Epidemiology of air pollution and diabetes

doi:10.1016/j.tem.2015.05.002

Trends in Endocrinology & Metabolism

Volume 26, Issue 7, July 2015, Pages 384-394

https://doi.org/10.1016/j.tem.2015.05.002 Get rights and content

Highlights

•
Diabetic patients may be more vulnerable to ambient air pollution exposure effects.
•
Studies have linked air pollution exposure to type 2 diabetes development.
•
Studies on insulin resistance, glycemic control, and gestational diabetes support this notion.

Air pollution affects a large proportion of the global population. Air pollutants are hypothesized to exert their effects via impaired endothelial function, elevated systemic inflammation, mitochondrial dysfunction, and oxidative stress, all of which are hallmarks of type 2 diabetes (T2D). Here we review epidemiological studies aimed at answering whether diabetes patients are more vulnerable to ambient (outdoor) air pollution exposure and whether air pollution is associated with diabetes development or other predisposing conditions for T2D. Current evidence suggests an association between air pollution exposure and T2D, but more critical analysis is warranted. Understanding the associations between air pollution exposure and the development of T2D is critical in our efforts to control sources of air pollution and their impact on the disease.

Section snippets

The diabetes epidemic and ubiquitous air pollution exposure

Air pollution is a ubiquitous exposure that affects large proportions of the global population [1]. Air pollutants are emitted from many sources, such as industrial facilities, cars, trucks, ships, and airplanes, but also from household combustion devices or during forest fires and volcanic eruptions. Ambient or outdoor air pollution (referred to as air pollution hereafter) comprises particulate matter (PM) (see Glossary) of various sizes [<10 μm in diameter, PM₁₀; <2.5 μm, PM_2.5; <100 nm,

Are diabetes patients more vulnerable to ambient air pollution exposure?

Mainly case-crossover and time-series study designs have been used to compare the effects of short-term exposure to air pollutants on all-cause mortality rates among the general population and diabetic patients. A total of seven studies have been conducted in American, Italian, Canadian, and European populations 25, 26, 27, 28, 29, 30, 31, 32 involving between 12 978 [25] and 2935 647 [30] subjects with diabetes (for an overview see Figure 1A, for details see Table 1). Diabetes was not the

Prospective cohort studies

As discussed above, diabetic patients might be more susceptible to air pollution effects. Prospective studies can elucidate whether air pollution exposure only leads to accelerated progression of the disease or whether it directly contributes to its development. Prospective studies follow participants without diabetes for several years and evaluate potential associations between air pollution exposure at baseline or average air pollution exposure during the whole follow-up period with newly

Is ambient air pollution exposure associated with predisposing conditions for diabetes?

Studies on diabetes-related traits, which might be altered in subjects who have a higher diabetes risk, can provide further insight into the association between air pollution exposure and diabetes as well as the potential biological mechanisms underlying any association. The results of such studies are summarized in Figure 3 (for study details see Table 4).

HbA1c is a marker of the average blood glucose levels in an individual during the previous 30–120 days. In 9102 newly diagnosed T2D patients

Concluding remarks and future perspectives

There appears to be evidence indicative of an association between long-term exposure to main air pollutants and the development of T2D and diabetes-related mortality in adults. The results from studies that have investigated precursors of diabetes in healthy individuals strengthen the support for a potential association. However, a firm conclusion regarding the association between ambient air pollution exposure and diabetes-related traits and gestational diabetes cannot be presently drawn due

Acknowledgments

The authors thank Dr Elaine Fuertes (Institute of Epidemiology I, Helmholtz Zentrum München, Germany) for editorial assistance in the preparation of the manuscript.

Glossary

Black carbon (BC): a fraction of PM_2.5 that is mainly emitted during open biomass burning and from diesel cars and trucks without soot particle filters.
Confidence interval (CI): an interval estimation of a parameter to show the reliability of the estimates. Typically, 95% CIs are reported, which represent an interval that contains the true value with a 95% probability.
Hazard ratio (HR): a measure of mortality risk between different groups corresponding to a certain period of time. It is defined as

References (67)

A.S. Shah
Global association of air pollution and heart failure: a systematic review and meta-analysis
Lancet
(2013)
O. Raaschou-Nielsen
Air pollution and lung cancer incidence in 17 European cohorts: prospective analyses from the European Study of Cohorts for Air Pollution Effects (ESCAPE)
Lancet Oncol.
(2013)
S.S. Lim
A comparative risk assessment of burden of disease and injury attributable to 67 risk factors and risk factor clusters in 21 regions, 1990-2010: a systematic analysis for the Global Burden of Disease Study 2010
Lancet
(2012)
S.B. Gordon
Respiratory risks from household air pollution in low and middle income countries
Lancet Respir. Med.
(2014)
M. Kampa et al.
Human health effects of air pollution
Environ. Pollut.
(2008)
L. Guariguata
Global estimates of diabetes prevalence for 2013 and projections for 2035
Diabetes Res. Clin. Pract.
(2014)
M.M. Finucane
National, regional, and global trends in body-mass index since 1980: systematic analysis of health examination surveys and epidemiological studies with 960 country-years and 9.1 million participants
Lancet
(2011)
R. Rückerl
Associations between ambient air pollution and blood markers of inflammation and coagulation/fibrinolysis in susceptible populations
Environ. Int.
(2014)
E.V. Balti
Air pollution and risk of type 2 diabetes mellitus: a systematic review and meta-analysis
Diabetes Res. Clin. Pract.
(2014)
M.S. Goldberg
Associations between ambient air pollution and daily mortality among persons with diabetes and cardiovascular disease
Environ. Res.
(2006)

M.S. Goldberg

Associations between ambient air pollution and daily mortality among elderly persons in Montreal

Quebec. Sci. Total Environ.

(2013)

E. Samoli

Which specific causes of death are associated with short term exposure to fine and coarse particles in Southern Europe? Results from the MED-PARTICLES project

Environ. Int.

(2014)

I.C. Eze

Long-term air pollution exposure and diabetes in a population-based Swiss cohort

Environ. Int.

(2014)

R.D. Brook

Reduced metabolic insulin sensitivity following sub-acute exposures to low levels of ambient fine particulate matter air pollution

Sci. Total Environ.

(2013)

R. Kelishadi

Lifestyle and environmental factors associated with inflammation, oxidative stress and insulin resistance in children

Atherosclerosis

(2009)

C.A. Robledo

Preconception and early pregnancy air pollution exposures and risk of gestational diabetes mellitus

Environ. Res.

(2015)

A. van Donkelaar

Use of satellite observations for long-term exposure assessment of global concentrations of fine particulate matter

Environ. Health Perspect.

(2015)

M.C. Turner

Long-term ambient fine particulate matter air pollution and lung cancer in a large cohort of never-smokers

Am. J. Respir. Crit. Care Med.

(2011)

H. Chen

Long-term exposure to traffic-related air pollution and cardiovascular mortality

Epidemiology

(2013)

G. Cesaroni

Long term exposure to ambient air pollution and incidence of acute coronary events: prospective cohort study and meta-analysis in 11 European cohorts from the ESCAPE Project

BMJ

(2014)

R.D. Brook

Particulate matter air pollution and cardiovascular disease: an update to the scientific statement from the American Heart Association

Circulation

(2010)

WHO

Global Status Report on Noncommunicable Diseases 2014

(2012)

S. Rajagopalan et al.

Air pollution and type 2 diabetes: mechanistic insights

Diabetes

(2012)

C. Liu

Epidemiological and experimental links between air pollution and type 2 diabetes

Toxicol. Pathol.

(2013)

M.A. Bind

Air pollution and markers of coagulation, inflammation, and endothelial function: associations and epigene–environment interactions in an elderly cohort

Epidemiology

(2012)

J.J. Carmona

Short-term airborne particulate matter exposure alters the epigenetic landscape of human genes associated with the mitogen-activated protein kinase network: a cross-sectional study

Environ. Health

(2014)

A.H. Lockwood

Diabetes and air pollution

Diabetes Care

(2002)

B. Wang

Effect of long-term exposure to air pollution on type 2 diabetes mellitus risk: a systemic review and meta-analysis of cohort studies

Eur. J. Endocrinol.

(2014)

M. Janghorbani

Systematic review and metaanalysis of air pollution exposure and risk of diabetes

Eur. J. Epidemiol.

(2014)

I.C. Eze

Association between ambient air pollution and diabetes mellitus in Europe and North America: systematic review and meta-analysis

Environ. Health Perspect.

(2015)

S.K. Park et al.

Ambient air pollution and type 2 diabetes: a systematic review of epidemiologic research

Curr. Environ. Health Rep.

(2014)

T.F. Bateson et al.

Who is sensitive to the effects of particulate air pollution on mortality? A case-crossover analysis of effect modifiers

Epidemiology

(2004)

F. Forastiere

Particulate matter and daily mortality: a case-crossover analysis of individual effect modifiers

Epidemiology

(2008)

Cited by (110)

Insurance and climate change
2024, Current Opinion in Environmental Sustainability
Climate change challenges are formidable, and especially so for the insurance sector for the economy-wide risk management role it plays. Extreme events, depicted by acute climate risk, and steady deterioration in climate elements, captured as chronic climate risk, pose specific challenges to different segments of the insurance sector. We review these challenges and mitigation, adaptation, and innovation responses being developed, as well as highlight the need for future research and advances to support a resilient global insurance sector.
Long-term exposure to air pollution and risk of insulin resistance: A systematic review and meta-analysis
2024, Ecotoxicology and Environmental Safety
The effects of air pollution on metabolism have become a popular research topic, and a large number of studies had confirmed that air pollution exposure could induce insulin resistance (IR) to varying degrees, but the results were inconsistent, especially for the long-term exposures. The aim of the current study was to further investigate the potential effects of air pollution on IR.
A systematic review and meta-analysis of four electronic databases, including PubMed, Embase, Web of Science and Cochrane were conducted, searching for relevant studies published before June 10, 2023, in order to explore the potential relationships between long-term exposure to air pollution and IR. A total of 10 studies were included for data analysis, including seven cohort studies and three cross-sectional studies. Four major components of air pollution, including PM_2.5 (particulate matter with an aerodynamic diameter of 2.5 µm or less), PM₁₀ (particulate matter with an aerodynamic diameter of 10 µm or less), NO₂, and SO₂ were selected, and each analyzed for the potential impacts on insulin resistance, in the form of adjusted percentage changes in the homeostasis assessment model of insulin resistance (HOMA-IR).
This systematic review and meta-analysis showed that for every 1 μg/m³ increase in the concentration of selected air pollutants, PM_2.5 induced a 0.40% change in HOMA-IR (95%CI: −0.03, 0.84; I² =67.4%, p = 0.009), while PM₁₀ induced a 1.61% change (95%CI: 0.243, 2.968; I² =49.1%, p = 0.001). Meanwhile, the change in HOMA-IR due to increased NO₂ or SO₂ exposure concentration was only 0.09% (95%CI: −0.01, 0.19; I² =83.2%, p = 0.002) or 0.01% (95%CI: −0.04, 0.06; I² =0.0%, p = 0.638), respectively.
Long-term exposures to PM_2.5, PM₁₀, NO₂ or SO₂ are indeed associated with the odds of IR. Among the analyzed pollutants, inhalable particulate matters appear to exert greater impacts on IR.
Hair and cord blood element levels and their relationship with air pollution, dietary intake, gestational diabetes mellitus, and infant neurodevelopment
2023, Clinical Nutrition
Exposure to a range of elements, air pollution, and specific dietary components in pregnancy has variously been associated with gestational diabetes mellitus (GDM) risk or infant neurodevelopmental problems. We measured a range of pregnancy exposures in maternal hair and/or infant cord serum and tested their relationship to GDM and infant neurodevelopment.
A total of 843 pregnant women (GDM = 224, Non-GDM = 619) were selected from the Complex Lipids in Mothers and Babies cohort study. Forty-eight elements in hair and cord serum were quantified using inductively coupled plasma-mass spectrometry analysis. Binary logistic regression was used to estimate the associations between hair element concentrations and GDM risk, while multiple linear regression was performed to analyze the relationship between hair/cord serum elements and air pollutants, diet exposures, and Bayley Scales of infant neurodevelopment at 12 months of age.
After adjusting for maternal age, BMI, and primiparity, we observed that fourteen elements in maternal hair were associated with a significantly increased risk of GDM, particularly Ta (OR = 9.49, 95% CI: 6.71, 13.42), Re (OR = 5.21, 95% CI: 3.84, 7.07), and Se (OR = 5.37, 95% CI: 3.48, 8.28). In the adjusted linear regression model, three elements (Rb, Er, and Tm) in maternal hair and infant cord serum were negatively associated with Mental Development Index scores. For dietary exposures, elements were positively associated with noodles (Nb), sweetened beverages (Rb), poultry (Cs), oils and condiments (Ca), and other seafood (Gd). In addition, air pollutants PM2.5 (LUR) and PM10 were negatively associated with Ta and Re in maternal hair.
Our findings highlight the potential influence of maternal element exposure on GDM risk and infant neurodevelopment. We identified links between levels of these elements in both maternal hair and infant cord serum related to air pollutants and dietary factors.
How heat waves, ozone and sunlight hours affect endocrine and metabolic diseases emergency admissions? A case study in the region of Madrid (Spain)
2023, Environmental Research
Studies which analyse the joint effect of acoustic or chemical air pollution variables and different meteorological variables on neuroendocrine disease are practically nonexistent. This study therefore sought to analyse the impact of air pollutants and environmental meteorological variables on daily unscheduled admissions due to endocrine and metabolic diseases in the Madrid Region from January 01, 2013 to December 31, 2018.
We conducted a longitudinal, retrospective, ecological study of daily time series analysed by Poisson regression, with emergency neuroendocrine-disease admissions in the Madrid Region as the dependent variable. The independent variables were: mean daily concentrations of PM₁₀, PM_2.5, NO₂ and O₃; acoustic pollution; maximum and minimum daily temperatures; hours of sunlight; relative humidity; wind speed; and air pressure above sea level. Estimators of the statistically significant variables were used to calculate the relative risks (RRs).
A statistically significant association was found between the increase in temperatures in heat waves, RR: 1.123 95% CI (1.001–1.018), and the number of emergency admissions, making it the main risk factor. An association between a decrease in sunlight and an increase in hospital admissions, RR: 1.005 95% CI (1.002 1.008), was likewise observed. Similarly, ozone, in the form of mean daily concentrations in excess of 44 μg/m³, had an impact on admissions due to neuroendocrine disease, RR: 1.010 95% CI (1.007–1.035). The breakdown by sex showed that in the case of women, NO₂ was also a risk factor, RR: 1.021 95% CI (1.007–1.035).
The results obtained in this study serve to identify risk factors for this disease, such as extreme temperatures in heat waves, O₃ or NO₂. The robust association found between the decrease in sunlight and increase in hospital admissions due to neuroendocrine disease serves to spotlight an environmental factor which has received scant attention in public health until now.
Long-term exposure to PM<inf>2.5</inf> and O<inf>3</inf> with cardiometabolic multimorbidity: Evidence among Chinese elderly population from 462 cities
2023, Ecotoxicology and Environmental Safety
Cardiometabolic multimorbidity (CMM) refers to the presence of multiple cardiovascular and metabolic diseases (CMDs), such as hypertension, diabetes, and cardio-cerebrovascular diseases (CCVD), in the same individual, and has emerge as a significant global health concern due to population aging. Although previous research has demonstrated the association between cardiovascular and metabolic diseases and air pollutants, evidence on the link between CMM and air pollution exposure among Chinese older adults is limited. To address this research gap, we conducted a national representative survey of 222,179 adults aged 60 and older to investigate the epidemiology of CMM and its association with long-term exposure to PM_2.5 and O₃ in China's elderly population. We found that the prevalence of CMM among Chinese older adults was 16.9%, and hypertension and CCVD were the most common CMM cluster (10.8%). After adjusting for confounding variables, we observed a significant positive association between PM_2.5 exposure and the prevalence of hypertension, diabetes, and CCVD, with a respective excess risk increase of 3.2%, 3.6%, and 5.5% for every 10-unit increase. Moreover, every 10-unit increase in PM_2.5 was linked to a higher risk of hypertension and diabetes (2.2%), hypertension and CCVD (5.4%), diabetes and CCVD (5.6%), and hypertension, diabetes, and CCVD combined (7.6%). We also found a U-shaped curve relationship between O₃ exposure and the occurrence of hypertension, diabetes, and CCVD, as well as different subtypes of CMM, with the lowest risk of O₃ exposure was observed near 75–80 μg/m³. Furthermore, we identified that female and rural residents are more vulnerable to the health risks of air pollution than male and urban residents. Given the increasing aging of the population and rising prevalence of multimorbidity, policymakers should focus more attention on the female and rural elderly population to prevent and control CMM. This study provides compelling evidence that reducing air pollution levels can be an effective strategy to prevent and manage CMM among older adults.
Exposure to various ambient air pollutants and 9 cardiovascular conditions among individuals with diabetes: A prospective analysis of the UK Biobank
2023, Atherosclerosis
The adverse effects of air pollutants on the risk of most cardiovascular diseases (CVDs) are well-established, but the risk of CVDs such as deep vein thrombosis, pulmonary embolism, or aortic valve stenosis have been underappreciated, especially in the diabetic population. This study aimed to evaluate associations between long-term air pollutants exposure and the risk of incident CVDs among participants with diabetes.
This study included 27,827 participants with baseline diabetes from the UK Biobank. We then estimated hazard ratios (HRs) and 95% confidence intervals (CIs) for CVDs associated with chronic air pollutant exposure in the diabetic population by fitting the Cox proportional hazards model. Moreover, we investigated the cardiovascular effects of air pollutants at concentrations below WHO guideline limits.
After multivariable adjustment, long-term NO₂ and NO_x exposures were positively associated with the development of 8 and 6 types of CVDs in participants with diabetes, respectively. In term of particulate matters, the effect estimates ranged from 1.51 (1.13, 2.03) (coronary artery disease) to 4.65 (2.73, 7.92) (peripheral arterial disease) per 10 μg/m³ increase in PM_2.5. Whereas, the effect estimates ranged from 1.15 (1.04, 1.27) (arterial hypertension) to 2.28 (1.40, 3.69) (pulmonary embolism) per 10 μg/m³ increase in PM₁₀. In addition, our study discovered that for most of the cardiovascular events (8 of 9), the deleterious effects of air pollutants persisted even when participants were exposed to air pollutants concentrations below WHO guideline limits.
Long-term exposure to ambient NO₂, NO_x, PM_2.5, and PM₁₀, either at normal or low level, increased risk of various cardiovascular outcomes in the diabetic population.

View all citing articles on Scopus

View full text

Trends in Endocrinology & Metabolism

ReviewEpidemiology of air pollution and diabetes

Highlights

Section snippets

The diabetes epidemic and ubiquitous air pollution exposure

Are diabetes patients more vulnerable to ambient air pollution exposure?

Prospective cohort studies

Is ambient air pollution exposure associated with predisposing conditions for diabetes?

Concluding remarks and future perspectives

Acknowledgments

Glossary

Lancet

Lancet Oncol.

Lancet

Lancet Respir. Med.

Environ. Pollut.

Diabetes Res. Clin. Pract.

Lancet

Environ. Int.

Diabetes Res. Clin. Pract.

Environ. Res.

Quebec. Sci. Total Environ.

Environ. Int.

Environ. Int.

Sci. Total Environ.

Atherosclerosis

Environ. Res.

Use of satellite observations for long-term exposure assessment of global concentrations of fine particulate matter

Environ. Health Perspect.

Long-term ambient fine particulate matter air pollution and lung cancer in a large cohort of never-smokers

Am. J. Respir. Crit. Care Med.

Long-term exposure to traffic-related air pollution and cardiovascular mortality

Epidemiology

Long term exposure to ambient air pollution and incidence of acute coronary events: prospective cohort study and meta-analysis in 11 European cohorts from the ESCAPE Project

BMJ

Particulate matter air pollution and cardiovascular disease: an update to the scientific statement from the American Heart Association

Circulation

Global Status Report on Noncommunicable Diseases 2014

Air pollution and type 2 diabetes: mechanistic insights

Diabetes

Epidemiological and experimental links between air pollution and type 2 diabetes

Toxicol. Pathol.

Air pollution and markers of coagulation, inflammation, and endothelial function: associations and epigene–environment interactions in an elderly cohort

Epidemiology

Short-term airborne particulate matter exposure alters the epigenetic landscape of human genes associated with the mitogen-activated protein kinase network: a cross-sectional study

Environ. Health

Diabetes and air pollution

Diabetes Care

Effect of long-term exposure to air pollution on type 2 diabetes mellitus risk: a systemic review and meta-analysis of cohort studies

Eur. J. Endocrinol.

Systematic review and metaanalysis of air pollution exposure and risk of diabetes

Eur. J. Epidemiol.

Association between ambient air pollution and diabetes mellitus in Europe and North America: systematic review and meta-analysis

Environ. Health Perspect.

Ambient air pollution and type 2 diabetes: a systematic review of epidemiologic research

Curr. Environ. Health Rep.

Who is sensitive to the effects of particulate air pollution on mortality? A case-crossover analysis of effect modifiers

Epidemiology

Particulate matter and daily mortality: a case-crossover analysis of individual effect modifiers

Epidemiology

Review
Epidemiology of air pollution and diabetes