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American Journal of Epidemiology Advance Access published online on December 5, 2007
American Journal of Epidemiology, doi:10.1093/aje/kwm343
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American Journal of Epidemiology Published by the Johns Hopkins Bloomberg School of Public Health 2007.

Original Contribution

Dietary Fiber, Lung Function, and Chronic Obstructive Pulmonary Disease in the Atherosclerosis Risk in Communities Study

Haidong Kan1, June Stevens2,3, Gerardo Heiss3, Kathryn M. Rose3 and Stephanie J. London1

1 Epidemiology Branch, National Institute of Environmental Health Sciences, National Institutes of Health, Department of Health and Human Services, Research Triangle Park, NC
2 Department of Nutrition, School of Public Health, The University of North Carolina at Chapel Hill, Chapel Hill, NC
3 Department of Epidemiology, School of Public Health, The University of North Carolina at Chapel Hill, Chapel Hill, NC

Correspondence to Dr. Stephanie J. London, Epidemiology Branch, National Institute of Environmental Health Sciences, P.O. Box 12233, Mail Drop A3-05, Research Triangle Park, NC 27709 (e-mail: london2{at}niehs.nih.gov).

Received for publication June 28, 2007. Accepted for publication October 25, 2007.


   ABSTRACT
TOP
 ABSTRACT
INTRODUCTION
 MATERIALS AND METHODS
 RESULTS
 DISCUSSION
 References
 
Recent data suggest beneficial effects of fiber intake on chronic respiratory symptoms in adults that are independent of antioxidant vitamin intake, but little is known about fiber consumption in relation to lung function and chronic obstructive pulmonary disease (COPD). The authors investigated the association of fiber intake with lung function and COPD in 11,897 US men and women from the Atherosclerosis Risk in Communities study (1987–1989). After control for potential confounders, positive associations were found between lung function and fiber intake from all sources as well as from cereal or fruit alone. Compared with those in the lowest quintile, participants in the highest quintile of total fiber intake had a 60.2-ml higher forced expiratory volume in 1 second (FEV1) (p for trend < 0.001), 55.2-ml higher forced vital capacity (FVC) (p = 0.001), 0.4% higher FEV1/FVC ratio (p = 0.040), 1.8% higher percent predicted FEV1 (p < 0.001), and 1.4% higher percent predicted FVC (p = 0.001). Adjusted odds ratios of COPD for the highest versus lowest quintiles of intake were 0.85 (p = 0.044) for total fiber, 0.83 (p = 0.021) for cereal fiber, and 0.72 (p = 0.005) for fruit fiber. This study provides the first known evidence that dietary fiber is independently associated with better lung function and reduced prevalence of COPD.

dietary fiber; forced expiratory volume; pulmonary disease, chronic obstructive; respiratory function tests; vital capacity

Abbreviations: ARIC, Atherosclerosis Risk in Communities; COPD, chronic obstructive pulmonary disease; FEV1, forced expiratory volume in 1 second; FVC, forced vital capacity


   INTRODUCTION
TOP
 ABSTRACT
 INTRODUCTION
MATERIALS AND METHODS
 RESULTS
 DISCUSSION
 References
 
Extensive research has focused on the protective effects of dietary fiber on cardiovascular diseases, including ischemic heart disease, stroke, peripheral arterial diseases, hypertension, and atherosclerosis (1). The antiinflammatory (2) and antioxidant (3, 4) properties of fiber may contribute to cardiovascular protection.

Chronic obstructive pulmonary disease (COPD), characterized by airflow limitation that is not fully reversible, is an important cause of mortality and morbidity (5). The prevalence of and mortality from COPD are increasing, even in developed countries (5, 6). Consistent with the potent inflammatory properties of tobacco smoke and the risk of COPD prominently associated with it (7), antiinflammatory nutrients may protect against the disease (8–12). A number of studies have found inverse associations between intake of antioxidant vitamins or fruits and respiratory symptoms or illness. In a large cohort of Chinese Singaporeans, higher consumption of fiber was protective against the development of symptoms of chronic bronchitis, independent of intake of antioxidant vitamins and fruits, and adjustment for fiber diminished or obliterated the beneficial associations with antioxidant vitamins or fruits (13). However, few studies have considered fiber in relation to lung function, respiratory symptoms, or COPD.

The purpose of this study was to test the hypothesis that dietary intake of fiber is independently associated with better lung function and a lower prevalence of COPD. We examined this hypothesis in the middle-aged men and women sampled from four US communities by the Atherosclerosis Risk in Communities (ARIC) study.


   MATERIALS AND METHODS
TOP
 ABSTRACT
 INTRODUCTION
 MATERIALS AND METHODS
RESULTS
 DISCUSSION
 References
 
Subjects
The design, objectives, and quality control of the ARIC study have been reported in detail previously (14). Participants were sampled from four US communities: Forsyth County, North Carolina; Jackson, Mississippi; northwest suburbs of Minneapolis, Minnesota; and Washington County, Maryland. The Jackson sample was 100 percent African American, and the other three were predominantly White. Eligible participants were interviewed at home and were then invited to a baseline clinical examination in 1987–1989, which was completed by 15,792 African-American and White men and women aged 44–66 years. For this analysis, the lung function variables collected during visit 1 (the baseline examination, 1987–1989) were used in combination with the dietary data in a cross-sectional analysis. Institutional review boards at the participating centers approved the study.

Lung function testing and chronic obstructive pulmonary disease
The main measures of lung function were forced expiratory volume in 1 second (FEV1), the volume of gas exhaled in the first second of expiration; forced vital capacity (FVC), the total volume of gas exhaled; the FEV1/FVC ratio; and percent predicted FEV1 and FVC. In accordance with American Thoracic Society criteria and a standardized protocol, trained clinic technicians used a Collins Survey II water-seal spirometer (Collins Medical, Inc., Braintree, Massachusetts) that was connected to an IBM PC/XT computer (IBM Inc., Armonk, New York) and controlled by the Pulmo-Screen II software system (PDS Healthcare Products, Inc., Louisville, Colorado). Quality control was carefully conducted throughout the study, as described previously (15). Sex-specific predicted values for FEV1 and FVC, adjusted for age and height, were computed from the equation of Crapo et al. (16). For Blacks, equation-derived predictions were multiplied by 0.88 (17).

We considered two COPD-related phenotypes. We defined chronic bronchitis by using self-reported persistent cough and production of phlegm on most days for at least 3 consecutive months of the year for 2 or more years. We used Global Initiative for Chronic Obstructive Lung Disease criteria (FEV1/FVC ratio < 0.7 and FEV1 < 80 percent predicted) to classify COPD based on spirometry, although postbronchodilator values were not available (18). We also created a composite COPD category of subjects who had either of the two phenotypes. In supplementary analyses, we also considered self-reported physician diagnosis of emphysema as an additional endpoint.

Dietary assessment
Participants' usual dietary intake over the preceding year was assessed by using an interviewer-administered, 66-item semiquantitative food frequency questionnaire, a modified version of the 61-item instrument designed and validated by Willett et al. (19) for self-administration. In the Nurses' Health Study, the correlation coefficient of energy-adjusted crude fiber between the questionnaire and four 1-week dietary records was 0.58 (19). To improve completeness and accuracy, our questionnaire was administered by trained interviewers. Participants were asked to report the frequency of consumption of each food in nine categories, ranging from never or less than one time per month to six or more times per day. Interviewers also obtained additional information, including the brand name of the breakfast cereal usually consumed. Each participant's daily intake of various nutrients was computed by multiplying the daily servings of each food item by their nutrient content. The nutrient content of food items was taken primarily from US Department of Agriculture sources (20, 21); dietary fiber content was obtained from a publication by Paul and Southgate (22). All dietary factors in our analysis were adjusted for total energy by using the residual method (23).

Other covariates
Anthropometric measures were determined by trained, certified technicians following a standardized protocol. Body mass index was calculated as weight in kilograms divided by height in meters squared. Interviewers collected information on age, ethnicity, gender, smoking, environmental tobacco smoke, occupation, education, medical history, and other factors. For smoking history, participants were first classified as current smokers, former smokers, and never smokers. Never and former smokers were classified as exposed to environmental tobacco smoke if they reported being in close contact with smokers for more than 1 hour per week (24). Thus, five strata for active and passive smoking were obtained: current smoker, former smoker exposed to environmental tobacco smoke, former smoker not exposed to environmental tobacco smoke, never smoker exposed to environmental tobacco smoke, and never smoker not exposed to environmental tobacco smoke. Residence-based traffic density was calculated as a measure of exposure to traffic-related air pollution (25).

Statistical analysis
We excluded persons who met the following criteria: ethnicity other than African American or White (n = 48) and, because of their small number (n = 55), African Americans from the Minnesota and Maryland field centers; missing data on spirometry (n = 127) or dietary fiber (n = 364); and missing or incomplete information on covariates, including active and passive smoking status (n = 1,871), total energy intake (n = 38), traffic exposure (n = 1,724), and diabetes (n = 148). Exclusions overlapped in some instances, leaving 11,897 subjects for analysis.

The relation between fiber intake and lung function measurements was explored by using linear regression. Our basic model included only age, sex, height, and square of height. On the basis of previous literature, we included the following additional factors in the adjusted models: study center, ethnicity, smoking status (current smoker, former smoker exposed to environmental tobacco smoke, former smoker not exposed to environmental tobacco smoke, never smoker exposed to environmental tobacco smoke, never smoker not exposed to environmental tobacco smoke), pack-years of smoking, body mass index, occupation, education, diabetes status, traffic density, total energy intake, glycemic index, micronutrients (carotenoids; vitamins C, D, and E; and omega-3 polyunsaturated fatty acids) from both food and supplements, and cured meat (processed meat, bacon, and hot dogs).

The association between fiber intake and binary outcomes (chronic bronchitis, emphysema, spirometry-defined COPD, and the composite COPD variable) was analyzed by using multiple logistic regression. Similarly, we conducted analyses by using both basic and adjusted models with the covariates listed above, except for height and square of height.

We analyzed energy-adjusted fiber intake according to quintiles. We estimated the adjusted values of lung function measurements at each quintile of intake and the odds ratios of COPD by comparing the highest with the lowest quintiles. In tests for linear trends across increasing quintiles of fiber intake, we used the median values in each quintile. Covariates that might modify the effects of fiber, such as gender, ethnicity, and smoking, were evaluated for possible inclusion as interaction terms with dietary fiber.

SAS software (version 9.1.2; SAS Institute, Inc., Cary, North Carolina) was used for all statistical analyses.


   RESULTS
TOP
 ABSTRACT
 INTRODUCTION
 MATERIALS AND METHODS
 RESULTS
DISCUSSION
 References
 
Table 1 shows the descriptive characteristics of the ARIC participants at visit 1, stratified by quintiles of energy-adjusted total dietary fiber. Participants with a higher fiber intake tended to have a higher intake of carotenoids; vitamins C, D, and E; and omega-3 polyunsaturated fatty acids and a lower intake of cured meat. Subjects in the highest quintile of fiber intake were generally slightly older, more likely to be White, female, leaner, and less likely to be current smokers.


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  		TABLE 1. Baseline characteristics of the Atherosclerosis Risk in Communities study population (1987–1989) stratified by energy-adjusted total dietary fiber intake (n = 11,897)*

 
Consistent with previous reports (26, 27), the prevalence of spirometry-defined COPD (11.1 percent; n = 1,321) was much higher than that of symptom-based chronic bronchitis (5.6 percent; n = 669). The prevalence of COPD was 14.7 percent (n = 1,753) when defined by either chronic bronchitis or spirometry. Among subjects with chronic bronchitis, 35.4 percent had spirometry-defined COPD, and 17.9 percent of those with spirometry-defined COPD had chronic bronchitis.

There was a statistically significant dose-response relation between lung function (FEV1, FVC, FEV1/FVC ratio, and percent predicted FEV1 and FVC) and dietary fiber from all sources in both basic models (data not shown) and adjusted models (table 2). Compared with those in the lowest quintile, participants in the highest quintile of total fiber intake had 60.2-ml higher FEV1 (p for trend across quintiles < 0.001), 55.2-ml higher FVC (p = 0.001), 0.4 percent higher FEV1/FVC ratio (p = 0.040), 1.8 percent higher percent predicted FEV1 (p < 0.001), and 1.4 percent higher percent predicted FVC (p = 0.001). Similar patterns were found for fiber intake from cereal and fruit sources (table 2). Vegetable fiber was not significantly associated with any of the lung function measures (data not shown).


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  		TABLE 2. Mean values of adjusted lung function measurements across quintiles of energy-adjusted fiber intake for Atherosclerosis Risk in Communities study participants (1987–1989) (n = 11,897)*

 
After multivariate adjustment, prevalences of both chronic bronchitis and spirometry-defined COPD declined across increasing quintiles of total fiber intake, but the associations were statistically significant for only spirometry-defined COPD (p for trend across quintiles = 0.035) (table 3). For cereal fiber, we found statistically significant associations with both chronic bronchitis (p = 0.028) and spirometry-defined COPD (p = 0.017). For fruit fiber, odds ratios tended to decline with increasing quintiles of intake, with trends statistically significant for chronic bronchitis (p = 0.004) but not for spirometry-defined COPD (p = 0.083). When COPD was defined by either chronic bronchitis or spirometry, the odds ratios for the highest quintile of intake compared with the lowest quintile were 0.85 (p = 0.044) for total fiber, 0.83 (p = 0.021) for cereal fiber, and 0.72 (p = 0.005) for fruit fiber. Similar to our findings for pulmonary function, vegetable fiber was not significantly associated with any COPD phenotypes (data not shown).


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  		TABLE 3. Adjusted odds ratios of COPD*-related phenotypes in relation to energy-adjusted fiber intake for Atherosclerosis Risk in Communities study participants (1987–1989) (n = 11,897){dagger}

 
We examined whether sex, ethnicity, and smoking status modified the associations of fiber with FEV1 and COPD (defined by either chronic bronchitis or spirometry). We observed statistically significant associations between total fiber and FEV1 in all subgroups, with little evidence of interaction (table 4). For COPD, the tests for interaction were significant for only ethnicity (p for interaction = 0.003) (table 5). We observed a significant association of total fiber with COPD in Whites (p for trend across quintiles = 0.016) but not in Blacks (p = 0.300). Although subgroup analyses were significant for only males or current and past smokers, these differences were not statistically significant (p for interaction = 0.429 for gender and p for interaction = 0.275 for smoking).


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  		TABLE 4. Mean FEV1* (ml) across quintiles of energy-adjusted intake of total fiber, stratified by sex, ethnicity, and smoking status, in participants in the Atherosclerosis Risk in Communities study (1987–1989){dagger}

 

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  		TABLE 5. Adjusted odds ratios of COPD* across quintiles of energy-adjusted intake of total fiber, stratified by sex, ethnicity, and smoking status, for participants in the Atherosclerosis Risk in Communities study (1987–1989){dagger}

 
We considered whether fiber intake attenuated associations of individual nutrients or foods previously associated with lung function or COPD. A statistically significant beneficial association of carotenoid intake with FEV1 was eliminated after adjustment for fiber (this information is described in Web table S1, the first of three supplementary tables; each is referred to as "Web table" in the text and is posted on the Journal's website (http://aje.oupjournals.org/)); likewise, a significant inverse association with preserved meats was attenuated by adjustment for fiber. None of the estimated vitamin intakes were associated with either of the COPD phenotypes examined.

In our supplemental analysis of self-reported physician diagnosis of emphysema (n = 211 cases, Web table S2), we observed significant inverse associations for the three fiber variables, which were statistically significant for total fiber (p = 0.025) and fruit fiber (p = 0.006).


   DISCUSSION
TOP
 ABSTRACT
 INTRODUCTION
 MATERIALS AND METHODS
 RESULTS
 DISCUSSION
References
 
In this cross-sectional analysis of middle-aged adults, we found beneficial associations of dietary fiber from all sources and from cereal and fruit with lung function and COPD. Of note, these beneficial associations of higher fiber intake were not explained by greater intake of other dietary nutrients including carotenoids; vitamins C, D, and E; or omega-3 polyunsaturated fatty acids, nor by lower intake of cured meat, nor by a large array of risk factors for reduced pulmonary function and COPD.

Higher intake of dietary antioxidants (e.g., vitamins C and E, β-carotene) (28–31), foods rich in antioxidants (e.g., fruits and vegetables) (32–34), omega-3 polyunsaturated fatty acids (35), and fish (35–37) has been associated with better lung function and reduction of COPD symptoms and mortality; conversely, frequent cured meat consumption has been associated with an obstructive pattern of lung function and increased odds of COPD (38). Some studies found stronger associations for fruit intake than for individual fruit-related nutrients such as vitamin C and carotenoids (9, 11), suggesting that other associated nutrients may be more relevant in protecting the lung from oxidative stressors. Dietary fiber is thought to contribute to the beneficial health effects on cardiovascular endpoints of intake of fruit, whole grains, and vegetables (3, 4, 39) but has seldom been studied in relation to lung disease. In the Singapore Chinese Health Study, nonstarch polysaccharides, a major component of dietary fiber, reduced the incidence of chronic bronchitis symptoms (13). Relevant to interpretation of previous findings on diet and lung disease that did not consider the role of fiber, in the Singapore study, adjustment for fiber intake eliminated univariate associations with intake of antioxidant micronutrients or fruit (13).

The hypothesis that higher dietary intake of fiber might protect against reduced lung function and COPD is biologically plausible. Both airway inflammation and oxidative stress play roles in the pathogenesis of chronic bronchitis, emphysema (5), and deterioration of lung function (40). The beneficial association of dietary fiber with lung function and COPD we observed may be due to the antiinflammatory and/or antioxidant properties of fiber (2–4, 41–46). Fiber intake has been associated with reduced level of C-reactive protein (43–46), a marker of systemic inflammation. Fiber may modulate inflammation by several mechanisms, including slowing the absorption of glucose (47), decreasing lipid oxidation (2), or influencing the production of antiinflammatory cytokines by the gut flora (48). Another possibility is that some constituents of fiber, such as trace elements or associated nutrients (e.g., flavonoids) that we could not assess with our questionnaire, may have beneficial effects on the lung (13, 49). Another mechanism that theoretically could come into play is a substitution effect, replacing the intake of foods with detrimental effects. However, it is notable that, in another study, fiber intake was protective for chronic bronchitis symptoms independently of a deleterious association with a dietary pattern characterized by high intake of preserved and fresh meat, sodium, and refined carbohydrates (50). Furthermore, the effect of fiber in our study persisted after adjustment for preserved meat intake, which was related to increased risk of adverse respiratory events in two studies (38, 50). Thus, our study adds to growing evidence that fiber intake per se may have beneficial effects on the lung, independent of intake of other foods or nutrients or dietary patterns.

The concern might be raised that fiber intake simply reflects related behavior or clinical characteristics, such as smoking (table 1), that influence respiratory risk. However, the association with dietary fiber remained significant after careful adjustment for smoking as well as a wide variety of demographic, lifestyle, and dietary characteristics. Moreover, the protective effect of dietary fiber on lung function was similar in both smokers and nonsmokers (table 4), indicating that the protective effects of dietary fiber on lung function were independent of smoking behavior (51).

Neither sex, ethnicity, nor smoking status significantly modified the associations of total fiber intake with lung function measurements (table 4). Finding a protective effect of fiber intake on lung function in both smokers and nonsmokers is not unexpected. For nonsmokers, fiber intake may protect against deleterious effects of indoor and ambient air pollutants (25). In stratified analyses for COPD, however, the effect of dietary fiber was limited to Whites, and a test for interaction by race was significant (table 5). Similarly, Stevens et al. (52) reported a protective role of cereal fiber on the development of diabetes limited to White ARIC participants. The lack of association among African Americans in the ARIC study may be due to the smaller sample size (2,798 African-American vs. 9,099 White participants), lower intake of dietary fiber (16.5 percent of African-American vs. 21.1 percent of White participants were in the highest quintile of total fiber intake), and lower prevalence of COPD (11.0 percent in African-American vs. 15.9 percent in White participants). Although upon stratification by smoking the inverse association appeared to be limited to current and past smokers, the test for interaction by smoking was not statistically significant, and, as expected, there were far fewer cases of COPD among never smokers, limiting power.

The association between carotenoids intake and lung function was attenuated after adjustment for fiber (Web table S1). This finding is consistent with a previous report that the inverse association between antioxidant vitamins and chronic bronchitis symptoms diminished after adjustment for fiber (13). The earlier studies on antioxidant vitamins and lung function did not consider the role of fiber (28–30); therefore, it is unclear whether the previously reported associations with those vitamins were independent of fiber intake.

We found significant associations of lung function and COPD with cereal and fruit fiber, but not with vegetable fiber. These findings are consistent with a pooled analysis of studies of diet and coronary heart disease in which fiber from cereal and fruit, but not from vegetables, was inversely associated with disease risk (53). The lack of association with vegetable fiber also mirrors results from the Singapore Chinese Health Study, a population with a low intake of whole-grain cereals, in which fiber from fruit and soy, but not from vegetables, was associated with reduced risk of chronic bronchitis symptoms (13). It is possible that fiber from cereal or fruit may have physiologic effects that are more beneficial to the respiratory system than fiber from vegetables.

Limitations of our analysis should be noted. The Global Initiative for Chronic Obstructive Lung Disease criteria for COPD are based on postbronchodilator FEV1 (54); however, as in other large epidemiologic studies (55–58), we did not administer a bronchodilator. Thus, we could not distinguish reversible from nonreversible airway obstruction, and, as a result, our spirometry-defined COPD group may have included asthmatics. Furthermore, a temporal relation between fiber intake and lung function and COPD could not be established in this cross-sectional analysis. It is possible that participants with symptoms or a diagnosis of COPD could have responded by changing to a healthier diet with increased intake of fruit and whole grains. However, few studies linked diet with COPD during the study period (1987–1989), making it quite unlikely that participants with COPD would have been advised to make these dietary changes. Although we had two measures of pulmonary function at both visits 1 and 2, the visits were only 3 years apart, which is probably insufficient to detect longitudinal effects of fiber intake (59). Nevertheless, we performed supplementary longitudinal analyses (Web table S3); we found significant inverse associations of declines in FEV1, FVC, and percent predicted FEV1 with cereal fiber, but not with total or fruit fiber.

We concluded that higher dietary intake of fiber was related to better lung function and reduced prevalence of COPD. These beneficial associations with fiber intake were independent of other nutrients or dietary patterns that have been suggested to have either beneficial or deleterious effects on respiratory health. To our knowledge, this study is the first to examine fiber intake in relation to pulmonary function and COPD. Our findings suggest that greater intake of dietary fiber may protect against deterioration of lung function, and possibly against COPD.


   ACKNOWLEDGMENTS
 
The Atherosclerosis Risk in Communities study is carried out as a collaborative study supported by National Heart, Lung, and Blood Institute contracts N01-HC-55015, N01-HC-55016, N01-HC-55018, N01-HC-55019, N01-HC-55020, N01-HC-55021, and N01-HC-55022. This work was also supported by the Intramural Research Program, National Institute of Environmental Health Sciences (project no. Z01 ES043012 [GenBank] ).

June Stevens' institution (Department of Nutrition) received unrestricted gifts from Sanofi-Aventis (Bridgewater, New Jersey) and the Gatorade Corporation (Barrington, Illinois).


   References
TOP
 ABSTRACT
 INTRODUCTION
 MATERIALS AND METHODS
 RESULTS
 DISCUSSION
 References
 

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J. A. Nettleton, J. L. Follis, and M. B. Schabath
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