Ω-3 fatty acids contribute to the asthma-protective effect of unprocessed cow's milk Tabea Brick, BA, Yvonne Schober, PhD, Christian Böcking, PhD, Juha.

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ω-3 fatty acids contribute to the asthma-protective effect of unprocessed cow's milk Tabea Brick, BA, Yvonne Schober, PhD, Christian Böcking, PhD, Juha Pekkanen, MD, Jon Genuneit, MD, MSc, Georg Loss, PhD, Jean- Charles Dalphin, MD, PhD, Josef Riedler, MD, Roger Lauener, MD, Wolfgang Andreas Nockher, MD, MSc, Harald Renz, MD, Outi Vaarala, MD, PhD, Charlotte Braun-Fahrländer, MD, Erika von Mutius, MD, MSc, Markus Johannes Ege, MD, MPH, Petra Ina Pfefferle, PhD, DrPH A. Karvonen, P. Tiittanen, M.-L. Dalphin, B. Schaub, M. Depner, S. Illi, M. Kabesch Tabea Brick, BA, Yvonne Schober, PhD, Christian Böcking, PhD, Juha Pekkanen, MD, Jon Genuneit, MD, MSc, Georg Loss, PhD, Jean-Charles Dalphin, MD, PhD, Josef Riedler, MD, Roger Lauener, MD, Wolfgang Andreas Nockher, MD, MSc, Harald Renz, MD, Outi Vaarala, MD, PhD, Charlotte Braun- Fahrländer, MD, Erika von Mutius, MD, MSc, Markus Johannes Ege, MD, MPH, Petra Ina Pfefferle, PhD, DrPH A. Karvonen, P. Tiittanen, M.-L. Dalphin, B. Schaub, M. Depner, S. Illi, M. Kabesch Journal of Allergy and Clinical Immunology Volume 137, Issue 6, Pages 1699-1706.e13 (June 2016) DOI: 10.1016/j.jaci.2015.10.042 Copyright © 2015 American Academy of Allergy, Asthma & Immunology Terms and Conditions

Fig 1 Selection of study population. *Exclusion of Finnish children because the milk module was not implemented in Finland. Journal of Allergy and Clinical Immunology 2016 137, 1699-1706.e13DOI: (10.1016/j.jaci.2015.10.042) Copyright © 2015 American Academy of Allergy, Asthma & Immunology Terms and Conditions

Fig 2 Frequency of milk types consumed over time (A) and effects on asthma (in the follow-up population, n = 751; B). Fig 2, A, Frequency of consumption of milk types from age 1 year until age 6 years. ∗No data on fat content of consumed milk was collected until age 2 years. Fig 2, B, Effects of consuming different milk types at different time points on asthma as defined by age 6 years. ORs were adjusted for center and farming because of the study design. *Significant values, P < .05. Journal of Allergy and Clinical Immunology 2016 137, 1699-1706.e13DOI: (10.1016/j.jaci.2015.10.042) Copyright © 2015 American Academy of Allergy, Asthma & Immunology Terms and Conditions

Fig 3 Change in estimate of the farm milk effect on asthma by distinct FA groups. Because of skewed distributions of some FA variables, all FA variables were used after rank transformation. CLA, Conjugated linoleic acid; MUFA, monounsaturated fatty acid; SFA, saturated fatty acid. Journal of Allergy and Clinical Immunology 2016 137, 1699-1706.e13DOI: (10.1016/j.jaci.2015.10.042) Copyright © 2015 American Academy of Allergy, Asthma & Immunology Terms and Conditions

Fig 4 ω-3 PUFA levels (log-transformed) in milk samples consumed by asthmatic and nonasthmatic children and geometric mean ratio (GMR). The GMR was calculated because of log-normal distribution of ω-3 levels. Journal of Allergy and Clinical Immunology 2016 137, 1699-1706.e13DOI: (10.1016/j.jaci.2015.10.042) Copyright © 2015 American Academy of Allergy, Asthma & Immunology Terms and Conditions

Fig 5 ω-3 PUFA levels in milk samples consumed by PASTURE children (A) and ω-6/ω-3 ratio in relation to milk processing (B). Fig 5, A, Different ω-3 PUFA levels (log-transformed) in milk samples “usually” consumed by PASTURE children. Fig 5, B, Different ω-6/ω-3 ratios (log-transformed) in milk samples “usually” consumed by PASTURE children in relation to milk processing. In Fig 5, A, the t test (2-sided) was used to calculate differences between milk variables. Fig 5, B, shows differences among high-fat milk samples. The P value refers to a trend test. Journal of Allergy and Clinical Immunology 2016 137, 1699-1706.e13DOI: (10.1016/j.jaci.2015.10.042) Copyright © 2015 American Academy of Allergy, Asthma & Immunology Terms and Conditions

Fig 6 Metabolism of linoleic and α-linolenic acid. In mammalians the PUFA profile is derived from essential FA precursors of both ω-3 and ω-6 PUFAs (α-linolenic acid [18:3 ω-3] and linoleic acid [18:2 ω-6], respectively). Long-chain PUFAs are synthesized endogenously through reactions of both insertion of additional double bonds (desaturases) and elongation of the acyl chain (elongase). ω-3 and ω-6 PUFAs compete for the same set of enzymes in this pathway, with a preferential affinity of ω-3 over ω-6 PUFAs. LTB, Leukotriene B; PGE, prostaglandin E. Journal of Allergy and Clinical Immunology 2016 137, 1699-1706.e13DOI: (10.1016/j.jaci.2015.10.042) Copyright © 2015 American Academy of Allergy, Asthma & Immunology Terms and Conditions

Fig E1 Correlation of milk consumption over time. Journal of Allergy and Clinical Immunology 2016 137, 1699-1706.e13DOI: (10.1016/j.jaci.2015.10.042) Copyright © 2015 American Academy of Allergy, Asthma & Immunology Terms and Conditions

Fig E2 Milk effect in the follow-up population compared with that in the analysis population (5 years). Journal of Allergy and Clinical Immunology 2016 137, 1699-1706.e13DOI: (10.1016/j.jaci.2015.10.042) Copyright © 2015 American Academy of Allergy, Asthma & Immunology Terms and Conditions

Fig E3 ORs for higher hsCRP values depending on ω-6/ω-3 ratios in consumed milk. Journal of Allergy and Clinical Immunology 2016 137, 1699-1706.e13DOI: (10.1016/j.jaci.2015.10.042) Copyright © 2015 American Academy of Allergy, Asthma & Immunology Terms and Conditions