer AJRCCM 20061731255
SMOKING DURING PREGNANCY
0 -1 -2 -3 -4 -5 -6 -7

• 20,000 children (aged 6-12 yr) from Europe and
  North America
• Exposure information by questionnaires

-1 in FEV1
-6 MEF25
39
MATERNAL AND GRANDMATERNAL SMOKING PATTERNS ARE
ASSOCIATED WITH EARLY CHILDHOOD ASTHMA Li YF
Chest 2005 127 1232
OR for asthma in the first 5 years of life
3 2 1 0
2.6

• 338 children with asthma diagnosed in
  the first 5 years of life
• 570 control subjects

1.8
1.3
Grandmaternal only smoking during the mothers
fetal period
Grandmaternal and maternal smoking
Smoking mother only
40
THE ADULT INCIDENCE OF ASTHMA AND RESPIRATORY
SYMPTOMS BY PASSIVE SMOKING IN UTERO OR IN
CHILDHOOD Skorge AJRCCM
2005 172 61
OR ratio for adult onset asthma
3 2 1 0

• Between 1985 and 1996/1997 an 11-year community
  cohort study on the incidence of asthma
• 3.786 subjects

3
Smoking mother
41
THE ADULT INCIDENCE OF ASTHMA AND RESPIRATORY
SYMPTOMS BY PASSIVE SMOKING IN UTERO OR IN
CHILDHOOD Skorge AJRCCM
2005 172 61
The adjusted attributable fractions of the adult
incidence of asthma were 17.3 caused by maternal
smoking and 9.3 caused by smoking by other
household members.
OR ratio for adult onset asthma
3 2 1 0

• Between 1985 and 1996/1997 an 11-year community
  cohort study on the incidence of asthma
• 3.786 subjects

3
Smoking mother
42
REGULAR SMOKING AND ASTHMA INCIDENCE IN
ADOLESCENTS Gilliland AJRCCM 2006 174 1094
RR FOR NEW ONSET OF ASTHMA

• 2,609 children with no lifetime history of
  asthma or wheezing
• Followed annually in
  schools
• Regular smoking was defined as
  smoking 300 cigarettes in the year
• New cases of physician-diagnosed asthma

4 3 2 1 0
3.9
In children smoking gt300 cigarettes/year
43
REGULAR SMOKING AND ASTHMA INCIDENCE IN
ADOLESCENTS Gilliland AJRCCM 2006 174 1094
RR FOR NEW ONSET OF ASTHMA
10- 8 6 4 2 0

• 2,609 children with no lifetime history of
  asthma or wheezing
• Followed annually in
  schools
• Regular smoking was defined as
  smoking 300 cigarettes in the year
• New cases of physician-diagnosed asthma

8.8
In children smoking gt300 cigarettes/year
and exposed to maternal smoking during gestation
44
ASTHMA ORIGINS

• Lung Development
• Immunologic Maturation
• Allergens
• Exposure to Tobacco Smoke

Smoking should always be avoided by anyone.
Attilio Boner
University of Verona, Italy
45
TO CHANGE ASTHMA NATURAL HISTORY A MITH?

• Introduction
• Genetic Factors
• Environmental Factors - allergens
  - tobacco smoke -
  pollutants - diet
  - life-style
  - psychology - treatment
• Conclusions

Attilio Boner
University of Verona, Italy
46
SYNTHETIC BEDDING AND WHEEZE IN CHILDHOOD.
Ponsonby Epidemilogy 20031437
7 6 5 4 3 2 1 0
OR for wheezing at 7 yrs

• Bedding type at 1mo
• Wheeze at 7 yrs
• (n6,378 ch)

5.2
2.5
synthetic pillow
synthetic quilt
47
A prospective association between synthetic
cocoon use in infancy and childhooh asthma.
Trevillian Paed Perin Epidem 200418281

At age 7 years OR for
5 - 4 - 3 2 1 0

• Sleeping environment of 863 infants
  evaluated at 1 month of life
• Follow-up 7 years

4.33
3.35
RECENT WHEEZE AT AGE 7 YEARS
NIGHT WHEEZE AT AGE 7 YEARS
IN CH. SLEEPING IN A SYNTHETIC COCOON AT 1 MONTH
OF AGE
48
Residential outdoor air pollution and allergen
sensitization in schoolchildren in Norway Oftedal
CEA 2007371632
2 - 1 0

• 2244 children 9-10 year old had lived in Oslo
  since birth
• Exposure to outdoor air pollution nitrogen
  dioxide (NO2), particulate matter (PM) with
  aerodynamic diameter lt10 µm (PM10)
  and lt2.5 µm (PM2.5)

OR FOR SENSITIZATION TO D.farinae
1.88
1.61
1.46
PM10
PM2.5
NO2
one interquartile increase of lifetime exposure to
49
LUNG FUNCTION GROWTH IN CHILDREN WITH LONG-TERM
EXPOSURE TO AIR POLLUTANTS IN MEXICO CITY
Rojas-Martinez AJRCCM 2007176377

• 3,170 children aged 8 years at baseline.
• Followed for 3 yrs and visited every 6 months.

Percentiles
Visits
Percentiles
Visits
50
IS IT TRAFFIC TYPE, VOLUME, OR DISTANCE? WHEEZING
IN INFANTS LIVING NEAR TRUCK AND BUS TRAFFIC Ryan
JACI 2005 116 279
OR for wheezing
3 2 1 0

• The relationship between types of traffic,
  traffic volume, and distance and wheezing among
  infants less than 1 year of age

2.5
In infants living very near (lt 100 m) to
stop-and-go bus and truck traffic
51
TRAFFIC EXPOSURE AND LUNG FUNCTION IN ADULTS
THE ATHEROSCLEROSIS RISK IN COMMUNITIES
STUDY Kan Thorax 2007 62 8 73
IN WOMEN LIVING WITHIN 150 M FROM MAJOR ROAD
0 -10 -20 -30

• 15792 middle aged men and women.
• Traffic density and distance to major roads were
  used as measures of traffic exposure.

-15.7 mL
FEV1
-24.2 mL
FVC
52
THE USE OF HOUSEHOLD CLEANING SPRAYS AND ADULT
ASTHMA Zock AJRCCM 2007176735
2 1 0
RR for new diagnosis of asthma

• European Community Respiratory Health Survey in
  10 countries.
• 3.503 persons doing the cleaning in their homes
  and who were free of asthma at baseline.

2.11
p.lt0.05
In person using cleaning spray at least 4 days
per week
53
ASTHMA ORIGINS

• Lung Development
• Immunologic Maturation
• Allergens
• Exposure to Tobacco Smoke
• Other adjuvant factors

• Early contact with
• Synthetic materials
• Chlorinated pools
• Pollution
• Detergents
• are important adjuvant factors.

Attilio Boner
University of Verona, Italy
54
ASTHMA ORIGINS

• Lung Development
• Immunologic Maturation
• Allergens
• Exposure to Tobacco Smoke
• Other adjuvant factors

• Early contact with
• Synthetic materials
• Chlorinated pools
• Pollution
• are important adjuvant factors.

• no synthetic materials in early llyfe
• Ask yourself what you can do to prevent pollution

Attilio Boner
University of Verona, Italy
55
TO CHANGE ASTHMA NATURAL HISTORY A MITH?

• Introduction
• Genetic Factors
• Environmental Factors - allergens
  - tobacco smoke -
  pollutants - diet
  - life-style
  - psychology - treatment
• Conclusions

Attilio Boner
University of Verona, Italy
56
MATERNAL INTAKE OF VITAMIN D DURING PREGNANCY
AND RISK OF RECURRENT WHEEZE IN CHILDREN AT 3 Y
OF AGE Camargo Am J Clin Nutr 2007 85 788
In 3 yrs-old children of mothers in the highest
quartile of vitamin D intake (724 IU) versus the
lowest quartile (356 IU) OR for

• 1.194 mother-child pairs
• Maternal intake of vitamin D during pregnancy
  with FFQ

1 0
0.39
plt0.001
Recurrent wheeze
57
MATERNAL VITAMIN D INTAKE DURING PREGNANCY AND
EARLY CHILDHOOD WHEEZING Devereux Am J Clin
Nutr 2007 85 853
In 5 year old children of mothers in the
highest versus the lowest quintiles of vit D
intake OR for

• Random sample of 2000 healthy pregnant
  women at approximately 12 wk
  gestation
• Maternal vitamin D intake ascertained at 32 wk of
  gestation with FFQ

1 0
0.48
0.35
0.33
Ever wheeze
Persistent wheeze
Wheeze in previous year
58
MATERNAL INTAKE OF VITAMIN D DURING PREGNANCY
AND RISK OF RECURRENT WHEEZE IN CHILDREN AT 3 Y
OF AGE Camargo Am J
Clin Nutr 2007 85 788
1)
2)
MATERNAL VITAMIN D INTAKE DURING PREGNANCY AND
EARLY CHILDHOOD WHEEZING Devereux Am J Clin
Nutr 2007 85 853
using data from the two birth cohorts with
maternal vitamin D assessment, we estimate that
the population attributable risk for asthma
incidence caused by vitamin D deficiency in
pregancy is about 40 of all cases. Weiss JACI
20071201031
59
LOW MATERNAL VITAMIN E INTAKE DURING PREGNANCY IS
ASSOCIATED WITH ASTHMA IN 5-YEARS-OLD CHILDREN
Devereux AJRCCM 2006 174 499
OR FOR WHEEZE WITHOUT A COLD IN THE LAST 12 MO
AT 5 YEARS OF AGE

• 1,861 children born to women recruited during
  pregnancy and followed up
• at 5 yr
• Maternal nutrient status by a food frequency
  questionnaire and plasma levels.

1-
1
p 0.02 for trend
0.56
0.50
0.53
0.22
1
2
3
4
5
QUINTILES OF VIT E INTAKE IN THE MOTHER
60
LOW MATERNAL VITAMIN E INTAKE DURING PREGNANCY IS
ASSOCIATED WITH ASTHMA IN 5-YEARS-OLD CHILDREN
Devereux AJRCCM 2006 174 499
OR FOR ATOPIC SENSITIZATION

• 1,861 children born to women recruited during
  pregnancy and followed up
• at 5 yr
• Maternal nutrient status by a food frequency
  questionnaire and plasma levels.

1-
0.60
in children of mothers with higher concentrations
of ? tocoferol at 12 wk gestation
61
LOW MATERNAL VITAMIN E INTAKE DURING PREGNANCY IS
ASSOCIATED WITH ASTHMA IN 5-YEARS-OLD CHILDREN
Devereux AJRCCM 2006 174 499
OR FOR EVER ASTHMA

• 1,861 children born to women recruited during
  pregnancy and followed up
• at 5 yr
• Maternal nutrient status by a food frequency
  questionnaire and plasma levels.

1-
1
p 0.04 for trend
0.59
0.55
0.51
0.44
1
2
3
4
5
QUINTILES OF ZINC INTAKE
62
LOW MATERNAL VITAMIN E INTAKE DURING PREGNANCY IS
ASSOCIATED WITH ASTHMA IN 5-YEARS-OLD CHILDREN
Devereux AJRCCM 2006 174 499
OR FOR EVER ASTHMA

• 1,861 children born to women recruited during
  pregnancy and followed up
• at 5 yr
• Maternal nutrient status by a food frequency
  questionnaire and plasma levels.

1-
1
p 0.04 for trend
0.59
0.55
0.51
0.44
1
2
3
4
5
QUINTILES OF ZINC INTAKE
63
ANTIOXIDANT INTAKE IN PREGNANCY IN RELATION TO
WHEEZE AND ECZEMA IN THE FIRST TWO YEARS OF LIFE
Martindale AJRCCM 2005 171 121
OR for wheeze in absence of a cold in the second
year

• 2000 women
• Prospective investigation of the influence of
  maternal antioxidant intake in pregnancy
  determined by food frequency questionnaire at 34
  weeks gestation
• Development of asthma and
  eczema in children (questionnaire)
• Follow up the 1,924 singleton children 6, 12 and
  24 months of age

1 0
1
p for trend 0.006
0.61
0.47
1 tertile 2 tertile 3 tertile
64
LOW MATERNAL VITAMIN E INTAKE DURING PREGNANCY IS
ASSOCIATED WITH ASTHMA IN 5-YEARS-OLD CHILDREN
Devereux AJRCCM 2006 174 499

• Vegetable oils (sunflower, rapeseed, corn)
• Margarine
• Wheat germ
• Nuts
• Sunflower seeds

Major diet source of Vit E
In animal models and humans, vit E and Zinc
1-

• Liver
• Wheat germ
• Lean red meat
• Seeds
• Nuts

Major diet source of Zinc
Th1 differentiation Th1 cytokines Th2 cytokines
65
MATERNAL FOOD CONSUMPTION DURING PREGNANCY AND
ASTHMA, RESPIRATORY AND ATOPIC SYMPTOMS IN
5-YER-OLD CHILDREN Willers Thorax 2007 62
773

• 1.924 children born to women recruited during
  pregnancy
• Maternal diet during pregnancy was assessed by
  food frequency questionnaire
• Followed up at 5 years by symptom questionnaire

Maternal apple consumption highest versus lowest
tertile OR for
1 0
0.63
0.54
0.47
Ever wheeze
Doctor asthma
Ever asthma
66
CHILDHOOD ASTHMA AND FRUIT CONSUMPTION
Okoko ERJ 2007291161
in children eating bananas at least once a day,
OR for
1.00 0.80 0.60 0.40 0.20 0

• 2.640 primary school children aged 510 yrs
• Information about asthma symptoms and fruit
  consumption by questionnaire.

0.80
0.66
0.69
Current wheeze
Ever wheeze
Ever asthma
67
CHILDHOOD ASTHMA AND FRUIT CONSUMPTION
Okoko ERJ 2007291161
in children drinking apple juice concentrate at
least once a day, OR for
1.00 0.80 0.60 0.40 0.20 0

• 2.640 primary school children aged 510 yrs
• Information about asthma symptoms and fruit
  consumption by questionnaire.

0.90
0.74
0.53
Current wheeze
Ever wheeze
Ever asthma
68
DIET, WHEEZE, AND ATOPY IN SCHOOL CHILDREN IN
MENORCA, SPAIN Chatzi Pediatr Allergy Immunol
2007 18 480
1 0
OR FOR WHEEZING

• A cross-sectional analysis was performed on 460
  children at age 6.5 yr
• Parents completed a questionnaire on allergic
  symptoms, and on food frequency.

0.38
plt0.05
In children consuming gt40 g/day of fruity
vegetable (tomatoes, eggplants, cucumber, green
beans, zucchini)
69
PROTECTIVE EFFECT OF FRUITS, VEGETABLES AND THE
MEDITERRANEAN DIET ON ASTHMA AND ALLERGIES AMONG
CHILDREN IN CRETE Chatzi Thorax 200762677
3 2 1 0
OR FOR WHEEZING

• Cross-sectional survey.
• 690 children aged 7-18 years in rural Crete.
• Questionaire on respiratory and allergic symptoms
  and a 58-item food frequency qestionaire.
• SPTs.

nuts
margarine
Hight intake gt 3 times a week
70
Maternal fish intake during pregnancy and atopy
and asthma in infancy. Romieu Clin Exp All
200737518
In children of mothers with fish intake during
pregnancy OR for

• A cohort of women (n462) enrolled during
  pregnancy
• Offspring followed up to 6 years

1 0
0.73
0.68
0.55
eczema at 1 yr
() SPT to HDM at age 6 yrs
Asthma at age 6 yrs
71
Maternal fish intake during pregnancy and atopy
and asthma in infancy. Romieu Clin Exp All
200737518

• The following changes in risk can be calculated
  for a change from
• once a month (0.25 per week) to once per week
  reduces the risk by 72
• twice per month (0.5 per week) to once per week
  by 32
• once a week to 2.5 times per week by 47.

Predicted probability of skin prick test
sensitivity to house dust mite (HDM) at 6 years
of age associated with weekly frequency of fish
intake (long scale)
72
DIET, WHEEZE, AND ATOPY IN SCHOOL CHILDREN IN
MENORCA, SPAIN Chatzi Pediatr Allergy Immunol
2007 18 480
1 0

• A cross-sectional analysis was performed on 460
  children at age 6.5.
• Parents completed a questionnaire on allergic
  symptoms, and a food frequency.

OR FOR ATOPY
0.43
p.lt0.05
Fish intake gt 60 g/day
73
Relationship of fish and cod oil intake with
adult asthma Laerum ClinExpAll 2007371616
OR FOR DOCTOR DIAGNOSED ASTHMA IN ADULHOOD

• 16187 subjects aged 23-54 years
• Postal questionnaire

2 1 0
2.03
X
X
X
X
Never had fish in childhood
74
POLYUNSATURATED FAT AND CYTOKINES
Linoleic acid (omega-6) (margarines)

Arachidonicacid
cyclo-oxygenase
Inhibition on IL-2 INF-Y
PGE
2
No effect on IL-4 IL-5
Th0 Th2 IgE
75
CURED MEAT CONSUMPTION, LUNG FUNCTION, AND
CHRONIC OBSTRUCTIVE PULMONARY DISEASE AMONG
UNITED STATES ADULTS Jiang AJRCCM
2007175798
Consumption of cured meat (times per month)
0 -20 -40 -60 -80 -100 -120
1-2
3-4
5-13
gt14

• 7,352 partecipants 45 years of age
• Cured meats, such as bacon, sausage, luncheon
  meats, and cured hams, are high in nitrites,
  which are added to meat products as a
  preservative, an antimicrobial agent, and a color
  fixative.

-11.5 ml
-37.6 ml
-42 ml
Plt0,001 for trend
-110 ml
ml in FEV1
76
FAST FOODS ARE THEY A RISK FACTOR FOR ASTHMA?
Wickens Allergy 2005 60 1537
2 1 0
OR for current wheeze
1.81

• ISAAC
• 1321 children
• SPTs
• EIA
• Body mass index

1.17
ltonce/week gtonce/week
77
ASTHMA ORIGINS

• Lung Development
• Immunologic Maturation
• Allergens
• Exposure to Tobacco Smoke
• Diet

Early life (conception to 2 years) dietary
exposure might be particularly important in the
development of childhood asthma.
Attilio Boner
University of Verona, Italy
78
ASTHMA ORIGINS

• Lung Development
• Immunologic Maturation
• Allergens
• Exposure to Tobacco Smoke
• Diet

Early life (conception to 2 years) dietary
exposure might be particularly important in the
development of childhood asthma.
Consumption of fresh fruit, vegetables, and fish
should be increased.
Attilio Boner
University of Verona, Italy
79
TO CHANGE ASTHMA NATURAL HISTORY A MITH?

• Introduction
• Genetic Factors
• Environmental Factors - allergens
  - tobacco smoke -
  pollutants - diet
  - life-style
  - psychology - treatment
• Conclusions

Attilio Boner
University of Verona, Italy
80
BOTTLE FEEDING IN BED OR CRIB BEFORE SLEEP TIME
AND WHEEZING IN EARLY CHILDHOOD. Celedon
Pediatrics 2002110e77
6 5 4 3 2 1 0
OR for asthma at age 5y

• 448 ch with parental history of atopy followed
  from birth to 5 years
• Parental report of wheeze

Bottle feeding in bed times in the first year
1 2 3 4 5 6
81
Low physical fitness in childhood is associated
with the development of asthma in young
adulthood the Odense school child study.
Rasmussen ERJ 200016866
ch who developed asthma in the 10 yrs
follow-up
10 8 6 4 2 0

• 757 healthy schoolchildren (mean age 9.7 yrs)
• Follow-up 10.5 yrs
• Progressive exercise test (maximal workload) on a
  bicycle ergometer

6.7
These children had a significant (p0.02) reduced
mean physical fitness at the time of enrolment
into the study.
82
Low physical fitness in childhood is associated
with the development of asthma in young
adulthood the Odense school child study.
Rasmussen ERJ 200016866
OR for Development of Physician Diagnosed
Asthma
2 1 0
The risk of developing asthma during adolescence
was reduced 7 by increasing the maximal workload
1 W x Kg(-1)

• 757 healthy schoolchildren (mean age 9.7 yrs)
• Follow-up 10.5 yrs
• Progressive exercise test (maximal workload) on a
  bicycle ergometer

0.93
in children with physical fitness gt 1 W x Kg(-1)
83
LEISURE TIME ACTIVITY AND NEW ONSET OF
WHEEZING DURING ADOLESCENCE
Vogelberg ERJ 200730672
15 10 5 0
ADOLESCENTS

• 2.910 adolescents without earlier episodes of
  wheezing in childhood.

11.3
NEW ONSET OF WHEEZE IN THE PREVIOUS 12 MONTHS
84
LEISURE TIME ACTIVITY AND NEW ONSET OF
WHEEZING DURING ADOLESCENCE
Vogelberg ERJ 200730672
SUBJECTS WITH NEW ONSET OF WHEEZE IN THE
PREVIOUS 12 MONTHS
15 10 5 0
P0.001
13.9
P0.02
12.9
9.9
8.2
YES
1/MONTH
NO
3/WEEK
VISITING DISCOTEQUES ON A REGULAR BASES
SPORT ACTIVITY
85
INCREASED INCIDENCE OF ASTHMALIKE SYMPTOMS IN
GIRLS WHO BECOME OVERWEIGHT OR OBESE DURING THE
SCHOOL YEARS Castro-Rodriguez AJRCCM 2001 163
1344
10 0
Likelyhood to develop new asthma symptoms at age
11-13 years

• Prevalence of asthma and body mass index at mean
  ages of 6.3 and 10.9 yr in the Tucson cohort

7 X
In females who became overweight or obese between
6 and 11 yrs
86
OVERWEIGHT, OBESITY, AND INCIDENT ASTHMA A
Meta-analysis of Prospective Epidemiologic
Studies Beuther AJRCCM 2007 175661
2 1.5 1 0.5 0
OR for incident asthma in adult
Plt0,0001 for trend

• Normal weight (BMIlt25), overweight (BMI,
  25-29,9), and obesity (BMI30)
• 7 studies (n 333,102
  subjects).

1.92
1.38
25-29.9
gt 30
BMI
87
OVERWEIGHT, OBESITY, AND INCIDENT ASTHMA A
Meta-analysis of Prospective Epidemiologic
Studies Beuther AJRCCM 2007 175661
2 1.5 1 0.5 0
A similar increase in the OR of incident asthma
due to the overweight and obesity was observed in
men and women
OR for incident asthma in adult
Plt0,0001 for trend

• Normal weight (BMIlt25), overweight (BMI,
  25-29,9), and obesity (BMI30)
• 7 studies (n 333,102
  subjects).

1.92
1.38
25-29.9
gt 30
BMI
88
OBESITY AND LEPTIN
Weiss S AJRCCM 2004 169 963
Adipocites Leptin

• Signals satiety to the
• hypothalamus
• Stimulate Th1, suppress Th2
• Proliferation of lung and
• airway cells
• Increase activity in
• sympatetic nerves
• Release of catecholamines
• from adrenal medulla

Increased secretion in obesity
In obese patients there is a resistance to the
effects of leptin which may favor a Th2
polarization and a reduction of lung size
89
ASTHMA ORIGINS

• Lung Development
• Immunologic Maturation
• Allergens
• Exposure to Tobacco Smoke
• Diet and life-style

life-style might be particularly important in
the development of adolescent and adulthood
asthma.
Attilio Boner
University of Verona, Italy
90
ASTHMA ORIGINS

• Lung Development
• Immunologic Maturation
• Allergens
• Exposure to Tobacco Smoke
• Diet and life-style

life-style might be particularly important in
the development of adolescent and adulthood
asthma.

• No bottle feeding in the crib
• Regular physical activity to maintain good
  fitness
• No increase in BMI

Attilio Boner
University of Verona, Italy
91
TO CHANGE ASTHMA NATURAL HISTORY A MITH?

• Introduction
• Genetic Factors
• Environmental Factors - allergens
  - tobacco smoke -
  pollutants - diet
  - life-style
  - psychology - treatment
• Conclusions

Attilio Boner
University of Verona, Italy
92
PARENTAL STRESS AS A PREDICTOR OF WHEEZING IN
INFANCY A PROSPECTIVE BIRTH-COHORT STUDY Wright
Am J Respir Crit Care Med 2002 165 358
RR of wheezing during the first 14 mo.

• influence of caregiver stress on wheeze in
  infancy
• genetically predisposed birth-cohort (n496)

1.6
1 -
Greater level of stress in caregivers
93
CHRONIC CAREGIVER STRESS AND IGE EXPRESSION,
ALLERGEN-INDUCED PROLIFERATION, AND CYTOKINE
PROFILES IN A BIRTH COHORT PREDISPOSED TO ATOPY
Wright JACI 2004 113 1051
OR in children (6-18 mo) for IgE gt 100 vs lt 100
UI/ml
3 - 2 1 0

• Caregiver stress evaluated by Perceived Stress
  Scale in the first 2 yrs
• Total IgE and proliferative response to HDM

2.03
With higher caregiver stress
94
BEHAVIOR PROBLEMS ANTECEDE THE DEVELOPMENT
OF WHEEZE IN CHILDHOOD
Calam Am
J Respir Crit Care Med 2005 171 323

• Psychologic factors at age 3 years and
  subsequent development of wheeze by age 5
  in an unselected birth cohort study
• Eyberg Child Behavior Inventory
• Children who had never wheezed (n397) and those
  developing late-onset wheezing (after
  age 3 years n 39)

children with Intense Behavior Problems
30 20 10 0
23.1
plt0.001
6
Never wheezers
Late onset wheezers
95
A TWIN STUDY OF POST-TRAUMATIC STRESS DISORDER
SYMPTOMS AND ASTHMA Goodwin
AJRCCM 2007176983
3 2 1 0
Likelihood ratio of developing asthma

• Association between post-traumatic stress
  disorder (PTSD) symptoms and asthma.
• Data from twins in the Vietnam Era Twin Registry.

2.3
Plt0.001
In veterans in the highest quartile of PTSD
compared to those in the lowest
96
ASTHMA ORIGINS

• Lung Development
• Immunologic Maturation
• Allergens
• Exposure to Tobacco Smoke
• Diet
• Psychological factors

Psychological factors may predispose to wheeze
and atopy through neuro-immunological
mechanisms.
Attilio Boner
University of Verona, Italy
97
ASTHMA ORIGINS

• Lung Development
• Immunologic Maturation
• Allergens
• Exposure to Tobacco Smoke
• Diet
• Psychological factors

• Take it easy
• Dont worry be happy
• Make love not war

Psychological factors may predispose to wheeze
and atopy through neuro-immunological
mechanisms.
Attilio Boner
University of Verona, Italy
98
TO CHANGE ASTHMA NATURAL HISTORY A MITH?

• Introduction
• Genetic Factors
• Environmental Factors - allergens
  - tobacco smoke -
  pollutants - diet
  - life-style
  - psychology - treatment
• Conclusions

Attilio Boner
University of Verona, Italy
99
PRENATAL PARACETAMOL EXPOSURE AND RISK OF ASTHMA
AND ELEVATED IMMUNOGLOBULIN E IN CHILDHOOD
Shaheen Clin. Exp. Allergy 2005 35 18

• Population-based Avon Longitudinal Study of
  Parents and Children
• Paracetamol and aspirin use in late pregnancy
  (20-32 weeks)
• Asthma, hayfever, eczema and wheezing
  in the offspring at 69-81 months

OR for different disease of offspring whose
mothers took paracetamol versus those who never
took it
2.0 1.5 1.0 5 0
1.62
1.52
1.22
1.14
MOST DAYS
MOST DAYS
SOMETIMES
SOMETIMES
ASTHMA TOTAL IgE
100
ARE ORAL CONTRACEPTIVE USE AND PREGNANCY
COMPLICATIONS RISK FACTORS FOR ATOPIC DISORDERS
AMONG OFFSPRING? Brooks Pediatr. Allergy
Immunol. 2004 15 487
OR for having a mother who used contraceptive
pills
2.0 1.5 1.0 5 0

• Oral contraceptive use before pregnancy
• OR for asthma in children
• Follow-up 11-12 yrs of 1720 children

1.81
In asthmatic children
101
OUTCOME OF ASTHMA AND WHEEZING IN THE FIRST 6
YEARS OF LIFE Morgan AJRCCM 2005 172 1253
0.4 0.2 0.0 -0.2 -0.4 -0.6 -0.8 -1.0 -1.2

• A population-based birth cohort in Tucson
• Maximal expiratory
• flows at ages
• 2.4 mo and 6, 11,
• and 16 yr
• for the preschool wheeze phenotypes

Z-Scores of Height Adjusted Flow (/-se)

Never Wheeze Transient Early Late Onset Persistent



0 2 4 6 8 10 12 14 16 18
Age, years
102
EARLY DETECTION OF AIRWAY WALL REMODELLING AND
EOSINOPHILIC INFLAMMATION IN PRESCHOOL
WHEEZERS Saglani AJRCCM 2007176858

• Endobronchial biopsy from wheezy preschool
  children (aged 3 months to 5 years)
• Subjects undergoing fibreoptic bronchoscopy to
  investigate stridor acted as non-asthma controls

RETICULAR BASE MEMBRANE THICKNESS (µ)
5 4 3 2 1 0
plt0.05
4.6
3.8
WHEEZING CONTROLS
103
LONG-TERM INHALED CORTICOSTEROIDS IN PRESCHOOL
CHILDREN AT HIGH RISK FOR ASTHMA Morgan NEJM
2006 354 1985
Bimonthly proportion of episode-free days during
the two year treatment
period and the observation period.

• 285 ch. 2-3 yrs old with () Asthma Predictive
  Index
• Fluticasone Prop. 100 µg x 2
  or placebo for 2 years
• 1 year follow-up without medication

104
REVERSAL OF ALLERGEN-INDUCED AIRWAY REMODELING BY
CYSLT1 RECEPTOR BLOCKADE Henderson AJRCCM 2006
173 718
(1) Sensitized by intraperitoneal ovalbumin
(2) Received intranasal OVA periodically Days
14-73
(3) Montelukast or dexamethasone or placebo from
Days 73-163
Montelukast, but not dexamethasone, reversed the
established increase in airway smooth muscle mass
and subepithelial collagen deposition
105
REVERSAL OF ALLERGEN-INDUCED AIRWAY REMODELING BY
CYSLT1 RECEPTOR BLOCKADE Henderson AJRCCM 2006
173 718
OVA sensitized and challenge mice in absence of
Montelukas
Controls on day 163
Collagen deposition
OVA sensitized and challenge mice in presence of
Montelukast
106
TO CHANGE ASTHMA NATURAL HISTORY A MITH?

• Introduction
• Genetic Factors
• Environmental Factors - allergens
  - tobacco smoke -
  pollutants - diet
  - life-style
  - psychology - treatment

• During pregnancy potentially harmfull drugs have
  to be avoided
• Pharmachological prevention strategies need to be
  explored in humans

Attilio Boner
University of Verona, Italy
107
TO CHANGE ASTHMA NATURAL HISTORY A MITH?

• Introduction
• Genetic Factors
• Environmental Factors
• Conclusions

Attilio Boner
University of Verona, Italy
108
STRATEGIES FOR PREVENTING WHEEZING AND ASTHMA IN
SMALL CHILDREN. Wickman Allergy 200358742

• Birth cohort 4089 ch
• Families who lived according the Swedish
  primary prevention guidelines
• breastfeeding
• no tabacco smoke
• good ventilation
• reduced dampness
• NOexposed to
• gt2 risk factors

RECURRENT WHEEZING AT 2 YRS
30- 20- 10- 0
24.1
12.6
YES
NO
living according to guidelines
109
STRATEGIES FOR PREVENTING WHEEZING AND ASTHMA IN
SMALL CHILDREN. Wickman Allergy 200358742

• Birth cohort 4089 ch
• Families who lived according the Swedish
  primary prevention guidelines
• breastfeeding
• no tabacco smoke
• good ventilation
• reduced dampness
• NOexposed to
• gt2 risk factors

RECURRENT WHEEZING AT 2 YRS
30- 20- 10- 0
24.1
12.6
YES
NO
living according to guidelines
110
STRATEGIES FOR PREVENTING WHEEZING AND ASTHMA IN
SMALL CHILDREN. Wickman Allergy 200358742

• Birth cohort 4089 ch
• Families who lived according the Swedish
  primary prevention guidelines
• breastfeeding
• no tabacco smoke
• good ventilation
• reduced dampness
• NOexposed to
• gt2 risk factors

ASTHMA AT AGE 2
20- 10- 0
17.9
6.8
YES
NO
111
THE BRITISH 1958 COHORT. A MESSAGE FOR
OBSTETRICIANS AND PEDIATRICIANS.
Boner AJRCCM 2007 175 298

• All effort should be made to prevent
  intrauterine insults that may perturb lung
  development
• No maternal smoking during pregnancy,
• No maternal undernutrition,
• No maternal hypertension which may cause
  placental hypoxia,
• No oligodramnios,
• No harmfull drugs,
• No stress.

112
THE BRITISH 1958 COHORT. A MESSAGE FOR
OBSTETRICIANS AND PEDIATRICIANS.
Boner AJRCCM 2007 175 298

• In children may be of help
• Reduction of allergen exposure in early life,
• Good care of the skin to maitain the barrier
  function?
• Regular consumption of fresh fruit, vegetables,
  and fish,
• Reduction of indoor and outdoor pollution,
• No smoking,
• No stress,
• Regular physical activity.

113
Thank you for your attention FORMAT 17-19/04/2008