Dietary Phenotype and Advanced Glycation End-Products Predict WTC-Obstructive Airways Disease: a Longitudinal Observational Study

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Diet is a modifier of metabolic syndrome which in turn is associated with World Trade Center Obstructive Airways Disease(WTC-OAD). We have designed this study to 1. assess the dietary phenotype(food types, physical activity, and dietary habits) of the Fire Department of New York(FDNY) WTC-Health Program(WTC-HP) cohort and 2. quantify the association of dietary quality and its advanced glycation end product(AGE) content with the development of WTC-OAD. METHODS. WTC-OAD, defined as developing WTC-Lung Injury(WTC-LI;FEV 1 <LLN) and/or airway hyperreactivity(AHR;positive methacholine and/or positive bronchodilator response). Rapid Eating and Activity Assessment for Participants-Short Version(REAP-S) deployed on 3/1/2018 in the WTC-HP annual monitoring assessment. Clinical and REAP-S data of consented subjects was extracted(7/17/2019). Diet quality[low-(15-19), moderate-(20-29), and high-(30-39)] and AGE content per REAP-S questionnaire were assessed for association with WTC-OAD. Regression models adjusted for smoking,hyperglycemia,hypertension,age on 9/11,WTC-exposure,BMI and job description. RESULTS. N=9,508 completed the annual questionnaire, while N=4,015 completed REAP-S and had spirometry. WTC-OAD developed in N=921, while N=3,094 never developed WTC-OAD. Low- and moderate-dietary quality, eating more (processed meats,fried foods,sugary drinks), fewer(vegetables,whole-grains),and having a diet abundant in AGEs were significantly associated with WTC-OAD. Smoking was not a significant risk factor of WTC-OAD. CONCLUSIONS. REAP-S was successfully implemented in the FDNY WTC-HP monitoring questionnaire and produced valuable dietary phenotyping. Our observational study has identified low dietary quality and AGE abundant dietary habits as risk factors for pulmonary disease in the context of WTC-exposure. Dietary phenotyping, not only focuses our metabolomic/biomarker profiling but also further informs future dietary interventions that may positively impact particulate matter associated lung disease. Nutrition & Dietetics Pulmonology metabolic syndrome nutrition diet Figures Figure 1 Figure 2 Figure 3 Figure 4 Background Diet and obesity play a role in the development of obstructive airways disease (OAD).(1-3) Diets focused on reducing inflammation and increasing vegetable and fish consumption reduced the risk of chronic obstructive pulmonary disease (COPD), whereas diets with increased pro-inflammatory advanced glycation end products (AGE) were associated with disease.(4-7) Low-calorie dietary interventions yielded weight loss and improved lung function in obese asthmatics.(8) The health benefits of weight loss, increased high density lipoprotein (HDL), and decreased triglyceride, have been extensively studied.(9-11) Specifically, Mediterranean diets characterized by high consumption of fruits, vegetables, and fish, were associated with lower COPD, whereas, western diets were significantly associated with higher risk of newly diagnosed COPD.(12-16) Metabolic syndrome (MetSyn) is a risk factor of cardiovascular, lung disease, and World Trade Center-OAD (WTC-OAD).(15, 16) MetSyn affects over 30% of US adults and 23% of participants in the Fire Department of New York (FDNY) WTC-Health Program (WTC-HP) program.(12-19) Furthermore, metabolic biomarkers, elevated BMI, and a >2 kg/m 2 BMI increase predicted WTC-OAD.(20-24) Since high-caloric diets are key contributors to MetSyn, nutritional interventions to potentially reverse pulmonary dysfunction have been studied.(14-16) Our in vitro and in vivo models identified that the receptor for AGE(RAGE) is associated with lung dysfunction after WTC-particulate matter (WTC-PM) exposure. Specifically, RAGE deficient WTC-PM exposed mice were protected against WTC-OAD.(25-27) Dietary and endogenous AGEs can impact signaling pathways such those in inflammatory diseases.(28) Despite evidence that diet and obesity are risks, studies have suggested obesity may have a protective effect on survival and lung function in COPD.(29, 30) Therefore, to further clarify the effect of diet on lung disease in our WTC-exposed cohort, we studied their dietary patterns. The Rapid Eating and Activity Assessment for Patients (REAP) and its short version (REAP-S) are advantageous over other independently developed and validated food questionnaires in the primary care setting because of their brevity and ability to quickly evaluate targeted food categories, potential barriers to high dietary quality, and dietary habits.(31-44) REAP-S score has also correlated with other questionnaires investigating OAD. (45-49) To inform our understanding of how diet is a modifier of WTC-OAD, we utilized REAP-S to assess dietary quality and estimate intake of foods such as fat, cholesterol, sugar, and meats and correlated it to disease outcome.(31, 44, 48-50) This study also prospectively evaluated potential barriers to high dietary quality, dietary habits, and food group stratification for AGE content. We hypothesized that WTC-exposed first responders with poor dietary quality and increased AGE content were more likely to have WTC-OAD at any timepoint after 9/11/2001 (9/11). Methods Study Design. This observational study targeted N=14,976 WTC-HP enrollees that had annual monitoring exams, including physical health and mental health questionnaires, Figure 1 . REAP-S was implemented in the annual questionnaire on March 1, 2018 and continuously accrued until July 17, 2019. Two questions were used to gauge interest in answering the REAP-S and screen for willingness to change diet, Supplemental Table 1 . Source cohort (N=9,508) completed a annual health questionnaire and consented to further physical health research. Subjects were further screened for the study cohort (N=4,015) if they met the following criteria: i. completed REAP-S ii. had reliable National Health and Nutrition Examination Survey (NHANES) and had iii. complete clinical data. Demographic characteristics, clinical data, 9/11 exposure characteristics, questionnaire answers, and lung function testing were obtained from the FDNY WTC-HP electronic medical record (EMR). Study approved by the Montefiore Medical Center/Albert Einstein College of Medicine IRB #07-09-320. WTC-OAD Case Definitions. Cases of WTC-OAD had either WTC-Lung Injury (WTC-LI; FEV 1 <LLN) and/or Airway Hyperresponsiveness (AHR;positive methacholine or positive bronchodilator testing) at any time point post-9/11 (N=921).(22-25, 51-67) Cases of WTC-OAD were compared to N=3,094 without WTC-OAD at any time after 9/11. Our group has utilized FEV 1 to define WTC-LI.(21-24, 54, 55, 62, 64, 65, 68-70) FEV 1 was measured prior to 9/11/2001 and is still performed at every FDNY-HP visit. This gives a comprehensive measure of changing lung function over time. Using abnormal FEV 1 as an outcome improves generalizability of our findings since it is a readily available measure that doesn’t require costly instrumentation. A vast majority of the WTC cohort had airflow obstruction.(52) Deterioration of FEV 1 <LLN is a robust disease definition, correlates with mortality and somewhat with OAD outcomes (severity leading to hospitalizations, exercise ability and measures of quality of life measures).(71-78) Using FEV 1 as single measure of lung function could lead to non-differential misclassification. Since FEV 1 is reduced in both restriction and obstruction FEV 1 <LLN does not distinguish between the two. In spite of the potential for non-differential information bias, using FEV 1 <LLN has yielded strong biomarkers-disease associations.(79, 80) Therefore, FEV 1 <LLN is a surrogate for obstruction in WTC exposed firefighters and was how we defined World Trade Center-Lung Injury (WTC-LI).(52, 81, 82) Nutritional Assessment. REAP-S was scored and summed as per guidelines, Table 2 and Supplemental Table 1 .(44) REAP-S scores can range from 15-39, and higher quantities represent dietary quality characterized by optimal intake of fruits, vegetables, and whole grains and decreased intake of sugary foods, processed meats, and fried foods. Scores were categorized into low-dietary (15-19), moderate-dietary (20-29), and high-dietary (30-39) quality, Table 3 . Additionally, REAP-S questions were assessed as distinct food categories. AGE Quantification (kU/serving) in food groups represented in REAP-S was compiled to a representative value per food group, Supplemental Figure 2 .(83) Statistics. Primary data storage/analyses performed with SPSS 25(IBM) and Prism 8 (Graphpad). Mean ± standard deviation (SD) expressed as continuous variables. Paired sample t-tests compared clinical parameters at two time points – first measurement post-9/11 and at REAP-S administration; student t-tests compared clinical data of those with WTC-OAD to those who never developed WTC-OAD. One-way ANOVA was used in a subgroup analysis of lung function and dietary quality. Counts and percentages describe categorical variables and compared groups using c 2 -test. Arrival time and smoking was self-reported and collected through the annual questionnaires/EMR. Arrival time data, used as a proxy for WTC-particulate matter(WTC-PM) exposure, was categorized into a dichotomous variable of “arrived at the site in the morning of 9/11” or “anytime thereafter”.(84) Smoking data was dichotomous representing ever or never smokers.(52, 62, 69, 81, 82, 85-90) Modeling Using Multivariable logistic regression estimated association of AGE abundancy, REAP-S scores, and the development of WTC-OAD. All models were adjusted for smoking, age at September 11, 2001, exposure intensity, BMI, and job description. We assumed that dietary habits remain relatively constant over time.(91-93) Models of WTC-OAD using components of REAP-S were corrected for multiple comparisons by Bonferroni, p<0.005. For all else, p was significant if <0.05 and omnibus testing assessed variance of data. Results 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 . Clinical Measures. Time to reach WTC-OAD case definition was(mean ± SD) 6.37 ± 7.23 years for the study cohort. For both ever WTC-OAD cases and never WTC-OAD subjects, BMI, blood pressure, and HDL were found to be significantly higher at time of REAP-S compared to immediately post-9/11, Table 1 . Similarly, their FEV 1%Pred , HDL, LDL, total cholesterol, and triglycerides were significantly lower at time of REAP-S, and FVC %Pred was not significantly different. WTC-OAD cases had significantly higher BMI, blood pressure, and triglycerides, and lower FEV 1%Pred , FVC %Pred at 1 st 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 1 st 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 . 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 . 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 comparing 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 FEV 1%Pred and FVC 1%Pred at both time points are significantly higher in those with higher dietary quality compared to those with lower dietary quality (p<0.05). FEV 1 /FVC ratio was not significantly associated with dietary quality at either timepoint, Table 3 . 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 and Figure 3 . Additionally, there was a dose response seen with increasing intake of processed meats (OR 1.64 (95%CI[1.23,2.19] ;p=0.001) and 1.27 (95%CI[1.08,1.48] ; p=0.003)) and less vegetables (OR 1.53(95%CI[1.24,1.90] ; p<0.001) and 1.31(95%CI[1.12, 1.55]; p=0.001)). 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 subjects trended towards increased fried food intake but these measures were not significant after Bonferroni correction (p=0.006), Table 2 and Figure 3. Dietary habit assessment showed that n ot 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 . 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 .(83) 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=0.04), 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 . Discussion This observational, prospective study of dietary phenotyping was successfully implemented at the FDNY WTC-HP annual monitoring exam. Dietary quality was correlated to FEV 1 and FVC even immediately after 9/11, and persisted at REAP-S. Since we assume that diet is constant throughout adult life, this could be due to the combined effect of dietary quality and WTC exposure. This is supported by our findings in which more frequent consumption of sugary drinks, processed meats, and decreased intake of vegetables and whole grains were identified as key components in development of WTC-OAD. Subjects with AGE-rich diets were also significantly more likely to develop WTC-OAD. Our findings parallel prior studies that have displayed the harmful role of processed meats in the increased risk of developing COPD due to its high level of pro-inflammatory AGE levels.(94-97) AGE formation via glycoxidation is promoted by the high temperatures and low moisture environments utilized in cooking meat, processed meat products, and fried foods.(83, 98-100) Associations with certain food groups are important because high levels of AGEs are linked to pathogenic effects, including the ability to promote high levels of oxidative stress and inflammation.(83, 99) Although sugary drinks are relatively low in AGEs, they are a prominent source of high fructose corn syrup.(28) The fructose can indirectly increase AGE intake because of its formation and accumulation of endogenous AGEs.(28) This could be a reason as to why sugary drinks have been associated with bronchitis and asthma in children, and increase likelihood of WTC-OAD.(101, 102) In contrast, carbohydrates and whole grains contain less AGE.(83, 100) Similar to our results, other studies have found that increased whole grain intake, part of a prudent dietary pattern, were associated with a reduced risk of developing COPD.(13) Moreover, it was positively associated with FEV 1 and negatively associated with COPD symptoms.(103) Although we showed that low intake of vegetables increased odds of developing WTC-OAD, there was no significant association found with fruit intake. While our results resonated with some studies on low intake of fruits and vegetables, others advocated for increased fruit intake, or found no difference in COPD.(83, 104-109) Although fruits and vegetables are relatively low in AGEs, they could confer antioxidant benefit and lower inflammation in diseases such as COPD. A randomized control trial focused on increased antioxidant intake through fruits and vegetables found that it could even help regain FEV 1 in COPD patients.(107) In contrast to our prior work, increasing BMI had a 3.6% decreased likelihood of developing WTC-OAD. One reason for this difference could be that while our prior work focused firefighters, we now also investigate EMS 1 st responders. Prior studies have shown that the firefighter and EMS cohort express different patterns of lung function decline, even after adjusting for BMI.(18) This expanded cohort potentially reflects concordance with studies showing obesity’s protective effect against mortality in COPD patients.(110, 111) This could also be a result of a healthy worker effect and the imperfect utilization of BMI to define obesity in firefighters with rigorous physical job requirements.(112) In addition, we optimized our model by adjusting for confounding of WTC-OAD cases by using BMI at the time of diagnosis, whereas for subjects that never developed WTC-OAD, BMI at REAP-S was used. Nevertheless, the results of the final model did not change significantly even when we also assessed the effects of BMI at the same time point (1 st post 9/11 and at REAP-S respectively). Moroever, we found that triglycerides decreased from post 9/11 to REAP-S. This could be an effect of the close monitoring that these patients received and/or other confounder such as triglyceride-lowering medications such as statin therapy in as per 2018 American Heart Association/American College of Cardiology guidelines.(113) Future studies could help differentiate the paradoxical effect of obesity vs. the healthy worker phenomena. There are several limitations to our investigation. Dietary habits and exposure are subject to self-reporting bias. Bias assessment has been performed on the FDNY WTC cohort, and found that self-reported asthma and exposure were consistent across several studies, and that significant findings were minimally affected by potential bias.(114) Thus, extension of the reliability of this data to our study is reasonable. We also assume that dietary habits remain relatively constant throughout a person’s adult life, an assumption supported by several large studies.(91, 115, 116) Additionally, REAP-S is a brief dietary instrument that limits our ability to differentiate subtypes of food consumed. Protein intake does not differentiate between beans, poultry, or red meat. Firefighters had pre-employment physical health assessments to ensure that they did not have pre-existing OAD, the pulmonary function for EMS prior to 9/11 was also assessed but these 1 st responders are not subject to the same standards. Therefore, our results are limited to correlation of dietary quality and OAD. Another possible limitation is that WTC-OAD subjects were more likely to be retired compared to those who never developed WTC-OAD. We also identified that not being well enough to shop and cook and frequent eating out had strong associations with WTC-OAD. Since this was assessed at a later time point, it is unclear if this reflects the burden of concurrent WTC-OAD. One study has found that physical factors with COPD patients such as being too tired to cook resulted in the shift in eating meals that have been easily prepared.(117) However, this is an important finding that highlights a potential barrier to access to healthier diets in this population. The limiting lifestyle imposed by WTC-OAD could further perpetuate an unforgiving cycle of lower dietary quality and worsening disease. This study identifies risk factors of worsening OAD, and demonstrates the potential for intervention. Further research is needed to determine if implementation of a diet focused on decreasing AGE-rich foods, increasing antioxidant intake, and targeting weight loss could prevent the development of WTC-OAD or in those with WTC-OAD, reverse or slow its progression. Our ongoing randomized clinical trial, the F ood I ntake Re striction for H ealth Ou tcome S upport and E ducation (FIREHOUSE) Trial , aims to assess the effects of technology-assisted social cognitive behavioral therapy and a low-caloric Mediterranean diet on the progression of WTC-LI. In summary, this observational study successfully used REAP-S to identify both low-dietary quality and AGE abundant foods as predictive of developing lung disease in this WTC-exposed population. Our findings indicate the potential impact of future research using dietary interventions not just in the FDNY WTC-HP, but also in other OAD cohorts, with or without WTC-exposure. Abbreviation List AGE Advanced Glycation End-products AHR Airway Hyperreactivity BMI Body Mass Index CI Confidence Interval DBP Diastolic blood pressure EMS Emergency Medical Services FDNY Fire Department of the City of New York FEV 1 Forced expiratory volume over 1 second FFQ Food Frequency Questionnaire FVC Forced Vital Capacity HDL High Density Lipoprotein HR Hazards Ratio LDL Low Density Lipoprotein LLN Lower Limit of Normal MetSyn Metabolic syndrome NHANES National Health and Nutrition Examination Survey OR Odds Ratio PFT Pulmonary function test PM Particulate matter PUFA Polyunsaturated fatty acids REAP-S Rapid Eating and Activity Assessment for Patients-Short Version SBP Systolic blood pressure SD Standard Deviation US United States WTC World Trade Center WTC-HP WTC-Health Program WTC-LI WTC-Lung Injury WTC-OAD WTC-Obstructive Airways Disease WTC-PM WTC-Particulate Matter Declarations Ethics approval and consent to participate Availability of data and materials Competing interests The authors report no conflicts of interest. Funding Sources: NHLBI R01HL119326, CDC/NIOSH U01-OH11300, Clinical Center of Excellence 200-2017-93426, Data Center 200-2017-93326 Author Contributions: RL, AN and SK participated in study conception and design; AN was the primary investigator and guarantor of the paper; RL, AN, SK, HC, AH, TS, RZO and DJP were responsible for data collection; AN and SK were responsible for data validation; RL, AN, SK, and GC participated in data analysis; AN, GC, ML, and SK undertook the statistical analysis. All authors participated in data interpretation, writing, and revision of the report and approval of the final version. References Hanson C, Rutten EP, Wouters EF, Rennard S. Influence of diet and obesity on COPD development and outcomes. Int J Chron Obstruct Pulmon Dis. 2014;9:723-33. Wood LG. Diet, Obesity, and Asthma. Ann Am Thorac Soc. 2017;14(Supplement_5):S332-S8. Napier CO, Mbadugha O, Bienenfeld LA, Doucette JT, Lucchini R, Luna-Sanchez S, et al. 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Tables 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 1 st Post-9/11 FEV 1%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/m 2 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 FEV 1%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/m 2 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 1 st 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. 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 16 th 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 (%); x 2 was done for comparison between Ever WTC-OAD and Never WTC-OAD. Significant values reported if p<0.05. Table 3. Dietary Quality Subgroup Analysis Time Spirometry Dietary Quality p Low (N=61) Moderate (N=1894) High (N=2060) 1 st Post-9/11 FEV 1%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 FEV 1 /FVC 0.83(0.05) 0.84(0.06) 0.84(0.06) 0.79 REAP-S FEV 1%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 FEV 1 /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. Supplementary Files SupplementalTable1.pptx Supplemental Table-1. Full Nutrition Questions. All of the nutrition questions that were incorporated into the WTC-HP annual questionnaire. SupplementalFigure1.pptx Supplemental Figure-1. Assessment of AGEs in REAP-S Food Groups. REAP-S identified food groups (fried foods, processed meats, and meats) that have the highest amounts of AGE (kU/serving) adapted from Uribarri J, et al. (83) Cite Share Download PDF Status: Published Journal Publication published 18 Jan, 2021 Read the published version in Respiratory Research → Version 2 posted Editorial decision: Accept 01 Dec, 2020 Review # 1 received at journal 26 Nov, 2020 Reviewer # 1 agreed at journal 25 Nov, 2020 Reviewers invited by journal 23 Nov, 2020 Editor assigned by journal 22 Nov, 2020 Submission checks completed at journal 22 Nov, 2020 Editor invited by journal 22 Nov, 2020 You are reading this latest preprint version Show more versions Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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FDNY Rescue/recovery Workers Exposed to World Trade Center Particulates. ","description":"","filename":"Figure1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-40956/v2/64d5d41b4d362ec8b88791b3.jpg"},{"id":4030719,"identity":"d2adb56f-d609-4370-97df-1650a0e5858f","added_by":"auto","created_at":"2020-12-04 21:25:12","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":34151,"visible":true,"origin":"","legend":"REAP-S Score Modeling of Associated WTC-OAD. Low nutrition is a significant risk factor of developing WTC-OAD. The model was adjusted for age on 9/11, ever smoking, BMI post 9/11, exposure intensity, and job description. ","description":"","filename":"Figure2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-40956/v2/71aab60c6fd467b23c922c5d.jpg"},{"id":4030721,"identity":"64dcb1eb-a55e-4228-9871-c4fbc8585cce","added_by":"auto","created_at":"2020-12-04 21:25:12","extension":"jpg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":72423,"visible":true,"origin":"","legend":" Food Groups Modeling of Associated WTC-OAD. Food groups represented by its corresponding REAP-S questions identified consumption of less vegetables, more processed meats, and some sugary drinks as significant risk factors. The model was adjusted for age on 9/11, ever smoking, BMI post 9/11, exposure intensity, and job description. *Not significant under Bonferroni correction of p\u003c0.005, but significant for p\u003c0.05. ","description":"","filename":"Figure3.jpg","url":"https://assets-eu.researchsquare.com/files/rs-40956/v2/09344ea3e1a9f992464edf73.jpg"},{"id":4030722,"identity":"550caacf-0f57-4a3d-ac68-1f5937e3e9d3","added_by":"auto","created_at":"2020-12-04 21:25:12","extension":"jpg","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":24047,"visible":true,"origin":"","legend":" AGEs and their Association with WTC-OAD. Forest plot of AGE in dietary habit represented by frequency of “usually/often” answers to questions on foods high in AGE (fried foods, processed meats, meats). Having a higher dietary habit of AGE is significantly associated with risk of WTC-OAD.","description":"","filename":"Figure4.jpg","url":"https://assets-eu.researchsquare.com/files/rs-40956/v2/395f46de1f5ee5d406dd4818.jpg"},{"id":13623953,"identity":"a40fe607-947c-41b5-88d7-7f7a326a49a9","added_by":"auto","created_at":"2021-09-17 07:20:35","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1356044,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-40956/v2/c470b176-8e04-4f22-bd5c-5f6a342a5cff.pdf"},{"id":4030718,"identity":"2a632c8a-6f3f-402f-9c59-7da5a194a22a","added_by":"auto","created_at":"2020-12-04 21:25:12","extension":"pptx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":44215,"visible":true,"origin":"","legend":"Supplemental Table-1. Full Nutrition Questions. All of the nutrition questions that were incorporated into the WTC-HP annual questionnaire.","description":"","filename":"SupplementalTable1.pptx","url":"https://assets-eu.researchsquare.com/files/rs-40956/v2/2c597f5b57d3b67a602de624.pptx"},{"id":4030720,"identity":"fc4345e8-97b1-49b5-b5c6-e5c4aabf1fc3","added_by":"auto","created_at":"2020-12-04 21:25:12","extension":"pptx","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":60855,"visible":true,"origin":"","legend":"Supplemental Figure-1. Assessment of AGEs in REAP-S Food Groups. REAP-S identified food groups (fried foods, processed meats, and meats) that have the highest amounts of AGE (kU/serving) adapted from Uribarri J, et al. (83)","description":"","filename":"SupplementalFigure1.pptx","url":"https://assets-eu.researchsquare.com/files/rs-40956/v2/9f626de383a01c1f2289087c.pptx"}],"financialInterests":"","formattedTitle":"Dietary Phenotype and Advanced Glycation End-Products Predict WTC-Obstructive Airways Disease: a Longitudinal Observational Study","fulltext":[{"header":"Background","content":"\u003cp\u003eDiet and obesity play a role in the development of obstructive airways disease (OAD).(1-3) Diets focused on reducing inflammation and increasing vegetable and fish consumption reduced the risk of chronic obstructive pulmonary disease (COPD), whereas diets with increased pro-inflammatory advanced glycation end products (AGE) were associated with disease.(4-7) Low-calorie dietary interventions yielded weight loss and improved lung function in obese asthmatics.(8) The health benefits of weight loss, increased high density lipoprotein (HDL), and decreased triglyceride, have been extensively studied.(9-11) Specifically, Mediterranean diets characterized by high consumption of fruits, vegetables, and fish, were associated with lower COPD, whereas, western diets were significantly associated with higher risk of newly diagnosed COPD.(12-16)\u003c/p\u003e\n\u003cp\u003eMetabolic syndrome (MetSyn) is a risk factor of cardiovascular, lung disease, and World Trade Center-OAD (WTC-OAD).(15, 16) MetSyn affects over 30% of US adults and 23% of participants in the Fire Department of New York (FDNY) WTC-Health Program (WTC-HP) program.(12-19) Furthermore, metabolic biomarkers, elevated BMI, and a \u0026gt;2 kg/m\u003csup\u003e2 \u003c/sup\u003e\u0026nbsp;BMI increase predicted WTC-OAD.(20-24)\u003c/p\u003e\n\u003cp\u003eSince high-caloric diets are key contributors to MetSyn, nutritional interventions to potentially reverse pulmonary dysfunction have been studied.(14-16) Our \u003cem\u003ein vitro\u003c/em\u003e and \u003cem\u003ein vivo\u003c/em\u003e models identified that the receptor for AGE(RAGE) is associated with lung dysfunction after WTC-particulate matter (WTC-PM) exposure. Specifically, RAGE deficient WTC-PM exposed mice were protected against WTC-OAD.(25-27) Dietary and endogenous AGEs can impact signaling pathways such those in inflammatory diseases.(28) Despite evidence that diet and obesity are risks, studies have suggested obesity may have a protective effect on survival and lung function in COPD.(29, 30) Therefore, to further clarify the effect of diet on lung disease in our WTC-exposed cohort, we studied their dietary patterns.\u003c/p\u003e\n\u003cp\u003eThe Rapid Eating and Activity Assessment for Patients (REAP) and its short version (REAP-S) are advantageous over other independently developed and validated food questionnaires in the primary care setting because of their brevity and ability to quickly evaluate targeted food categories, potential barriers to high dietary quality, and dietary habits.(31-44) REAP-S score has also correlated with other questionnaires investigating OAD. (45-49)\u003c/p\u003e\n\u003cp\u003eTo inform our understanding of how diet is a modifier of WTC-OAD, we utilized REAP-S to assess dietary quality and estimate intake of foods such as fat, cholesterol, sugar, and meats and correlated it to disease outcome.(31, 44, 48-50) This study also prospectively evaluated potential barriers to high dietary quality, dietary habits, and food group stratification for AGE content. We hypothesized that WTC-exposed first responders with poor dietary quality and increased AGE content were more likely to have WTC-OAD at any timepoint after 9/11/2001 (9/11).\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003e\u003cstrong\u003eStudy Design. \u003c/strong\u003eThis observational study targeted N=14,976 WTC-HP enrollees that had annual monitoring exams, including physical health and mental health questionnaires, \u003cstrong\u003eFigure 1\u003c/strong\u003e. REAP-S was implemented in the annual questionnaire on March 1, 2018 and continuously accrued until July 17, 2019. Two questions were used to gauge interest in answering the REAP-S and screen for willingness to change diet, \u003cstrong\u003eSupplemental Table 1\u003c/strong\u003e.\u003c/p\u003e\n\u003cp\u003eSource cohort (N=9,508) completed a annual health questionnaire and consented to further physical health research. Subjects were further screened for the study cohort (N=4,015) if they met the following criteria: i. completed REAP-S ii. had reliable National Health and Nutrition Examination Survey (NHANES) and had iii. complete clinical data. Demographic characteristics, clinical data, 9/11 exposure characteristics, questionnaire answers, and lung function testing were obtained from the FDNY WTC-HP electronic medical record (EMR). Study approved by the Montefiore Medical Center/Albert Einstein College of Medicine IRB #07-09-320.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eWTC-OAD Case Definitions. \u003c/strong\u003eCases of WTC-OAD had either WTC-Lung Injury (WTC-LI; FEV\u003csub\u003e1\u003c/sub\u003e\u0026lt;LLN) and/or Airway Hyperresponsiveness (AHR;positive methacholine or positive bronchodilator testing) at any time point post-9/11 (N=921).(22-25, 51-67) Cases of WTC-OAD were compared to N=3,094 without WTC-OAD at any time after 9/11.\u003c/p\u003e\n\u003cp\u003eOur group has utilized FEV\u003csub\u003e1\u003c/sub\u003e to define WTC-LI.(21-24, 54, 55, 62, 64, 65, 68-70) FEV\u003csub\u003e1\u003c/sub\u003e was measured prior to 9/11/2001 and is still performed at every FDNY-HP visit. This gives a comprehensive measure of changing lung function over time. Using abnormal FEV\u003csub\u003e1\u003c/sub\u003e as an outcome improves generalizability of our findings since it is a readily available measure that doesn\u0026rsquo;t require costly instrumentation. A vast majority of the WTC cohort had airflow obstruction.(52) Deterioration of FEV\u003csub\u003e1\u003c/sub\u003e\u0026lt;LLN is a robust disease definition, correlates with mortality and somewhat with OAD outcomes (severity leading to hospitalizations, exercise ability and measures of quality of life measures).(71-78) Using FEV\u003csub\u003e1\u003c/sub\u003e as single measure of lung function could lead to non-differential misclassification. Since FEV\u003csub\u003e1\u003c/sub\u003e is reduced in both restriction and obstruction FEV\u003csub\u003e1\u003c/sub\u003e\u0026lt;LLN does not distinguish between the two. In spite of the potential for non-differential information bias, using FEV\u003csub\u003e1\u003c/sub\u003e\u0026lt;LLN has yielded strong biomarkers-disease associations.(79, 80) Therefore, FEV\u003csub\u003e1\u003c/sub\u003e\u0026lt;LLN is a surrogate for obstruction in WTC exposed firefighters and was how we defined World Trade Center-Lung Injury (WTC-LI).(52, 81, 82)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eNutritional Assessment. \u003c/strong\u003eREAP-S was scored and summed as per guidelines, \u003cstrong\u003eTable 2 \u003c/strong\u003eand \u003cstrong\u003eSupplemental Table 1\u003c/strong\u003e.(44) REAP-S scores can range from 15-39, and higher quantities represent dietary quality characterized by optimal intake of fruits, vegetables, and whole grains and decreased intake of sugary foods, processed meats, and fried foods. Scores were categorized into \u003cu\u003elow-dietary\u003c/u\u003e (15-19), \u003cu\u003emoderate-dietary\u003c/u\u003e (20-29), and \u003cu\u003ehigh-dietary\u003c/u\u003e (30-39) quality, \u003cstrong\u003eTable 3\u003c/strong\u003e. Additionally, REAP-S questions were assessed as distinct food categories.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAGE Quantification \u003c/strong\u003e(kU/serving) in food groups represented in REAP-S was compiled to a representative value per food group, \u003cstrong\u003eSupplemental Figure 2\u003c/strong\u003e.(83)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStatistics. \u003c/strong\u003ePrimary data storage/analyses performed with SPSS 25(IBM) and Prism 8 (Graphpad). Mean \u0026plusmn; standard deviation (SD) expressed as continuous variables. Paired sample t-tests compared clinical parameters at two time points \u0026ndash; first measurement post-9/11 and at REAP-S administration; student t-tests compared clinical data of those with WTC-OAD to those who never developed WTC-OAD. One-way ANOVA was used in a subgroup analysis of lung function and dietary quality. Counts and percentages describe categorical variables and compared groups using c\u003csup\u003e2\u003c/sup\u003e-test.\u003c/p\u003e\n\u003cp\u003eArrival time and smoking was self-reported and collected through the annual questionnaires/EMR. Arrival time data, used as a proxy for WTC-particulate matter(WTC-PM) exposure, was categorized into a dichotomous variable of \u0026ldquo;arrived at the site in the morning of 9/11\u0026rdquo; or \u0026ldquo;anytime thereafter\u0026rdquo;.(84) Smoking data was dichotomous representing ever or never smokers.(52, 62, 69, 81, 82, 85-90)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eModeling Using \u003c/strong\u003eMultivariable logistic regression estimated association of AGE abundancy, REAP-S scores, and the development of WTC-OAD. All models were adjusted for smoking, age at September 11, 2001, exposure intensity, BMI, and job description. We assumed that dietary habits remain relatively constant over time.(91-93) Models of WTC-OAD using components of REAP-S were corrected for multiple comparisons by Bonferroni, p\u0026lt;0.005. For all else, p was significant if \u0026lt;0.05 and omnibus testing assessed variance of data.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003e\u003cstrong\u003eFDNY Nutrition Cohort Characteristics.\u003c/strong\u003e 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.\u003c/p\u003e\n\u003cp\u003eSubjects 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\u0026lt;0.001), \u003cstrong\u003eTable 1\u003c/strong\u003e. Of note, age at 9/11, smoking status, and race were no different in the WTC-OAD and never WTC-OAD populations, \u003cstrong\u003eTable 1\u003c/strong\u003e.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical Measures. \u003c/strong\u003eTime to reach WTC-OAD case definition was(mean \u0026plusmn; SD)\u0026nbsp; 6.37 \u0026plusmn; 7.23 years for the study cohort. For both ever WTC-OAD cases and never WTC-OAD subjects, BMI, blood pressure, and HDL were found to be significantly higher at time of REAP-S compared to immediately post-9/11, \u003cstrong\u003eTable 1\u003c/strong\u003e. Similarly, their FEV\u003csub\u003e1%Pred\u003c/sub\u003e, HDL, LDL, total cholesterol, and triglycerides were significantly lower at time of REAP-S, and FVC\u003csub\u003e%Pred\u003c/sub\u003e was not significantly different. WTC-OAD cases had significantly higher BMI, blood pressure, and triglycerides, and lower FEV\u003csub\u003e1%Pred\u003c/sub\u003e, FVC\u003csub\u003e%Pred\u003c/sub\u003e at 1\u003csup\u003est\u003c/sup\u003e 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 1\u003csup\u003est\u003c/sup\u003e post-9/11 assessment. In contrast, at the time of the REAP-S questionnaire, those subjects with WTC-OAD had lower total cholesterol,\u003cstrong\u003e Table 1\u003c/strong\u003e.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eREAP-S Questionnaire Responses.\u003c/strong\u003e Length of time between initial post 9/11 assessment and REAP-S administration was (mean \u0026plusmn; SD) 16.59 \u0026plusmn; 0.49 years. The study cohort had a mean\u0026plusmn;SD REAP-S score of 29.46 \u0026plusmn; 4.22. Subjects with WTC-OAD had significantly lower mean REAP-S score of 28.99 \u0026plusmn; 4.37 compared to those who never developed WTC-OAD with 29.60 \u0026plusmn; 4.17; p\u0026lt;0.01. In contrast,\u0026nbsp; 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), \u003cstrong\u003eTable 2\u003c/strong\u003e. 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\u0026lt;0.05), \u003cstrong\u003eTable 2\u003c/strong\u003e.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eQuality of Diet assessed by REAP-S.\u003c/strong\u003e Low-dietary quality was significantly associated with 2.67 odds (95%CI[1.57,4.52]; p\u0026lt;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 comparing to high-dietary quality as a reference group,\u003cstrong\u003e Figure 2\u003c/strong\u003e. Increasing BMI had a small but significant protective odds ratio of 0.97(95%CI[0.95, 0.98]; p\u0026lt;0.01). Job description was significant, at 1.60 odds (95%CI[1.26,2.03]; p\u0026lt;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, \u003cstrong\u003eFigure 2\u003c/strong\u003e.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDietary Quality Subgroups and Lung Function \u003c/strong\u003eof those with low-, moderate-, or high-dietary quality are shown in \u003cstrong\u003eTable 3\u003c/strong\u003e. Mean FEV\u003csub\u003e1%Pred\u003c/sub\u003e and FVC\u003csub\u003e1%Pred\u003c/sub\u003e at both time points are significantly higher in those with higher dietary quality compared to those with lower dietary quality (p\u0026lt;0.05). FEV\u003csub\u003e1\u003c/sub\u003e/FVC ratio was not significantly associated with dietary quality at either timepoint,\u003cstrong\u003e Table 3\u003c/strong\u003e.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eProcessed meat, sugary drinks, and vegetable intake Impacted the Odds of Developing WTC-OAD. \u003c/strong\u003eAssessment 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), \u003cstrong\u003eTable 2 \u003c/strong\u003eand \u003cstrong\u003eFigure 3\u003c/strong\u003e. Additionally, there was a dose response seen with increasing intake of processed meats (OR 1.64 (95%CI[1.23,2.19] ;p=0.001) and 1.27 (95%CI[1.08,1.48] ; p=0.003)) and less vegetables (OR 1.53(95%CI[1.24,1.90] ; p\u0026lt;0.001) and 1.31(95%CI[1.12, 1.55]; p=0.001)). 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 subjects trended towards increased fried food intake but these measures were not significant after Bonferroni correction (p=0.006),\u003cstrong\u003e Table 2 and Figure 3.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDietary habit assessment showed that n\u003c/strong\u003e\u003cstrong\u003eot being well enough to cook\u003c/strong\u003e\u003cem\u003e, \u003c/em\u003e\u003cstrong\u003eskipping breakfast, and eating out increase odds of WTC-OAD. \u003c/strong\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003eNot feeling well enough to cook (Q15) increased odds of developing WTC-OAD by 1.91(95%CI[1.33, 2.73]; p\u0026lt;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), \u003cstrong\u003eTable 2\u003c/strong\u003e.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAGE Rich Foods Confer a Higher Likelihood of Developing WTC-OAD. \u003c/strong\u003eUsing data adapted from Uribarri et al., we summarized the amount of AGE in food groups represented in REAP-S, \u003cstrong\u003eSupplemental Figure 1\u003c/strong\u003e.(83) 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=0.04), 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), \u003cstrong\u003eFigure 4\u003c/strong\u003e.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis observational, prospective study of dietary phenotyping was successfully implemented at the FDNY WTC-HP annual monitoring exam. Dietary quality was correlated to FEV\u003csub\u003e1\u003c/sub\u003e and FVC even immediately after 9/11, and persisted at REAP-S. Since we assume that diet is constant throughout adult life, this could be due to the combined effect of dietary quality and WTC exposure.\u0026nbsp; This is supported by our findings in which more frequent consumption of sugary drinks, processed meats, and decreased intake of vegetables and whole grains were identified as key components in development of WTC-OAD. Subjects with AGE-rich diets were also significantly more likely to develop WTC-OAD.\u003c/p\u003e\n\u003cp\u003eOur findings parallel prior studies that have displayed the harmful role of processed meats in the increased risk of developing COPD due to its high level of pro-inflammatory AGE levels.(94-97) AGE formation via glycoxidation is promoted by the high temperatures and low moisture environments utilized in cooking meat, processed meat products, and fried foods.(83, 98-100)\u0026nbsp; Associations with certain food groups are important because high levels of AGEs are linked to pathogenic effects, including the ability to promote high levels of oxidative stress and inflammation.(83, 99)\u003c/p\u003e\n\u003cp\u003eAlthough sugary drinks are relatively low in AGEs, they are a prominent source of high fructose corn syrup.(28) The fructose can indirectly increase AGE intake because of its formation and accumulation of endogenous AGEs.(28) This could be a reason as to why sugary drinks have been associated with bronchitis and asthma in children, and increase likelihood of WTC-OAD.(101, 102) In contrast, carbohydrates and whole grains contain less AGE.(83, 100) Similar to our results, other studies have found that increased whole grain intake, part of a prudent dietary pattern, were associated with a reduced risk of developing COPD.(13) Moreover, it was positively associated with FEV\u003csub\u003e1 \u003c/sub\u003eand negatively associated with COPD symptoms.(103)\u003c/p\u003e\n\u003cp\u003eAlthough we showed that low intake of vegetables increased odds of developing WTC-OAD, there was no significant association found with fruit intake. While our results resonated with some studies on low intake of fruits and vegetables, others advocated for increased fruit intake, or found no difference in COPD.(83, 104-109) Although fruits and vegetables are relatively low in AGEs, they could confer antioxidant benefit and lower inflammation in diseases such as COPD. A randomized control trial focused on increased antioxidant intake through fruits and vegetables found that it could even help regain FEV\u003csub\u003e1\u003c/sub\u003e in COPD patients.(107)\u003c/p\u003e\n\u003cp\u003eIn contrast to our prior work, increasing BMI had a 3.6% decreased likelihood of developing WTC-OAD. One reason for this difference could be that while our prior work focused firefighters, we now also investigate EMS 1\u003csup\u003est\u003c/sup\u003e responders. Prior studies have shown that the firefighter and EMS cohort express different patterns of lung function decline, even after adjusting for BMI.(18) This expanded cohort potentially reflects concordance with studies showing obesity\u0026rsquo;s protective effect against mortality in COPD patients.(110, 111) This could also be a result of a healthy worker effect and the imperfect utilization of BMI to define obesity in firefighters with rigorous physical job requirements.(112) In addition, we optimized our model by adjusting for confounding of WTC-OAD cases by using BMI at the time of diagnosis, whereas for subjects that never developed WTC-OAD, BMI at REAP-S was used. Nevertheless, the results of the final model did not change significantly even when we also assessed the effects of BMI at the same time point (1\u003csup\u003est\u003c/sup\u003e post 9/11 and at REAP-S respectively). Moroever, we found that triglycerides decreased from post 9/11 to REAP-S. This could be an effect of the close monitoring that these patients received and/or other confounder such as triglyceride-lowering medications such as statin therapy in as per 2018 American Heart Association/American College of Cardiology guidelines.(113) Future studies could help differentiate the paradoxical effect of obesity vs. the healthy worker phenomena.\u003c/p\u003e\n\u003cp\u003eThere are several limitations to our investigation. Dietary habits and exposure are subject to self-reporting bias. Bias assessment has been performed on the FDNY WTC cohort, and found that self-reported asthma and exposure were consistent across several studies, and that significant findings were minimally affected by potential bias.(114) Thus, extension of the reliability of this data to our study is reasonable. We also assume that dietary habits remain relatively constant throughout a person\u0026rsquo;s adult life, an assumption supported by several large studies.(91, 115, 116) Additionally, REAP-S is a brief dietary instrument that limits our ability to differentiate subtypes of food consumed. Protein intake does not differentiate between beans, poultry, or red meat.\u0026nbsp; Firefighters had pre-employment physical health assessments to ensure that they did not have pre-existing OAD, the pulmonary function for EMS prior to 9/11 was also assessed but these 1\u003csup\u003est\u003c/sup\u003e responders are not subject to the same standards. Therefore, our results are limited to correlation of dietary quality and OAD.\u003c/p\u003e\n\u003cp\u003eAnother possible limitation is that WTC-OAD subjects were more likely to be retired compared to those who never developed WTC-OAD. We also identified that not being well enough to shop and cook and frequent eating out had strong associations with WTC-OAD. Since this was assessed at a later time point, it is unclear if this reflects the burden of concurrent WTC-OAD. One study has found that physical factors with COPD patients such as being too tired to cook resulted in the shift in eating meals that have been easily prepared.(117) However, this is an important finding that highlights a potential barrier to access to healthier diets in this population. The limiting lifestyle imposed by WTC-OAD could further perpetuate an unforgiving cycle of lower dietary quality and worsening disease.\u003c/p\u003e\n\u003cp\u003eThis study identifies risk factors of worsening OAD, and demonstrates the potential \u0026nbsp;for intervention. Further research is needed to determine if implementation of a diet focused on decreasing AGE-rich foods, increasing antioxidant intake, and targeting weight loss could prevent the development of WTC-OAD or in those with WTC-OAD, reverse or slow its progression. Our ongoing randomized clinical trial, the \u003cstrong\u003e\u003cu\u003eF\u003c/u\u003e\u003c/strong\u003e\u003cstrong\u003eood \u003cu\u003eI\u003c/u\u003entake \u003cu\u003eRe\u003c/u\u003estriction for \u003cu\u003eH\u003c/u\u003eealth \u003cu\u003eOu\u003c/u\u003etcome \u003cu\u003eS\u003c/u\u003eupport and \u003cu\u003eE\u003c/u\u003education (FIREHOUSE) Trial\u003c/strong\u003e, aims to assess the effects of technology-assisted social cognitive behavioral therapy and a low-caloric Mediterranean diet on the progression of WTC-LI.\u003c/p\u003e\n\u003cp\u003eIn summary, this observational study successfully used REAP-S to identify both low-dietary quality and AGE abundant foods as predictive of developing lung disease in this WTC-exposed population. Our findings indicate the potential impact of future research using dietary interventions not just in the FDNY WTC-HP, but also in other OAD cohorts, with or without WTC-exposure.\u003c/p\u003e"},{"header":"Abbreviation List","content":"\u003cp\u003e\u003cstrong\u003eAGE\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp; \u003c/strong\u003eAdvanced Glycation End-products\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAHR\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp; \u003c/strong\u003eAirway Hyperreactivity\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eBMI\u003c/strong\u003e\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp; Body Mass Index\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCI\u003c/strong\u003e\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp; Confidence Interval\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDBP\u003c/strong\u003e \u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp; Diastolic blood pressure\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEMS\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp; \u003c/strong\u003eEmergency Medical Services\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFDNY\u003c/strong\u003e \u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;Fire Department of the City of New York\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFEV\u003csub\u003e1\u003c/sub\u003e\u003c/strong\u003e \u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp; Forced expiratory volume over 1 second\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFFQ\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp; \u003c/strong\u003eFood Frequency Questionnaire\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFVC\u003c/strong\u003e\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp; Forced Vital Capacity\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eHDL\u003c/strong\u003e \u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp; High Density Lipoprotein\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eHR\u003c/strong\u003e\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp; Hazards Ratio\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eLDL\u003c/strong\u003e\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp; Low Density Lipoprotein\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eLLN\u003c/strong\u003e \u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp; Lower Limit of Normal\u003cbr /\u003e \u003cstrong\u003eMetSyn\u003c/strong\u003e \u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp; Metabolic syndrome\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eNHANES\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp; \u003c/strong\u003eNational Health and Nutrition Examination Survey\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eOR\u003c/strong\u003e\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp; Odds Ratio\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePFT\u003c/strong\u003e \u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp; Pulmonary function test\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePM\u003c/strong\u003e \u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp; Particulate matter\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePUFA\u003c/strong\u003e \u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;Polyunsaturated fatty acids\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eREAP-S\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp; \u003c/strong\u003eRapid Eating and Activity Assessment for Patients-Short Version\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSBP\u003c/strong\u003e \u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp; Systolic blood pressure\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSD\u003c/strong\u003e\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp; Standard Deviation\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eUS\u003c/strong\u003e\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp; United States\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eWTC\u003c/strong\u003e \u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp; World Trade Center\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eWTC-HP\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp; \u003c/strong\u003eWTC-Health Program\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eWTC-LI\u003c/strong\u003e\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp; WTC-Lung Injury\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eWTC-OAD\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp; \u003c/strong\u003eWTC-Obstructive Airways Disease\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eWTC-PM\u003c/strong\u003e\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp; WTC-Particulate Matter\u003c/p\u003e"},{"header":"Declarations","content":"\u003cul\u003e\n\u003cli\u003e\u003cstrong\u003eEthics\u003c/strong\u003e approval and consent to participate\u003c/li\u003e\n\u003cli\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/li\u003e\n\u003c/ul\u003e\n\u003cul\u003e\n\u003cli\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e The authors report no conflicts of interest.\u003c/li\u003e\n\u003cli\u003e\u003cstrong\u003eFunding Sources:\u003c/strong\u003e NHLBI R01HL119326, CDC/NIOSH U01-OH11300, Clinical Center of Excellence 200-2017-93426, Data Center 200-2017-93326\u003c/li\u003e\n\u003cli\u003e\u003cstrong\u003eAuthor Contributions:\u003c/strong\u003e RL, AN and SK participated in study conception and design; AN was the primary investigator and guarantor of the paper; RL, AN, SK, HC, AH, TS, RZO and DJP were responsible for data collection; AN and SK were responsible for data validation; RL, AN, SK, and GC participated in data analysis; AN, GC, ML, and SK undertook the statistical analysis. All authors participated in data interpretation, writing, and revision of the report and approval of the final version.\u003c/li\u003e\n\u003c/ul\u003e"},{"header":"References","content":"\n\u003col\u003e\n\u003cli\u003eHanson C, Rutten EP, Wouters EF, Rennard S. Influence of diet and obesity on COPD development and outcomes. Int J Chron Obstruct Pulmon Dis. 2014;9:723-33.\u003c/li\u003e\n\u003cli\u003eWood LG. Diet, Obesity, and Asthma. Ann Am Thorac Soc. 2017;14(Supplement_5):S332-S8.\u003c/li\u003e\n\u003cli\u003eNapier CO, Mbadugha O, Bienenfeld LA, Doucette JT, Lucchini R, Luna-Sanchez S, et al. Obesity and weight gain among former World Trade Center workers and volunteers. Arch Environ Occup H. 2017;72(2):106-10.\u003c/li\u003e\n\u003cli\u003eGuo WA, Davidson BA, Ottosen J, Ohtake PJ, Raghavendran K, Mullan BA, et al. Effect of High Advanced Glycation End-Product Diet on Pulmonary Inflammatory Response and Pulmonary Function Following Gastric Aspiration. 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Respir Res. 2014;15:5.\u003c/li\u003e\n\u003cli\u003eMovassagh EZ, Baxter-Jones ADG, Kontulainen S, Whiting SJ, Vatanparast H. Tracking Dietary Patterns over 20 Years from Childhood through Adolescence into Young Adulthood: The Saskatchewan Pediatric Bone Mineral Accrual Study. Nutrients. 2017;9(9).\u003c/li\u003e\n\u003cli\u003eMikkila V, Rasanen L, Raitakari OT, Marniemi J, Pietinen P, Ronnemaa T, et al. Major dietary patterns and cardiovascular risk factors from childhood to adulthood. The Cardiovascular Risk in Young Finns Study. The British journal of nutrition. 2007;98(1):218-25.\u003c/li\u003e\n\u003cli\u003eNewby PK, Weismayer C, Akesson A, Tucker KL, Wolk A. Long-term stability of food patterns identified by use of factor analysis among Swedish women. 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Formation of advanced glycation endproducts in foods during cooking process and underlying mechanisms: a comprehensive review of experimental studies. Nutr Res Rev. 2019:1-13.\u003c/li\u003e\n\u003cli\u003eSharma C, Kaur A, Thind SS, Singh B, Raina S. Advanced glycation End-products (AGEs): an emerging concern for processed food industries. J Food Sci Technol. 2015;52(12):7561-76.\u003c/li\u003e\n\u003cli\u003eGoldberg T, Cai W, Peppa M, Dardaine V, Baliga BS, Uribarri J, et al. Advanced glycoxidation end products in commonly consumed foods. J Am Diet Assoc. 2004;104(8):1287-91.\u003c/li\u003e\n\u003cli\u003ePark S, Blanck HM, Sherry B, Jones SE, Pan L. Regular-soda intake independent of weight status is associated with asthma among US high school students. J Acad Nutr Diet. 2013;113(1):106-11.\u003c/li\u003e\n\u003cli\u003eDeChristopher LR, Uribarri J, Tucker KL. Intakes of apple juice, fruit drinks and soda are associated with prevalent asthma in US children aged 2-9 years. Public Health Nutr. 2016;19(1):123-30.\u003c/li\u003e\n\u003cli\u003eTabak C, Smit HA, Heederik D, Ocke MC, Kromhout D. Diet and chronic obstructive pulmonary disease: independent beneficial effects of fruits, whole grains, and alcohol (the MORGEN study). Clin Exp Allergy. 2001;31(5):747-55.\u003c/li\u003e\n\u003cli\u003eWalda IC, Tabak C, Smit HA, Rasanen L, Fidanza F, Menotti A, et al. Diet and 20-year chronic obstructive pulmonary disease mortality in middle-aged men from three European countries. Eur J Clin Nutr. 2002;56(7):638-43.\u003c/li\u003e\n\u003cli\u003eKaluza J, Larsson SC, Orsini N, Linden A, Wolk A. Fruit and vegetable consumption and risk of COPD: a prospective cohort study of men. Thorax. 2017;72(6):500-9.\u003c/li\u003e\n\u003cli\u003eMeteran H, Thomsen SF, Miller MR, Hjelmborg J, Sigsgaard T, Backer V. Self-reported intake of fruit and vegetables and risk of chronic obstructive pulmonary disease: A nation-wide twin study. Respiratory medicine. 2018;144:16-21.\u003c/li\u003e\n\u003cli\u003eKeranis E, Makris D, Rodopoulou P, Martinou H, Papamakarios G, Daniil Z, et al. Impact of dietary shift to higher-antioxidant foods in COPD: a randomised trial. Eur Respir J. 2010;36(4):774-80.\u003c/li\u003e\n\u003cli\u003eBaldrick FR, Elborn JS, Woodside JV, Treacy K, Bradley JM, Patterson CC, et al. Effect of fruit and vegetable intake on oxidative stress and inflammation in COPD: a randomised controlled trial. The European respiratory journal. 2012;39(6):1377-84.\u003c/li\u003e\n\u003cli\u003eHolt EM, Steffen LM, Moran A, Basu S, Steinberger J, Ross JA, et al. Fruit and vegetable consumption and its relation to markers of inflammation and oxidative stress in adolescents. J Am Diet Assoc. 2009;109(3):414-21.\u003c/li\u003e\n\u003cli\u003eCao C, Wang R, Wang J, Bunjhoo H, Xu Y, Xiong W. Body mass index and mortality in chronic obstructive pulmonary disease: a meta-analysis. PloS one. 2012;7(8):e43892.\u003c/li\u003e\n\u003cli\u003eSun Y, Milne S, Jaw JE, Yang CX, Xu F, Li X, et al. BMI is associated with FEV1 decline in chronic obstructive pulmonary disease: a meta-analysis of clinical trials. Respir Res. 2019;20(1):236.\u003c/li\u003e\n\u003cli\u003eJitnarin N, Poston WS, Haddock CK, Jahnke SA, Day RS. Accuracy of Body Mass Index-defined Obesity Status in US Firefighters. Saf Health Work. 2014;5(3):161-4.\u003c/li\u003e\n\u003cli\u003eGrundy. AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA Guideline on the Management of Blood Cholesterol: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines (vol 139, pg e1082, 2019). Circulation. 2019;139(25):E1182-E6.\u003c/li\u003e\n\u003cli\u003eKim H, Baidwan NK, Kriebel D, Cifuentes M, Baron S. Asthma among World Trade Center First Responders: A Qualitative Synthesis and Bias Assessment. Int J Env Res Pub He. 2018;15(6).\u003c/li\u003e\n\u003cli\u003eMikkilae V, Rasnan L, Raitakari OT, Marniemi J, Pietinen P, Ronnemaa T, et al. Major dietary patterns and cardiovascular risk factors from childhood to adulthood. The Cardiovascular Risk in Young Finns Study. Brit J Nutr. 2007;98(1):218-25.\u003c/li\u003e\n\u003cli\u003eNewby PK, Weismayer C, Akesson A, Tucker KL, Wolk A. Long-term stability of food patterns identified by use of factor analysis among Swedish women. J Nutr. 2006;136(3):626-33.\u003c/li\u003e\n\u003cli\u003eOdencrants S, Ehnfors M, Grobe SJ. Living with chronic obstructive pulmonary disease: part I. Struggling with meal-related situations: experiences among persons with COPD. Scand J Caring Sci. 2005;19(3):230-9.\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\n\u003ctable border=\"1\" width=\"641\"\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"6\" width=\"641\"\u003e\n\u003cp\u003e\u003cstrong\u003eTable 1: Demographic and Clinical Data \u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"2\" rowspan=\"2\" width=\"231\"\u003e\n\u003cp\u003e\u003cstrong\u003eMEASURES\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd rowspan=\"2\" width=\"119\"\u003e\n\u003cp\u003e\u003cstrong\u003eStudy\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCohort\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eN=4,015\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" width=\"222\"\u003e\n\u003cp\u003e\u003cstrong\u003eWTC-OAD\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd rowspan=\"2\" width=\"68\"\u003e\n\u003cp\u003e\u003cstrong\u003ep\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"110\"\u003e\n\u003cp\u003e\u003cstrong\u003eEver\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eN=921\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"112\"\u003e\n\u003cp\u003e\u003cstrong\u003eNever\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eN=3,094\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd rowspan=\"6\" width=\"48\"\u003e\n\u003cp\u003e\u003cstrong\u003eDemographics\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"183\"\u003e\n\u003cp\u003e\u003cstrong\u003eAge on 9/11\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"119\"\u003e\n\u003cp\u003e40.55(7.40)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"110\"\u003e\n\u003cp\u003e40.64(7.12)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"112\"\u003e\n\u003cp\u003e40.53(7.48)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"68\"\u003e\n\u003cp\u003e0.68\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"183\"\u003e\n\u003cp\u003e\u003cstrong\u003eRetired at Exam \u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"119\"\u003e\n\u003cp\u003e3077(76.60%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"110\"\u003e\n\u003cp\u003e765(83.10%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"112\"\u003e\n\u003cp\u003e2312(74.70%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"68\"\u003e\n\u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"183\"\u003e\n\u003cp\u003e\u003cstrong\u003eFirefighter \u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"119\"\u003e\n\u003cp\u003e3637(90.60%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"110\"\u003e\n\u003cp\u003e806(87.50%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"112\"\u003e\n\u003cp\u003e2831(91.50%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"68\"\u003e\n\u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"183\"\u003e\n\u003cp\u003e\u003cstrong\u003eEver Smokers\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"119\"\u003e\n\u003cp\u003e1291(32.20%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"110\"\u003e\n\u003cp\u003e315(34.20%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"112\"\u003e\n\u003cp\u003e976(31.50%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"68\"\u003e\n\u003cp\u003e0.13\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"183\"\u003e\n\u003cp\u003e\u003cstrong\u003eCaucasian\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"119\"\u003e\n\u003cp\u003e3819(95.10%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"110\"\u003e\n\u003cp\u003e886(96.20%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"112\"\u003e\n\u003cp\u003e2933(94.80%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"68\"\u003e\n\u003cp\u003e0.08\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"183\"\u003e\n\u003cp\u003e\u003cstrong\u003eArrived Morning of 9/11\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"119\"\u003e\n\u003cp\u003e679(16.90%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"110\"\u003e\n\u003cp\u003e183(19.90%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"112\"\u003e\n\u003cp\u003e496(16%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"68\"\u003e\n\u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd rowspan=\"9\" width=\"48\"\u003e\n\u003cp\u003e\u003cstrong\u003e1\u003csup\u003est\u003c/sup\u003e\u0026nbsp;Post-9/11\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"183\"\u003e\n\u003cp\u003e\u003cstrong\u003eFEV\u003csub\u003e1%Pred\u003c/sub\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"119\"\u003e\n\u003cp\u003e96.92(14.02)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"110\"\u003e\n\u003cp\u003e83.93(13.10)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"112\"\u003e\n\u003cp\u003e100.79(11.78)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"68\"\u003e\n\u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"183\"\u003e\n\u003cp\u003e\u003cstrong\u003eFVC\u003csub\u003e%Pred \u003c/sub\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"119\"\u003e\n\u003cp\u003e92.36(12.15)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"110\"\u003e\n\u003cp\u003e83.58(11.58)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"112\"\u003e\n\u003cp\u003e94.88(11.09)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"68\"\u003e\n\u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"183\"\u003e\n\u003cp\u003e\u003cstrong\u003eBMI \u003c/strong\u003ekg/m\u003csup\u003e2\u003c/sup\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"119\"\u003e\n\u003cp\u003e29.02(3.78)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"110\"\u003e\n\u003cp\u003e29.59(4.16)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"112\"\u003e\n\u003cp\u003e28.84(3.65)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"68\"\u003e\n\u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"183\"\u003e\n\u003cp\u003e\u003cstrong\u003eSystolic BP \u003c/strong\u003emmHg\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"119\"\u003e\n\u003cp\u003e117.91(14.37)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"110\"\u003e\n\u003cp\u003e119.27(14.58)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"112\"\u003e\n\u003cp\u003e117.51(14.28)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"68\"\u003e\n\u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"183\"\u003e\n\u003cp\u003e\u003cstrong\u003eDiastolic BP \u003c/strong\u003emmHg\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"119\"\u003e\n\u003cp\u003e74.15(9.26)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"110\"\u003e\n\u003cp\u003e75.01(9.40)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"112\"\u003e\n\u003cp\u003e73.89(9.20)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"68\"\u003e\n\u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"183\"\u003e\n\u003cp\u003e\u003cstrong\u003eHDL \u003c/strong\u003emg/dL\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"119\"\u003e\n\u003cp\u003e48.02(11.58)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"110\"\u003e\n\u003cp\u003e47.54(11.80)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"112\"\u003e\n\u003cp\u003e48.16(11.51)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"68\"\u003e\n\u003cp\u003e0.20\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"183\"\u003e\n\u003cp\u003e\u003cstrong\u003eLDL \u003c/strong\u003emg/dL\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"119\"\u003e\n\u003cp\u003e126.54(36.08)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"110\"\u003e\n\u003cp\u003e127.08(34.65)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"112\"\u003e\n\u003cp\u003e126.39(36.5)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"68\"\u003e\n\u003cp\u003e0.63\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"183\"\u003e\n\u003cp\u003e\u003cstrong\u003eCholesterol\u003c/strong\u003e(Total) mg/dL\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"119\"\u003e\n\u003cp\u003e208.72(43.89)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"110\"\u003e\n\u003cp\u003e212.07(59.80)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"112\"\u003e\n\u003cp\u003e207.73(37.84)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"68\"\u003e\n\u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"183\"\u003e\n\u003cp\u003e\u003cstrong\u003eTriglyceride \u003c/strong\u003emg/dL\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"119\"\u003e\n\u003cp\u003e179.91(131.57)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"110\"\u003e\n\u003cp\u003e191.93(137.60)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"112\"\u003e\n\u003cp\u003e176.34(129.52)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"68\"\u003e\n\u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd rowspan=\"9\" width=\"48\"\u003e\n\u003cp\u003e\u003cstrong\u003eAt REAP-S \u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"183\"\u003e\n\u003cp\u003e\u003cstrong\u003eFEV\u003csub\u003e1%Pred\u003c/sub\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"119\"\u003e\n\u003cp\u003e93.01(14.33)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"110\"\u003e\n\u003cp\u003e77.89(14.18)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"112\"\u003e\n\u003cp\u003e97.44(10.95)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"68\"\u003e\n\u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"183\"\u003e\n\u003cp\u003e\u003cstrong\u003eFVC\u003csub\u003e%Pred \u003c/sub\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"119\"\u003e\n\u003cp\u003e91.59(12.51)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"110\"\u003e\n\u003cp\u003e80.42(12.92)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"112\"\u003e\n\u003cp\u003e94.86(10.31)\u003cstrong\u003e*\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"68\"\u003e\n\u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"183\"\u003e\n\u003cp\u003e\u003cstrong\u003eBMI \u003c/strong\u003ekg/m\u003csup\u003e2\u003c/sup\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"119\"\u003e\n\u003cp\u003e30.34(4.87)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"110\"\u003e\n\u003cp\u003e31.15(5.49)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"112\"\u003e\n\u003cp\u003e30.09(4.65)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"68\"\u003e\n\u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"183\"\u003e\n\u003cp\u003e\u003cstrong\u003eSystolic BP \u003c/strong\u003emmHg\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"119\"\u003e\n\u003cp\u003e126.06(12.99)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"110\"\u003e\n\u003cp\u003e127.19(13.10)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"112\"\u003e\n\u003cp\u003e125.72(12.94)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"68\"\u003e\n\u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"183\"\u003e\n\u003cp\u003e\u003cstrong\u003eDiastolic BP \u003c/strong\u003emmHg\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"119\"\u003e\n\u003cp\u003e78.70(8.38)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"110\"\u003e\n\u003cp\u003e79.28(8.10)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"112\"\u003e\n\u003cp\u003e78.53(8.46)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"68\"\u003e\n\u003cp\u003e0.020\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"183\"\u003e\n\u003cp\u003e\u003cstrong\u003eHDL \u003c/strong\u003emg/dL\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"119\"\u003e\n\u003cp\u003e53.76(14.61)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"110\"\u003e\n\u003cp\u003e53.01(14.68)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"112\"\u003e\n\u003cp\u003e53.97(14.58)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"68\"\u003e\n\u003cp\u003e0.18\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"183\"\u003e\n\u003cp\u003e\u003cstrong\u003eLDL \u003c/strong\u003emg/dL\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"119\"\u003e\n\u003cp\u003e116.93(33.64)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"110\"\u003e\n\u003cp\u003e113.76(34.16)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"112\"\u003e\n\u003cp\u003e117.82(33.45)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"68\"\u003e\n\u003cp\u003e0.001\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"183\"\u003e\n\u003cp\u003e\u003cstrong\u003eCholesterol\u003c/strong\u003e(Total) mg/dL\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"119\"\u003e\n\u003cp\u003e194.91(39.45)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"110\"\u003e\n\u003cp\u003e191.33(41.32)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"112\"\u003e\n\u003cp\u003e195.91(38.86)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"68\"\u003e\n\u003cp\u003e0.020\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"183\"\u003e\n\u003cp\u003e\u003cstrong\u003eTriglyceride \u003c/strong\u003emg/dL\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"119\"\u003e\n\u003cp\u003e129.16(223.39)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"110\"\u003e\n\u003cp\u003e135.54(80.60)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"112\"\u003e\n\u003cp\u003e127.38(249.01)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"68\"\u003e\n\u003cp\u003e0.46\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"6\" width=\"641\"\u003e\n\u003cp\u003eAll available measures are Mean (SD) or N(%).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e* \u003c/strong\u003eFVC\u003csub\u003e%Pred \u003c/sub\u003e\u0026nbsp;for Never WTC-OAD comparing 1\u003csup\u003est\u003c/sup\u003e\u0026nbsp;Post-9/11 and REAP-S by Paired t-tests was not significant, all other measures were p\u0026lt;0.05.\u003c/p\u003e\n\u003cp\u003ep-values displayed represent comparisons between Ever / Never WTC-OAD by Student\u0026rsquo;s t-tests.\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cbr /\u003e \u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" width=\"1066\"\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"6\" width=\"1066\"\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2: Nutrition Questions Incorporated into the WTC-HP Annual Questionnaire. \u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"2\" width=\"688\"\u003e\n\u003cp\u003e\u003cstrong\u003eItem\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"90\"\u003e\n\u003cp\u003e\u003cstrong\u003eAll\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"102\"\u003e\n\u003cp\u003e\u003cstrong\u003eEver WTC-OAD\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"108\"\u003e\n\u003cp\u003e\u003cstrong\u003eNever WTC-OAD\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"78\"\u003e\n\u003cp\u003e\u003cstrong\u003ep\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd rowspan=\"5\" width=\"526\"\u003e\n\u003cp\u003e\u003cstrong\u003e1.How willing are you to make changes in your eating habits in order to be healthier? *\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"162\"\u003e\n\u003cp\u003e\u003cstrong\u003e1\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eVery Willing\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"90\"\u003e\n\u003cp\u003e\u003cstrong\u003e2096\u003c/strong\u003e(52.2)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"102\"\u003e\n\u003cp\u003e\u003cstrong\u003e473\u003c/strong\u003e(51.4)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"108\"\u003e\n\u003cp\u003e\u003cstrong\u003e1626\u003c/strong\u003e(62.5)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd rowspan=\"5\" width=\"78\"\u003e\n\u003cp\u003e0.129\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"162\"\u003e\n\u003cp\u003e\u003cstrong\u003e2\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"90\"\u003e\n\u003cp\u003e1105(27.5)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"102\"\u003e\n\u003cp\u003e239(26)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"108\"\u003e\n\u003cp\u003e866(28)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"162\"\u003e\n\u003cp\u003e\u003cstrong\u003e3\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"90\"\u003e\n\u003cp\u003e6565(16.3)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"102\"\u003e\n\u003cp\u003e173(18.8)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"108\"\u003e\n\u003cp\u003e483(15.6)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"162\"\u003e\n\u003cp\u003e\u003cstrong\u003e4\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"90\"\u003e\n\u003cp\u003e110(2.7)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"102\"\u003e\n\u003cp\u003e22(2.4)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"108\"\u003e\n\u003cp\u003e88(2.8)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"162\"\u003e\n\u003cp\u003e\u003cstrong\u003e5\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eNot at all Willing\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"90\"\u003e\n\u003cp\u003e49(1.2)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"102\"\u003e\n\u003cp\u003e14(1.5)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"108\"\u003e\n\u003cp\u003e35(1.1)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"526\"\u003e\n\u003cp\u003e\u003cstrong\u003e2. Are you willing to answer 15 questions about your diet? **\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"162\"\u003e\n\u003cp\u003e\u003cstrong\u003eYes\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"90\"\u003e\n\u003cp\u003e4015 (100)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"102\"\u003e\n\u003cp\u003e-\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"108\"\u003e\n\u003cp\u003e-\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"78\"\u003e\n\u003cp\u003e-\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"6\" width=\"1066\"\u003e\n\u003cp\u003e\u003cstrong\u003e* This is the 16\u003csup\u003eth\u003c/sup\u003e\u0026nbsp;REAP-S question.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e** If participant answers \u0026ldquo;Yes\u0026rdquo;, the participant will be prompted to answer the 15 questions from REAP-S\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"2\" width=\"688\"\u003e\n\u003cp\u003e\u003cstrong\u003eIn an average week, how often do you:\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"90\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd width=\"102\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd width=\"108\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd width=\"78\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd rowspan=\"3\" width=\"526\"\u003e\n\u003cp\u003e\u003cstrong\u003e1. Skip breakfast?\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"162\"\u003e\n\u003cp\u003e\u003cstrong\u003eUsually/Often (1)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"90\"\u003e\n\u003cp\u003e839(20.9)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"102\"\u003e\n\u003cp\u003e215(23.3)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"108\"\u003e\n\u003cp\u003e624(20.2)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd rowspan=\"3\" width=\"78\"\u003e\n\u003cp\u003e0.030\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"162\"\u003e\n\u003cp\u003e\u003cstrong\u003eSometimes \u003c/strong\u003e\u003cstrong\u003e(2)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"90\"\u003e\n\u003cp\u003e1180(29.4)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"102\"\u003e\n\u003cp\u003e281(30.5)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"108\"\u003e\n\u003cp\u003e899(29.1)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"162\"\u003e\n\u003cp\u003e\u003cstrong\u003eRarely/Never (3)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"90\"\u003e\n\u003cp\u003e1996(49.7)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"102\"\u003e\n\u003cp\u003e425(46.1)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"108\"\u003e\n\u003cp\u003e1571(50.8)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd rowspan=\"3\" width=\"526\"\u003e\n\u003cp\u003e\u003cstrong\u003e2. Eat \u003cu\u003e4 or more\u003c/u\u003e meals from sit-down or take out restaurants?\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"162\"\u003e\n\u003cp\u003e\u003cstrong\u003eUsually/Often (1)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"90\"\u003e\n\u003cp\u003e532(13.3)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"102\"\u003e\n\u003cp\u003e135(14.5)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"108\"\u003e\n\u003cp\u003e398(12.9)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd rowspan=\"3\" width=\"78\"\u003e\n\u003cp\u003e0.016\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"162\"\u003e\n\u003cp\u003e\u003cstrong\u003eSometimes \u003c/strong\u003e\u003cstrong\u003e(2)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"90\"\u003e\n\u003cp\u003e1182(29.4)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"102\"\u003e\n\u003cp\u003e297(32.3)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"108\"\u003e\n\u003cp\u003e885(28.6)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"162\"\u003e\n\u003cp\u003e\u003cstrong\u003eRarely/Never (3)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"90\"\u003e\n\u003cp\u003e2301(57.3)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"102\"\u003e\n\u003cp\u003e490(53.2)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"108\"\u003e\n\u003cp\u003e1811(58.5)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd rowspan=\"3\" width=\"526\"\u003e\n\u003cp\u003e\u003cstrong\u003e3. \u003c/strong\u003e\u003cstrong\u003eEat less than 2 servings of whole grain products or high fiber starches a day? \u003c/strong\u003eServing = 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, \u0026frac12; cup brown rice or whole wheat pasta, boiled or baked potatoes, yuca, yams or plantain.\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"162\"\u003e\n\u003cp\u003e\u003cstrong\u003eUsually/Often (1)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"90\"\u003e\n\u003cp\u003e74418.5)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"102\"\u003e\n\u003cp\u003e176(19.1)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"108\"\u003e\n\u003cp\u003e568(18.4)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd rowspan=\"3\" width=\"78\"\u003e\n\u003cp\u003e0.016\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"162\"\u003e\n\u003cp\u003e\u003cstrong\u003eSometimes (2)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"90\"\u003e\n\u003cp\u003e1624(40.4)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"102\"\u003e\n\u003cp\u003e404(43.9)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"108\"\u003e\n\u003cp\u003e1220(39.4)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"162\"\u003e\n\u003cp\u003e\u003cstrong\u003eRarely/Never (3)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"90\"\u003e\n\u003cp\u003e1647(41)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"102\"\u003e\n\u003cp\u003e341(37)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"108\"\u003e\n\u003cp\u003e1306(42.2)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd rowspan=\"3\" width=\"526\"\u003e\n\u003cp\u003e\u003cstrong\u003e4. \u003c/strong\u003e\u003cstrong\u003eEat less than 2 servings of fruit a day? Serving = \u0026frac12; cup or 1 med. fruit or \u0026frac34; cup 100% fruit juice. \u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"162\"\u003e\n\u003cp\u003e\u003cstrong\u003eUsually/Often (1)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"90\"\u003e\n\u003cp\u003e1016(25.3)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"102\"\u003e\n\u003cp\u003e246(26.7)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"108\"\u003e\n\u003cp\u003e770(24.9)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd rowspan=\"3\" width=\"78\"\u003e\n\u003cp\u003e0.191\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"162\"\u003e\n\u003cp\u003e\u003cstrong\u003eSometimes \u003c/strong\u003e\u003cstrong\u003e(2)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"90\"\u003e\n\u003cp\u003e1682(41.9)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"102\"\u003e\n\u003cp\u003e395(42.9)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"108\"\u003e\n\u003cp\u003e1287(41.6)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"162\"\u003e\n\u003cp\u003e\u003cstrong\u003eRarely/Never (3)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"90\"\u003e\n\u003cp\u003e1317(32.8)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"102\"\u003e\n\u003cp\u003e280(30.4)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"108\"\u003e\n\u003cp\u003e1037(33.5)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd rowspan=\"3\" width=\"526\"\u003e\n\u003cp\u003e\u003cstrong\u003e5. \u003c/strong\u003e\u003cstrong\u003eEat less than 2 servings of vegetables a day? Serving = \u0026frac12; cup vegetables, or 1 cup leafy raw vegetables. \u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"162\"\u003e\n\u003cp\u003e\u003cstrong\u003eUsually/Often (1)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"90\"\u003e\n\u003cp\u003e618(15.4)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"102\"\u003e\n\u003cp\u003e169(18.3)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"108\"\u003e\n\u003cp\u003e449(14.5)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd rowspan=\"3\" width=\"78\"\u003e\n\u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"162\"\u003e\n\u003cp\u003e\u003cstrong\u003eSometimes (2)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"90\"\u003e\n\u003cp\u003e1603(39.9)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"102\"\u003e\n\u003cp\u003e394(42.8)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"108\"\u003e\n\u003cp\u003e1209(39.1)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"162\"\u003e\n\u003cp\u003e\u003cstrong\u003eRarely/Never (3)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"90\"\u003e\n\u003cp\u003e1794(44.7)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"102\"\u003e\n\u003cp\u003e358(38.9)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"108\"\u003e\n\u003cp\u003e1436(46.4)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd rowspan=\"3\" width=\"526\"\u003e\n\u003cp\u003e\u003cstrong\u003e6. \u003c/strong\u003e\u003cstrong\u003eEat or drink less than 2 servings of milk, yogurt, or cheese a day? Serving = 1 cup milk or yogurt; 1\u0026frac12; - 2 ounces cheese. \u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"162\"\u003e\n\u003cp\u003e\u003cstrong\u003eUsually/Often (1)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"90\"\u003e\n\u003cp\u003e826(20.6)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"102\"\u003e\n\u003cp\u003e209(22.7)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"108\"\u003e\n\u003cp\u003e617(19.9)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd rowspan=\"3\" width=\"78\"\u003e\n\u003cp\u003e0.125\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"162\"\u003e\n\u003cp\u003e\u003cstrong\u003eSometimes (2)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"90\"\u003e\n\u003cp\u003e1491(37.1)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"102\"\u003e\n\u003cp\u003e344(37.4)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"108\"\u003e\n\u003cp\u003e1147(37.1)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"162\"\u003e\n\u003cp\u003e\u003cstrong\u003eRarely/Never (3)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"90\"\u003e\n\u003cp\u003e1698(42.3)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"102\"\u003e\n\u003cp\u003e368(40)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"108\"\u003e\n\u003cp\u003e1330(43)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd rowspan=\"3\" width=\"526\"\u003e\n\u003cp\u003e\u003cstrong\u003e7. \u003c/strong\u003e\u003cstrong\u003eEat more than 8 ounces (see sizes below) of meat, chicken, turkey or fish per day? \u003c/strong\u003eNote: 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.\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"162\"\u003e\n\u003cp\u003e\u003cstrong\u003eUsually/Often (1)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"90\"\u003e\n\u003cp\u003e2008(50)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"102\"\u003e\n\u003cp\u003e468(50.8)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"108\"\u003e\n\u003cp\u003e1540(49.8)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd rowspan=\"3\" width=\"78\"\u003e\n\u003cp\u003e0.705\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"162\"\u003e\n\u003cp\u003e\u003cstrong\u003eSometimes (2)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"90\"\u003e\n\u003cp\u003e1450(36.1)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"102\"\u003e\n\u003cp\u003e322(35)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"108\"\u003e\n\u003cp\u003e1128(36.5)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"162\"\u003e\n\u003cp\u003e\u003cstrong\u003eRarely/Never \u003c/strong\u003e\u003cstrong\u003eor Rarely eat meat, chicken, turkey or fish (3)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"90\"\u003e\n\u003cp\u003e557(13.9)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"102\"\u003e\n\u003cp\u003e131(14.2)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"108\"\u003e\n\u003cp\u003e426(13.8)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd rowspan=\"3\" width=\"526\"\u003e\n\u003cp\u003e\u003cstrong\u003e8. \u003c/strong\u003e\u003cstrong\u003eUse 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)? \u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"162\"\u003e\n\u003cp\u003e\u003cstrong\u003eUsually/Often (1)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"90\"\u003e\n\u003cp\u003e271(6.7)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"102\"\u003e\n\u003cp\u003e80(8.7)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"108\"\u003e\n\u003cp\u003e191(6.2)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd rowspan=\"3\" width=\"78\"\u003e\n\u003cp\u003e0.001\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"162\"\u003e\n\u003cp\u003e\u003cstrong\u003eSometimes (2)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"90\"\u003e\n\u003cp\u003e1784(44.4)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"102\"\u003e\n\u003cp\u003e432(46.9)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"108\"\u003e\n\u003cp\u003e1352(43.7)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"162\"\u003e\n\u003cp\u003e\u003cstrong\u003eRarely/Never or \u003c/strong\u003e\u003cstrong\u003eRarely(3)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"90\"\u003e\n\u003cp\u003e1960(48.8)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"102\"\u003e\n\u003cp\u003e409(44.4)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"108\"\u003e\n\u003cp\u003e1551(50.1)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd rowspan=\"3\" width=\"526\"\u003e\n\u003cp\u003e\u003cstrong\u003e9. \u003c/strong\u003e\u003cstrong\u003eEat fried foods such as fried chicken, fried fish, French fries, fried plantains, tostones or fried yuca? \u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"162\"\u003e\n\u003cp\u003e\u003cstrong\u003eUsually/Often (1)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"90\"\u003e\n\u003cp\u003e174(4.3)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"102\"\u003e\n\u003cp\u003e54(5.9)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"108\"\u003e\n\u003cp\u003e120(3.9)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd rowspan=\"3\" width=\"78\"\u003e\n\u003cp\u003e0.024\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"162\"\u003e\n\u003cp\u003e\u003cstrong\u003eSometimes (2)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"90\"\u003e\n\u003cp\u003e1895(47.2)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"102\"\u003e\n\u003cp\u003e417(45.3)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"108\"\u003e\n\u003cp\u003e1478(47.8)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"162\"\u003e\n\u003cp\u003e\u003cstrong\u003eRarely/Never (3)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"90\"\u003e\n\u003cp\u003e1946(48.5)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"102\"\u003e\n\u003cp\u003e450(48.9)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"108\"\u003e\n\u003cp\u003e1496(48.4)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd rowspan=\"3\" width=\"526\"\u003e\n\u003cp\u003e\u003cstrong\u003e10. \u003c/strong\u003e\u003cstrong\u003eEat regular potato chips, nacho chips, corn chips, crackers, regular popcorn, nuts instead of pretzels, low-fat chips or lowfat crackers, air-popped popcorn? \u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"162\"\u003e\n\u003cp\u003e\u003cstrong\u003eUsually/Often (1)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"90\"\u003e\n\u003cp\u003e338(8.4)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"102\"\u003e\n\u003cp\u003e79(8.6)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"108\"\u003e\n\u003cp\u003e259(8.4)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd rowspan=\"3\" width=\"78\"\u003e\n\u003cp\u003e0.111\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"162\"\u003e\n\u003cp\u003e\u003cstrong\u003eSometimes (2)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"90\"\u003e\n\u003cp\u003e181545.2)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"102\"\u003e\n\u003cp\u003e389(42.2)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"108\"\u003e\n\u003cp\u003e1426(46.1)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"162\"\u003e\n\u003cp\u003e\u003cstrong\u003eRarely/Never or Rarely eat these snack foods (3)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"90\"\u003e\n\u003cp\u003e1862(46.4)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"102\"\u003e\n\u003cp\u003e453(49.2)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"108\"\u003e\n\u003cp\u003e1409(45.5)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd rowspan=\"3\" width=\"526\"\u003e\n\u003cp\u003e\u003cstrong\u003e11. \u003c/strong\u003e\u003cstrong\u003eAdd butter, margarine or oil to bread, potatoes, rice or vegetables at the table? \u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"162\"\u003e\n\u003cp\u003e\u003cstrong\u003eUsually/Often (1)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"90\"\u003e\n\u003cp\u003e1059(26.4)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"102\"\u003e\n\u003cp\u003e252(27.4)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"108\"\u003e\n\u003cp\u003e807(26.1)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd rowspan=\"3\" width=\"78\"\u003e\n\u003cp\u003e0.290\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"162\"\u003e\n\u003cp\u003e\u003cstrong\u003eSometimes (2)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"90\"\u003e\n\u003cp\u003e1619(40.3)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"102\"\u003e\n\u003cp\u003e382(41.5)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"108\"\u003e\n\u003cp\u003e1237(40)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"162\"\u003e\n\u003cp\u003e\u003cstrong\u003eRarely/Never (3)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"90\"\u003e\n\u003cp\u003e1337(33.3)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"102\"\u003e\n\u003cp\u003e287(31.2)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"108\"\u003e\n\u003cp\u003e1050(33.9)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd rowspan=\"3\" width=\"526\"\u003e\n\u003cp\u003e\u003cstrong\u003e12. \u003c/strong\u003e\u003cstrong\u003eEat sweets like cake, cookies, pastries, donuts, muffins, chocolate and candies more than 2 times per day. \u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"162\"\u003e\n\u003cp\u003e\u003cstrong\u003eUsually/Often (1)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"90\"\u003e\n\u003cp\u003e678(16.9)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"102\"\u003e\n\u003cp\u003e165(17.9)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"108\"\u003e\n\u003cp\u003e513(16.6)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd rowspan=\"3\" width=\"78\"\u003e\n\u003cp\u003e0.432\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"162\"\u003e\n\u003cp\u003e\u003cstrong\u003eSometimes (2)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"90\"\u003e\n\u003cp\u003e1676(41.7)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"102\"\u003e\n\u003cp\u003e369(40.1)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"108\"\u003e\n\u003cp\u003e1307(42.2)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"162\"\u003e\n\u003cp\u003e\u003cstrong\u003eRarely/Never (3)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"90\"\u003e\n\u003cp\u003e1661(41.4)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"102\"\u003e\n\u003cp\u003e387(42)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"108\"\u003e\n\u003cp\u003e1274(41.2)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd rowspan=\"3\" width=\"526\"\u003e\n\u003cp\u003e\u003cstrong\u003e13. \u003c/strong\u003e\u003cstrong\u003eDrink 16 ounces or more of non-diet soda, fruit drink/punch or Kool-Aid a day? Note: 1 can of soda = 12 ounces \u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"162\"\u003e\n\u003cp\u003e\u003cstrong\u003eUsually/Often (1)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"90\"\u003e\n\u003cp\u003e259(6.5)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"102\"\u003e\n\u003cp\u003e72(7.8)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"108\"\u003e\n\u003cp\u003e187(6)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd rowspan=\"3\" width=\"78\"\u003e\n\u003cp\u003e0.001\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"162\"\u003e\n\u003cp\u003e\u003cstrong\u003eSometimes (2)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"90\"\u003e\n\u003cp\u003e573(14.3)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"102\"\u003e\n\u003cp\u003e159(17.3)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"108\"\u003e\n\u003cp\u003e414(13.4)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"162\"\u003e\n\u003cp\u003e\u003cstrong\u003eRarely/Never (3)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"90\"\u003e\n\u003cp\u003e3183(79.3)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"102\"\u003e\n\u003cp\u003e690(74.9)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"108\"\u003e\n\u003cp\u003e2493(80.6)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"526\"\u003e\n\u003cp\u003e\u003cstrong\u003e14. \u003c/strong\u003e\u003cstrong\u003eYou or a member of your family usually shops and cooks rather than eating sit-down or take-out restaurant food? \u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"162\"\u003e\n\u003cp\u003e\u003cstrong\u003eYes \u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"90\"\u003e\n\u003cp\u003e3673(91.5)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"102\"\u003e\n\u003cp\u003e831(90.2)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"108\"\u003e\n\u003cp\u003e2842(91.9)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"78\"\u003e\n\u003cp\u003e0.120\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"526\"\u003e\n\u003cp\u003e\u003cstrong\u003e15. \u003c/strong\u003e\u003cstrong\u003eUsually feel well enough to shop or cook. \u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"162\"\u003e\n\u003cp\u003e\u003cstrong\u003eYes\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"90\"\u003e\n\u003cp\u003e3876(96.5)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"102\"\u003e\n\u003cp\u003e872(94.7)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"108\"\u003e\n\u003cp\u003e3004(97.1)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"78\"\u003e\n\u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"6\" width=\"1066\"\u003e\n\u003cp\u003eValues represented by N (%); x\u003csup\u003e2 \u003c/sup\u003ewas done for comparison between Ever WTC-OAD and Never WTC-OAD. Significant values reported if p\u0026lt;0.05.\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cu\u003e\u003cbr /\u003e \u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cu\u003e\u0026nbsp;\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" width=\"616\"\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"6\" width=\"616\"\u003e\n\u003cp\u003e\u003cstrong\u003eTable 3. Dietary Quality Subgroup Analysis \u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd rowspan=\"2\" width=\"111\"\u003e\n\u003cp\u003e\u003cstrong\u003eTime\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd rowspan=\"2\" width=\"111\"\u003e\n\u003cp\u003e\u003cstrong\u003eSpirometry\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"3\" width=\"321\"\u003e\n\u003cp\u003e\u003cstrong\u003eDietary Quality\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd rowspan=\"2\" width=\"72\"\u003e\n\u003cp\u003e\u003cstrong\u003ep\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"112\"\u003e\n\u003cp\u003e\u003cstrong\u003eLow\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e(N=61)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"112\"\u003e\n\u003cp\u003e\u003cstrong\u003eModerate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e(N=1894)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"97\"\u003e\n\u003cp\u003e\u003cstrong\u003eHigh\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e(N=2060)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd rowspan=\"3\" width=\"111\"\u003e\n\u003cp\u003e\u003cstrong\u003e1\u003csup\u003est\u003c/sup\u003e\u0026nbsp;Post-9/11\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"111\"\u003e\n\u003cp\u003e\u003cstrong\u003eFEV\u003csub\u003e1%Pred\u003c/sub\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"112\"\u003e\n\u003cp\u003e93.57(15.34)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"112\"\u003e\n\u003cp\u003e96.28(14.01)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"97\"\u003e\n\u003cp\u003e97.61(13.94)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"72\"\u003e\n\u003cp\u003e\u0026lt;0.01\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"111\"\u003e\n\u003cp\u003e\u003cstrong\u003eFVC\u003csub\u003e%Pred\u003c/sub\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"112\"\u003e\n\u003cp\u003e90.30(13.28)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"112\"\u003e\n\u003cp\u003e91.95(12.15)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"97\"\u003e\n\u003cp\u003e92.81(12.09)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"72\"\u003e\n\u003cp\u003e0.04\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"111\"\u003e\n\u003cp\u003e\u003cstrong\u003eFEV\u003csub\u003e1\u003c/sub\u003e/FVC\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"112\"\u003e\n\u003cp\u003e0.83(0.05)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"112\"\u003e\n\u003cp\u003e0.84(0.06)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"97\"\u003e\n\u003cp\u003e0.84(0.06)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"72\"\u003e\n\u003cp\u003e0.79\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd rowspan=\"3\" width=\"111\"\u003e\n\u003cp\u003e\u003cstrong\u003eREAP-S\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"111\"\u003e\n\u003cp\u003e\u003cstrong\u003eFEV\u003csub\u003e1%Pred\u003c/sub\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"112\"\u003e\n\u003cp\u003e86.45(19.87)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"112\"\u003e\n\u003cp\u003e91.95(14.28)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"97\"\u003e\n\u003cp\u003e94.12(14.08)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"72\"\u003e\n\u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"111\"\u003e\n\u003cp\u003e\u003cstrong\u003eFVC\u003csub\u003e%Pred\u003c/sub\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"112\"\u003e\n\u003cp\u003e85.82(14.86)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"112\"\u003e\n\u003cp\u003e90.58(12.32)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"97\"\u003e\n\u003cp\u003e92.64(12.51)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"72\"\u003e\n\u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"111\"\u003e\n\u003cp\u003e\u003cstrong\u003eFEV\u003csub\u003e1\u003c/sub\u003e/FVC\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"112\"\u003e\n\u003cp\u003e0.77(0.08)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"112\"\u003e\n\u003cp\u003e0.77(0.06)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"97\"\u003e\n\u003cp\u003e0.77(0.05)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"72\"\u003e\n\u003cp\u003e0.46\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"6\" width=\"616\"\u003e\n\u003cp\u003eAll values displayed as mean(SD). p-value calculated by ANOVA.\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e\n"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"respiratory-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"rere","sideBox":"Learn more about [Respiratory Research](http://respiratory-research.biomedcentral.com/)","snPcode":"12931","submissionUrl":"https://submission.nature.com/new-submission/12931/3","title":"Respiratory Research","twitterHandle":"@RespiratoryBMC","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"metabolic syndrome, nutrition, diet","lastPublishedDoi":"10.21203/rs.3.rs-40956/v2","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-40956/v2","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBACKGROUND.\u003c/strong\u003e Diet is a modifier of metabolic syndrome which in turn is associated with World Trade Center Obstructive Airways Disease(WTC-OAD). We have designed this study to \u003cstrong\u003e1.\u003c/strong\u003eassess the dietary phenotype(food types, physical activity, and dietary habits) of the Fire Department of New York(FDNY) WTC-Health Program(WTC-HP) cohort and \u003cstrong\u003e2.\u003c/strong\u003equantify the association of dietary quality and its advanced glycation end product(AGE) content with the development of WTC-OAD.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eMETHODS.\u003c/strong\u003e WTC-OAD, defined as developing WTC-Lung Injury(WTC-LI;FEV\u003csub\u003e1\u003c/sub\u003e\u0026lt;LLN) and/or airway hyperreactivity(AHR;positive methacholine and/or positive bronchodilator response). Rapid Eating and Activity Assessment for Participants-Short Version(REAP-S)\u003cstrong\u003e \u003c/strong\u003edeployed on 3/1/2018 in the WTC-HP annual monitoring assessment. Clinical and REAP-S data of consented subjects was extracted(7/17/2019). Diet quality[low-(15-19), moderate-(20-29), and high-(30-39)] and AGE content per REAP-S questionnaire were assessed for association with WTC-OAD. Regression models adjusted for smoking,hyperglycemia,hypertension,age on 9/11,WTC-exposure,BMI and job description. \u003c/p\u003e\u003cp\u003e\u003cstrong\u003eRESULTS. \u003c/strong\u003eN=9,508 completed the annual questionnaire, while N=4,015 completed REAP-S and had spirometry. WTC-OAD developed in N=921, while N=3,094 never developed WTC-OAD. Low- and moderate-dietary quality, eating more (processed meats,fried foods,sugary drinks), fewer(vegetables,whole-grains),and having a diet abundant in AGEs were significantly associated with WTC-OAD. Smoking was not a significant risk factor of WTC-OAD. \u003c/p\u003e\u003cp\u003e\u003cstrong\u003eCONCLUSIONS. \u003c/strong\u003eREAP-S was successfully implemented in the FDNY WTC-HP monitoring questionnaire and produced valuable dietary phenotyping. Our observational study has identified low dietary quality and AGE abundant dietary habits as risk factors for pulmonary disease in the context of WTC-exposure. Dietary phenotyping, not only focuses our metabolomic/biomarker profiling but also further informs future dietary interventions that may positively impact particulate matter associated lung disease.\u003c/p\u003e","manuscriptTitle":"Dietary Phenotype and Advanced Glycation End-Products Predict WTC-Obstructive Airways Disease: a Longitudinal Observational Study","msid":"","msnumber":"","nonDraftVersions":[{"code":2,"date":"2020-12-04 21:25:10","doi":"10.21203/rs.3.rs-40956/v2","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Accept","date":"2020-12-02T00:00:00+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2020-11-27T00:00:00+00:00","index":1,"fulltext":"Recommendation: Reviewer's comments unavailable due to the journal's policy.\n"},{"type":"reviewerAgreed","content":"","date":"2020-11-26T00:00:00+00:00","index":1,"fulltext":""},{"type":"reviewersInvited","content":"","date":"2020-11-24T00:00:00+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2020-11-23T00:00:00+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2020-11-22T23:00:00+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2020-11-22T23:00:00+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"respiratory-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"rere","sideBox":"Learn more about [Respiratory Research](http://respiratory-research.biomedcentral.com/)","snPcode":"12931","submissionUrl":"https://submission.nature.com/new-submission/12931/3","title":"Respiratory Research","twitterHandle":"@RespiratoryBMC","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true}},{"code":1,"date":"2020-07-15 19:23:56","doi":"10.21203/rs.3.rs-40956/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2020-10-15T12:00:00+00:00","index":2,"fulltext":"Recommendation: Reviewer's comments unavailable due to the journal's policy.\n"},{"type":"decision","content":"Major revision","date":"2020-10-15T12:00:00+00:00","index":"","fulltext":""},{"type":"reviewerAgreed","content":"","date":"2020-09-30T12:00:00+00:00","index":2,"fulltext":""},{"type":"editorInvitedReview","content":"","date":"2020-08-30T12:00:00+00:00","index":1,"fulltext":"Recommendation: Reviewer's comments unavailable due to the journal's policy.\n"},{"type":"reviewerAgreed","content":"","date":"2020-08-17T12:00:00+00:00","index":1,"fulltext":""},{"type":"reviewersInvited","content":"","date":"2020-08-14T12:00:00+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2020-07-10T12:00:00+00:00","index":"","fulltext":""},{"type":"submitted","content":"","date":"2020-07-09T12:00:00+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2020-07-09T12:00:00+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2020-07-09T12:00:00+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"respiratory-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"rere","sideBox":"Learn more about [Respiratory Research](http://respiratory-research.biomedcentral.com/)","snPcode":"12931","submissionUrl":"https://submission.nature.com/new-submission/12931/3","title":"Respiratory Research","twitterHandle":"@RespiratoryBMC","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"a53dbf06-112f-48f1-bd46-3341fc977c0f","owner":[],"postedDate":"December 4th, 2020","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[{"id":162412,"name":"Nutrition \u0026 Dietetics"},{"id":162413,"name":"Pulmonology"}],"tags":[],"updatedAt":"2021-01-26T15:04:14+00:00","versionOfRecord":{"articleIdentity":"rs-40956","link":"https://doi.org/10.1186/s12931-020-01596-6","journal":{"identity":"respiratory-research","isVorOnly":false,"title":"Respiratory Research"},"publishedOn":"2021-01-18 15:02:14","publishedOnDateReadable":"January 18th, 2021"},"versionCreatedAt":"2020-12-04 21:25:10","video":"","vorDoi":"10.1186/s12931-020-01596-6","vorDoiUrl":"https://doi.org/10.1186/s12931-020-01596-6","workflowStages":[]},"version":"v2","identity":"rs-40956","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-40956","identity":"rs-40956","version":["v2"]},"buildId":"cBFmMYwuxLRRLfASyISRj","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}