Background

Factors related to nutrition are implicated in the pathogenesis of a wide variety of diseases. In striking contrast to the situation pertaining of the relationship between diet, energy imbalance (obesity) and cardiovascular disease, particularly coronary artery disease, the relation between diet and lung disease has not received much attention.^[1], ^[2] The critical role of nutrition has been recognized also with regard to chronic disease states of the other organ systems, such as endocrine system (e.g. diabetes), digestive system (e.g. Fatty Liver), Immune system (e.g. Anemia), renal system (e.g. Nephrotic syndrome), Circulatory system (e.g. Hypertension), Skeletal System (e.g. Osteoporosis). The part played by nutrition in the pathogenesis of cancer has also been the subject of extensive research.^[3] But the standard texts on nutrition make little or no reference to the respiratory system.^[4] This relative neglect is due to the relation between nutrition and the fatal diseases of the respiratory system disease is not directly causal.^[1]

However, interesting new evidence which has emerged over the past decade suggests that there might be a significant link between dietary intake of certain nutrients and lung health.^[5], ^[6] While there is widespread acknowledgement that malnutrition in pregnant women adversely effects of the lung development of the fetus.^[7]

This process of complex interactions could be better understood with the vicious cycle below in [Figure 1] that shows the development of nutritional deficiencies early in life leading to malnutrition and hence poor lung development.

Nutritional status is clearly recognized as a factor that is tightly intertwined in this process, and the temporality of this association has long been debated.

Aim

The aim of the present review is to summarize the information currently available on the links between nutrition and lung health, addressing the effect of nutrition (and dietary habits) on lung function and disease focusing the role of omega 3 fatty acid on lung health.

Protective and harmful effects of diet on respiratory diseases

Interesting new evidence is, however, beginning to emerge from sources as varied as molecular biology laboratories and epidemiological units. This suggests that a relation may exist between intake of certain dietary elements and lung disease^[9] and that the links may have a practical importance.

The most popular dietary patterns for good lung health are Mediterranean diet and Prudent diet. The Mediterranean diet is based on the regional foods of Greece, Italy, and other nations that border the Mediterranean Sea. The foundation of Mediterranean diet is plant-based foods including whole grain cereals, green vegetables, pulses and legumes, fruits, seeds, nuts, herbs and spices. ^[10] While the diet pattern of prudent diet has been used to refer to the low-fat, low-cholesterol diet i.e., characterized by a high intake of fruits, vegetables, legumes, fish and whole grain products. ^[11]

On a contrary note, Traditional Indian diet that emphasizes on a high consumption of plant-based foods like vegetables, fruits, lentils with low intake of meat, is also gaining popularity all around the world and is being promoted for keeping lungs healthy. Not only the diet patterns but also how specific nutrients are responsible for prevention from lung diseases are shown in [Table 2].

S.No.	Protective effect of	Source	Protective effect against Diseases	References
1.	Mediterranean Diet	High intake of minimally processed plant foods, namely; fruit, vegetables, breads, cereals, beans, nuts and seeds, low to moderate intake of dairy foods, fish, poultry, wine, low intake of red meat & saturated fat	• Allergic respiratory diseases • Atopy, wheezing and asthma symptoms	[12], [13], [14]
2.	Prudent Diet	Increased intake of fruits, vegetables, legumes, fish whole grain products and other sea foods	• Lung function improvement • Reduced risk of COPD	[15]
3.	Indian Diet	Whole cereals and millets, variety of lentils, wide variety of fruit and vegetables, variety of herbs, spices and flavorings, low saturated fat, dairy foods, high fiber and regionally diverse nuts	• Help to Breathe easily and with comfort • Strengthen lung immunity and fight against infections • Reduces inflammation in lungs • Protect the lung tissues from damage • Boost lung function	[16], [17]
4.	Fruits and Vegetables		• Weaken COPD development • Decreased risk of asthma exacerbation • Reduces the risk of childhood wheezing • Improvement in lung function • Reduces the risk of lung cancer by approximately 25%	[18], [19]
5.	Vitamin C	Fruits: papaya, cantaloupe, citrus fruits, strawberries Vegetables: cauliflower, broccoli, Brussels sprouts, kale, sweet peppers	• A positive association with lung function • Important in COPD pathogenesis and management • Prevent smoke induced emphysema • Restore damaged lung tissue • Inverse relationship with bronchitis	[20], [21], [22], [23]
6.	Vitamin E	Vegetable & seed oils (corn, safflower, soy bean) Eggs Green vegetables	• Reduce biomarkers of oxidative stress in COPD patients • Reduces risk of childhood asthma and wheeze	[24], [25], [26], [27]
7.	Provitamin A carotenoids	Liver, Egg yolk, Milk fat, Fish oils	• Early lung development • Conservation of lung function • Partially prevent chronic lung disease • Decreased risk in lung cancer	[28], [29]
8.	Lycopene	Predominant in tomatoes; red, orange and yellow fruits, vegetables: sweet potato, carrots, winter squash, green vegetables	• Positively correlated with FEV1 in both asthma and COPD • Suppress neutrophilic airway inflammation in asthma	[30], [31]
9.	Flavonoids	Apples, lemons, oranges, potatoes, cauliflower, tea, skin of tubers and roots, red wine	• Lessening the development of lung diseases such as COPD, lung cancer, ARDS, and asthma • Ameliorating lung disorders	[32]
10.	Vitamin D	Sun exposure, milk, mushrooms, egg, fatty fish	• Protective role against asthma and COPD • Decrease COPD incidence	[33], [34]
11.	Magnesium	Nuts, legumes Cereal grains Corn, peas, carrots, parsley, spinach, lima beans Brown rice Seafood	• Have beneficial bronchodilator effects in asthma • Lowers risk factor for airway diseases	[35], [36]
12.	Selenium	Animal products, especially organ meats and seafood	Inversely associated with risk of asthma in children	[37], [38]
13.	Sulforaphane	Broccoli and wasabi, sprouts, kale, cabbage, cauliflower and curcumin (pigment in turmeric)	• Have beneficial antioxidant properties • Benefits in COPD	[39], [40], [41]
14.	Branched chain amino acid	Whey, milk, and soy proteins, corn, beef, chicken, fish, eggs, baked beans, chickpeas, lentils, whole wheat & brown rice.	Associated with positive results in COPD including increases in whole body protein synthesis, body weight, fat free mass and arterial blood oxygen levels	[42], [43]
15.	Cysteine	Cysteine or methionine as precursors of glutathione	Prevent increased susceptibility to lung injury	[44]

Table 2 Protective effect of Diet and nutrients against respiratory diseases

Diet can not only promote lung health but also can hinder lung function when taken in little or excess amounts of certain unhealthy foods or by following unhealthy food habits. Something similar happens in western diet pattern as well, which is characterized by high intake of refined grains, cured and red meats, sweets, desserts, high fat dairy products, processed foods and pre-packaged foods.^[45] While fast foods are high in sugar, salt, saturated fat or trans fats, and calories. It constitutes pre-prepared ingredients, pre-cooked foods, frozen beef patties, vegetables etc. as well as many processed preservatives and ingredients.^[46], ^[47] These impart harmful effect on lung health. [[Table 3]]

S.No.	Harmful effect of:	Source	Harmful effect	References
1.	Western Diet	High consumption of refined grains, cured and red meats, desserts and sweets and high-fat dairy products	Increased frequency of asthma exacerbation and is related to COPD risk.	[45]
2.	Fast Food	Hamburgers, Sandwich, French Fries, Potato chips, Pizza, Processed meat, Bakery products, Sweet drinks, Carbonated drinks, etc.	• Increased risk of COPD • Correlated with the presence of asthma, wheezing and airway hyper responsiveness (AHR)	[46], [47], [48]

Table 3 Harmful effect of diet leading to respiratory diseases

Magnitude of the disease burden

The World Health Organization (WHO) estimates that 6% of all diseases in the world are caused by respiratory infections. ^[49] The [Table 4] below shows the current scenario of respiratory disease burden.

S.No.	Respiratory problems	Global	Indian	References
		Burden	Deaths/year	Burden	Deaths/year
1.	Tuberculosis	10.6 million	1.6 million	2.59 million	4 lakhs	[50], [51], [52]
2.	Asthma	339 million	4.61 lakhs	34.3 million	> 1lakh	[53], [54], [55], [56]
3.	COPD	391.9 million	3.23 million	55.3milion	8.48 lakhs	[57], [58], [59]
4.	Lung Cancer	2.21 million	1.80 million	14.61 lakhs	8.08 lakhs	[60], [61], [62]
5.	Pneumonia	450 million	3.0 million	30 million	1.4 lakhs	[63], [64]
6.	Tobacco use	1.7 billion	> 8 million	267 million	1.35 million	[65], [66], [67]

Table 4 Current scenario of Global and Indian Respiratory Disease Burden

Asthma has affected an estimated number of 262 million people in 2019 and has caused 455,000 deaths. ^[68] Approximately 9.7% of adult females and 6.2% of adult males have asthma. It is the most common chronic illness among children. ^[69] Chronic obstructive pulmonary disease (COPD) is the third most common killer in the world, causing 3.23 million fatalities in 2019. Over 70% of instances of COPD in high-income nations are caused by tobacco use. ^[70] There is a 2% annual decline in TB incidence. ^[71]

The estimated global incidence of community-acquired pneumonia, which is influenced by the geographical characteristics, the season, and demographic characteristics, ranges from 1.5 to 14 cases per 1,000 person-years. ^[72] Overall, 3.1% of people self-reported having symptoms of chronic bronchitis, with 3.6% of men and 2.6% of women reporting these symptoms. ^[73]

Pulmonary edema related to cardiac reasons (heart failure) is a diagnosis given to more than 1 million individuals each year. ^[74] An estimated 190,000 patients are reported with acute lung damage annually. ^[75] Overall, men have a 1 in 16 lifetime risk of developing lung cancer; women have a 1 in 17 lifetime risk.  ^[76] Currently, 74% of the world's population—or close to 545 million people—live with a chronic respiratory disease. ^[77]

What is omega 3

Omega-3 fatty acids (omega-3s) are polyunsaturated fats that perform important functions in human body. Human body does not synthesize the amount of omega-3s needed for survival. So, omega-3 fatty acids are essential fatty acids, which has to be consumed through foods we eat. Omega-3 are essential nutrients that you need to get from your diet.

The three main omega-3 fatty acids are:

Alpha-linolenic acid (ALA)

Eicosapentaenoic acid (EPA)

Docosahexaenoic acid (DHA)

Sources of omega 3

These diets high in omega-3 fatty acids include both plant and fish-driven [[Figure 2]]

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