Send Orders for Reprints to reprints@benthamscience.net Endocrine, Metabolic & Immune Disorders - Drug Targets, 2014, 14, 000-000 1 1871-5303/14 $58.00+.00 © 2014 Bentham Science Publishers Investigating the Associations between Mediterranean Diet, Physical Activity and Living Environment with Childhood Asthma using Path Analysis George Αntonogeorgos 1 , Demosthenes B. Panagiotakos 1, * , Dimitra Grigoropoulou 1 , Konstantina Yfanti 1 , Constantina Papoutsakis 2 , Anastasios Papadimitriou 3 , Michael B. Anthracopoulos 4 , Chryssa Bakoula 5 and Kostas N. Priftis 3 1 Department of Nutrition and Dietetics, Harokopio University, Athens, Greece; 2 Department of Nursing, National and Kapodistrian University of Athens, Athens, Greece; 3 Third Department of Pediatrics, Attikon Hospital, University of Athens Medical School, Athens, Greece; 4 Respiratory Unit, Department of Pediatrics, University of Patras Medical School, Patras, Greece; 5 Second Department of Pediatrics, Aglaia Kyriakou Hospital, University of Athens Medical School, Athens, Greece Abstract: Objective: To investigate the role of the Mediterranean diet and physical activity with relation to living environment and childhood asthma. Methods: 1125 children (529 boys), 10 to 12 years old were recruited either in an urban environment (Athens, n = 700) or rural environment (n = 425) in Greece. A path analytic model was developed to assess the causal relation between urban environment and asthma prevalence (standardized ISAAC questionnaire), through the mediation of the Mediterranean diet (evaluated by the KIDMED food frequency questionnaire) and physical activity (evaluated by the PALQ physical activity questionnaire). Results: The proposed model had a very good fit (χ 2 /df ratio =1.05, RMSEA=0.007, 90% confidence interval: 0.01 to 0.046, p=0.97, CFI = 0.98). A significant total positive effect was found between urban environment and asthma symptoms (standardized beta= 0.09, p<0.001). Adherence to the Mediterranean diet was related negatively with asthma symptoms (standardized beta = -0.224, p<0.001). An inverse mediating effect of the Mediterranean diet was observed for the urban environment – asthma relation (standardized beta=-0.029, p<0.001) while physical activity had no significant contribution (p=0.62), adjusted for several confounders. Conclusions: The Mediterranean diet may protect against the harmful effect of urban environment on childhood asthma. Keywords: Asthma, children, living environment, mediation, physical activity, urban, diet. INTRODUCTION Asthma has become a modern epidemic and constitutes a major public health issue. Over the past twenty years, the prevalence of asthma symptoms has increased substantially, especially among children [1]. From an environmental perspective, a proportion of the high asthma rates has been attributed to factors associated with urbanization such as air pollution, environmental tobacco smoke, and decreased exposure to infectious agents. The higher asthma prevalence has been related to higher morbidity in children residing in urban areas, mainly due to traffic-related pollutants such as carbon monoxide and nitric oxide, highlighting the contribution of living environment [2-4]. According to accumulating evidence, obesity and asthma may be linked during childhood. In consequence, the *Address correspondence to this author at the Dept Nutrition and Dietetics, Harokopio University, Athens, Greece, 46 Paleon Polemiston St., 16674 Glyfada, Greece; Tel: +30210 9603116; Fax: +3-210 9600719; E-mail: d.b.panagiotakos@usa.net possible relation between asthma and diet has also been studied. Recent studies have focused on the Mediterranean diet, as a dietary pattern that exerts a protective effect against various chronic diseases both in adults and in children [5-7]. Another environmental factor linked to the pathophysiology of asthma is physical activity. Decreased levels of physical activity and patterns of inactive lifestyle, like prolonged computing, television viewing, and playing video games, have been related to increased probability of coughing and wheezing in childhood [8]. The intense interest in the study of environmental factors in the causation of chronic disease arises from the fact that environmental factors may be modified, which in turn could impact favorably the disease occurrence rates. However, the degree of modification is greatly dependent on the nature of the factor. Thus, environmental pollution is much less modifiable than factors such as dietary and physical activity patterns. Moreover, the complex interrelationships among living environment, diet and physical activity, often complicate the estimation of the true effect of the living environment on the prevalence of childhood asthma.