Doctor of Philosophy / Department of Human Nutrition / Craig A. Harms / The overall aim of this dissertation was to ascertain the influences of lifestyle factors on airway health in children and young adults. In Study 1 (Chapter 2) the effect of a high-fat meal on airway inflammation and hyper-responsiveness was examined. Results revealed a post-prandial increase (p<0.05) in total cholesterol (~4%), triglycerides (~93%), and exhaled nitric oxide (a marker of airway inflammation, ~19%) two-hours following a high-fat meal (74.2±4.1g fat). These novel findings suggest that a high-fat meal may contribute to impaired airway function. In study 2 (Chapter 3) we assessed the role of body fat and physical activity (PA) on airway health in prepubescent children. This study revealed that children with higher-body-fat levels (>21%), who were not meeting current PA recommendations, experienced greater (p<0.05) amounts of post-exercise airway narrowing (FEV1, forced expiratory volume in 1-second, ~11%), as compared to children with lower-body-fat (<21%), who were meeting PA guidelines. These findings suggest that elevated adiposity and low PA levels may place children at risk for development of asthma and asthma-like symptoms. In study 3 (Chapter 4), based on study 2 results, we assessed the impact of 8 weeks of high-intensity interval training on airway health in children who were not meeting PA guidelines. We determined that high-intensity training significantly increased V02max (~24%), and decreased total cholesterol (~11%) and LDL cholesterol (~35%). Additionally, we found improvements (p<0.05) in ∆FEV1 both post-exercise (pre: -7.6±2.2%, post: -1.3±1.8%) and post-eucapnic voluntary hyperventilation (pre: -6.7±2.2%, post: -1.4±1.5%) with training. Further, Lower-body-fat and higher V02max subjects experienced significantly greater improvement in ∆FEV1 following training than higher-body-fat and lower V02max subjects (r=-0.80, r=0.73, respectively). These results suggest that in children, high-intensity training can ameliorate the negative health consequences of inactivity. However, increased body fat, and low V02max levels may constrain these improvements. This series of studies underscores the importance of dietary habits, body composition, and PA for airway health in children and young adults. These findings may be useful in determining policies and practices impacting children’s health, and could facilitate protocol development for prevention of asthma-like symptoms.

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Ozone, being an unstable molecule, is believed to be one of the strongest oxidant agents known to man. Rapid growth in the application of ozone — both as disinfectant and as form of alternative medicine — led to questions about the effects of uncontrolled ozone exposure and inhalation, whether intentional or unintentional, on the human body. This study specifically focussed on examining, identifying and substantiating the respiratory effect of acute exposure (10 min or less) to considerably higher ozone concentrations than reported on before (19.5 ± 0.5 ppm). Respiratory tissue of rodents (Duncan–Hartley guinea pigs of both sexes and Male Wistar rats) was subjected to ozone by utilising three distinctly diverse models of ozone introduction: (a) in vitro exposure, (b) in vivo exposure, and (c) ex vivo by employing an isolated lung perfusion model which allows for real–time, breath–by–breath data acquisition of ozone’s effect on respiratory mechanics. The effect of ozone on the isolated trachea in the presence of various drugs with well–known effects, including methacholine, isoproterenol and ascorbic acid was also examined. The results found in this study identified two direct effects on the isolated trachea due to ozone exposure: (1) a definite contraction of the isolated trachea immediately after exposure to ozone, and (2) a clearly visible and significant hyper responsiveness of the isolated trachea to irritants, e.g. methacholine. Although ozone has a negative effect on the trachea, it was concluded that ozone has no adverse effect on muscarinic acetylcholine receptors. An apparent EC50 value of ozone on the trachea was established by two different methods as (2.77 ± 0.02) x 10–3 M and (2.10 ± 0.03) x 10–3 M, respectively. Ozone furthermore displayed an attenuation of the beneficial pharmacological response of –sympathomimetic drugs (i.e. isoproterenol), while isoproterenol itself has a relaxing effect on the ozone–induced contraction of the isolated trachea. Indomethacin pre–treatment of isolated tracheal tissue significantly (77%) reduced the ozone–induced contraction of tracheal smooth muscle, suggesting that COXproducts of arachidonic acid play a prominent role in the development of pulmonary function decrements consequent to acute high–dose ozone exposure. Ascorbic acid exhibited a meaningful prophylactic effect on ozone–induced contraction of both isolated tracheal tissue and in the isolated lung perfusion model, emphasising the major role antioxidants play in both the epithelium lining fluid (ELF) of the respiratory system and in plasma throughout the body in protecting against the destructive effects of ozone. Surprisingly, pre–treatment with ascorbic acid did not prevent hyper responsiveness of isolated tracheal preparations to methacholine after a 10 min ozone (19.5 ± 0.5 ppm) exposure. In the lung perfusion model, the presence of ascorbic acid in the perfusion medium did, however, significantly reduce the magnitude and rate of decline in lung compliance after ozone exposure (46% decline with ascorbic acid versus 96% in the control study without ascorbic acid). Examination of a lung perfusion model exposed to ozone (19.5 ± 0.5 ppm O3; 5 seconds) presented a significant decline in lung compliance (95.6% within 2 min), tidal volume (70%) and maximum inspiratory flow (71.2%), with an ensuing reduction in lung elasticity and severely hampered breathing pattern. Microscopic examination after acute high–dose inhalation studies did not display any significant cellular damage, oedema or inflammation after acute high–dose ozone exposure. This suggests that significant cellular injury and inflammation is possibly not the causative factor of early breathing difficulty experienced after acute high–dose ozone inhalation, as these symptoms and particularly the result of inflammatory precursors, is believed to probably only set in at a later stage. Although the potential advantages of ozone in certain fields of medicine are not disputed, ozone, depending on its concentration and cumulative dose, can be either therapeutic or toxic. Observations in this study emphasised that even short bursts of high–dose ozone inhalation have deleterious effects on respiratory health and care should be taken not to jump to conclusions regarding ozone’s medical application without relevant scientific evidence. It must be stressed that high–dose inhalation of ozone should be avoided at all cost – especially by those with existing airway diseases. / Thesis (Ph.D. (Pharmacology))--North-West University, Potchefstroom Campus, 2011.

Ozone, being an unstable molecule, is believed to be one of the strongest oxidant agents known to man. Rapid growth in the application of ozone — both as disinfectant and as form of alternative medicine — led to questions about the effects of uncontrolled ozone exposure and inhalation, whether intentional or unintentional, on the human body. This study specifically focussed on examining, identifying and substantiating the respiratory effect of acute exposure (10 min or less) to considerably higher ozone concentrations than reported on before (19.5 ± 0.5 ppm). Respiratory tissue of rodents (Duncan–Hartley guinea pigs of both sexes and Male Wistar rats) was subjected to ozone by utilising three distinctly diverse models of ozone introduction: (a) in vitro exposure, (b) in vivo exposure, and (c) ex vivo by employing an isolated lung perfusion model which allows for real–time, breath–by–breath data acquisition of ozone’s effect on respiratory mechanics. The effect of ozone on the isolated trachea in the presence of various drugs with well–known effects, including methacholine, isoproterenol and ascorbic acid was also examined. The results found in this study identified two direct effects on the isolated trachea due to ozone exposure: (1) a definite contraction of the isolated trachea immediately after exposure to ozone, and (2) a clearly visible and significant hyper responsiveness of the isolated trachea to irritants, e.g. methacholine. Although ozone has a negative effect on the trachea, it was concluded that ozone has no adverse effect on muscarinic acetylcholine receptors. An apparent EC50 value of ozone on the trachea was established by two different methods as (2.77 ± 0.02) x 10–3 M and (2.10 ± 0.03) x 10–3 M, respectively. Ozone furthermore displayed an attenuation of the beneficial pharmacological response of –sympathomimetic drugs (i.e. isoproterenol), while isoproterenol itself has a relaxing effect on the ozone–induced contraction of the isolated trachea. Indomethacin pre–treatment of isolated tracheal tissue significantly (77%) reduced the ozone–induced contraction of tracheal smooth muscle, suggesting that COXproducts of arachidonic acid play a prominent role in the development of pulmonary function decrements consequent to acute high–dose ozone exposure. Ascorbic acid exhibited a meaningful prophylactic effect on ozone–induced contraction of both isolated tracheal tissue and in the isolated lung perfusion model, emphasising the major role antioxidants play in both the epithelium lining fluid (ELF) of the respiratory system and in plasma throughout the body in protecting against the destructive effects of ozone. Surprisingly, pre–treatment with ascorbic acid did not prevent hyper responsiveness of isolated tracheal preparations to methacholine after a 10 min ozone (19.5 ± 0.5 ppm) exposure. In the lung perfusion model, the presence of ascorbic acid in the perfusion medium did, however, significantly reduce the magnitude and rate of decline in lung compliance after ozone exposure (46% decline with ascorbic acid versus 96% in the control study without ascorbic acid). Examination of a lung perfusion model exposed to ozone (19.5 ± 0.5 ppm O3; 5 seconds) presented a significant decline in lung compliance (95.6% within 2 min), tidal volume (70%) and maximum inspiratory flow (71.2%), with an ensuing reduction in lung elasticity and severely hampered breathing pattern. Microscopic examination after acute high–dose inhalation studies did not display any significant cellular damage, oedema or inflammation after acute high–dose ozone exposure. This suggests that significant cellular injury and inflammation is possibly not the causative factor of early breathing difficulty experienced after acute high–dose ozone inhalation, as these symptoms and particularly the result of inflammatory precursors, is believed to probably only set in at a later stage. Although the potential advantages of ozone in certain fields of medicine are not disputed, ozone, depending on its concentration and cumulative dose, can be either therapeutic or toxic. Observations in this study emphasised that even short bursts of high–dose ozone inhalation have deleterious effects on respiratory health and care should be taken not to jump to conclusions regarding ozone’s medical application without relevant scientific evidence. It must be stressed that high–dose inhalation of ozone should be avoided at all cost – especially by those with existing airway diseases. / Thesis (Ph.D. (Pharmacology))--North-West University, Potchefstroom Campus, 2011.

Background Iron deficiency (ID) is the world‟s most prevalent micronutrient deficiency and predominantly affects developing countries, also South Africa. In areas with low fish consumption and high n-6 PUFA vegetable oil intake, there is a risk for having inadequate n-3 PUFA status. Both iron and n-3 PUFA play important roles in the immune response, and supplementation is a strategy to alleviate deficiencies. However, little is known about potential interactive effects between concurrent iron and n-3 PUFA supplementation on the immune system. This is also important in the context that iron supplementation may be unsafe and may increase morbidity and mortality. Aim The overall aim of this thesis was to assess the effects of iron and docosahexaenoic (DHA)/eicosapentaenoic acid (EPA) supplementation, alone and in combination, on the immune system of ID children. More specifically, these effects were investigated on the occurrence and duration of illness and school-absenteeism due to illness, peripheral blood mononuclear cell (PBMC), red blood cell (RBC) and plasma total phospholipid fatty acid composition, iron status, fatty acid-derived immune modulators and targeted PBMC gene expression. Furthermore, association of PBMC, RBC and plasma total phospholipid fatty acid composition with allergic disease, were also examined. Design In a 2-by-2 factorial, randomised, double-blind, placebo-controlled trial, South African children (n = 321, aged 6–11 y) were randomly assigned to receive oral supplements of either 1) iron (50 mg as ferrous sulphate) plus placebo; 2) DHA/EPA (420/80 mg) plus placebo; 3) iron plus DHA/EPA (420/80 mg); or 4) placebo plus placebo for 8.5 mo, four times per week. Absenteeism and illness symptoms were recorded and biochemical parameters for compliance as well as parameters fundamental to immune function were assessed at baseline and endpoint. Furthermore, in a cross-sectional design, associations of allergic disease with baseline fatty acid composition of PBMC, RBC and plasma were examined. Results The combination of iron and DHA/EPA significantly attenuated respiratory illness caused by iron supplementation. DHA/EPA supplementation alone improved respiratory symptoms at school, but increased headache-related absenteeism. DHA/EPA and iron supplementation individually tended to increase and decrease anti-inflammatory DHA and EPA-derived mediators, respectively. Furthermore the anti-inflammatory DHA-derived immune mediator, 17HDHA was higher in the DHA/EPA plus placebo and iron plus DHA/EPA groups than in the iron plus placebo group. Also, the pro-inflammatory arachidonic acid (AA)-derived modulators (5- and 15-hydroxyeicosapentaenoic acid) were significantly lower in the iron plus DHA/EPA group compared to the placebo plus placebo groups. In the study population, 27.2% of the children had allergic disease and AA in PBMC phospholipids was significantly lower in the allergic children than in the non-allergic children. In RBC phospholipids dihomo-gamma-linolenic acid (DGLA) and the ratio of DGLA: linoleic acid (LA) correlated negatively and the n-6:n-3 PUFA ratio positively with total immunoglobulin E (tIgE). Furthermore, trans-C18:1n-9, tended to be higher in the allergic group. Conclusion DHA/EPA prevented respiratory illness caused by iron supplementation and although DHA/EPA on its own reduced respiratory morbidity when the children were present at school, surprisingly it increased the likelihood of being absent with headache and fever. The biochemical findings compliment the clinical results and support previous observations about DHA/EPA supplementation to reduce inflammation, but add to the current knowledge base that a relatively high oral dose of non-haem iron modulates circulating lipid-derived immune modulators and related gene expression. Furthermore, when supplementing with iron and DHA/EPA combined, in this ID population with low fish intake, the anti-inflammatory effect of DHA/EPA is maintained concurrently with attenuation of respiratory morbidity. This finding support the notion that excess iron (probably as non-transferrin bound iron) becomes available for pathogens and is probably why we found that iron increased respiratory infectious morbidity. The improved clinical outcome with combined supplementation seems to be related to increased lipid-mediator synthesis gene expression and the availability of DHA/EPA, leading to a more pro-resolving profile and enhanced immune competence. Overall these results give better insight into immune function and infectious morbidity in relation to n-3 PUFA and iron status and treatment, as well as the possible association of fatty acid status with allergic disease in young South-African school children. / PhD (Nutrition), North-West University, Potchefstroom Campus, 2015

Background Iron deficiency (ID) is the world‟s most prevalent micronutrient deficiency and predominantly affects developing countries, also South Africa. In areas with low fish consumption and high n-6 PUFA vegetable oil intake, there is a risk for having inadequate n-3 PUFA status. Both iron and n-3 PUFA play important roles in the immune response, and supplementation is a strategy to alleviate deficiencies. However, little is known about potential interactive effects between concurrent iron and n-3 PUFA supplementation on the immune system. This is also important in the context that iron supplementation may be unsafe and may increase morbidity and mortality. Aim The overall aim of this thesis was to assess the effects of iron and docosahexaenoic (DHA)/eicosapentaenoic acid (EPA) supplementation, alone and in combination, on the immune system of ID children. More specifically, these effects were investigated on the occurrence and duration of illness and school-absenteeism due to illness, peripheral blood mononuclear cell (PBMC), red blood cell (RBC) and plasma total phospholipid fatty acid composition, iron status, fatty acid-derived immune modulators and targeted PBMC gene expression. Furthermore, association of PBMC, RBC and plasma total phospholipid fatty acid composition with allergic disease, were also examined. Design In a 2-by-2 factorial, randomised, double-blind, placebo-controlled trial, South African children (n = 321, aged 6–11 y) were randomly assigned to receive oral supplements of either 1) iron (50 mg as ferrous sulphate) plus placebo; 2) DHA/EPA (420/80 mg) plus placebo; 3) iron plus DHA/EPA (420/80 mg); or 4) placebo plus placebo for 8.5 mo, four times per week. Absenteeism and illness symptoms were recorded and biochemical parameters for compliance as well as parameters fundamental to immune function were assessed at baseline and endpoint. Furthermore, in a cross-sectional design, associations of allergic disease with baseline fatty acid composition of PBMC, RBC and plasma were examined. Results The combination of iron and DHA/EPA significantly attenuated respiratory illness caused by iron supplementation. DHA/EPA supplementation alone improved respiratory symptoms at school, but increased headache-related absenteeism. DHA/EPA and iron supplementation individually tended to increase and decrease anti-inflammatory DHA and EPA-derived mediators, respectively. Furthermore the anti-inflammatory DHA-derived immune mediator, 17HDHA was higher in the DHA/EPA plus placebo and iron plus DHA/EPA groups than in the iron plus placebo group. Also, the pro-inflammatory arachidonic acid (AA)-derived modulators (5- and 15-hydroxyeicosapentaenoic acid) were significantly lower in the iron plus DHA/EPA group compared to the placebo plus placebo groups. In the study population, 27.2% of the children had allergic disease and AA in PBMC phospholipids was significantly lower in the allergic children than in the non-allergic children. In RBC phospholipids dihomo-gamma-linolenic acid (DGLA) and the ratio of DGLA: linoleic acid (LA) correlated negatively and the n-6:n-3 PUFA ratio positively with total immunoglobulin E (tIgE). Furthermore, trans-C18:1n-9, tended to be higher in the allergic group. Conclusion DHA/EPA prevented respiratory illness caused by iron supplementation and although DHA/EPA on its own reduced respiratory morbidity when the children were present at school, surprisingly it increased the likelihood of being absent with headache and fever. The biochemical findings compliment the clinical results and support previous observations about DHA/EPA supplementation to reduce inflammation, but add to the current knowledge base that a relatively high oral dose of non-haem iron modulates circulating lipid-derived immune modulators and related gene expression. Furthermore, when supplementing with iron and DHA/EPA combined, in this ID population with low fish intake, the anti-inflammatory effect of DHA/EPA is maintained concurrently with attenuation of respiratory morbidity. This finding support the notion that excess iron (probably as non-transferrin bound iron) becomes available for pathogens and is probably why we found that iron increased respiratory infectious morbidity. The improved clinical outcome with combined supplementation seems to be related to increased lipid-mediator synthesis gene expression and the availability of DHA/EPA, leading to a more pro-resolving profile and enhanced immune competence. Overall these results give better insight into immune function and infectious morbidity in relation to n-3 PUFA and iron status and treatment, as well as the possible association of fatty acid status with allergic disease in young South-African school children. / PhD (Nutrition), North-West University, Potchefstroom Campus, 2015