• body mass index
• asthma
• children
• obesity
• breastfeeding

We read with interest the report by von Mutius et al on the association between body mass index (BMI) and asthma in children.¹ The finding that the association between asthma and obesity may be mediated by mechanical factors or by an alternative inflammatory mechanism rather than eosinophilic inflammation is important and contributes to our understanding of the causal pathway.

With regard to breastfeeding, the authors state: “Breast feeding was no longer a significant predictor of asthma once BMI was introduced into the model. However, this may be because the intermediate variable (BMI) was introduced in the model.” The authors then surmise that BMI is an independent variable, and the results of their multivariate analyses—including breastfeeding—do not support the notion that “BMI might be an intermediate step”. However, if the former is correct, then lack of breastfeeding is the problem and a reduction of BMI may not reduce asthma, as claimed by the authors. The conclusions drawn appear to be contradictory and also do not reflect the limitations of cross sectional analyses.

The question is whether: (1) lack of breastfeeding results in increased BMI and increased BMI is an intermediate step in the aetiology of asthma; or (2) the association between BMI and asthma is a spurious correlation and both are caused by lack of breastfeeding; or (3) both increased BMI and shortened breastfeeding are independent risk factors.

Acknowledging the restriction of cross sectional analyses, the authors need to clarify their conclusions and provide the respective models and path (or partial) coefficients that support one or other of the models suggested above.