1. Do fast foods cause asthma, rhinoconjunctivitis and eczema? Philippa Ellwood Senior Research Fellow Department of Paediatrics: Child and Youth Health, The University of Auckland http://www.globalasthmanetwork.org

2. Global findings from the International Study of Asthma and Allergies in Childhood (ISAAC) Phase Three Ellwood P, Asher MI, García-Marcos L, Williams H, Keil U, Robertson C, Nagel G and the ISAAC Phase Three Study Group. Do fast foods cause asthma, rhinoconjunctivitis and eczema? Global findings from the International Study of Asthma and Allergies in Childhood (ISAAC) Phase Three. Thorax 2013; 68(4):351-360.

3. © ISAAC 2012 http://isaac.auckland.ac.nz 1991-2012

4. Thanks to Children Parents School staff Funders

5. ●The Asthma and Respiratory Foundation of NZ ●The Auckland Medical Research Foundation ●The Health Research Council of NZ ●The National Child Health Research Foundation ●The Hawke's Bay Medical Research Foundation ●The Waikato Medical Research Foundation ●Glaxo Wellcome NZ, and International Medical Affairs ●Astra NZ ●Maurice & Phyllis Paykel Trust ●BUPA Foundation ●NZ Lotteries Commission ●The University of Auckland Funders of The ISAAC Programme in New Zealand

6. © ISAAC 2012 ISAAC Network : 306 research centres in 105 countries

7. © ISAAC 2012 ISAAC studied three diseases http://isaac.auckland.ac.nz

8. Asthma

9. Rhinoconjunctivitis

10. Eczema

11. Number of Centres and Countries ISAAC Phase Three Field work 2001 - 2003

12. Number of Centres and Countries Adolescent group – 233 centres from 97 countries ISAAC Phase Three

13. Number of Centres and Countries Adolescent group – 233 centres from 97 countries Childrens group – 144 centres from 61 countries Asher MI et al. Eur Resp J 1995; 8: 483-91 Ellwood P et al. Int J Tub Lung Dis 2005; 9: 10-16 ISAAC Phase Three

14. 13–14 year old adolescents and (optional) 6–7 year old children Phase Three Methods ISAAC multicentre, multicountry, cross-sectional study ISAAC multicentre, multicountry, cross-sectional study

15. 13–14 year old adolescents and (optional) 6–7 year old children Standardised core written questionnaires Phase Three Methods ISAAC multicentre, multicountry, cross-sectional study ISAAC multicentre, multicountry, cross-sectional study

16. 13–14 year old adolescents and (optional) 6–7 year old children Standardised core written questionnaires A video with clinical signs and symptoms for the adolescents Phase Three Methods ISAAC multicentre, multicountry, cross-sectional study ISAAC multicentre, multicountry, cross-sectional study

17. 13–14 year old adolescents and (optional) 6–7 year old children Standardised core written questionnaires A video with clinical symptoms and signs for the adolescents An optional environmental questionnaire Phase Three Methods ISAAC multicentre, multicountry, cross-sectional study ISAAC multicentre, multicountry, cross-sectional study

18. 13–14 year old adolescents and (optional) 6–7 year old children Standardised core written questionnaires A video with clinical symptoms and signs for the adolescents An optional environmental questionnaire Questionnaires were self-completed by adolescents and by parents of the children Phase Three Methods ISAAC multicentre, multicountry, cross-sectional study ISAAC multicentre, multicountry, cross-sectional study

19. Randomly selected schools from a defined area Phase Three Methods ISAAC multicentre, multicountry, cross-sectional study ISAAC multicentre, multicountry, cross-sectional study

20. Randomly selected schools from a defined area 3000 of each age group Phase Three Methods ISAAC multicentre, multicountry, cross-sectional study ISAAC multicentre, multicountry, cross-sectional study

21. Randomly selected schools from a defined area 3000 of each age group Centres followed written guidelines for fieldworkers Phase Three Methods ISAAC multicentre, multicountry, cross-sectional study ISAAC multicentre, multicountry, cross-sectional study

22. Randomly selected schools from a defined area 3000 of each age group Centres followed written guidelines for fieldworkers Questionnaires translated 53 languages & back translated Phase Three Methods ISAAC multicentre, multicountry, cross-sectional study ISAAC multicentre, multicountry, cross-sectional study

23. Randomly selected schools from a defined area 3000 of each age group Centres followed written guidelines for fieldworkers Questionnaires translated 53 languages & back translated Ethical approval obtained by each centre Phase Three Methods ISAAC multicentre, multicountry, cross-sectional study ISAAC multicentre, multicountry, cross-sectional study

24. Randomly selected schools from a defined area 3000 of each age group Centres followed written guidelines for fieldworkers Questionnaires translated 53 languages & back translated Ethical approval obtained by each centre Centres found their own funding Phase Three Methods ISAAC multicentre, multicountry, cross-sectional study ISAAC multicentre, multicountry, cross-sectional study

25. Detailed methodology (centre report) and data checks Phase Three Methods ISAAC multicentre, multicountry, cross-sectional study ISAAC multicentre, multicountry, cross-sectional study

26. Detailed methodology (centre report) and data checks Adherence to the ISAAC protocol was assessed and centres with following response rates were excluded: Phase Three Methods ISAAC multicentre, multicountry, cross-sectional study ISAAC multicentre, multicountry, cross-sectional study

27. Detailed methodology (centre report) and data checks Adherence to the ISAAC protocol was assessed and centres with following response rates were excluded: <70% for the adolescent group Phase Three Methods ISAAC multicentre, multicountry, cross-sectional study ISAAC multicentre, multicountry, cross-sectional study

28. Detailed methodology (centre report) and data checks Adherence to the ISAAC protocol was assessed and centres with following response rates were excluded: <70% for the adolescent group <60% for the children Phase Three Methods ISAAC multicentre, multicountry, cross-sectional study ISAAC multicentre, multicountry, cross-sectional study

29. Detailed methodology (centre report) and data checks Adherence to the ISAAC protocol was assessed and centres with following response rates were excluded: <70% for the adolescent group <60% for the children <1000 participants for both age groups Phase Three Methods ISAAC multicentre, multicountry, cross-sectional study ISAAC multicentre, multicountry, cross-sectional study

30. Auckland

32. Beijing

33. Guangzhou

34. HongKong

35. Hungary

36. Jaipur

37. Sweden

38. Samoa

39. Tokelau

40. Core questionnaires - wheeze

41. Current symptoms of wheeze: ‘Have you (has your child) had wheezing or whistling in the chest in the past 12 months?’ Core questionnaires - wheeze

42. Current symptoms of wheeze: ‘Have you (has your child) had wheezing or whistling in the chest in the past 12 months?’ Severe wheeze symptoms: Defined as participants who in the past 12 months had ≥4 attacks of wheeze, or ≥1 night per week sleep disturbance from wheeze, or wheeze affecting speech Core questionnaires - wheeze

43. Current symptoms of wheeze: ‘Have you (has your child) had wheezing or whistling in the chest in the past 12 months?’ Severe wheeze symptoms: Defined as participants who in the past 12 months had ≥4 attacks of wheeze, or ≥1 night per week sleep disturbance from wheeze, or wheeze affecting speech For adolescents (video): ‘Has your breathing ever been like this in the past 12 months?’ was defined as ‘current wheeze (VQ)’ Core questionnaires - wheeze

44. Core questionnaires – rhinoconjunctivitis

45. Current symptoms of rhinoconjunctivitis : ‘In the past 12 months ‘have you (has your child) had a problem with sneezing or a runny or blocked nose when you (he/she) DID NOT have a cold or flu?’ and ‘In the past 12 months, has this nose problem been accompanied by itchy watery eyes?’ Core questionnaires – rhinoconjunctivitis

46. Current symptoms of rhinoconjunctivitis : ‘In the past 12 months ‘have you (has your child) had a problem with sneezing or a runny or blocked nose when you (he/She) DID NOT have a cold or flu?’ and ‘In the past 12 months, has this nose problem been accompanied by itchy watery eyes?’ Severe symptoms of rhinoconjunctivitis: Defined as participants who, in the past 12 months, had itchy watery eyes and who answered ‘a lot’ to their nose problems interfering with their daily activities Core questionnaires – rhinoconjunctivitis

47. Core questionnaires – eczema

48. Current symptoms of eczema: ‘Have you (has your child) had this itchy rash at any time in the past 12 months?’ and ‘Has this itchy rash at any time affected any of the following places: the folds of the elbows, behind the knees, in front of the ankles, under the buttocks, or around the neck, ears or eyes?’ question preceded by: Have you/has your child ever had an itchy rash coming and going for at least 6 months? Core questionnaires – eczema

49. Current symptoms of eczema: ‘Have you (has your child) had this itchy rash at any time in the past 12 months?’ and ‘Has this itchy rash at any time affected any of the following places: the folds of the elbows, behind the knees, in front of the ankles, under the buttocks, or around the neck, ears or eyes?’ question preceded by: Have you/has your child ever had an itchy rash coming and going for at least 6 months? Severe symptoms of eczema: Defined as participants who, in the past 12 months, had sleep disturbance one or more times per week Core questionnaires – eczema

50. DIET

51. Current symptoms of eczema: ‘Have you (has your child) had this itchy rash at any time in the past 12 months?’ and ‘Has this itchy rash at any time affected any of the following places: the folds of the elbows, behind the knees, in front of the ankles, under the buttocks, or around the neck, ears or eyes?’ question preceded by: Have you/has your child ever had an itchy rash coming and going for at least 6 months? Severe symptoms of eczema: Defined as participants who in the past 12 months had sleep disturbance one or more times per week. Core questionnaires – eczema

54. The environmental questionnaire diet questions

55. Respondents were asked: ‘In the past 12 months how often, on average, did you (did your child) eat or drink the following food groups: The environmental questionnaire diet questions

56. Respondents were asked: ‘In the past 12 months how often, on average, did you (did your child) eat or drink the following food groups: Meat, seafood, fruit, vegetables (green and root), pulses (peas, beans, lentils), cereal (including bread), pasta, rice, butter, margarine, nuts, potatoes, milk, eggs and fast food/burgers. The environmental questionnaire diet questions

57. The environmental questionnaire food intake categories

58. The three categories for food intake were: The environmental questionnaire food intake categories

59. The three categories for food intake were: Never or occasionally The environmental questionnaire food intake categories

60. The three categories for food intake were: Never or occasionally Once or twice per week The environmental questionnaire food intake categories

61. The three categories for food intake were: Never or occasionally Once or twice per week And ≥ 3 times per week The environmental questionnaire food intake categories

62. Analyses Prevalence odd ratios (ORs) were calculated from the individual level data using generalised linear mixed models with a binomial distribution and logit link, With the centres modelled as a random effect

63. The Univariate analyses adjusted for: Analyses

64. Univariate analyses adjusted for: Gender Analyses

65. Univariate analyses adjusted for: Gender Region of the world Analyses

66. Univariate analyses adjusted for: Gender Region of the world Language Analyses

67. Univariate analyses adjusted for: Gender Region of the world Language Per capita gross national income (world bank categories) Analyses

68. The Univariate analyses adjusted for: Gender Region of the world Language Per capita gross national income (world bank categories) Further multiple regression analyses adjusted for Analyses

69. Univariate analyses adjusted for: Gender Region of the world Language Per capita gross national income (world bank categories) Further multiple regression analyses adjusted for Analyses Exercise

70. Univariate analyses adjusted for: Gender Region of the world Language Per capita gross national income (world bank categories) Further multiple regression analyses adjusted for Analyses Exercise Television watching

71. Univariate analyses adjusted for: Gender Region of the world Language Per capita gross national income (world bank categories) Further multiple regression analyses adjusted for Analyses Exercise Television watching Maternal education

72. Univariate analyses adjusted for: Gender Region of the world Language Per capita gross national income (world bank categories) Further multiple regression analyses adjusted for Analyses Exercise Television watching Maternal education Maternal smoking (first year of life and current)

73. Univariate analyses adjusted for: Gender Region of the world Language Per capita gross national income (world bank categories) Further multiple regression analyses adjusted for Analyses Exercise Television watching Maternal education Maternal smoking (first year of life and current) Body Mass Index (showed no effect)

74. Number of participants:

75. The diet analysis involved: Number of participants:

76. The diet analysis involved: 319 196 adolescents from 107 centres in 51 countries Number of participants:

77. The diet analysis involved: 319 196 adolescents from 107 centres in 51 countries 181 631 children from 64 centres in 31 countries Number of participants:

78. Results

79. The Adolescent age group (13-14 years) Results

80. The Adolescent age group (13-14 years) Protective foods All centres combined. Intake once or twice per week and ≥ 3 times per week for current & severe wheeze Results

81. The Adolescent age group (13-14 years) Protective foods All centres combined. Intake once or twice per week and ≥ 3 times per week for current & severe wheeze Fruit (and for current rhinoconjunctivitis) Results

82. The Adolescent age group (13-14 years) Protective foods All centres combined. Intake once or twice per week and ≥ 3 times per week for current & severe wheeze Fruit (and for current rhinoconjunctivitis) Milk (≥ 3 times per week severe asthma, current eczema) Results

83. The Adolescent age group (13-14 years) Protective foods All centres combined. Intake once or twice per week and ≥ 3 times per week for current & severe wheeze Fruit (and for current rhinoconjunctivitis) Milk (≥ 3 times per week severe asthma, current eczema) Vegetables (≥ 3 times per week current asthma only) Results

84. The Adolescent age group (13-14 years) Results

85. The Adolescent age group (13-14 years) Risk factor foods All centres combined intake ≥ 3 times per week for all three conditions Results

86. The Adolescent age group (13-14 years) Risk factor foods All centres combined intake ≥ 3 times per week for all three conditions Fast food (strongest association) Results

87. The Adolescent age group (13-14 years) Risk factor foods All centres combined intake ≥ 3 times per week for all three conditions Fast food (strongest association) Margarine, nuts, butter, pasta Results

88. The Adolescent age group (13-14 years) Risk factor foods All centres combined intake ≥ 3 times per week for all three conditions Fast food (strongest association) Margarine, nuts, butter, pasta Eggs (≥ 3 times per week for severe asthma & severe rhinoconjunctivitis Results

89. The childrens age group (6-7 years) Results

90. The childrens age group (6-7 years) Protective foods All centres combined. Intake ≥ 3 times per week for all three conditions (severe) Results

91. The childrens’ age group (6-7 years) Protective foods All centres combined. Intake ≥ 3 times per week for all three conditions (severe) Eggs, fruit, meat, Milk Results

92. The childrens’ age group (6-7 years) Protective foods All centres combined. Intake ≥ 3 times per week for all three conditions (severe) Eggs, fruit, meat, Milk Seafood (current and severe asthma only) Results

93. The childrens’ age group (6-7 years) Protective foods All centres combined. Intake ≥ 3 times per week for all three conditions (severe) Eggs, fruit, meat, Milk Seafood (current and severe asthma only) Vegetables (except for severe eczema) Results

94. The childrens age group (6-7 years) Results

95. The childrens age group (6-7 years) Risk factor foods All centres combined. Intake ≥ 3 times per week for current & severe wheeze, current and severe rhinoconjunctivitis and severe eczema Results

96. The childrens age group (6-7 years) Risk factor foods All centres combined. Intake ≥ 3 times per week for current & severe wheeze, current and severe rhinoconjunctivitis and severe eczema Fast food Results

97. The childrens age group (6-7 years) Risk factor foods All centres combined. Intake ≥ 3 times per week for current & severe wheeze, current and severe rhinoconjunctivitis and severe eczema Fast food Margarine (current rhinoconjunctivitis only) Results

99. Current wheeze and frequent consumption of fast food, 6-7 year age group Ellwood P et al. Do fast foods cause asthma, rhinoconjunctivitis and eczema? Global findings from the International Study of Asthma and Allergies in Childhood (ISAAC) Phase Three. Thorax 2013; 68(4):351-360.

100. Severe asthma and frequent consumption of fast food, 6-7 year age group Ellwood P et al. Do fast foods cause asthma, rhinoconjunctivitis and eczema? Global findings from the International Study of Asthma and Allergies in Childhood (ISAAC) Phase Three. Thorax 2013; 68(4):351-360.

101. Discussion Potential Implications

102. Discussion Potential Implications Findings are consistent with two previous analyses which found positive associations between fast food consumption and prevalence of wheeze Wickens K, et al. Fast foods - are they a risk factor for asthma?. Allergy 2005; 60(12): 1537-41.Robertson CF. The association between fast food outlets and the prevalence of symptoms of asthma from the International Study of Asthma and Allergies in Childhood (ISAAC)[Abstract]. Eur Resp J 1998; 12: Suppl 28.

103. Discussion Potential Implications Findings are consistent with two previous analyses which found positive associations between fast food consumption and prevalence of wheeze Biologically plausible mechanisms could be related to higher saturated fatty acids, trans fatty acids, sodium, carbohydrates and sugar levels of fast food and of preservatives

104. Conclusions

105. Fast food was the only food type to show the same associations across the two age groups and all regions

106. Conclusions Fast food was the only food type to show the same associations across the two age groups and all regions Fast food consumption may be contributing to the increasing prevalence of asthma, rhinoconjunctivitis and eczema in adolescents and children although the mechanism is unclear

107. Conclusions Fast food was the only food type to show the same associations across the two age groups and all regions Fast food consumption may be contributing to the increasing prevalence of asthma, rhinoconjunctivitis and eczema in adolescents and children although the mechanism is unclear Diets that have a regular consumption of fruit and vegetables are likely to protect against asthma, rhinoconjunctivitis and eczema in adolescents and children

108. Conclusions For other foods, the picture for adolescents and children is less clear

109. Conclusions For other foods, the picture for adolescents and children is less clear Further work is required in this area

110. Conclusions For other foods, the picture for adolescents and children is less clear Further work is required in this area The Global Asthma Network has been established to continue the work of ISAAC (formed by some former members of ISAAC and from The International Union against Tuberculosis and Lung Disease [The Union])

111. http://www.globalasthmanetwork.org Established 2012 © GAN

112. Global Asthma Network 204 centres in 92 countries http://www.globalasthmanetwork.org/ © GAN