Academic journal article Environmental Health Perspectives

Association between Ambient Air Pollution and Diabetes Mellitus in Europe and North America: Systematic Review and Meta-Analysis

Academic journal article Environmental Health Perspectives

Association between Ambient Air Pollution and Diabetes Mellitus in Europe and North America: Systematic Review and Meta-Analysis

Article excerpt


Ambient air pollution ranks high among risk factors for the global burden of disease (Lim et al. 2012), and is linked to several chronic noncommunicable conditions such as cardiovascular diseases (Bauer et al. 2010; Brook et al. 2010; Kunzli et al. 2010), asthma (Bui et al. 2013; Jacquemin et al. 2012; Kunzli et al. 2009), chronic obstructive pulmonary diseases (COPD) (Andersen et al. 2011; Schikowski et al. 2014; Zanobetti et al. 2008), and cancers including lung (Raaschou-Nielsen et al. 2013a), cervical, and brain cancers (Raaschou-Nielsen et al. 2011). Persons with type 2 diabetes mellitus (T2DM) are at increased risk to develop micro- and macrovascular diseases and reduced lung function (Jones et al. 2014; Kinney et al. 2014). Air pollution has also been shown to be more detrimental to diabetic patients, worsening their clinical outcomes (O'Neill et al. 2005; Raaschou-Nielsen et al. 2013b; Whitsel et al. 2009; Zanobetti and Schwartz 2001).

More recent evidence is supportive of an air pollution effect on diabetes risk. Experimental evidence show that possible pathways may include endothelial dysfunction, overactivity of the sympathetic nervous system (Rajagopalan and Brook 2012), immune response alterations in visceral adipose tissues; endoplasmic reticulum stress resulting in alterations in insulin transduction (Sun et al. 2009), insulin sensitivity, and glucose metabolism; and alterations in mitochondria and brown adipocytes (Liu et al. 2013; Rajagopalan and Brook 2012).

Papazafiropoulou et al. (2011) systematically reviewed the etiologic association between environmental pollution and diabetes, taking into account studies on organic pollutants and secondary effects of air pollution on diabetic patients published up to November 2010. They described a positive association between environmental pollution and prevalent diabetes, as well as increased morbidity and mortality among diabetic patients. A number of pertinent studies have been published since this review, and thus far there is, to the best of our knowledge, no meta-analysis of the available evidence. We therefore systematically identified and reviewed the epidemiological evidence on the association between air pollution and diabetes mellitus, and synthesized the results of studies on the association with T2DM.


Search strategy. We systematically searched electronic literature databases [MEDLINE ( html), EMBASE (https://www.embase. com), and ISI Web of Science (http://www.] for pertinent literature published up to 3 February 2014. Terms used in this search included "air pollution," "air pollutants," "particulate matter," "PM10," "[PM.sub.2.5]," "nitrogen dioxide," "N[O.sub.2]," "[NO.sub.x]," "ozone," "soot," "smog," "diabetes mellitus," "diabetes," "T1DM," "T2DM," "type 1 DM," "type 2 DM," "IDDM," "NIDDM," alone and in combination. We applied no filters for study designs. Reference lists of eligible articles were searched for further pertinent articles. After de-duplication, titles and abstracts were screened for eligibility and potentially relevant articles were retrieved as full texts. Screening was performed independently by two reviewers and any discrepancies were resolved by discussion.

Inclusion and exclusion criteria. We included only original research published in English as a full publication in a peer-reviewed journal. We accepted any type of study design. In eligible studies, the definition of air pollution and diabetes mellitus had to be clearly stated. Air pollution had to be outdoor (ambient, including traffic-related), and we accepted any type of assessment including particle concentration in the air or indicators of long-term traffic exposure. Diabetes mellitus had to be physician diagnosed or based on the use of antidiabetic medications. We included any type of diabetes mellitus (type 1, type 2, and gestational). …

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