The Division of Lung Diseases at the National Heart, Lung, and Blood Institute (NHLBI) of the National Institutes of Health (NIH) convened a two-day virtual workshop titled “Advancing Nutrition Research to Promote Respiratory Health in Adults” on September 19th and 20th, 2024, from 10:00 AM - 4:00 PM EST. This workshop brought together multidisciplinary experts, including those specializing in nutrition and dietetics, pulmonary medicine, basic science, and data science, to discuss the current state of science regarding nutrition and diet in respiratory health and diseases and to identify critical research gaps, challenges, and opportunities. The primary goal of this workshop was to advance nutrition research to promote respiratory health and to aid in the prevention and management of chronic respiratory diseases in adults. This workshop underscores the NHLBI's commitment to advancing public health by integrating nutrition science into the prevention and treatment of respiratory conditions, ultimately aiming to improve health outcomes for adults worldwide.

Overall Objectives

• Utilize Epidemiological Insights: Harness epidemiological data to understand the influence of nutrition and diet on the prevalence and outcomes of respiratory health and diseases in adults, with a focus on vulnerable populations.
• Examine Environmental Impact: Understand the consequences of environmental disasters on food systems and security, and explore their subsequent effects on respiratory health and diseases.
• Uncover Mechanistic Pathways: Decipher the molecular mechanisms by which nutrition and diet impact respiratory health and disease onset and progression.
• Adopt Precision Nutrition Approaches: Embrace cutting-edge precision nutrition measures in both epidemiological and intervention studies to enhance the accuracy and efficacy of dietary assessments.
• Evaluate Dietary Interventions: Critically assess the existing evidence on efficacy of dietary and nutritional interventions on prevention and management of respiratory diseases, and explore potential strategies for implementation.

Background

Chronic lung diseases such as asthma, chronic obstructive pulmonary disease (COPD), obstructive sleep apnea (OSA), and pulmonary fibrosis, pose significant challenges for patients and healthcare providers. An often overlooked yet crucial aspect of managing these diseases is nutrition. Patients with chronic lung conditions frequently experience increased metabolic demands due to the energy required for breathing, which is further complicated by disease conditions and treatments. Evidence suggests that patients who maintain a healthy diet and exercise regimen during treatment tend to achieve better outcomes. Nutritional management is particularly vital for patients facing obesity, unintended weight loss (as seen in COPD), or malnutrition (often due to appetite suppression and/or treatments like immunotherapy). While growing evidence from clinical observational studies and clinical trials indicates that nutrition and dietary patterns can influence the prevalence and outcomes of lung diseases, the intersection of nutrition with factors such as genetics, medical conditions, environmental exposures, physical activity, sleep, and social determinants of health remains poorly understood. The mechanisms by which nutrition and dietary patterns affect lung health and resilience, and their interactions with factors like the microbiome, metabolic reprogramming, lipid metabolism, and immune function, are not yet fully elucidated. The field faces several challenges, including the complexity of nutrients and diets, variability in individual responses to nutrition interventions, inconsistent research findings, ethical considerations in long-term trials, the need for accurate longitudinal nutrient measurements, and long-term adherence to healthier diets. To address these challenges and develop practical solutions, the NHLBI convened a two-day workshop to explore the current landscape of science regarding nutrition and diet in respiratory health and disease. The workshop aimed to identify critical research gaps, challenges, and opportunities, with the primary goal of advancing nutrition research to promote respiratory health and aid in the prevention and management of respiratory diseases in adults. This workshop aligns with the 2020-2030 Strategic Plan for NIH Nutrition Research, NHLBI Strategic Vision Refresh (including NHLBI Nutrition Research Implementation Plan), and HHS MAHA initiative.

Summary of Presentation and Discussion

SESSION 1: IMPACT OF NUTRITION AND DIET ON PREVALENCE AND OUTCOMES OF RESPIRATORY HEALTH AND DISEASES IN ADULTS

This session delved into the significant role of dietary patterns and supplements, such as fatty acids, antioxidants, and flavonoids, in influencing respiratory health and disease, with a focus on asthma, COPD, and OSA. It highlighted the potential contribution of modern US dietary habits—such as increased consumption of processed foods and reduced intake of fruits and vegetables—to the growing prevalence of asthma. The discussion covered the impact of different fatty acids, revealing that polyunsaturated fatty acids (PUFAs), like omega-3s, show promise in managing asthma and COPD, while saturated fatty acids (SFAs) may increase inflammation and asthma risk. Additionally, dietary antioxidants and flavonoids appear beneficial for some patients with chronic lung diseases, including asthma, COPD, and respiratory infections. However, further research is needed to identify which specific subclasses of dietary supplements are most effective and to determine which population groups, based on genetics, race, ethnicity, social determinants of health (SDOH), and co-existing medical conditions, would benefit most from dietary interventions. Major challenges include the complexity of nutrient interactions and variability in research findings. Experts recommended advancing personalized nutrition approaches, implementing standardized data collection tools, and conducting further intervention trials that focus on dietary patterns rather than isolated nutrients, to effectively address respiratory health.

SESSION 2: IMPACT OF ENVIROMENTAL DISASTERS ON FOOD SYSTEMS AND SECURITY AND IMPLICATION IN RESPIRATORY HEALTH AND DISEASES

The session delved into the intricate relationships between environmental disasters, extreme weather events, food systems, and respiratory health. It was emphasized how extreme weather can profoundly affect food production, manifesting through direct impacts such as heat stress on crops and livestock, and indirect effects like increased water salinity and declining pollinator populations that threaten agricultural yields. Rising CO2 levels further complicate the issue by reducing essential nutrients such as iron, zinc, and protein in crops. Additionally, fisheries and global food trade face significant disruptions due to extreme weather patterns. These environmental challenges also have direct repercussions on respiratory health, as they contribute to deteriorating air quality, heightened allergen levels, and increased pressure on healthcare systems. To address these multifaceted issues, the session recommended implementing innovative agricultural practices, promoting crop diversification, and leveraging technological advancements to enhance resilience. Shifting dietary patterns towards plant-based foods, while strategically increasing the consumption of poultry, dairy, and fish, was also advised to improve nutritional outcomes. Moreover, the discussions underscored the importance of community-based adaptation strategies and the application of implementation science as critical components in building resilience against the intersecting challenges posed by extreme weather, food security, and respiratory health.

SECTION 3: MECHANISMS UNDERLYING NUTRITION AND DIET IMPACT ON RESPIRATORY HEALTH AND DISEASES

This session explored the complex mechanisms through which diet and nutrition affect respiratory health and disease. It focused on how diet and nutrition modulate metabolism, lipid mediators, immune cell function, the microbiome, and the gut-lung axis. The discussions emphasized the impact of nutritional inputs like carbohydrates and fats on cellular energetics and metabolism, which in turn influence weight gain and lung function. The session highlighted the benefits of dietary antioxidants, omega-3 fatty acids, and micronutrients such as zinc and vitamins C and D in reducing oxidative stress and inflammation in both the whole body system and the lungs. Additionally, dietary fibers were noted for supporting a healthy gut microbiome, which produces metabolites like short-chain fatty acids that enhance lung immunity and maintain respiratory health. The concept of therapeutic ketosis was discussed, showing promise in improving asthma outcomes by enhancing mitochondrial function and reducing airway inflammation. Time-restricted feeding (TRF) was also examined, suggesting that limiting eating windows may help regulate immune responses and improve metabolic health. Despite these insights, there remains a significant gap in understanding the cellular and molecular mechanisms by which specific nutrients or dietary patterns impact human health and disease, underscoring the need for more human-based research.

SESSION 4: EMERGING PRECISION MEASURES OF DIET AND NUTRITION IN STUDIES OF RESPIRATORY HEALTH AND DISEASES

This session explored the emerging cutting-edge approaches in precision nutrition, emphasizing the promising role of nutritional biomarkers. Traditional dietary assessments, such as food frequency questionnaires, 24-hour dietary recalls, and indices like the energy-adjusted dietary inflammatory index (E-DII) for pro-inflammatory diets and the alternative healthy eating index (AHEI-2010) for high dietary quality, often face challenges such as recall bias and measurement errors. In contrast, nutritional biomarkers offer a more accurate reflection of dietary intake and absorption. The field of dietary metabolomics shows great potential for the development of these biomarkers, as certain dietary metabolites are linked to the severity and outcomes of respiratory diseases. For instance, plasma sphingolipids like ceramide are associated with COPD phenotypes; plasma Omega-3 fatty acids correlate with improved survival in pulmonary fibrosis; and urinary carnitine metabolites are linked to severe asthma. Additionally, dietary fatty acid-derived specialized pro-resolving mediators (SPMs) play a crucial role in regulating inflammation, with dysregulation linked to reduced FEV1 and FVC in asthma patients. The session also highlighted the integration of BMI with body composition markers such as the fat-free mass index (FFMI) and unintentional weight loss as predictive biomarkers for malnutrition and disease severity in COPD. Despite these advancements, there is a pressing need for large, longitudinal cohort studies with extended follow-up periods to assess the prognostic value of these markers. Further challenges include standardizing measurement techniques and deepening our understanding of how dietary changes impact these biomarkers and lung health outcomes.

SECTION 5: DIETARY AND NUTRITIONAL INTERVENTION IN THE PREVENTION AND MANAGEMENT OF RESPIRATORY DISEASES

This session delved into the critical role of dietary and nutritional interventions in the prevention and management of respiratory diseases, especially among vulnerable populations who often face food insecurity, poor diet quality, and limited access to healthcare. Targeted nutrient supplementation, including omega-3 fatty acids, vitamin D, and vitamin C, has shown potential in alleviating symptoms and reducing exacerbations in conditions such as COPD and asthma. Additionally, whole food-based interventions, such as diets rich in fruits and vegetables, the Mediterranean diet, and the DASH diet, have demonstrated promising outcomes in managing asthma, COPD, and OSA by mitigating airway inflammation. Conversely, fast food and saturated fat intervention produced negative respiratory effects. Chrononutrition, circadian clock, and time-restricted feeding (TRF) in management of respiratory disease was explored, revealing that limiting eating windows could regulate immune responses and improve metabolic health, though more research is needed to assess its effects on lung function. The session also highlighted the challenges of nutrient supplementation in critical care settings, where aggressive early feeding may be detrimental, underscoring the need for personalized nutrition strategies. The discussion concluded with a call for large-scale, long-term, precision-based dietary intervention trials tailored to specific respiratory conditions and informed by baseline nutrient levels to effectively address these complex health issues.

Conclusion

The workshop emphasized the vital role of nutrition in both preventing and managing chronic lung diseases, highlighting its potential to significantly influence disease progression and quality of life, especially in vulnerable populations. It was concluded that no single nutrient or vitamin can currently be recommended for the prevention or treatment of lung diseases. Instead, overall dietary patterns hold greater importance than individual nutrients or vitamins. Consuming a diet rich in fruits and vegetables while minimizing saturated fats, trans fats, sugars, and salt is particularly beneficial for respiratory health promotion and disease prevention, especially in high-risk groups. Additionally, dietary PUFAs, antioxidants, and flavonoids may offer advantages for certain patients with chronic lung conditions. However, further research is required to identify which specific subclasses of dietary supplements are most effective and to determine the population groups that would benefit most from targeted interventions.

The primary challenges in the field include complexity and the intricate interactions between nutrients, the variability in responses to nutritional interventions among individuals and populations, and the difficulty in maintaining long-term adherence to healthier dietary patterns. To address these issues, future research and clinical practice should prioritize precision nutrition, implement accurate and standardized data collection methods, and deepen the understanding of the therapeutic efficacy and mechanisms of nutrition and dietary interventions in respiratory health and disease.

RESEARCH GAPS, OPPORTINITIES AND RECOMMENDATION

• Long-term dietary interventional trials: Well-designed and well-conducted efficacy trials of nutrition and dietary interventions are needed that address well-defined populations and disease outcomes for respiratory health promotion and disease prevention.
• Molecular mechanisms: Roles of microbiome, gut-lung axis, host-pathogen interactions, immune pathways, lipidome, metabolome, epigenome, bioactive oxylipin in mediating the impact of nutrition and diet on respiratory health and disease prevention are needed.
• Precision nutrition approaches: We should prioritize precision nutrition interventions that address biological, genetic, SNPs, metabolism, microbiome composition, nutrient levels, social determinants of health, behavioral factors and underlying health/medical conditions.
• Biomarker discovery and Integration: Innovative precision nutrition measures of dietary intake based on dietary biomarkers, such as serum metabolites and plasma proteomic profiling are needed.
• Maximizing existing resources: We should leverage existing cohorts, biobanks, and intervention studies to accelerate discoveries.
• Leverage technological advances: Multi-omics, artificial intelligence, machine learning, dietary apps, and digital wearable technology should be utilized to improve precision in measuring nutrition and lung health.
• Cross-disciplinary collaboration: We should enhance collaboration with cardiometabolic medicine to discover shared mechanisms and interventions that benefit both cardiovascular and respiratory health.

Workshop Co-Chairs

• Jun Ma, MD, Ph.D., University Illinois Chicago
• Vanessa Garcia-Larson, Ph.D., PAHO, Johns Hopkins University

Speakers and Moderators

• Shilpa Bhupathiraju, Ph.D., Brigham and Women's Hospital, Harvard T.H. Chan School of Public Health
• Emily Brigham, M.D., University of British Columbia
• Peter GJ Burney, M.D., National Heart and Lung Institute, Imperial College London
• Carlos A. Camargo, M.D., Dr.PH, Harvard University, Massachusetts General Hospital
• Salvatore Carbone, Ph.D., Virginia Commonwealth University
• Juan C. Celedón, M.D., Dr.PH, University of Pittsburgh, UPMC Children’s Hospital of Pittsburgh
• Melody G. Duvall, M.D., Ph.D., Harvard Medical School, Brigham and Women’s Hospital, Boston Children’s Hospital
• Kymberly Gowdy, Ph.D., Ohio State University
• Corrine Hanson, Ph.D., University of Nebraska Medical Center
• Nadia Hansel, M.D., MPH, Johns Hopkins Hospital, Johns Hopkins Medicine
• Maureen Lichtveld, M.D., MPH, University of Pittsburgh
• Felipe V. C. Machado, Ph.D., Hasselt University, Belgium
• Justin M. Oldham, M.D., University of Michigan
• Satchidananda Panda, Ph.D., Salk Institute
• Matthew E. Poynter, Ph.D., University of Vermont
• Arun Prakash, M.D., Ph.D., University of California San Francisco, San Francisco General Hospital
• Marie-Pierre St-Onge, Ph.D., Columbia University Irving Medical Center
• Katri V. Typpo, M.D., MPH, Baylor College of Medicine, Texas Children's Hospital
• Lisa Wood, Ph.D., University of Newcastle, Australia

NHLBI Planning Committee

• Qing Lu, Ph.D. (Lead)
• Michelle Freemer, M.D., MPH
• Alfonso Alfini, Ph.D.
• Christian Gomez, Ph.D.
• Marrah Lachowicz-Scroggins, Ph.D.
• Aaron Laposky, Ph.D.
• Emmanuel Mongodin, Ph.D.
• Charlotte Pratt, Ph.D.
• Beena Sood, M.D.

Agenda: See the agenda.

NIH Videocast:

• Day 1: https://videocast.nih.gov/watch=55142
• Day 2: https://videocast.nih.gov/watch=55143