The Role of Biodiversity in the Development of Asthma and Allergic Sensitization: A State-of-the-Science Review.

BACKGROUND: Changes in land use and climate change have been reported to reduce biodiversity of both the environment and human microbiota. These reductions in biodiversity may lead to inadequate and unbalanced stimulation of immunoregulatory circuits and, ultimately, to clinical diseases, such as asthma and allergies. OBJECTIVE: We summarized available empirical evidence on the role of inner (gut, skin, and airways) and outer (air, soil, natural waters, plants, and animals) layers of biodiversity in the development of asthma, wheezing, and allergic sensitization. METHODS: We conducted a systematic search in SciVerse Scopus, PubMed MEDLINE, and Web of Science up to 5 March 2024 to identify relevant human studies assessing the relationships between inner and outer layers of biodiversity and the risk of asthma, wheezing, or allergic sensitization. The protocol was registered in PROSPERO (CRD42022381725). RESULTS: A total of 2,419 studies were screened and, after exclusions and a full-text review of 447 studies, 82 studies were included in the comprehensive, final review. Twenty-nine studies reported a protective effect of outer layer biodiversity in the development of asthma, wheezing, or allergic sensitization. There were also 16 studies suggesting an effect of outer layer biodiversity on increasing asthma, wheezing, or allergic sensitization. However, there was no clear evidence on the role of inner layer biodiversity in the development of asthma, wheezing, and allergic sensitization (13 studies reported a protective effect and 15 reported evidence of an increased risk). CONCLUSIONS: Based on the reviewed literature, a future systematic review could focus more specifically on outer layer biodiversity and asthma. It is unlikely that association with inner layer biodiversity would have enough evidence for systematic review. Based on this comprehensive review, there is a need for population-based longitudinal studies to identify critical periods of exposure in the life course into adulthood and to better understand mechanisms linking environmental exposures and changes in microbiome composition, diversity, and/or function to development of asthma and allergic sensitization. https://doi.org/10.1289/EHP13948.

Residential greenness during pregnancy and early life and development of asthma up to 27 years of age: The Espoo Cohort Study.

Previous studies have suggested that living close to green spaces has protective health effects, but potential effects on asthma are contradictory. We investigated the association between the amount of greenness in the residential area during pregnancy and early life and development of asthma in the first 27 years of life. The study population included all 2568 members of the Espoo Cohort Study, Finland. We calculated individual-level exposure to green space measured as cumulative Normalized Difference Vegetation Index (cumNDVI in unit-months) within 300 m of the participant's residence during pregnancy and the first two years of life in both spring and summer seasons. The onset of asthma was assessed using information from the baseline and follow-up surveys. Exposure to residential greenness in the spring season during pregnancy was associated with an increased risk of asthma up to 6 years of age, with an adjusted hazard ratio (aHR) of 3.72 (95% confidence interval (CI): 1.11, 12.47) per 1 unit increase in cumNDVI. Increased greenness in the summer during pregnancy associated with asthma up to 6 years, with an aHR of 1.41 (95% CI: 0.85, 2.32). The effect was found to be related to increased greenness particularly during the third trimester of pregnancy, with an aHR of 2.37 (95% CI: 1.36, 4.14) per 1 unit increase of cumNDVI. These associations were weaker at the ages of 12 and 27 years. No association was found between NDVI in the first two years of life and the development of asthma. Our findings provide novel evidence that exposure to greenness during pregnancy increases the risk of developing asthma. The adverse effects were strongest for the prenatal greenness in the spring season and in the third trimester of pregnancy. Both the season and trimester of exposure to greenness are critical in the development of asthma.

A toolbox of machine learning software to support microbiome analysis.

The human microbiome has become an area of intense research due to its potential impact on human health. However, the analysis and interpretation of this data have proven to be challenging due to its complexity and high dimensionality. Machine learning (ML) algorithms can process vast amounts of data to uncover informative patterns and relationships within the data, even with limited prior knowledge. Therefore, there has been a rapid growth in the development of software specifically designed for the analysis and interpretation of microbiome data using ML techniques. These software incorporate a wide range of ML algorithms for clustering, classification, regression, or feature selection, to identify microbial patterns and relationships within the data and generate predictive models. This rapid development with a constant need for new developments and integration of new features require efforts into compile, catalog and classify these tools to create infrastructures and services with easy, transparent, and trustable standards. Here we review the state-of-the-art for ML tools applied in human microbiome studies, performed as part of the COST Action ML4Microbiome activities. This scoping review focuses on ML based software and framework resources currently available for the analysis of microbiome data in humans. The aim is to support microbiologists and biomedical scientists to go deeper into specialized resources that integrate ML techniques and facilitate future benchmarking to create standards for the analysis of microbiome data. The software resources are organized based on the type of analysis they were developed for and the ML techniques they implement. A description of each software with examples of usage is provided including comments about pitfalls and lacks in the usage of software based on ML methods in relation to microbiome data that need to be considered by developers and users. This review represents an extensive compilation to date, offering valuable insights and guidance for researchers interested in leveraging ML approaches for microbiome analysis.

Mediterranean Diet and Airway Inflammation in School-Aged Children.

There seems to exist an intricate relationship between airway inflammation, body mass index (BMI), and diet. The intake of specific foods or food groups has been suggested to suppress the oxidative stress and inflammatory processes that characterize airway inflammation, but little is known about dietary patterns and their complex interplay with BMI and airway inflammation. Therefore, this cross-sectional study aimed to explore the association between adherence to the Mediterranean diet (MD), a characteristic European diet, and levels of airway inflammation in school-aged children, taking into account their BMI. This cross-sectional analysis comprised 660 children: 49.1% females, 7-12 years old. Adherence to the MD was assessed through the alternate Mediterranean score (aMED). Higher scores represent a healthier diet (0-8). Airway inflammation was assessed measuring exhaled fractional nitric oxide (eNO). Two categories of BMI were considered: non-overweight/non-obese (p < 85th) and overweight/obese (p ≥ 85th). The associations between diet and airway inflammation were estimated using logistic regression models. Higher scores of the aMED were associated with decreased odds of having eNO ≥ 35 ppb, but only in non-overweight/non-obese children (OR = 0.77; 95% CI, 0.61-0.97). For overweight/obese children, the previous association was not significant (OR = 1.57, 95% CI, 0.88-2.79). Our findings suggest that adherence to the MD is associated with lower levels of airway inflammation among non-overweight/non-obese children.

The Influence of Obesity in the Autonomic Nervous System Activity in School-Aged Children in Northern Portugal: A Cross-Sectional Study.

INTRODUCTION: Obesity is one of the most prevalent chronic diseases in childhood, being an important public health issue. Excessive weight has been associated with autonomic dysfunction but the evidence in children is scarce. Therefore, the aim of this study was to assess the effect of overweight and obesity on the autonomic nervous system activity, in children. MATERIAL AND METHODS: Data from a cross-sectional study of 1602 children, aged 7 to 12 years, was used and 858 children were included in the analysis. Body mass index was calculated and classified according to criteria of the World Health Organization (WHO), Centers for Disease Control and Prevention (CDC) and the International Obesity Task Force (IOTF). Body composition was characterized by bioelectrical impedance. Linear regression models were used to determine the association between body mass index, body composition and the autonomic nervous system activity, assessed by pupillometry. RESULTS: Average dilation velocity was higher among children with obesity, according to the CDC and percentage of body fat criteria (ß = 0.053, 95% CI = 0.005 to 0.101 and ß = 0.063, 95% CI = 0.016 to 0.109, respectively). The same trend was observed for WHO and IOTF criteria (ß = 0.045, 95% CI = -0.001 to 0.091, and ß = 0.055, 95% CI = -0.001 to 0.111, respectively). CDC and WHO body mass index z-scores were also positively associated with the values of average dilation velocity (rs = 0.030, p = 0.048; and rs = 0.027, p = 0.042, respectively). CONCLUSION: Our findings suggest an association between body mass and changes in the autonomic activity, Moreover, this study provides proof of concept for interventions targeting the prevention/treatment of obesity in children that may offer some benefit in re-establishing the balance of the autonomic nervous system, and subsequently preventing the consequences associated with the autonomic nervous system dysfunction.

Diet Quality and Exhaled Breath Condensate Markers in a Sample of School-Aged Children.

Exhaled breath condensate (EBC) analysis is a recently developed, non-invasive method used to identify and quantify biomarkers, mainly those coming from the lower respiratory tract. It seems that diet can influence the airway's inflammation and change the exhaled breath composition. This study aimed to assess the association between diet quality intake and markers in EBC among school-aged children. A cross-sectional analysis included 150 children (48.3% females, aged 7-12 years, mean age: 8.7 ± 0.8 years) from 20 schools across Porto, Portugal. We assessed diet quality through the Healthy Eating Index (HEI)-2015, which was estimated based on a single 24 h food recall questionnaire. EBC samples were collected, and we assessed their ionic content (Na+, K+) and conductivity. The association between diet quality and Na+, K+, Na+/K+ ratio and conductivity was estimated using logistic regression models adjusted for potential confounders. After adjustment, a higher quality diet score increases the odds of higher conductivity values of the EBC (aOR = 1.04, 95%CI 1.00; 1.08). Our findings suggest that a higher diet quality in school-aged children is associated with higher conductivity levels of the EBC.

Green and blue spaces and lung function in the Generation XXI cohort: a life-course approach.

BACKGROUND: Exposure to natural environments may affect respiratory health. This study examined the association of exposure to green and blue spaces with lung function in children, and assessed the mediation effect of air pollution and physical activity. METHODS: The study used data from the Generation XXI, a population-based birth cohort from the Porto Metropolitan Area (Portugal). Residential Normalised Difference Vegetation Index (NDVI) at different buffers (100, 250 and 500 m), the accessibility to urban green spaces (UGS) within 400 and 800 m and the minimum distance to the nearest UGS and to the nearest blue spaces were assessed at birth, 4, 7 and 10 years of age. Three life-course measures were calculated: averaged exposure, early-life exposure (birth) and exposure trend over time (change in exposure). Forced vital capacity (FVC), forced expiratory volume in 1 s (FEV1) and forced expiratory flow between 25% and 75% of FVC (FEF25-75%) at 10 years were used as outcomes. To assess associations, linear regression models and path analysis were used. RESULTS: This study included 3278 children. The adjusted models showed that increasing the NDVI exposure over time within 100 m of the child's residence was associated with higher values of FEV1 (L) and FEF25-75% (L·s-1) (ß 0.01, 95% CI 0.0002-0.03 and ß 0.02, 95% CI 0.001-0.05, respectively). No significant associations were observed for the remaining measures of exposure, and no mediation effect was found for pollution or physical activity. CONCLUSION: Increasing exposure to greenness at close proximity from residences was associated with improved lung function. While the mechanism remains unknown, this study brings evidence that city greening may improve children's respiratory health.

Neighbourhood Socioeconomic Processes and Dynamics and Healthy Ageing: A Scoping Review.

Elderly citizens are concentrated in urban areas and are particularly affected by the immediate residential environment. Cities are unequal and segregated places, where there is an intensification of urban change processes such as gentrification and displacement. We aimed to understand how neighbourhood socioeconomic processes and dynamics influence older people's health. Three bibliographic databases-PubMed, Web of Science, and Scopus-were used to identify evidence of the influence of neighbourhood socioeconomic deprivation, socio-spatial segregation, urban renewal, and gentrification on healthy ageing. We followed the method of Arksey and O'Malley, Levac and colleagues, the Joanna Briggs Institute, and the PRISMA-ScR. The included studies (n = 122) were published between 2001 and 2021. Most evaluated neighbourhood deprivation (n = 114), followed by gentrification (n = 5), segregation (n = 2), and urban renewal (n = 1). Overall, older people living in deprived neighbourhoods had worse healthy ageing outcomes than their counterparts living in more advantaged neighbourhoods. Older adults pointed out more negative comments than positive ones for gentrification and urban renewal. As to segregation, the direction of the association was not entirely clear. In conclusion, the literature has not extensively analysed the effects of segregation, gentrification, and urban renewal on healthy ageing, and more quantitative and longitudinal studies should be conducted to draw better inferences.

Environmental inequality: Air pollution and asthma in children.

INTRODUCTION: Whether you benefit from high-quality urban environments, such as those rich in green and blue spaces, that may offer benefits to allergic and respiratory health depends on where you live and work. Environmental inequality, therefore, results from the unequal distribution of the risks and benefits that stem from interactions with our environment. METHODS: Within this perspective, this article reviews the evidence for an association between air pollution caused by industrial activities, traffic, disinfection-by-products, and tobacco/e-cigarettes, and asthma in children. We also discuss the proposed mechanisms by which air pollution increases asthma risk, including environmental epigenetic regulations, oxidative stress, and damage, disrupted barrier integrity, inflammatory pathways, and enhancement of respiratory sensitization to aeroallergens. RESULTS AND CONCLUSIONS: Environmental air pollution is a major determinant of childhood asthma, but the magnitude of effect is not shared equally across the population, regions, and settings where people live, work, and spend their time. Improvement of the exposure assessment, a better understanding of critical exposure time windows, underlying mechanisms, and drivers of heterogeneity may improve the risk estimates. Urban conditions and air quality are not only important features for national and local authorities to shape healthy cities and protect their citizens from environmental and health risks, but they also provide opportunities to mitigate inequalities in the most deprived areas where the environmental burden is highest. Actions to avoid exposure to indoor and outdoor air pollutants should be complementary at different levels-individual, local, and national levels-to take effective measures to protect children who have little or no control over the air they breathe.

Cost-effectiveness analysis of house dust mite allergen immunotherapy in children with allergic asthma.

BACKGROUND: Cost-effectiveness studies evaluating allergen immunotherapy (AIT) in children are limited but needed to drive clinical and policy-making decisions such as reimbursement of new interventions. In this study, we compared the cost effectiveness of subcutaneous (SCIT) and sublingual immunotherapy (SLIT) tablets to the standard of care (SOC) treatment in children with house dust mite-driven (HDM) allergic asthma. METHODS: We developed a hypothetical Markov model based on the Global Initiative for Asthma (GINA) severity steps to compare the three strategies over a 10-year horizon divided by cycles of 6 months. SOC was used as a reference to calculate the incremental cost-effectiveness ratio (ICER). Deterministic and probabilistic sensitivity analyses were used to assess models' uncertainty. Other scenarios were evaluated to strengthen the presentation of results. RESULTS: The ICER for SCIT and SLIT tablets was 1281€ and 7717€, respectively. The cost-effectiveness threshold for Portugal was 18,482.80€; both treatment approaches were below this limit. The major contributors to these results were the AIT effects on reducing moderate and severe exacerbations and asthma controller medication. In the sensitivity analysis, SCIT revealed a higher probability of cost-effectiveness than SLIT. When including allergic rhinitis as comorbidity, ICER values reduced markedly, especially for SCIT intervention. CONCLUSIONS: AIT was cost effective in children with HDM-driven allergic asthma, especially when given by the subcutaneous route. The high probability of cost effectiveness, especially for SCIT, may drive future policy decisions and AIT-prescribing habits. AIT adherence greatly influenced the results highlighting the value of implementing strategies to promote adherence rates.

Dietary Acid Load Modulation of Asthma-Related miRNAs in the Exhaled Breath Condensate of Children.

Individual nutrients and bioactive compounds have been implicated in the expression of microRNAs (miRNAs), which are related to inflammation and asthma. However, evidence about the impact of diet is scarce. Therefore, we aimed to assess the association between dietary acid load and asthma-related miRNA in the exhaled breath condensate (EBC) of school-aged children. This cross-sectional analysis included 150 participants aged 7 to 12 years (52% girls) from a nested case-control study, which randomly selected 186 children attending 71 classrooms from 20 public schools located in city of Porto, Portugal. Dietary data were collected by one 24 h-recall questionnaire. Dietary acid load was assessed using the potential renal acid load (PRAL) and net endogenous acid production (NEAP) scores. Based on previous studies, eleven asthma-related miRNAs were chosen and analyzed in EBC by reverse transcription-quantitative real-time PCR. PRAL, NEAP and miRNAs were categorized as high or low according to the median. Logistic regression models were performed to assess the association between dietary acid load scores and miRNAs. Children in high dietary acid load groups (PRAL ≥ 14.43 and NEAP ≥ 55.79 mEq/day) have significantly increased odds of having high miR-133a-3p levels. In conclusion, higher dietary acid loads possibly modulate asthma-related miRNAs of school-aged children.

Allergen immunotherapy for asthma prevention: A systematic review and meta-analysis of randomized and non-randomized controlled studies.

BACKGROUND: Allergen immunotherapy (AIT) is a disease-modifying treatment for IgE-mediated diseases. Randomized controlled trials (RCTs) support AIT's potential role in asthma prevention but evidence from non-randomized studies of interventions (NRSI) and longitudinal observational studies has been poorly addressed. Therefore, we aimed to conduct a systematic review and meta-analysis to assess clinical data from all study types to evaluate quantitatively the preventive role of AIT in asthma onset. METHODS: We search three databases. Studies were screened, selected and evaluated for quality using risk-of-bias (ROB) tools. Data were descriptively summarized and meta-analysed using random effects. We performed a sensitivity, influence and subgroup analyses. Publication bias and heterogeneity were assessed. RESULTS: From the 4549 identified studies, 24 (12 RCTs and 12 NRSI) were included in the qualitative synthesis and 18 underwent meta-analysis. One study was at low ROB, seven had moderate ROB, and 15 were proven of high ROB. Random-effects analysis showed a significant decrease in the risk of developing asthma following AIT by 25% (RR, 95% CI: 0.75, 0.64-0.88). This effect was not significant in the sensitivity analysis. Publication bias raised concerns, together with the moderate heterogeneity between studies (I2  = 58%). Subgroup analysis showed a remarkable preventive effect of AIT in children (RR, 95% CI: 0.71, 0.53-0.96), when completing 3 years of therapy (RR, 95% CI: 0.64, 0.47-0.88), and in mono-sensitized patients (RR, 95% CI: 0.49, 0.39-0.61). CONCLUSIONS: Our findings support a possible preventive effect of AIT in asthma onset and suggest an enhanced effect when administered in children, mono-sensitized, and for at least 3 years, independently of allergen type.

AlergiaPT: A Portuguese media campaign to inspire people with allergies to make a positive change in their life.

Allergic diseases comprise a significant cause of morbidity worldwide and a substantial burden on the health and medical systems of both developed and emerging economies. Although highly prevalent, relatively severe, and largely impactful on the quality of life of patients, allergic diseases are commonly trivialized. Increasing awareness of the relevance of allergic diseases as a major public health problem might lead to an improved acknowledgment by governments and health authorities. Based on the positive impact that media campaigns might have on health-related behaviors, as well as the large use of social media by different types of users, social media might be used as a powerful tool for spreading awareness and education even more effective than traditional face-to-face communication. Therefore, we aimed to develop a social media-based communication program, the AlergiaPT, reaching all stakeholders, to increase the awareness of allergic diseases tackling the causes, prevention, control, and economic impact. The AlergiaPT will provide user-generated and interactive content toward engagement, include both long-form and short-form video productions toward education, as well as stories and time-sensitive content toward empowerment. It will be targeted to all populations, engaging different stakeholders. Contents will address the 5 campaign goals: i) allergy health is promoted; ii) tolerance is actively reinforced, and avoidance reduced; iii) treatment control and guided self-management of patients of asthma, rhinitis, food allergy, and atopic eczema are strengthened; iv) recognition and treatment of severe allergy and anaphylaxis are improved, and v) indoor air quality is promoted. Engagement on the campaign will be promoted through stepwise educational takeaways meetings using different social media, and targeting all audience groups, by promoting the organization of resources for common goals and the involvement of social media to improve public awareness. The impact of AlergiaPT will be assessed through google analytics.

Association between Land Use Mix and Respiratory Symptoms and Asthma in Children from the Generation XXI Birth Cohort.

Land use mix (LUM) in the neighbourhoods has been associated with healthier lifestyles. However, less is known about the association between LUM and health outcomes, namely during childhood. The objective of this study was to evaluate the association between different LUM indexes for Porto Metropolitan Area and asthma and respiratory symptoms in children. A cross-sectional analysis was performed involving 6260 children enrolled in Generation XXI. Land use around the child's residence was assessed with the Portuguese official map of land cover using a GIS. Generalized linear mixed-effects models were fitted to estimate the association between LUM and respiratory symptoms and asthma at 7 years of age. Adjusted associations were quantified using odds ratio (OR) and 95% confidence interval (95% CI). After adjustment, LUM was associated with a lower odds of wheezing in the last 12 months [OR (95% CI) = 0.37 (0.15; 0.93) using Shannon's Evenness Index within 500 m; and OR = 0.93 (0.89; 0.98) using the number of different land use types within 250 m]. Living in neighbourhoods with high LUM has a protective effect on current wheezing symptoms. Our results highlight the association between LUM and respiratory symptoms among children, suggesting that public health considerations should be incorporated in land use decision-making.

Eosinophil cationic protein (ECP) correlates with eosinophil cell counts in the induced sputum of elite swimmers.

Introduction: Swimming practice has been associated with eosinophilic inflammation, however, the underlying mechanisms are not fully understood. The eosinophil cationic protein (ECP) in induced sputum may be used as a potential biomarker to assess airway eosinophilic inflammation among elite swimmers. The objective of this study is to characterize ECP levels in sputum supernatant in elite swimmers and evaluate ECP as an eosinophilic inflammatory marker. Material and methods: Elite swimmers annually screened in our department (n = 27) were invited to participate in this cross-sectional study. Swimmers who agreed to participate (n = 24, 46% girls) performed lung function and skin-prick tests. Induced sputum was also collected and analyzed for differential cell counts and ECP measurements in sputum supernatant (ImmunoCAPTM 100, ECP, Thermo Fisher Scientific, Uppsala, Sweden). Results: The median ECP level was 15.60 µg/L (6.02-38.75 µg/L) and higher levels were found among boys (27.90 (11.20-46.30) µg/L vs 6.65 (2.82-22.80) µg/L, P = .02). In addition, ECP levels in the sputum supernatant were positively correlated with eosinophil cell counts in the induced sputum (r = 0.583, P = .08). Conclusions: ECP levels correlated positively with eosinophil counts in the induced sputum in elite swimmers. The measurement of ECP in sputum supernatant may be a useful marker to assess and manage eosinophilic inflammatory changes in the airways of elite swimmers.

Exhaled breath condensate pH determinants in school-aged children: A population-based study.

BACKGROUND: Exhaled breath condensate (EBC) pH is a promising biomarker of airway inflammation. Lack of method standardization and interstudy variability precludes its use in clinical practice. While endogenous determinants have been described, underlying mechanisms for variability are mostly unknown. Thus, we aimed to assess the association between asthma and EBC pH in children, while studying potential environmental factors for interstudy variability. METHODS: A cross-sectional analysis of exhaled breath condensates from 613 children, aged 7-12 years, was conducted. Assessments included lung function and airway reversibility, exhaled nitric oxide, allergic sensitization, and body mass index (BMI). Indoor air quality (IAQ) was assessed in children's classrooms during 5 school days. Post-deaeration EBC pH showed a bimodal distribution, and the sample was split into acidic and alkaline groups. Regression models were constructed to assess the effects of asthma and asthma adjusted to IAQ parameters on EBC pH. RESULTS: Following adjustment to gender and BMI, asthma was significantly associated with a lower EBC pH in the acidic group. The effect of asthma on EBC pH was independent of IAQ, in both groups. In the acidic group, EBC pH was significantly affected by temperature [ß = -0.09 (-0.15, -0.02)] and PM 2.5 concentration [ß = -0.16 (-0.32, -0.01)], and in the alkaline group by relative humidity [ß = 0.07 (0.02, 0.13)] and concentration of endotoxins [ß = -0.06 (-0.1, -0.01)]. CONCLUSION: Our study shows that in addition to individual determinants such as asthma, environmental factors may influence and should be taken into consideration when interpreting EBC pH level in children.

The Influence of Eating at Home on Dietary Diversity and Airway Inflammation in Portuguese School-Aged Children.

Considering the negative impact of a lack of dietary diversity on children's nutritional status, we aimed to describe dietary variety according to eating at home frequency and assessed its association with respiratory outcomes in school-aged children. This cross-sectional study included 590 children (49% girls) aged 7 to 12 years from 20 public schools located in city of Porto, Portugal. Daily frequency of eating at home groups were calculated and dietary diversity was calculated using a 10-food group score from a 24 h recall questionnaire. Spirometry and exhaled nitric oxide levels (eNO; <35 and ≥35 ppb) were assessed. The comparison of diet diversity according to the groups was performed by ANOVA and ANCOVA. The association between dietary diversity and respiratory outcomes was examined using regression models. In multivariate analysis, children in the highest group of eating at home episodes (≥4 occasions) obtained the lowest dietary diversity mean score, while the lowest group (<2) had the highest mean score (p-value 0.026). After adjustment for confounders, higher diet diversity (≥5 food groups) significantly decreased the odds of having an eNO ≥35. Diet diversity might decrease the chance of airway inflammation among children. However, having more eating episodes at home could be a barrier to a more diverse diet.