Asthma, PTSD, BMI Linked to GERD in 9/11 Responders

Marcia Frellick

September 08, 2016

Two papers published in a special September 11 edition of the American Journal of Industrial Medicine look more deeply into one of the prominent adverse effects seen among responders to and survivors of the 2001 World Trade Center (WTC) attacks: gastroesophageal reflux disease (GERD).

Studies have found that GERD, with symptoms of acid reflux, sore throat, chest burning/tightness, and difficulty swallowing, persists among responders who developed the condition after WTC exposure.

The papers are part of a package of stories detailing physical and mental health effects 15 years after 9/11.

In the first GERD study, Nikolina Icitovic, MAS, from the Department of Preventive Medicine at the Icahn School of Medicine at Mount Sinai in New York City, and colleagues found an elevated risk for GERD among general responders, regardless of body mass index (BMI), compared with the general population, but also that high BMI exacerbates the risk.

A previous study had found that 34% of adults in the WTC health registry were in the overweight range, and 43% were obese. Because of the potential that losing weight could modify GERD, researchers wanted to study the link between the disease and BMI.

They found that the rates of GERD in all three responder body size groups were higher than the 20% prevalence in the general US population, as reported by the National Institute of Diabetes and Digestive and Kidney Diseases in 2014. Of the normal weight responders (<25 kg/m2), 33% had certified GERD compared with 36% of overweight (25-30 kg/m2) responders and 39% of those who were obese (>30 kg/m2).

The hazard ratio for normal vs overweight was 0.81 (95% confidence interval [CI], 0.75 - 0.88), normal vs obese was 0.71 (95% CI, 0.66 - 0.77), and overweight vs obese was 0.88 (95% CI, 0.83 - 0.92).

"The results of this analysis indicate that WTC responders who are overweight or obese might reduce their risk of developing GERD via weight reduction programs," the authors write. "Participation in preventive programs such as weight reduction has the potential to improve the overall quality of life of the responders, in addition to reducing the medical care that responders might require."

Links Between Asthma, PTSD, and GERD

In another study, Jiehui Li, MBBS, from the New York City Department of Health and Mental Hygiene, and colleagues examine the links between asthma and posttraumatic stress disorder (PTSD) and GERD onset after WTC exposure.

Studies have shown that prevalence of GERD symptoms ranges from 18% to 28% among US adults, but is much higher among those with asthma (up to 59%).

In the current study, Dr Li and colleagues found that in addition to a direct association between early diagnosed asthma and late-onset GERD, there was an indirect association between the conditions mediated by PTSD.

Of 29,406 enrollees in the WTC health registry, 23% reported GERD symptoms at follow-up in 2011 to 2012. Early post-9/11 asthma and PTSD each were independently linked with both the persistence of GERD at baseline and the development of GERD in people without a history of the symptoms.

"It is theorized that stress may cause changes in the brain that sensitize pain receptors and thus heighten awareness of slight increases in gastric acid levels," the authors write. "Stress may also increase gastric acid production or decrease the pressure of the lower esophageal sphincter."

Given these results, the authors recommend that clinicians assess patients with post-9/11 GERD symptoms for signs of comorbid asthma and PTSD and integrate treatment for these conditions. Successfully treating asthma and PTSD may reduce the risk for onset and persistence of GERD, they explain. And the findings may have broader meaning as well.

"The potential relationship between aero-digestive disorders and mental health should be recognized in future events where survivors experience a mixture of airborne and psychological exposures," the authors conclude.

The study by Dr Icitovic and colleagues was supported by the Centers for Disease Control and Prevention/National Institute for Occupational Safety and Health (CDC/NIOSH). The study by Dr Li and colleagues was supported by CDC/NIOSH with support from New York City Department of Health and Mental Hygiene. The authors have disclosed no relevant financial relationships.

Am J Ind Med. 2016;59:761-766, 805-814. Icitovic abstract, Lee abstract

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