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JAMA Netw Open. 2019 Mar 1;2(3):e190318. doi: 10.1001/jamanetworkopen.2019.0318.

Association of Long-term Exposure to Ambient Air Pollutants With Risk Factors for Cardiovascular Disease in China.

Author information

Guangzhou Key Laboratory of Environmental Pollution and Health Risk Assessment, Guangdong Provincial Engineering Technology Research Center of Environmental and Health Risk Assessment, Department of Occupational and Environmental Health, School of Public Health, Sun Yat-sen University, Guangzhou, China.
Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia.
Institute of Epidemiology, Helmholtz Zentrum München-German Research Center for Environmental Health, Neuherberg, Germany.
Division of Metabolic and Nutritional Medicine, Dr von Hauner Children's Hospital, Ludwig Maximilian University of Munich, Munich, Germany.
Institute and Clinic for Occupational, Social and Environmental Medicine, University Hospital of Munich, Munich, Germany.
Department of Epidemiology and Biostatistics, College for Public Health and Social Justice, Saint Louis University, St Louis, Missouri.
Department of Environmental Health Sciences, University at Albany, State University of New York, Rensselaer, New York.
Department of Epidemiology and Biostatics, University at Albany, State University of New York, Rensselaer, New York.
Comprehensive Pneumology Center Munich, German Center for Lung Research, Munich, Germany.
Allergy and Lung Health Unit, Centre for Epidemiology and Biostatistics, School of Population and Global Health, The University of Melbourne, Melbourne, Australia.
Murdoch Children Research Institute, Melbourne, Australia.
Finnish Meteorological Institute, Kuopio, Finland.
The National Institute of Fundamental Studies, Kandy, Sri Lanka.



Which cardiometabolic risk factors (eg, hypertension, type 2 diabetes, overweight or obesity, and dyslipidemia) are more sensitive to long-term exposure to ambient air pollution and whether participants with these conditions are more susceptible to the cardiovascular effects of air pollution remain unclear.


To evaluate the associations among long-term exposure to air pollutants, cardiometabolic risk factors, and cardiovascular disease (CVD) prevalence.

Design, Setting, and Participants:

This population-based cross-sectional study was conducted from April 1 through December 31, 2009, in 3 cities in Northeastern China. Participants were adults aged 18 to 74 years who had lived in study area for 5 years or longer. Data analysis was performed from May 1 through December 31, 2018.


Long-term (2006-2008) exposure to air pollutants was measured using a spatiotemporal statistical model (particulate matter with an aerodynamic diameter of ≤2.5 μm [PM2.5] and ≤1.0 μm [PM1.0]) and data from air monitoring stations (particulate matter with an aerodynamic diameter of ≤10.0 μm [PM10.0], sulfur dioxide [SO2], nitrogen dioxide [NO2], and ozone [O3]).

Main Outcomes and Measures:

Cardiovascular disease was determined by self-report of physician-diagnosed CVD. Blood pressure, body mass index, and levels of triglycerides and low-density lipoprotein cholesterol were measured using standard methods.


Participants included 15 477 adults (47.3% women) with a mean (SD) age of 45.0 (13.5) years. The prevalence of CVD was 4.8%, and the prevalence of cardiometabolic risk factors ranged from 8.6% (hyperbetalipoproteinemia) to 40.5% (overweight or obesity). Mean (SD) air pollutant concentrations ranged from 35.3 (5.5) μg/m3 (for NO2) to 123.1 (14.6) μg/m3 (for PM10.0). Associations with air pollutants were identified for individuals with hyperbetalipoproteinemia (eg, odds ratio [OR], 1.36 [95% CI, 1.03-1.78] for a 10-μg/m3 increase in PM1.0) and the weakest association for those with for overweight or obesity (eg, OR, 1.06 [95% CI, 1.02-1.09] for a 10-μg/m3 increase in PM1.0). Cardiometabolic risk factors only partially mediated associations between air pollution and CVD. However, they modified the associations such that greater associations were found in participants with these cardiometabolic conditions (eg, ORs for CVD and per 10-μg/m3 increase in PM1.0, 1.22 [95% CI, 1.12-1.33] in participants with hyperbetalipoproteinemia and 1.07 [95% CI, 0.98-1.16] in participants without hyperbetalipoproteinemia).

Conclusions and Relevance:

In this population-based study of Chinese adults with CVD, long-term exposure to air pollution was associated with a higher prevalence of cardiometabolic risk factors, and the strongest associations were observed for hyperbetalipoproteinemia. In addition, participants with cardiometabolic risk factors may have been more vulnerable to the effects of air pollution on CVD.

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