Trends in the prevalence of asthma.

The asthma epidemic of the last few decades may have peaked; studies suggest that the incidence and prevalence of asthma has decreased in some countries in the last few years, although other studies suggest continuing small increases in prevalence. Increasing awareness and changing diagnostic habits make precise evaluation of epidemiologic trends difficult in the absence of a gold-standard test for asthma, and on a global basis uncertainty persists. Trends in prevalence in some populations (eg, immigrants, farming communities) suggest both adverse and beneficial effects of specific environmental factors. Although the effects of indoor allergens, dampness, and mold and of outdoor air pollutants, especially traffic related, have traditionally dominated risk-factor research, more recent epidemiologic and clinical studies have focused on metabolic and nutritional factors, including maternal obesity and vitamin D levels, mode of delivery and its effect on the infant microbiome, fetal and infant growth, the psychosocial environment, and medication use by mother and infant. It is likely that changes in incidence and prevalence are due to multiple factors, each contributing a relatively small effect. Longitudinal studies from pregnancy through childhood to adulthood will yield greater insights into the complex pathways leading to asthma.