FDNY Nutrition Cohort Characteristics
There were no significant demographic differences between the source cohort (N=9,508) and the study cohort (N=4,015/9,508; 42.23%) Out of the total subjects with WTC-OAD (N=921), 586 subjects (63.62%) had WTC-LI only, 197 subjects (21.39%) had AHR only, and 138 subjects (14.98%) had both WTC-LI and AHR. Within those with AHR (N=335), 126 (37.61%) had a positive bronchodilator, 175 (52.24%) had a positive methacholine, and 34 (10.15%) had both.
Subjects with WTC-OAD were more likely to be retired, member of the emergency medical services (EMS) rather than firefighter, and exposed the morning of 9/11 when compared to those who never developed WTC-OAD (p<0.001), Table 1. Of note, age at 9/11, smoking status, and race were no different in the WTC-OAD and never WTC-OAD populations, Table 1.
Table 1: Demographic and Clinical Data
|
MEASURES
|
Study
Cohort
N=4,015
|
WTC-OAD
|
p
|
Ever
N=921
|
Never
N=3,094
|
Demographics
|
Age on 9/11
|
40.55(7.40)
|
40.64(7.12)
|
40.53(7.48)
|
0.68
|
Retired at Exam
|
3077(76.60%)
|
765(83.10%)
|
2312(74.70%)
|
<0.001
|
Firefighter
|
3637(90.60%)
|
806(87.50%)
|
2831(91.50%)
|
<0.001
|
Ever Smokers
|
1291(32.20%)
|
315(34.20%)
|
976(31.50%)
|
0.13
|
Caucasian
|
3819(95.10%)
|
886(96.20%)
|
2933(94.80%)
|
0.08
|
Arrived Morning of 9/11
|
679(16.90%)
|
183(19.90%)
|
496(16%)
|
<0.001
|
1st Post-9/11
|
FEV1%Pred
|
96.92(14.02)
|
83.93(13.10)
|
100.79(11.78)
|
<0.001
|
FVC%Pred
|
92.36(12.15)
|
83.58(11.58)
|
94.88(11.09)
|
<0.001
|
BMI kg/m2
|
29.02(3.78)
|
29.59(4.16)
|
28.84(3.65)
|
<0.001
|
Systolic BP mmHg
|
117.91(14.37)
|
119.27(14.58)
|
117.51(14.28)
|
<0.001
|
Diastolic BP mmHg
|
74.15(9.26)
|
75.01(9.40)
|
73.89(9.20)
|
<0.001
|
HDL mg/dL
|
48.02(11.58)
|
47.54(11.80)
|
48.16(11.51)
|
0.20
|
LDL mg/dL
|
126.54(36.08)
|
127.08(34.65)
|
126.39(36.5)
|
0.63
|
Cholesterol(Total) mg/dL
|
208.72(43.89)
|
212.07(59.80)
|
207.73(37.84)
|
<0.001
|
Triglyceride mg/dL
|
179.91(131.57)
|
191.93(137.60)
|
176.34(129.52)
|
<0.001
|
At REAP-S
|
FEV1%Pred
|
93.01(14.33)
|
77.89(14.18)
|
97.44(10.95)
|
<0.001
|
FVC%Pred
|
91.59(12.51)
|
80.42(12.92)
|
94.86(10.31)*
|
<0.001
|
BMI kg/m2
|
30.34(4.87)
|
31.15(5.49)
|
30.09(4.65)
|
<0.001
|
Systolic BP mmHg
|
126.06(12.99)
|
127.19(13.10)
|
125.72(12.94)
|
<0.001
|
Diastolic BP mmHg
|
78.70(8.38)
|
79.28(8.10)
|
78.53(8.46)
|
0.020
|
HDL mg/dL
|
53.76(14.61)
|
53.01(14.68)
|
53.97(14.58)
|
0.18
|
LDL mg/dL
|
116.93(33.64)
|
113.76(34.16)
|
117.82(33.45)
|
0.001
|
Cholesterol(Total) mg/dL
|
194.91(39.45)
|
191.33(41.32)
|
195.91(38.86)
|
0.020
|
Triglyceride mg/dL
|
129.16(223.39)
|
135.54(80.60)
|
127.38(249.01)
|
0.46
|
All available measures are Mean (SD) or N(%).
* FVC%Pred for Never WTC-OAD comparing 1st Post-9/11 and REAP-S by Paired t-tests was not significant, all other measures were p<0.05.
p-values displayed represent comparisons between Ever / Never WTC-OAD by Student’s t-tests.
|
Clinical Measures
Time to reach WTC-OAD case definition was(mean ± SD) 6.37 ± 7.23 years for the study cohort. With the exception of triglyceride, there were similar trends of clinical measures over time in the study cohort, Table 1. WTC-OAD cases had significantly higher BMI, blood pressure, and triglycerides, and lower FEV1%Pred, FVC%Pred at 1st post 9/11 and at the time of REAP-S assessment compared to those who never developed WTC-OAD. Subjects with WTC-OAD had an elevated total cholesterol compared to those that never developed WTC-OAD at their 1st post-9/11 assessment. In contrast, at the time of the REAP-S questionnaire, those subjects with WTC-OAD had lower total cholesterol, Table 1.
REAP-S Questionnaire Responses
Length of time between initial post 9/11 assessment and REAP-S administration was (mean ± SD) 16.59 ± 0.49 years. The study cohort had a mean±SD REAP-S score of 29.46 ± 4.22. Subjects with WTC-OAD had significantly lower mean REAP-S score of 28.99 ± 4.37 compared to those who never developed WTC-OAD with 29.60 ± 4.17; p<0.01. In contrast, 50% of our study cohort often eat more than the recommended amount of meat per day (Q7), 79.30% rarely drink sugary drinks (Q13), 48.80% rarely eat processed meats (Q8), 48.50% rarely eat fried foods (Q9), and 46.40% rarely eat snacks (Q10), Table 2 (at the end of the manuscript). WTC-OAD cases had significantly higher reported consumption of processed meat (Q8) and sugary drinks (Q13), and decreased intake of grain products (Q3), vegetables (Q5), and fried foods (Q9). WTC-OAD also skipped breakfast more often (Q1), ate out more frequently (Q2), and did not feel well as often to shop or cook (Q15) (p<0.05), Table 2 (at the end of the manuscript).
Quality of Diet assessed by REAP-S
Low-dietary quality was significantly associated with 2.67 odds (95%CI[1.57,4.52]; p<0.01) of developing WTC-OAD whereas moderate-dietary quality was associated with 1.22 odds (95%CI[1.05,1.42]; p=0.01), when co mparing to high-dietary quality as a reference group, Figure 2. Increasing BMI had a small but significant protective odds ratio of 0.97(95%CI[0.95, 0.98]; p<0.01). Job description was significant, at 1.60 odds (95%CI[1.26,2.03]; p<0.01). Exposure intensity was a time-dependent risk factor, with 1.29 odds (95%CI[1.07, 1.56]; p=0.01). Age at 9/11 and smoking were not significant risk factors in this model. Overall, job description, exposure, and BMI were found to have significant odds of developing WTC-OAD, while age at 9/11 and smoking were not, Figure 2.
Dietary Quality Subgroups and Lung Function of those with low-, moderate-, or high-dietary quality are shown in Table 3. Mean FEV1%Pred and FVC1%Pred at both time points are significantly higher in those with higher dietary quality compared to those with lower dietary quality (p<0.05). FEV1/FVC ratio was not significantly associated with dietary quality at either timepoint, Table 3.
Table 3. Dietary Quality Subgroup Analysis
|
Time
|
Spirometry
|
Dietary Quality
|
p
|
Low
(N=61)
|
Moderate
(N=1894)
|
High
(N=2060)
|
1st Post-9/11
|
FEV1%Pred
|
93.57(15.34)
|
96.28(14.01)
|
97.61(13.94)
|
<0.01
|
FVC%Pred
|
90.30(13.28)
|
91.95(12.15)
|
92.81(12.09)
|
0.04
|
FEV1/FVC
|
0.83(0.05)
|
0.84(0.06)
|
0.84(0.06)
|
0.79
|
REAP-S
|
FEV1%Pred
|
86.45(19.87)
|
91.95(14.28)
|
94.12(14.08)
|
<0.001
|
FVC%Pred
|
85.82(14.86)
|
90.58(12.32)
|
92.64(12.51)
|
<0.001
|
FEV1/FVC
|
0.77(0.08)
|
0.77(0.06)
|
0.77(0.05)
|
0.46
|
All values displayed as mean(SD). p-value calculated by ANOVA.
|
Processed meat, sugary drinks, and vegetable intake Impacted the Odds of Developing WTC-OAD. Assessment of individual REAP-S questions highlighted that WTC-OAD was more likely in subjects with increased consumption of processed meats (Q8) and sugary drinks (Q13), and decreased intake of vegetables (Q5), Table 2 (at the end of the manuscript) and Figure 3. Additionally, there was a dose response seen with increasing intake of processed meats and less vegetables, OR 1.64 (95%CI[1.23,2.19] ;p=0.001) and 1.27 (95%CI[1.08,1.48] ; p=0.003); 1.53(95%CI[1.24,1.90] ; p<0.001) and 1.31(95%CI[1.12, 1.55]; p=0.001) respectively. Less whole grain consumption is also associated with higher risk of WTC-OAD (Q3), 1.26(95%CI[1.08, 1.46]; p=0.004). WTC-OAD also had trends of increased fried food intake and more often skipped breakfast, but was not significant after Bonferroni correction (p=0.006 and 0.015 respectively), Table 2 (at the end of the manuscript) and Figure 3.
Dietary habit assessment showed that not being well enough to cook, skipping breakfast, and eating out increase odds of WTC-OAD. Not feeling well enough to cook (Q15) increased odds of developing WTC-OAD by 1.91(95%CI[1.33, 2.73]; p<0.001) whereas skipping breakfast (Q1) was 1.20(95%CI[1.04, 1.40]; p=0.015). Eating out (Q2) also had odds of 1.25(95%CI[1.08, 1.45]; p=0.003), Table 2 (at the end of the manuscript).
AGE Rich Foods Confer a Higher Likelihood of Developing WTC-OAD. Using data adapted from Uribarri et al., we summarized the amount of AGE in food groups represented in REAP-S, Supplemental Figure 1.(53) Fried foods (3971.86 kU/serving), processed meats (3925.89 kU/serving), and meats (3687.58 kU/serving) were identified as having the highest AGEs per serving. Sugary foods and drinks (7.2 kU/serving) do not naturally have high level of AGEs but instead cause high levels of endogenous AGEs. Frequency of eating foods highest in AGEs, meat (Q7), processed meats (Q8), and fried foods (Q9), was assessed by logistic regression model adjusted for age, smoking, BMI, exposure, and job description. An AGE-rich exposure response gradient was identified with the odds of developing WTC-OAD: not significantly increased in participants answering usual/often consumption of one AGE-rich food group, significantly increased in participants answering usual/often consumption to any two AGE-rich food groups, 1.50(95%CI[1.14, 1.97]; p=004), and highly significant in those answering usual/often consumption to all three AGE-rich food groups, 2.31(95%CI[1.35, 3.95]; p=0.002), Figure 4.
Table 2: Nutrition Questions Incorporated into the WTC-HP Annual Questionnaire.
|
Item
|
All
|
Ever WTC-OAD
|
Never WTC-OAD
|
p
|
1.How willing are you to make changes in your eating habits in order to be healthier? *
|
1
Very Willing
|
2096(52.2)
|
473(51.4)
|
1626(62.5)
|
0.129
|
2
|
1105(27.5)
|
239(26)
|
866(28)
|
3
|
6565(16.3)
|
173(18.8)
|
483(15.6)
|
4
|
110(2.7)
|
22(2.4)
|
88(2.8)
|
5
Not at all Willing
|
49(1.2)
|
14(1.5)
|
35(1.1)
|
2. Are you willing to answer 15 questions about your diet? **
|
Yes
|
4015 (100)
|
-
|
-
|
-
|
* This is the 16th REAP-S question.
** If participant answers “Yes”, the participant will be prompted to answer the 15 questions from REAP-S
|
In an average week, how often do you:
|
|
|
|
|
1. Skip breakfast?
|
Usually/Often (1)
|
839(20.9)
|
215(23.3)
|
624(20.2)
|
0.030
|
Sometimes (2)
|
1180(29.4)
|
281(30.5)
|
899(29.1)
|
Rarely/Never (3)
|
1996(49.7)
|
425(46.1)
|
1571(50.8)
|
2. Eat 4 or more meals from sit-down or take out restaurants?
|
Usually/Often (1)
|
532(13.3)
|
135(14.5)
|
398(12.9)
|
0.016
|
Sometimes (2)
|
1182(29.4)
|
297(32.3)
|
885(28.6)
|
Rarely/Never (3)
|
2301(57.3)
|
490(53.2)
|
1811(58.5)
|
3. Eat less than 2 servings of whole grain products or high fiber starches a day? Serving = 1 slice of 100% whole grain bread; 1 cup whole grain cereal like Shredded Wheat, Wheaties, Grape Nuts, high fiber cereals, oatmeal, 3-4 whole grain crackers, ½ cup brown rice or whole wheat pasta, boiled or baked potatoes, yuca, yams or plantain.
|
Usually/Often (1)
|
74418.5)
|
176(19.1)
|
568(18.4)
|
0.016
|
Sometimes (2)
|
1624(40.4)
|
404(43.9)
|
1220(39.4)
|
Rarely/Never (3)
|
1647(41)
|
341(37)
|
1306(42.2)
|
4. Eat less than 2 servings of fruit a day? Serving = ½ cup or 1 med. fruit or ¾ cup 100% fruit juice.
|
Usually/Often (1)
|
1016(25.3)
|
246(26.7)
|
770(24.9)
|
0.191
|
Sometimes (2)
|
1682(41.9)
|
395(42.9)
|
1287(41.6)
|
Rarely/Never (3)
|
1317(32.8)
|
280(30.4)
|
1037(33.5)
|
5. Eat less than 2 servings of vegetables a day? Serving = ½ cup vegetables, or 1 cup leafy raw vegetables.
|
Usually/Often (1)
|
618(15.4)
|
169(18.3)
|
449(14.5)
|
<0.001
|
Sometimes (2)
|
1603(39.9)
|
394(42.8)
|
1209(39.1)
|
Rarely/Never (3)
|
1794(44.7)
|
358(38.9)
|
1436(46.4)
|
6. Eat or drink less than 2 servings of milk, yogurt, or cheese a day? Serving = 1 cup milk or yogurt; 1½ - 2 ounces cheese.
|
Usually/Often (1)
|
826(20.6)
|
209(22.7)
|
617(19.9)
|
0.125
|
Sometimes (2)
|
1491(37.1)
|
344(37.4)
|
1147(37.1)
|
Rarely/Never (3)
|
1698(42.3)
|
368(40)
|
1330(43)
|
7. Eat more than 8 ounces (see sizes below) of meat, chicken, turkey or fish per day? Note: 3 ounces of meat or chicken is the size of a deck of cards or ONE of the following: 1 regular hamburger, 1 chicken breast or leg (thigh and drumstick), or 1 pork chop.
|
Usually/Often (1)
|
2008(50)
|
468(50.8)
|
1540(49.8)
|
0.705
|
Sometimes (2)
|
1450(36.1)
|
322(35)
|
1128(36.5)
|
Rarely/Never or Rarely eat meat, chicken, turkey or fish (3)
|
557(13.9)
|
131(14.2)
|
426(13.8)
|
8. Use regular processed meats (like bologna, salami, corned beef, hotdogs, sausage or bacon) instead of low fat processed meats (like roast beef, turkey, lean ham; low-fat cold cuts/hotdogs)?
|
Usually/Often (1)
|
271(6.7)
|
80(8.7)
|
191(6.2)
|
0.001
|
Sometimes (2)
|
1784(44.4)
|
432(46.9)
|
1352(43.7)
|
Rarely/Never or Rarely(3)
|
1960(48.8)
|
409(44.4)
|
1551(50.1)
|
9. Eat fried foods such as fried chicken, fried fish, French fries, fried plantains, tostones or fried yuca?
|
Usually/Often (1)
|
174(4.3)
|
54(5.9)
|
120(3.9)
|
0.024
|
Sometimes (2)
|
1895(47.2)
|
417(45.3)
|
1478(47.8)
|
Rarely/Never (3)
|
1946(48.5)
|
450(48.9)
|
1496(48.4)
|
10. Eat regular potato chips, nacho chips, corn chips, crackers, regular popcorn, nuts instead of pretzels, low-fat chips or lowfat crackers, air-popped popcorn?
|
Usually/Often (1)
|
338(8.4)
|
79(8.6)
|
259(8.4)
|
0.111
|
Sometimes (2)
|
181545.2)
|
389(42.2)
|
1426(46.1)
|
Rarely/Never or Rarely eat these snack foods (3)
|
1862(46.4)
|
453(49.2)
|
1409(45.5)
|
11. Add butter, margarine or oil to bread, potatoes, rice or vegetables at the table?
|
Usually/Often (1)
|
1059(26.4)
|
252(27.4)
|
807(26.1)
|
0.290
|
Sometimes (2)
|
1619(40.3)
|
382(41.5)
|
1237(40)
|
Rarely/Never (3)
|
1337(33.3)
|
287(31.2)
|
1050(33.9)
|
12. Eat sweets like cake, cookies, pastries, donuts, muffins, chocolate and candies more than 2 times per day.
|
Usually/Often (1)
|
678(16.9)
|
165(17.9)
|
513(16.6)
|
0.432
|
Sometimes (2)
|
1676(41.7)
|
369(40.1)
|
1307(42.2)
|
Rarely/Never (3)
|
1661(41.4)
|
387(42)
|
1274(41.2)
|
13. Drink 16 ounces or more of non-diet soda, fruit drink/punch or Kool-Aid a day? Note: 1 can of soda = 12 ounces
|
Usually/Often (1)
|
259(6.5)
|
72(7.8)
|
187(6)
|
0.001
|
Sometimes (2)
|
573(14.3)
|
159(17.3)
|
414(13.4)
|
Rarely/Never (3)
|
3183(79.3)
|
690(74.9)
|
2493(80.6)
|
14. You or a member of your family usually shops and cooks rather than eating sit-down or take-out restaurant food?
|
Yes
|
3673(91.5)
|
831(90.2)
|
2842(91.9)
|
0.120
|
15. Usually feel well enough to shop or cook.
|
Yes
|
3876(96.5)
|
872(94.7)
|
3004(97.1)
|
<0.001
|
Values represented by N (%); x2 was done for comparison between Ever WTC-OAD and Never WTC-OAD. Significant values reported if p<0.05.
|