Grantee Research Project Results
Final Report: Comparing Urban and Rural Effects of Poverty on COPD (CURE COPD)
EPA Grant Number: R836150Center: Comparing Urban and Rural Effects of Poverty on COPD
Center Director: Hansel, Nadia
Title: Comparing Urban and Rural Effects of Poverty on COPD (CURE COPD)
Investigators: Hansel, Nadia , Matsui, Elizabeth C. , McCormack, Meredith , Rand, Cynthia , Koehler, Kirsten
Institution: The Johns Hopkins University
EPA Project Officer: Callan, Richard
Project Period: July 1, 2015 through June 30, 2020 (Extended to June 30, 2022)
Project Amount: $1,500,000
RFA: NIH/EPA Centers of Excellence on Environmental Health Disparities Research (2015) RFA Text | Recipients Lists
Research Category: Human Health
Objective:
The Center’s aim was to increase understanding of the role of indoor air pollution to the COPD health disparities identified in low-income settings; we have chosen to focus our studies on the role of indoor air pollution (particulate matter, PM and nitrogen dioxide, NO2) exposures on COPD morbidity in two different low-income US communities: an urban community (Baltimore City) and a rural community (Appalachian region). We also have a specific focus on understanding the role of obesity and poor dietary intake (low anti-oxidant, pro-inflammatory diet) as factors that are common in low-income communities and may increase susceptibility to indoor pollution exposure.
Project 1:
Title: Obesity and adverse dietary patterns as susceptibility factors to pollutant exposure in urban COPD
The goal of Project 1 was to fully understand the complex interplay between poverty, air pollutants, obesity and diet, in two independent low-income urban and rural cohorts. In particular, Project 1 through an observational study, focused on low-income adults in an urban setting, aiming to determine whether elevated fat mass and body composition, adverse diet patterns increase susceptibility to indoor pollution in low income adults with COPD.
Project 2
Title: Indoor air pollution and COPD in rural Appalachia
The goal of the Program is to fully understand the complex interplay between poverty, air pollutants, obesity and diet, in two independent low-income urban and rural cohorts. In particular, Project 2 investigated the role of indoor air quality on respiratory health of residents of rural Appalachia.
Summary/Accomplishments (Outputs/Outcomes):
All projects included measures of outdoor and/or indoor air pollutants, including PM2.5, NO2 and airborne nicotine. The projects contribute to understanding the mechanisms by which these pollutants affect human health. Furthermore, air quality standards are informed by health effects in susceptible populations and these study results provide critical evidence to define susceptibility factors affected the adverse health effects of PM and NO2 exposure. In addition, the Community Engagement Core (CEC) worked successfully to educate the public about indoor air quality concerns and promote public action to reduce potential risks in homes, including among those with most exposure to indoor air pollutants (poor urban and rural residents) and those most susceptible (i.e., obese adults with COPD and those with poor dietary intake).
Project 1:
Project 1 telephone screened 995 potential eligible participants, of which 399 were eligible according to the phone screener. Of the 244 participants that signed a consent form, 115 qualified to actively take part in the study based on our clinical screening criteria (exhaled carbon monoxide, pre and post spirometry).
All 115 enrolled subjects completed screening questionnaires, exhaled carbon monoxide (eCO) and spirometry testing in order to confirm our case definition, which is based upon GOLD guidelines (http://goldcopd.org/wp-content/uploads/2017/11/GOLD-2018-v6.0-FINAL-revised-20-Nov_WMS.pdf). From the 115 enrolled and eligible, 99 completed their baseline clinic and home visit to assess the indoor air quality (PM, nitrogen dioxide and air nicotine), 86 completed their 6-month follow-up.
Participants enrolled were 57% Black, 57% female, and had an average of age of 66 years. 17.4% of the enrolled participants did not finish high school, 67% reported a yearly income lower than $30,000, and 26% report some degree of food insecurity based on the Household Food Insecurity Score.
Participants have a mean BMI of 32.3 (59.6% obese), and the correlation between BMI and body fat percentage obtained through Densitometry (DEXA) assessment was moderate- high (0.70, p<0.001).
Food Frequency Questionnaires were completed and analyzed on 95 participants at baseline and during each follow-up clinic visit. Participant’s mean total calorie intake was 2029 kcal and they consumed in average a low omega-3 (EPA +DHA) intake (0.31±0.34g) and a high omega-6 intake (14.6±8.3g) suggestive trends towards unhealthy diets.Indoor PM2.5, PM10 and NO2 were shown to be associated with increased COPD morbidity (see Table below) as shown in previous studies. In addition, pollution effects are worse in participants with low omega-3, specifically EPA/DHA intake. For example, PM2.5 and PM10 effects were worse among those with low EPA/DHA intake for CAT score, and cough /sputum symptoms. NO2 similarly had worse impact on cough / sputum symptoms and severe exacerbation risk (pint < 0.10).
Furthermore, when objectively measuring poor food quality intake (as measured by low omega-3 or EPA/DHA plasma levels) low omega-3 fatty acid intake was associated with poor respiratory outcome; as was food insecurity.
For Dr. Laura Paulin’s career development award (K23ES025781), we completed data collection for 59 participants into this ancillary study. Participant’s mean expectorated total mucin concentration was 8.43±11.36mg/mL and mean mucus percentage solid was 3.63±2.47. The mean percent mucociliary clearance (MCC) measure through 60 minutes and 90 minutes were 12.4±9.1 and 15.9±10.8 respectively. Preliminary analysis suggests that higher total mucin concentration worsens the adverse association between indoor nitrogen dioxide (NO2) and several COPD severity measures, including COPD assessment test score (CAT), and lung function as measured by FEV1 percent predicted.
In addition, 1) Dr. Ashraf Fawzy received a K23 award to look at markers of platelet activation to determine associations with indoor air pollution and respiratory outcomes; 2) Dr. Vickram Tejani investigated the role of macrophage black carbon as a marker of COPD worse clinical outcomes (Tejwani et al. COPD. 2021); and 3) Dr. Lesliam Quiroz and Dr. Daniel Belz are investigating the association between Phthalates (measured in urine samples) and COPD morbidity as part of an NRSA award; 4) Dr. Sarath Raju was recently awarded a K12 award “Understanding the Respiratory Health Effects of Air Pollution among Persons Living with HIV” and received an impact score of 20 on his recently submitted K23 award, entitled “Air Pollution’s Impact on Lung Aging in HIV”.
Finally, Associate Professor of Medicine, Dr. Nirupama Putcha, has published Home Dust Allergen Exposure is Associated with Outcomes Among Sensitized Individuals with COPD (Putcha et al. AJRCCM 2021). This study demonstrates that allergen exposures are common in COPD and associated with adverse outcomes among those with concomitant allergen sensitization. This work is novel in that it is the first to show that home allergen exposure may impact respiratory health in patients with COPD, regardless of eosinophil levels.
Project 2
Project 2 enrolled 124 COPD participants (78 completed baseline visits). Our second location is the George W. Comstock Center for Public Health Research and Prevention (the JHU Comstock Center) in Hagerstown, Maryland. Johns Hopkins University’s Comstock Center has a well-established relationship with the residents of Washington County and surrounding areas.
Participants enrolled were mostly white (98%), 58% male, and had an average age of 71.7 years and a mean BMI of 30.7 (51% obese). 26% of the enrolled participants did not finish high school, 44% reported a yearly income lower than $30,000 representing a relatively low-income population with COPD .Study results demonstrate that indoor air pollution is associated with increased respiratory morbidity among participants with COPD.
Conclusions:
Several publications have identified environmental and contextual factors in low income communities that are linked with respiratory morbidity and health disparities. These results are aligned with the original aims of the application aimed to understand social-environmental factors (i.e., diet, obesity and indoor air pollution) and their independent and combined effects on respiratory morbidity in patients with chronic lung disease.
In summary, these are some of our main findings:
- Indoor pollutants, specifically particulate matter (PM) and nitric oxide (NO2), are elevated in both urban and rural low-income communities, compared to outdoor concentrations
- Elevation in indoor PM concentrations is associated with adverse respiratory symptoms in patients with COPD in urban communities
- Elevation in indoor PM concentrations is associated with adverse respiratory symptoms in patients with COPD in rural communities
- Food insecurity and poor diet quality, specifically low omega-3 intake, are associate with adverse respiratory outcomes
- Adults with COPD and low omega-3 intake may have increased sensitivity to pollution exposure, resulting in worse respiratory outcomes
Our results have been disseminated through national and international meetings and symposiums and publications. During the award period 34 manuscripts were published by our investigative team, in addition to abstracts submitted to the ATS Conferences during the period. We anticipate that numerous manuscripts will continue to be published utilizing the rich data collected as part of this Center.
The Community Engagement Core (CEC) created the “Lung Health Ambassadors Program” (LHAP) which is a novel engagement and dissemination strategy developed over the course of the program award period. The LHAP developed and delivered training on issues of smoking, air pollution, lung health, obstructive lung diseases to middle and high-school students. Over the course of the program period we greatly expanded school engagement from Baltimore City to Baltimore County, Calvert County and St. Mary’s County in southern Maryland. Over one thousand and twenty-three (1023) 7th thru 12th grade school students representing 14 middle and high schools and two Baltimore City Recreation Centers participated in and completed training to become “Lung Health Ambassadors.” In response to the COVID-19 pandemic, we developed a new virtual learning program, where Johns Hopkins University students and staff shared information about the coronavirus with school kids to build K-12 student awareness about the science of COVID-19 and the public health response. The virtual platform necessitated by the pandemic allowed us to reach a greater and broader audience than we had previously been able to do. The COVID-19 curriculum has been distributed to 42 schools in 27 states and 7 countries and has been translated into 3 languages: Greek, Arabic, Spanish. To date more than 10,000 students have accessed the curriculum.
Overall, the work of the Center, identified that indoor pollutants are consistently associated with respiratory morbidity in several low-income settings, including both urban and rural communities. The work highlights that home indoor air is a potential modifiable environmental exposure which may improve respiratory health in those with chronic lung disease across multiple settings. Further, results from the Center support the hypothesis that poor diet quality may increase susceptibility to these adverse pollutant effects. Thus, work from the Center identifies other potential strategies, such as diet improvement, which may reduce harmful impacts of pollutants. The testing of the effectiveness and economic feasibility of intervention approaches are needed to further identify solutions for these important environmental problems. Broad community and student engagement to understand and work on environmental solutions is feasible through in-person and virtual formats.
Project 1
Based on preliminary data supporting the role of omega-3 consumption in COPD outcomes, we completed a feasibility pilot of a dietary intervention (food voucher program + dietary counseling) to increase Omega-3 intake. The pilot study randomized 20 participants (10 intervention group and 10 control group). At 4 weeks, intervention group reported a 4-fold increase in high-omega-3 rich fish and seafood intake (p=0.002); 43% increase in plasma EPA+DHA levels compared to control. This highlights the potential role of dietary approaches as a novel approach to improve respiratory disease management. Dr Hansel was awarded a new R01 award from NHLBI which will support a full trial of this hypothesis and related aims.
Journal Articles: 35 Displayed | Download in RIS Format
Other center views: | All 49 publications | 35 publications in selected types | All 35 journal articles |
---|
Type | Citation | ||
---|---|---|---|
|
Belli AJ, Bose S, Aggarwal N, DaSilva C, Thapa S, Grammer L, Paulin LM, Hansel NN. Indoor particulate matter exposure is associated with increased black carbon content in airway macrophages of former smokers with COPD. Environmental Research 2016;150:398-402. |
R836150 (2017) R836150 (2019) R836150 (2020) R836152 (2019) R836152 (2020) |
Exit |
|
Galiatsatos P, Kineza C, Hwang S, Pietri J, Brigham E, Putcha N, Rand CS, McCormack M, Hansel NN. Neighbourhood characteristics and health outcomes:evaluating the association between socioeconomic status, tobacco store density and health outcomes in Baltimore City. Tobacco Control 2018;27(e1):e19-e24. |
R836150 (2018) R836150 (2020) R836152 (2018) R836152 (2019) R836152 (2020) |
Exit |
|
Lambert AA, Putcha N, Drummond MB, Boriek AM, Hanania NA, Kim V, Kinney GL, McDonald MN, Brigham EP, Wise RA, McCormack MC, Hansel NN, COPDGene Investigators. Obesity is associated with increased morbidity in moderate to severe COPD. Chest 2017;151(1):68-77. |
R836150 (2017) R836150 (2019) R836150 (2020) R836152 (2019) R836152 (2020) |
Exit |
|
Lemoine C, Brigham E, Woo H, Koch A, Hanson C, Hoffman E, Putcha N, McCormack M, Hansel N. Relationship between Omega-3 and Omega-6 Fatty Acid Intake and Chronic Obstructive Pulmonary Disease Morbidity. ANNALS OF THE AMERICAN THORACIC SOCIETY 2020;17(3):379-383. |
R836150 (2021) |
Exit Exit |
|
Levy JI, Quiros-Alcala L, Fabian MP, Basra K, Hansel NN. Established and emerging environmental contributors to disparities in asthma and chronic obstructive pulmonary disease. Current Epidemiology Reports 2018;5(2):114-124. |
R836150 (2019) R836150 (2020) R836152 (2018) R836152 (2019) R836152 (2020) R836156 (2018) R836156 (2019) R836156 (2020) |
Exit |
|
McCormack MC, Belli AJ, Waugh D, Matsui EC, Peng RD, Williams DL, Paulin L, Saha A, Aloe CM, Diette GB, Breysse PN, Hansel NN. Respiratory effects of indoor heat and the interaction with air pollution in chronic obstructive pulmonary disease. Annals of the American Thoracic Society 2016;13(12):2125-2131. |
R836150 (2019) R836150 (2020) R836152 (2018) R836152 (2019) R836152 (2020) |
Exit Exit Exit |
|
McCormack MC, Paulin LM, Gummerson CE, Peng RD, Diette GB, Hansel NN. Colder temperature is associated with increased COPD morbidity. European Respiratory Journal 2017;49(6):1601501. |
R836150 (2018) R836150 (2019) R836150 (2020) R836152 (2019) R836152 (2020) |
Exit |
|
McCormack M, Balsubramanian A, Wise R, Keet C, Matsui E, Peng R. Reply by McCormack et al. to Townsend and Cowl, and to Miller et al. AMERICAN JOURNAL OF RESPIRATORY AND CRITICAL CARE MEDICINE 2022;206(6):795-796. |
R836150 (2021) |
Exit Exit |
|
Moughames E, Galiatsatos P, Woo H, Romero-Rivero K, Raju S, Hoffman E, Ortega V, Parekh T, Krishnan J, Drummond M, Buhr R, Comellas A, Couper D, Paine R, Paulin L, Putcha N, Hansel N. Disparities in access to food and chronic obstructive pulmonary disease (COPD)-related outcomes:a cross-sectional analysis. AMERICAN JOURNAL OF RESPIRATORY AND CRITICAL CARE MEDICINE 2021;21(1):139. |
R836150 (2021) |
Exit Exit |
|
Peterson CE, Rauscher GH, Johnson TP, Kirschner CV, Barrett RE, Kim S, Fitzgibbon ML, Joslin CE, Davis FG. The association between neighborhood socioeconomic status and ovarian cancer tumor characteristics. Cancer Causes and Control 2014;25(5):633-637. |
R836150 (2020) NIMHD002 (Final) |
Exit |
|
Tejwani V, Rueda A, Khare P, Zhang C, Le A, Putcha N, D'Alessio F, Alexis N, Hansel N, Fawzy A. Airway and Systemic Prostaglandin E2 Association with COPD Symptoms and Macrophage Phenotype. CHRONIC OBSTRUCTIVE PULMONARY DISEASES - JOURNALF OF THE COPD FOUNDATION 2023;10(2):159-169 |
R836150 (2021) |
Exit |
|
Wu T, Fawzy A, Brigham E, McCormack M, Rosas I, Villareal D, Hanania N. Association of Triglyceride-Glucose Index and Lung Health A Population-Based Study. CHEST 2021;160(3):1026-1034 |
R836150 (2021) R836152 (Final) |
Exit |
|
Younas H, Vieira M, Gu C, Lee R, Shin MK, Berger S, Loube J, Nelson A, Bevans-Fonti S, Zhong Q, D’Alessio FR. Caloric restriction prevents the development of airway hyperresponsiveness in mice on a high fat diet. Scientific reports 2019;9(1):1-9. |
R836150 (2020) R834510 (Final) R836152 (Final) |
Exit |
|
Raju S, Keet CA, Paulin LM, Matsui EC, Peng RD, Hansel NN, McCormack MC. Rural residence and poverty are independent risk factors for chronic obstructive pulmonary disease in the United States. American journal of respiratory and critical care medicine. 2019;199(8):961-969. |
R836150 (2019) R836150 (2020) R836152 (2019) R836152 (2020) |
Exit |
|
Tsou PY, McCormack MC, Matsui EC, Peng RD, Diette GB, Hansel NN, Davis MF. The effect of dog allergen exposure on asthma morbidity among inner‐city children with asthma. Pediatric Allergy and Immunology 2020;31(2):210-3. |
R836150 (2020) R832139 (Final) R834510 (Final) R836152 (Final) |
Exit |
|
Paulin LM, Gassett AJ, Alexis NE, Kirwa K, Kanner RE, Peters S, Krishnan JA, Paine R, Dransfield M, Woodruff PG, Cooper CB. Association of long-term ambient ozone exposure with respiratory morbidity in smokers. JAMA internal medicine 2020;180(1):106-15. |
R836150 (2020) |
Exit |
|
Tarazona-Meza CE, Hanson C, Pollard SL, Rivero KM, Davila RM, Talegawkar S, Rojas C, Rice JL, Checkley W, Hansel NN. Dietary patterns and asthma among Peruvian children and adolescents. BMC pulmonary medicine 2020;20(1):1-9. |
R836150 (2020) |
Exit |
|
Zuidema C, Stebounova LV, Sousan S, Gray A, Stroh O, Thomas G, Peters T, Koehler K. Estimating personal exposures from a multi-hazard sensor network. Journal of exposure science & environmental epidemiology 2020;30(6):1013-22. |
R836150 (2020) |
Exit |
|
Hersh CP, Zacharia S, Chelvan RP, Hayden LP, Mirtar A, Zarei S, Putcha N, COPDGene® Investigators. Immunoglobulin E as a biomarker for the overlap of atopic asthma and chronic obstructive pulmonary disease. Chronic Obstructive Pulmonary Diseases:Journal of the COPD Foundation 2020;7(1):1. |
R836150 (2020) |
|
|
Koch AL, Brown RH, Woo H, Brooker AC, Paulin LM, Schneider H, Schwartz AR, Diette GB, Wise RA, Hansel NN, Putcha N. Obstructive Sleep Apnea and Airway Dimensions in Chronic Obstructive Pulmonary Disease. Annals of the American Thoracic Society 2020;17(1):116-8. |
R836150 (2020) |
Exit |
|
Galiatsatos P, Gomez E, Lin CT, Illei PB, Shah P, Neptune E. Secondhand smoke from electronic cigarette resulting in hypersensitivity pneumonitis. BMJ Case Reports CP 2020;13(3):e233381. |
R836150 (2020) |
Exit |
|
Ghosh B, Park B, Bhowmik D, Nishida K, Lauver M, Putcha N, Gao P, Ramanathan Jr M, Hansel N, Biswal S, Sidhaye VK. Strong correlation between air-liquid interface cultures and in vivo transcriptomics of nasal brush biopsy. American Journal of Physiology-Lung Cellular and Molecular Physiology 2020;318(5):L1056-62. |
R836150 (2020) |
Exit |
|
Galiatsatos P, Woo H, Paulin LM, Kind A, Putcha N, Gassett AJ, Cooper CB, Dransfield MT, Parekh TM, Oates GR, Barr RG. The Association Between Neighborhood Socioeconomic Disadvantage and Chronic Obstructive Pulmonary Disease. International Journal of Chronic Obstructive Pulmonary Disease 2020;15:981. |
R836150 (2020) |
|
|
Galiatsatos P, Follin A, Alghanim F, Sherry M, Sylvester C, Daniel Y, Chanmugam A, Townsend J, Saria S, Kind AJ, Chen E. The Association Between Neighborhood Socioeconomic Disadvantage and Readmissions for Patients Hospitalized With Sepsis. Critical Care Medicine 2020;48(6):808-14. |
R836150 (2020) |
|
|
Raju S, Brigham EP, Paulin LM, Putcha N, Balasubramanian A, Hansel NN, McCormack MC. The Burden of Rural Chronic Obstructive Pulmonary Disease:Analyses from the National Health and Nutrition Examination Survey. American journal of respiratory and critical care medicine 2020;201(4):488-91. |
R836150 (2020) |
Exit |
|
Wu TD, Fawzy A, Kinney GL, Bon J, Neupane M, Tejwani V, Hansel NN, Wise RA, Putcha N, McCormack MC. Metformin use and respiratory outcomes in asthma-COPD overlap. Respiratory research 2021;22(1):1-8. |
R836150 (2021) R836152 (Final) |
Exit |
|
Afshar-Mohajer N, Wu TD, Shade R, Brigham E, Woo H, Wood M, Koehl R, Koehler K, Kirkness J, Hansel NN, Ramchandran G. Obesity, tidal volume, and pulmonary deposition of fine particulate matter in children with asthma. European Respiratory Journal 2022;59(3). |
R836150 (2021) R836152 (Final) |
Exit |
|
Galiatsatos P, Brigham E, Krasnoff R, Rice J, Van Wyck L, Sherry M, Rand CS, Hansel NN, McCormack MC. Association between neighborhood socioeconomic status, tobacco store density and smoking status in pregnant women in an urban area. Preventive Medicine 2020:106107. |
R836150 (2020) |
Exit |
|
Eakin MN, Eckmann T, Dinglas VD, Akinremi AA, Hosey M, Hopkins RO, Needham DM. Association between participant contact attempts and reports of being bothered in a national, longitudinal cohort study of ARDS survivors. Chest 2020 Mar 17. |
R836150 (2020) |
Exit |
|
Sharp M, Brown T, Chen ES, Rand CS, Moller DR, Eakin MN. Association of Medication Adherence and Clinical Outcomes in Sarcoidosis. Chest 2020 Feb 4. |
R836150 (2020) |
Exit |
|
Burkes RM, Ceppe AS, Doerschuk CM, Couper D, Hoffman EA, Comellas AP, Barr RG, Krishnan JA, Cooper C, Labaki WW, Ortega VE. Associations Among 25-Hydroxyvitamin D Levels, Lung Function, and Exacerbation Outcomes in COPD:An Analysis of the SPIROMICS Cohort. Chest 2020 Jan 17. |
R836150 (2020) |
Exit |
|
Balasubramanian A, Kolb TM, Damico RL, Hassoun PM, McCormack MC, Mathai SC. Diffusing Capacity is an Independent Predictor of Outcomes in Pulmonary Hypertension Associated with Chronic Obstructive Pulmonary Disease. Chest 2020 Mar 14. |
R836150 (2020) |
Exit |
|
Tarazona-Meza CE, Nicholson A, Romero KM, Pollard SL, Gálvez-Davila RM, Hansel NN, Checkley W. Household food insecurity is associated with asthma control in Peruvian children living in a resource-poor setting. Journal of Asthma 2019 Aug 26:1-8. |
R836150 (2020) |
Exit |
|
Hanson C, Brigham E. Maternal nutrition and child respiratory outcomes:paradigms of lung health and disease. Eur Respir J |
R836150 (2020) |
Exit |
|
Swarr D, Putcha N, Zacharias W. “PIK” ing Out New Epigenetic Markers in Lung Disease. Am J Respir Crit Care Med . |
R836150 (2020) |
Exit |
Supplemental Keywords:
ndoor air pollution, COPD, obesity, diet, rural, urbanRelevant Websites:
The JHU study website Exit , ETSU study website Exit
Progress and Final Reports:
Original Abstract Subprojects under this Center: (EPA does not fund or establish subprojects; EPA awards and manages the overall grant for this center).
R836150C001 Obesity and Adverse Dietary Patterns as Susceptibility Factors to Pollutant Exposure in Urban COPD
R836150C002 Environmental Health Disparities in Rural Appalachia: The impact of air pollution, obesity and diet on COPD morbidity
The perspectives, information and conclusions conveyed in research project abstracts, progress reports, final reports, journal abstracts and journal publications convey the viewpoints of the principal investigator and may not represent the views and policies of ORD and EPA. Conclusions drawn by the principal investigators have not been reviewed by the Agency.
Project Research Results
- 2021 Progress Report
- 2020 Progress Report
- 2019 Progress Report
- 2018 Progress Report
- 2017 Progress Report
- 2016 Progress Report
- Original Abstract
35 journal articles for this center