Objective: Co-occurrence of pediatric asthma and obesity has been widely reported, yet the causal directions between these two disorders are still not well-understood. The objective of this meta-analysis is to explore whether there is a possibility of a bidirectional association for these two disorders in children and adolescents.Methods: PubMed, Embase, Web of Science, and CENTRAL databases were searched up to August 2020. Cohort studies reporting the associations of obesity with risk of physician-diagnosed asthma or physician-diagnosed asthma with risk of obesity in children and adolescents were eligible for the review.Results: A total of 3,091 records were identified from the four databases, with final inclusion of nine. Six studies reported the association between obesity and risk of asthma; three studies reported the association between asthma and risk of childhood obesity. As evaluated by the Newcastle-Ottawa quality assessment scale, all studies were assessed as high-quality studies. There was a statistically significant association between obesity and increased risk of physician-diagnosed asthma in children and adolescents. The pooled RR was 1.39 (95% CI: 1.28, 1.50; p < 0.001), with significant heterogeneity across studies (I 2 = 81.7%; p heterogeneity < 0.001). The pooled RR in boys was 1.53 (95% CI: 1.17, 1.99; p = 0.002), but such a significant association was not observed in girls (RR = 1.17, 95% CI: 0.79, 1.72; p = 0.434). For the association of asthma with risk of childhood obesity, the pooled RR was 1.47 (95%CI: 1.25, 1.72; p < 0.001) without statistical heterogeneity (I 2 = 0%, p heterogeneity = 0.652). Conclusion:There is a bidirectional association between obesity and asthma during childhood and adolescence, suggesting that childhood obesity drives an increase in the onset of asthma; meanwhile, childhood asthma may also increase risk of obesity for children and adolescents.

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Children exposed to common aeroallergens may develop asthma that progresses into adulthood. Inflammation regulated by T helper 2 (Th2) cells, a specific subpopulation of CD4+ T lymphocytes, is involved in asthmatic injury. Herein, our microarray data indicated that microRNA-451a-5p (miRNA-451a) expression decreased by 4.6-fold and ETS proto-oncogene 1 (ETS1) increased by 2.2-fold in the peripheral blood lymphocytes isolated from asthmatic children (<i>n</i> = 4) as compared to control individuals (<i>n</i> = 4). The negative correlation between miRNA-451a and ETS1 was further validated in 40 CD4+ T cell samples (10 healthy vs. 30 asthmatic samples). In vitro, naïve CD4+ T cells isolated from control individuals were cultured under Th2 cell polarizing condition. miRNA-451a expression decreased while ETS1 increased in CD4+ T cells in the setting of Th2 cell polarization. Moreover, miRNA-451a knockdown enhanced Th2 cell polarization – cells positive for both GATA3 (GATA binding protein 3, a Th2-transcription factor) and CD4 increased, and the generation of Th2 cell cytokines, interleukin (IL)5 and IL13, increased. In contrast, miRNA-451a overexpression inhibited Th2 cell differentiation. Interestingly, dual-Luciferase assay proved ETS1 as a novel target of miRNA-451a. Moreover, enforced expression of ETS1 partially restored miRNA-451a-induced inhibition of IL5 and IL13, and increased the GATA3+CD4+ cell population. Collectively, our work demonstrates that downregulation of miRNA-451a upregulates ETS1 expression in CD4+ T cells, which may contribute to Th2 cell differentiation in pediatric asthma.