Original article Adherence to the Mediterranean diet and fresh fruit intake are associated with improved asthma control Asthma control still remains difficult to attain in all patients (1). The remarkable variation in asthma preva- lence between countries or geographically adjacent areas suggests that environmental factors play a determinant role both in asthma prevalence and severity. The marked changes in dietary patterns in recent decades – e.g. decrease in intake of antioxidant micronutrients and fatty acids – may explain some of the variation (2). Interven- tions with supplementation of a single nutrient have been disappointing (3–5), and it may be important to consider the diet as a whole to understand the possible synergistic effects of various food components. Several studies have shown that asthma outcomes were negatively associated with citrus fruits (6), apples, pears (7–9), tomato, carrots, leafy vegetables (7), butter, whole milk (9) and nonpas- teurized farm milk (10), and positively associated with fast foods (11). However, studies addressing the associ- ations between different dietary patterns and asthma are still lacking. Mediterranean diet, a cultural model for healthy eating, has been associated with low incidence of mortality and morbidity by chronic diseases in Medi- terranean populations, compared to US or Northern Europe (12, 13). A similar north-south gradient has been observed for asthma (14), with some Southern Mediterranean countries such as Greece or Albania, presenting the lowest prevalence. Mediterranean diet is characterized by high intake of vegetables, pulses, fruit, nuts, whole grain cereals and unsaturated fatty acids, mainly from olive oil, as well as by low intake of meat and meat products. Furthermore, the diet contains lot of fish; moderately dairy products, mostly cheese or yogurt; and ethanol regularly but with moderate amounts (15). Mediterranean diet is a ÔcocktailÕ of Background: The traditional Mediterranean diet is claimed to possess antioxi- dant and immune-regulatory properties in several chronic diseases. Typical Mediterranean foods have recently been associated with improvement of symptoms of asthma and rhinitis in children. However the effect of adherence to Mediterranean diet on adult asthma outcomes is unknown. We aimed to investigate the association between adherence to Mediterranean diet and asthma control. Methods: Cross sectional study of 174 asthmatics, mean (SD) age of 40 (15) years. The patients were defined as controlled, in contrast to noncontrolled, if they showed FEV1 ‡ 80% of predicted, exhaled nitric oxide (NO) £ 35 ppb, and Asthma Control Questionnaire score <1. Dietary intake was obtained by a food frequency questionnaire, and Mediterranean diet was assessed by alternate Mediterranean Diet (aMED) Score. Logistic regression models adjusting for confounders were performed to estimate the association between Mediterranean diet and asthma control. Results: Controlled asthmatics (23%) had significantly higher aMED Score, intake of fresh fruit, and lower intake of ethanol compared to noncontrolled (77%). High adherence to Mediterranean diet reduced 78% the risk of non- controlled asthma after adjusting for gender, age, education, inhaled corticos- teroids and energy intake (OR = 0.22; 95% CI = 0.05–0.85; P-trend = 0.028). The higher intake of fresh fruit decreased the probability of having noncon- trolled asthma (OR = 0.29; 95% CI = 0.10–0.83; P-trend = 0.015), while the higher intake of ethanol had the opposite effect (OR = 3.16; 95% CI = 1.10– 9.11; P-trend = 0.035). Conclusion: High adherence to traditional Mediterranean diet increased the likelihood of asthma to be under control in adults. The study introduces a novel link between diet and asthma control, as measured by symptoms, lung function and exhaled NO. R. Barros 1,2 , A. Moreira 2,3 , J. Fonseca 2,4 , J. Ferraz de Oliveira 2 , L. Delgado 2,3 , M. G. Castel-Branco 2 , T. Haahtela 5 , C. Lopes 6 , P. Moreira 1,7 1 Faculty of Nutrition and Food Sciences, University of Porto, Porto, Portugal; 2 Department of Immunoallergology, Hospital of S. Jo¼o, Porto, Portugal; 3 Department of Immunology and 4 Department of Biostatistics and Medical Informatics, Faculty of Medicine, University of Porto, Porto, Portugal; 5 Skin and Allergy Hospital, Helsinki University Central Hospital, Helsinki, Finland; 6 Department of Hygiene and Epidemiology, University of Porto Medical School, Porto, Portugal; 7 CIAFEL – Research Centre in Physical Activity and Leisure, University of Porto, Porto, Portugal Key words: airway inflammation; asthma; exhaled nitric oxide; mediterranean diet; nutrition. Renata Barros Faculty of Nutrition and Food Sciences University of Porto Rua Roberto Frias 4200-465 Porto Portugal Accepted for publication 4 January 2008 Allergy 2008: 63: 917–923 Ó 2008 The Authors Journal compilation Ó 2008 Blackwell Munksgaard DOI: 10.1111/j.1398-9995.2008.01665.x 917