Use of an Exposome Approach to Understand the Effects of Exposures From the Natural, Built, and Social Environments on Cardio-Vascular Disease Onset, Progression, and Outcomes

External exposome and all-cause mortality in European cohorts: the EXPANSE project

Background

Many studies reported associations between long-term exposure to environmental factors and mortality; however, little is known on the combined effects of these factors and health. We aimed to evaluate the association between external exposome and all-cause mortality in large administrative and traditional adult cohorts in Europe.

Methods

Data from six administrative cohorts (Catalonia, Greece, Rome, Sweden, Switzerland and the Netherlands, totaling 27,913,545 subjects) and three traditional adult cohorts (CEANS-Sweden, EPIC-NL-the Netherlands, KORA-Germany, totaling 57,653 participants) were included. Multiple exposures were assigned at the residential addresses, and were divided into three a priori defined domains: (1) air pollution [fine particulate matter (PM2.5), nitrogen dioxide (NO₂), black carbon (BC) and warm-season Ozone (warm-O3)]; (2) land/built environment (Normalized Difference Vegetation Index-NDVI, impervious surfaces, and distance to water); (3) air temperature (cold- and warm-season mean and standard deviation). Each domain was synthesized through Principal Component Analysis (PCA), with the aim of explaining at least 80% of its variability. Cox proportional-hazards regression models were applied and the total risk of the external exposome was estimated through the Cumulative Risk Index (CRI). The estimates were adjusted for individual- and area-level covariates.

Results

More than 205 million person-years at risk and more than 3.2 million deaths were analyzed. In single-component models, IQR increases of the first principal component of the air pollution domain were associated with higher mortality [HRs ranging from 1.011 (95% CI: 1.005-1.018) for the Rome cohort to 1.076 (1.071-1.081) for the Swedish cohort]. In contrast, lower levels of the first principal component of the land/built environment domain, pointing to reduced vegetation and higher percentage of impervious surfaces, were associated with higher risks. Finally, the CRI of external exposome increased mortality for almost all cohorts. The associations found in the traditional adult cohorts were generally consistent with the results from the administrative ones, albeit without reaching statistical significance.

Discussion

Various components of the external exposome, analyzed individually or in combination, were associated with increased mortality across European cohorts. This sets the stage for future research on the connections between various exposure patterns and human health, aiding in the planning of healthier cities.

Geospatial Science for the Environmental Epidemiology of Cancer in the Exposome Era

Geospatial science is the science of location or place that harnesses geospatial tools, such as geographic information systems (GIS), to understand the features of the environment according to their locations. Geospatial science has been transformative for cancer epidemiologic studies through enabling large-scale environmental exposure assessments. As the research paradigm for the exposome, or the totality of environmental exposures across the life course, continues to evolve, geospatial science will serve a critical role in determining optimal practices for how to measure the environment as part of the external exposome. The objectives of this article are to provide a summary of key concepts, present a conceptual framework that illustrates how geospatial science is applied to environmental epidemiology in practice and through the lens of the exposome, and discuss the following opportunities for advancing geospatial science in cancer epidemiologic research: enhancing spatial and temporal resolutions and extents for geospatial data; geospatial methodologies to measure climate change factors; approaches facilitating the use of patient addresses in epidemiologic studies; combining internal exposome data and geospatial exposure models of the external exposome to provide insights into biological pathways for environment-disease relationships; and incorporation of geospatial data into personalized cancer screening policies and clinical decision making.

Understanding risk and causal mechanisms for developing obesity in infants and young children: A National Institutes of Health workshop

Obesity in children remains a major public health problem, with the current prevalence in youth ages 2-19 years estimated to be 19.7%. Despite progress in identifying risk factors, current models do not accurately predict development of obesity in early childhood. There is also substantial individual variability in response to a given intervention that is not well understood. On April 29-30, 2021, the National Institutes of Health convened a virtual workshop on "Understanding Risk and Causal Mechanisms for Developing Obesity in Infants and Young Children." The workshop brought together scientists from diverse disciplines to discuss (1) what is known regarding epidemiology and underlying biological and behavioral mechanisms for rapid weight gain and development of obesity and (2) what new approaches can improve risk prediction and gain novel insights into causes of obesity in early life. Participants identified gaps and opportunities for future research to advance understanding of risk and underlying mechanisms for development of obesity in early life. It was emphasized that future studies will require multi-disciplinary efforts across basic, behavioral, and clinical sciences. An exposome framework is needed to elucidate how behavioral, biological, and environmental risk factors interact. Use of novel statistical methods may provide greater insights into causal mechanisms.

Questionnaire-based exposome-wide association studies for common diseases in the Personalized Environment and Genes Study

The exposome collectively refers to all exposures, beginning in utero and continuing throughout life, and comprises not only standard environmental exposures such as point source pollution and ozone levels but also exposures from diet, medication, lifestyle factors, stress, and occupation. The exposome interacts with individual genetic and epigenetic characteristics to affect human health and disease, but large-scale studies that characterize the exposome and its relationships with human disease are limited. To address this gap, we used extensive questionnaire data from the diverse North Carolina-based Personalized Environment and Genes Study (PEGS, n = 9, 429) to evaluate exposure associations in relation to common diseases. We performed an exposome-wide association study (ExWAS) to examine single exposure models and their associations with 11 common complex diseases, namely allergic rhinitis, asthma, bone loss, fibroids, high cholesterol, hypertension, iron-deficient anemia, ovarian cysts, lower GI polyps, migraines, and type 2 diabetes. Across diseases, we found associations with lifestyle factors and socioeconomic status as well as asbestos, various dust types, biohazardous material, and textile-related exposures. We also found disease-specific associations such as fishing with lead weights and migraines. To differentiate between a replicated result and a novel finding, we used an AI-based literature search and database tool that allowed us to examine the current literature. We found both replicated findings, especially for lifestyle factors such as sleep and smoking across diseases, and novel findings, especially for occupational exposures and multiple diseases.

Interdisciplinary fetal-neonatal neurology training applies neural exposome perspectives to neurology principles and practice

An interdisciplinary fetal-neonatal neurology (FNN) program over the first 1,000 days teaches perspectives of the neural exposome that are applicable across the life span. This curriculum strengthens neonatal neurocritical care, pediatric, and adult neurology training objectives. Teaching at maternal-pediatric hospital centers optimally merges reproductive, pregnancy, and pediatric approaches to healthcare. Phenotype-genotype expressions of health or disease pathways represent a dynamic neural exposome over developmental time. The science of uncertainty applied to FNN training re-enforces the importance of shared clinical decisions that minimize bias and reduce cognitive errors. Trainees select mentoring committee participants that will maximize their learning experiences. Standardized questions and oral presentations monitor educational progress. Master or doctoral defense preparation and competitive research funding can be goals for specific individuals. FNN principles applied to practice offer an understanding of gene-environment interactions that recognizes the effects of reproductive health on the maternal-placental-fetal triad, neonate, child, and adult. Pre-conception and prenatal adversities potentially diminish life-course brain health. Endogenous and exogenous toxic stressor interplay (TSI) alters the neural exposome through maladaptive developmental neuroplasticity. Developmental disorders and epilepsy are primarily expressed during the first 1,000 days. Communicable and noncommunicable illnesses continue to interact with the neural exposome to express diverse neurologic disorders across the lifespan, particularly during the critical/sensitive time periods of adolescence and reproductive senescence. Anomalous or destructive fetal neuropathologic lesions change clinical expressions across this developmental-aging continuum. An integrated understanding of reproductive, pregnancy, placental, neonatal, childhood, and adult exposome effects offers a life-course perspective of the neural exposome. Exosome research promises improved disease monitoring and drug delivery starting during pregnancy. Developmental origins of health and disease principles applied to FNN practice anticipate neurologic diagnoses with interventions that can benefit successive generations. Addressing health care disparities in the Global South and high-income country medical deserts require constructive dialogue among stakeholders to achieve medical equity. Population health policies require a brain capital strategy that reduces the global burden of neurologic diseases by applying FNN principles and practice. This integrative neurologic care approach will prolong survival with an improved quality of life for persons across the lifespan confronted with neurological disorders.

Saliva as a diagnostic tool to measure polycyclic aromatic hydrocarbon exposure in dental patients exposed to intimate partner violence (IPV)

BACKGROUND

Social habits such as tobacco use, alcohol consumption, and chemically contaminated diet contribute to poor oral health. Intimate Partner Violence (IPV) is a global public health epidemic which can exacerbate the prevalence of health conditions affecting a victim's lifespan. This study investigates using saliva as a biomarker for detecting levels of benzo(a)pyrene [B(a)P]; a toxicant present in cigarette smoke and barbecued meat in a population of IPV + female patients.

METHODS

A cross-sectional IRB-approved study utilized 63 female participants (37 African Americans [AA], and 26 non-African Americans [NAA]), who provided consent for the study. Participants submitted samples of saliva, as well as questionnaires about demographics, health history, and a well-validated (IPV) screen.

RESULTS

The prevalence of IPV was greater in AA compared to NAA. While the concentrations of PAHs/B(a)P detected in saliva of IPV samples in NAA were generally within the range of B(a)P reported for saliva from elsewhere, the concentrations were high in some IPV positive samples. Among the B(a)P metabolites, the concentrations of B(a)P 7,8-diol, B(a)P 3,6- and 6,12-dione metabolites were greater than the other metabolite in both AA and non-AA groups who were positive.

CONCLUSION

Our study supports the use of saliva as a potential "diagnostic rheostat" to identify toxicants that may exacerbate/precipitate systemic disease in female victims of IPV. In addition, our study is the first to report that IPV may precipitate the accumulation of B(a)P in oral cavity that can alter inflammatory cascades and increase risk of poor health outcomes in this population of patients.

Seminar: Scalable Preprocessing Tools for Exposomic Data Analysis

BACKGROUND

The exposome serves as a popular framework in which to study exposures from chemical and nonchemical stressors across the life course and the differing roles that these exposures can play in human health. As a result, data relevant to the exposome have been used as a resource in the quest to untangle complicated health trajectories and help connect the dots from exposures to adverse outcome pathways.

OBJECTIVES

The primary aim of this methods seminar is to clarify and review preprocessing techniques critical for accurate and effective external exposomic data analysis. Scalability is emphasized through an application of highly innovative combinatorial techniques coupled with more traditional statistical strategies. The Public Health Exposome is used as an archetypical model. The novelty and innovation of this seminar's focus stem from its methodical, comprehensive treatment of preprocessing and its demonstration of the positive effects preprocessing can have on downstream analytics.

DISCUSSION

State-of-the-art technologies are described for data harmonization and to mitigate noise, which can stymie downstream interpretation, and to select key exposomic features, without which analytics may lose focus. A main task is the reduction of multicollinearity, a particularly formidable problem that frequently arises from repeated measurements of similar events taken at various times and from multiple sources. Empirical results highlight the effectiveness of a carefully planned preprocessing workflow as demonstrated in the context of more highly concentrated variable lists, improved correlational distributions, and enhanced downstream analytics for latent relationship discovery. The nascent field of exposome science can be characterized by the need to analyze and interpret a complex confluence of highly inhomogeneous spatial and temporal data, which may present formidable challenges to even the most powerful analytical tools. A systematic approach to preprocessing can therefore provide an essential first step in the application of modern computer and data science methods. https://doi.org/10.1289/EHP12901.

Community-level exposomics: a population-centered approach to address public health concerns

Environmental factors affecting health and vulnerability far outweigh genetics in accounting for disparities in health status and longevity in US communities. The concept of the exposome, the totality of exposure from conception onwards, provides a paradigm for researchers to investigate the complex role of the environment on the health of individuals. We propose a complementary framework, community-level exposomics, for population-level exposome assessment. The goal is to bring the exposome paradigm to research and practice on the health of populations, defined by various axes including geographic, social, and occupational. This framework includes the integration of community-level measures of the built, natural and social environments, environmental pollution-derived from conventional and community science approaches, internal markers of exposure that can be measured at the population-level and early responses associated with health status that can be tracked using population-based monitoring. Primary challenges to the implementation of the proposed framework include needed advancements in population-level measurement, lack of existing models with the capability to produce interpretable and actionable evidence and the ethical considerations of labeling geographically-bound populations by exposomic profiles. To address these challenges, we propose a set of recommendations that begin with greater engagement with and empowerment of affected communities and targeted investment in community-based solutions. Applications to urban settings and disaster epidemiology are discussed as examples for implementation.

The built environment and cardiovascular disease: an umbrella review and meta-meta-analysis

AIMS

To provide a comprehensive overview of the current evidence on objectively measured neighbourhood built environment exposures in relation to cardiovascular disease (CVD) events in adults.

METHODS AND RESULTS

We searched seven databases for systematic reviews on associations between objectively measured long-term built environmental exposures, covering at least one domain (i.e. outdoor air pollution, food environment, physical activity environment like greenspace and walkability, urbanization, light pollution, residential noise, and ambient temperature), and CVD events in adults. Two authors extracted summary data and assessed the risk of bias independently. Robustness of evidence was rated based on statistical heterogeneity, small-study effect, and excess significance bias. Meta-meta-analyses were conducted to combine the meta-analysis results from reviews with comparable exposure and outcome within each domain. From the 3304 initial hits, 51 systematic reviews were included, covering 5 domains and including 179 pooled estimates. There was strong evidence of the associations between increased air pollutants (especially PM2.5 exposure) and increased residential noise with greater risk of CVD. Highly suggestive evidence was found for an association between increased ambient temperature and greater risk of CVD. Systematic reviews on physical activity environment, food environment, light pollution, and urbanization in relation to CVD were scarce or lacking.

CONCLUSION

Air pollutants, increased noise levels, temperature, and greenspace were associated with CVD outcomes. Standardizing design and exposure assessments may foster the synthesis of evidence. Other crucial research gaps concern the lack of prospective study designs and lack of evidence from low-to-middle-income countries (LMICs).

REGISTRATION

PROSPERO: CRD42021246580.

The contribution of the exposome to the burden of cardiovascular disease

Large epidemiological and health impact assessment studies at the global scale, such as the Global Burden of Disease project, indicate that chronic non-communicable diseases, such as atherosclerosis and diabetes mellitus, caused almost two-thirds of the annual global deaths in 2020. By 2030, 77% of all deaths are expected to be caused by non-communicable diseases. Although this increase is mainly due to the ageing of the general population in Western societies, other reasons include the increasing effects of soil, water, air and noise pollution on health, together with the effects of other environmental risk factors such as climate change, unhealthy city designs (including lack of green spaces), unhealthy lifestyle habits and psychosocial stress. The exposome concept was established in 2005 as a new strategy to study the effect of the environment on health. The exposome describes the harmful biochemical and metabolic changes that occur in our body owing to the totality of different environmental exposures throughout the life course, which ultimately lead to adverse health effects and premature deaths. In this Review, we describe the exposome concept with a focus on environmental physical and chemical exposures and their effects on the burden of cardiovascular disease. We discuss selected exposome studies and highlight the relevance of the exposome concept for future health research as well as preventive medicine. We also discuss the challenges and limitations of exposome studies.

Environment and child well-being: A scoping review of reviews to guide policies

Background

Acting on social determinants is the most effective, efficient, and fairest strategy to improve population health and health equity. Because of their vulnerability and dependence, children are particularly exposed to the deleterious effects of their living environment. Taking these issues into account in the development of public policies and identifying levers for action are crucial. The objective of this scoping review of reviews is to identify the main environmental determinants on children's health and development, and their mechanisms of effect, to be addressed by public policies.

Methods

We conducted a scoping review of reviews in accordance with the method developed by Arksey and O'Malley, and Levac and colleagues' methodology advancement and the PRISMA guideline. Inclusion criteria were identified with the PICos (population-phenomena of interest-context-study design) framework. We used the PubMed database and conducted a thematic analyze.

Results

Forty-seven articles were selected. Their analysis allowed us to identify five categories of interdependent environmental determinants of child health: i) urban design ii) contaminants, iii) parenting environment, iv) social conditions, v) climate change. Together and in a systemic way, they act on the health of the child.

Conclusion

The review carried out allows us to propose a pragmatic framework for clarifying the effects of the physical, social, and economic environment on children's health and wellbeing.

Concomitant Coronary Artery Disease in Identical Twins: Case Report and Systematic Literature Review

Coronary artery disease (CAD) is multifactorial and strongly affected by genetic, epigenetic and environmental factors. Several studies have reported development of concomitant CAD in identical twins. We report a case in which a pair of Caucasian male monozygotic twins presented almost concomitantly with acute coronary syndrome (ACS) and had concordant coronary anatomy and identical site of occlusion. We performed a systematic literature review of PubMed, Web Of Science and Scopus databases from inception until 28 February 2023 of case reports/case series reporting the concomitant development of CAD in monozygotic twins. We found 25 eligible case reports with a total of 31 monozygotic twin pairs (including the case from our center) suffering from CAD and presenting (most of them simultaneously) with ACS (mean age of presentation: 45 ± 12 years, males: 81%). Coronary angiograms demonstrated lesion and anatomy concordance in 77% and 79% of the twin pairs, respectively. Screening for disease-related genetic mutations was performed in six twin pairs leading to the identification of five CAD-related genetic polymorphisms. This is the first systematic literature review of studies reporting identical twin pairs suffering from CAD. In summary, there is high concordance of coronary anatomy and clinical presentation between monozygotic twins. Future monozygotic twin studies-unbiased by age effects-can provide insights into CAD heritability being able to disentangle the traditional dyad of genetic and environmental factors and investigate the within-pair epigenetic drift.

The Exposome and Cardiovascular Health

The study of the interplay between social factors, environmental hazards, and health has garnered much attention in recent years. The term "exposome" was coined to describe the total impact of environmental exposures on an individual's health and well-being, serving as a complementary concept to the genome. Studies have shown a strong correlation between the exposome and cardiovascular health, with various components of the exposome having been implicated in the development and progression of cardiovascular disease. These components include the natural and built environment, air pollution, diet, physical activity, and psychosocial stress, among others. This review provides an overview of the relationship between the exposome and cardiovascular health, highlighting the epidemiologic and mechanistic evidence of environmental exposures on cardiovascular disease. The interplay between various environmental components is discussed, and potential avenues for mitigation are identified.

Mono-(2-ethylhexyl)-phthalate potentiates methylglyoxal-induced blood-brain barrier damage via mitochondria-derived oxidative stress and bioenergetic perturbation

Phthalates in contaminated foods and personal care products are one of the most frequently exposed chemicals with a public health concern. Phthalate exposure is related to cardiovascular diseases, including diabetic vascular complications and cerebrovascular diseases, yet the mechanism is still unclear. The blood-brain barrier (BBB) integrity disruption is strongly associated with cardiovascular and neurological disease exacerbation. We investigated BBB damage by di-(2-ethylhexyl) phthalate (DEHP) or its metabolite mono-(2-ethylhexyl) phthalate (MEHP) using brain endothelial cells and rat models. BBB damage by the subthreshold level of MEHP, but not a DEHP, significantly increased by the presence of methylglyoxal (MG), a reactive dicarbonyl compound whose levels increase in the blood in hyperglycemic conditions in diabetic patients. Significant potentiation in apoptosis and autophagy activation, mitochondria-derived reactive oxygen species (ROS) production, and mitochondrial metabolic disturbance were observed in brain ECs by co-exposure to MG and MEHP. N-acetyl cysteine (NAC) restored autophagy activation as well as tight junction protein impairment induced by co-exposure to MG and MEHP. Intraperitoneal administration of MG and MEHP significantly altered mitochondrial membrane potential and tight junction integrity in rat brain endothelium. This study may provide novel insights into enhancing phthalate toxicity in susceptible populations, such as diabetic patients.

Air Pollution, Built Environment, and Early Cardiovascular Disease

As the world's population becomes increasingly urbanized, there is growing concern about the impact of urban environments on cardiovascular health. Urban residents are exposed to a variety of adverse environmental exposures throughout their lives, including air pollution, built environment, and lack of green space, which may contribute to the development of early cardiovascular disease and related risk factors. While epidemiological studies have examined the role of a few environmental factors with early cardiovascular disease, the relationship with the broader environment remains poorly defined. In this article, we provide a brief overview of studies that have examined the impact of the environment including the built physical environment, discuss current challenges in the field, and suggest potential directions for future research. Additionally, we highlight the clinical implications of these findings and propose multilevel interventions to promote cardiovascular health among children and young adults.

A Collaborative Approach to Address Racism in a Community-Academic Partnership

The HERCULES Exposome Research Center at Emory University uses an exposome approach to study the environment's effect on health and community well-being. HERCULES is guided by a Stakeholder Advisory Board (SAB) that includes representatives of neighborhoods, nonprofit organizations, government agencies, and academic institutions in the Atlanta metropolitan region. This region (and the SAB) has a large proportion of Black residents, many of whom live in areas experiencing environmental injustices. Historic and current racial injustices in Atlanta and public health research made it imperative to initiate dialogue and implement actions to address racism and power dynamics that may impact research and partnerships between affected communities and our institution.After initial discussion, the HERCULES Community Engagement Core and SAB members formed a workgroup to develop an internal anti-racism process. The workgroup drafted an Anti-Racism Commitment, hosted a Racism and Equity Dialogue Series, and initiated a strategic planning process to implement the resulting recommendations, which fell into the following categories: anti-racist guidance/policies and recommendations for research, community engagement, and the department. Center leadership and the SAB were engaged throughout the iterative process.This deliberate and ongoing process allows HERCULES to identify and begin implementing action items that go beyond a written proclamation to address racialized power imbalances and systemic inequities. HERCULES is committed to working collaboratively to earn community trust while addressing systemic issues, recognizing that these are essential to forming research partnerships that address health inequities.

Modeling historic environmental pollutant exposures and non-Hodgkin lymphoma risk

Environmental exposures to chemicals are suspected risk factors for non-Hodgkin lymphoma (NHL), but few studies have assessed historic environmental risk factors. In this study, we estimated the associations between NHL and 1) historic environmental pollutant emissions from the Risk Screening Environmental Indicators (RSEI) model, which uses a database from the Environmental Protection Agency of toxic release emissions to air, water, and land, and 2) chemical mixtures measured in house dust (groups of PCBs, PAHs, and two mixtures of pesticides) for study participants enrolled in the NCI-SEER population-based case-control study (1998-2000) at four SEER centers - Detroit, Iowa, Los Angeles County, and Seattle. We assigned 11 years of annual temporally-varying historic environmental exposure scores by intersecting residential locations from participants' residential histories with a fine grid from the RSEI model and by performing inverse distance weighting between facilities releasing specific carcinogenic chemicals and residential locations for spatially-precise exposure assignments. We used Bayesian index low-rank kriging multiple membership models to identify important lag times for RSEI scores, cumulative effects of RSEI scores, and specific carcinogenic chemical releases into the environment. We found a significant positive association between RSEI scores and NHL at the maximum time lag of 11 years (OR = 1.17, 95% CI (1.06, 1.32)) and a significant cumulative RSEI score effect (OR = 1.30, 95% CI (1.02, 1.84)) for long-term residents in Detroit, where benzene and trichloroethylene were the most important chemicals driving this association. Additionally, we identified significant inverse associations for two study centers and time lags that did not persist in cumulative exposure models. Large weights for dichloromethane and pentachlorophenol in models of cumulative exposure also support evidence for their association with NHL risk. These results underscore the importance of considering historic and cumulative environmental exposures and using residential histories for diseases with long latency periods such as NHL.

State of the science on outdoor air pollution exposure and liver cancer risk

Background

There is emerging evidence that air pollution exposure increases the risk of developing liver cancer. To date, there have been four epidemiologic studies conducted in the United States, Taiwan, and Europe showing generally consistent positive associations between ambient exposure to air pollutants, including particulate matter <2.5 μm in aerodynamic diameter (PM2.5) and nitrogen dioxide (NO2), and liver cancer risk. There are several research gaps and thus valuable opportunities for future work to continue building on this expanding body of literature. The objectives of this paper are to narratively synthesize existing epidemiologic literature on the association between air pollution exposure and liver cancer incidence and describe future research directions to advance the science of understanding the role of air pollution exposure in liver cancer development.

Future research directions

include 1) accounting for potential confounding by established risk factors for the predominant histological subtype, hepatocellular carcinoma (HCC); 2) examination of incident primary liver cancer outcomes with consideration of potential differential associations according to histology; 3) air pollution exposure assessments considering early-life and/or historical exposures, residential histories, residual confounding from other sources of air pollution (e.g., tobacco smoking), and integration of geospatial ambient exposure modeling with novel biomarker technologies; 4) examination of air pollution mixtures experienced in the exposome; 5) consideration of increased opportunities for exposure to outdoor air pollution due to climate change (e.g., wildfires); and 6) consideration of modifying factors for air pollution exposure, such as socioeconomic status, that may contribute to disparities in liver cancer incidence.

Conclusions

In light of mounting evidence demonstrating that higher levels of air pollution exposure increase the risk for developing liver cancer, methodological considerations primarily concerning residual confounding and improved exposure assessment are warranted to robustly demonstrate an independent association for air pollution as a hepatocarcinogen.

Consequences of the exposome to gestational diabetes mellitus

The exposome is the cumulative measure of environmental influences and associated biological responses throughout the lifespan, including those from the environment, diet, behaviour, and endogenous processes. The exposome concept and the 2030 Agenda for the Sustainable Development Goals (SDGs) from the United Nations are the basis for understanding the aetiology and consequences of non-communicable diseases, including gestational diabetes mellitus (GDM). Pregnancy may be developed in an environment with adverse factors part of the immediate internal medium for fetus development and the external medium to which the pregnant woman is exposed. The placenta is the interface between maternal and fetal compartments and acts as a protective barrier or easing agent to transfer exposome from mother to fetus. Under and over-nutrition in utero, exposure to adverse environmental pollutants such as heavy metals, endocrine-disrupting chemicals, pesticides, drugs, pharmaceuticals, lifestyle, air pollutants, and tobacco smoke plays a determinant role in the development of GDM. This phenomenon is worsened by metabolic stress postnatally, such as obesity which increases the risk of GDM and other diseases. Clinical risk factors for GDM development include its aetiology. It is proposed that knowledge-based interventions to change the potential interdependent ecto-exposome and endo-exposome could avoid the occurrence and consequences of GDM.

Exposome approach for identifying modifiable factors for the prevention of colorectal cancer

Previous studies have shown certain exposure factors (such as lifestyle and metabolism) are associated with colorectal cancer (CRC) events. However, the application of the exposome theoretical frame and the extent to which the exposome domain can modulate the risk of CRC remain unknown. Our study aimed to construct valid exposome measurements and examine the relationship between exposome counts and the risk of CRC. This study included 335,370 individuals in the UK Biobank. We used exploratory factor analysis to identify a valid construct of exposome factors. We then summed the exposome counts within each domain. Cox proportional hazard models were used to estimate the hazard ratios and 95% confidence intervals of CRC risk related to the exposome factors and counts. During an 8.69 year median follow-up, 10,702 CRC cases were identified. Five domains were extracted from 12 variables, including ecosystem, lifestyle, tobacco and alcohol use, social economics, and social support. The Cox model results showed that the ecosystem was positively related to the reduced CRC risk (HR = 0.970; 95% CI 0.952-0.989). Similar results were also found among the domains of healthy lifestyles (HR = 0. 889; 95% CI 0.871-0.907), and no tobacco and alcohol use (HR = 0.892; 95% CI 0.876-0.909). The disadvantageous social economic (HR = 1.081; 95% CI 1.058-1.105) and insufficient social support domains (HR = 1.036; 95% CI 1.017-1.056) were associated with an increased risk of CRC. Similar risk trends were also observed across the exposome count groups with CRC incidence. Our findings suggest that certain exposure domains are related to the incidence of CRC. Ecosystem, lifestyle, and social factors can be incorporated into prediction models to identify individuals at high risk of CRC.

The public health exposome and pregnancy-related mortality in the United States: a high-dimensional computational analysis

BACKGROUND

Racial inequities in maternal mortality in the U.S. continue to be stark.

METHODS

The 2015-2018, 4-year total population, county-level, pregnancy-related mortality ratio (PRM; deaths per 100,000 live births; National Center for Health Statistics (NCHS), restricted use mortality file) was linked with the Public Health Exposome (PHE). Using data reduction techniques, 1591 variables were extracted from over 62,000 variables for use in this analysis, providing information on the relationships between PRM and the social, health and health care, natural, and built environments. Graph theoretical algorithms and Bayesian analysis were applied to PHE/PRM linked data to identify latent networks.

RESULTS

PHE variables most strongly correlated with total population PRM were years of potential life lost and overall life expectancy. Population-level indicators of PRM were overall poverty, smoking, lack of exercise, heat, and lack of adequate access to food.

CONCLUSIONS

In this high-dimensional analysis, overall life expectancy, poverty indicators, and health behaviors were found to be the strongest predictors of pregnancy-related mortality. This provides strong evidence that maternal death is part of a broader constellation of both similar and unique health behaviors, social determinants and environmental exposures as other causes of death.

Silicone wristbands as personal passive sampling devices: Current knowledge, recommendations for use, and future directions

Personal chemical exposure assessment is necessary to determine the frequency and magnitude of individual chemical exposures, especially since chemicals present in everyday environments may lead to adverse health outcomes. In the last decade, silicone wristbands have emerged as a new chemical exposure assessment tool and have since been utilized for assessing personal exposure to a wide range of chemicals in a variety of populations. Silicone wristbands can be powerful tools for quantifying personal exposure to chemical mixtures in a single sample, associating exposure with health outcomes, and potentially overcoming some of the challenges associated with quantifying the chemical exposome. However, as their popularity grows, it is crucial that they are used in the appropriate context and within the limits of the technology. This review serves as a guide for researchers interested in utilizing silicone wristbands as a personal exposure assessment tool. Along with briefly discussing the passive sampling theory behind silicone wristbands, this review performs an in-depth comparison of wristbands to other common exposure assessment tools, including biomarkers of exposure measured in biospecimens, and evaluates their utility in exposure assessments and epidemiological studies. Finally, this review includes recommendations for utilizing silicone wristbands to evaluate personal chemical exposure and provides suggestions on what research is needed to recognize silicone wristbands as a premier chemical exposure assessment tool.

Assessing How Social Exposures Are Integrated in Exposome Research: A Scoping Review

BACKGROUND

Exposome research aims to describe and understand the extent to which all the exposures in human environments may affect our health over the lifetime. However, the way in which humans interact with their environment is socially patterned. Failing to account for social factors in research exploring the exposome may underestimate the magnitude of the effect of exposures or mask inequalities in the distribution of both exposures and outcomes.

OBJECTIVES

We aimed to describe the extent to which social factors appear in the exposome literature, the manner in which they are used in empirical analyses and statistical modeling, and the way in which they are considered in the overall scientific approach.

METHODS

We conducted a scoping review of the literature using three databases (PubMed, Embase, and Web of Science) up to January 2022. We grouped studies based on the way in which the social variables were used in the analyses and quantified the type and frequency of social variables mentioned in the articles. We also qualitatively described the scientific approach used by authors to integrate social variables.

RESULTS

We screened 1,001 records, and 73 studies were included in the analysis. Fifty-five (∼75%) used social variables as exposures or confounders or both, and a wide array of social variables were represented in the articles. Individual-level social variables were more often found, especially education and race/ethnicity, as well as neighborhood-level deprivation indices. Half of the studies used a hypothesis-free approach and the other half, a hypothesis-driven approach. However, in the latter group, of 35 studies, only 8 reported and discussed at least one possible social mechanism underlying the relationship observed between the social variable and the outcome.

DISCUSSION

Social factors in exposome research should be considered in a more systematic way, considering their role in structuring both the specific external and the internal exposome. Doing so could help to understand the mechanisms of construction and, potentially, alleviate social inequalities in health and mitigate the emergence of new ones. https://doi.org/10.1289/EHP11015.

Questionnaire-based exposome-wide association studies (ExWAS) reveal expected and novel risk factors associated with cardiovascular outcomes in the Personalized Environment and Genes Study

While multiple factors are associated with cardiovascular disease (CVD), many environmental exposures that may contribute to CVD have not been examined. To understand environmental effects on cardiovascular health, we performed an exposome-wide association study (ExWAS), a hypothesis-free approach, using survey data on endogenous and exogenous exposures at home and work and data from health and medical histories from the North Carolina-based Personalized Environment and Genes Study (PEGS) (n = 5015). We performed ExWAS analyses separately on six cardiovascular outcomes (cardiac arrhythmia, congestive heart failure, coronary artery disease, heart attack, stroke, and a combined atherogenic-related outcome comprising angina, angioplasty, atherosclerosis, coronary artery disease, heart attack, and stroke) using logistic regression and a false discovery rate of 5%. For each CVD outcome, we tested 502 single exposures and built multi-exposure models using the deletion-substitution-addition (DSA) algorithm. To evaluate complex nonlinear relationships, we employed the knockoff boosted tree (KOBT) algorithm. We adjusted all analyses for age, sex, race, BMI, and annual household income. ExWAS analyses revealed novel associations that include blood type A (Rh-) with heart attack (OR[95%CI] = 8.2[2.2:29.7]); paint exposures with stroke (paint related chemicals: 6.1[2.2:16.0], acrylic paint: 8.1[2.6:22.9], primer: 6.7[2.2:18.6]); biohazardous materials exposure with arrhythmia (1.8[1.5:2.3]); and higher paternal education level with reduced risk of multiple CVD outcomes (stroke, heart attack, coronary artery disease, and combined atherogenic outcome). In multi-exposure models, trouble sleeping and smoking remained important risk factors. KOBT identified significant nonlinear effects of sleep disorder, regular intake of grapefruit, and a family history of blood clotting problems for multiple CVD outcomes (combined atherogenic outcome, congestive heart failure, and coronary artery disease). In conclusion, using statistics and machine learning, these findings identify novel potential risk factors for CVD, enable hypothesis generation, provide insights into the complex relationships between risk factors and CVD, and highlight the importance of considering multiple exposures when examining CVD outcomes.

Chronic obstructive pulmonary disease

Chronic obstructive pulmonary disease (COPD) is a major cause of morbidity, mortality, and health-care use worldwide. COPD is caused by exposure to inhaled noxious particles, notably tobacco smoke and pollutants. However, the broad range of factors that increase the risk of development and progression of COPD throughout the life course are increasingly being recognised. Innovations in omics and imaging techniques have provided greater insight into disease pathobiology, which might result in advances in COPD prevention, diagnosis, and treatment. Although few novel treatments have been approved for COPD in the past 5 years, advances have been made in targeting existing therapies to specific subpopulations using new biomarker-based strategies. Additionally, COVID-19 has undeniably affected individuals with COPD, who are not only at higher risk for severe disease manifestations than healthy individuals but also negatively affected by interruptions in health-care delivery and social isolation. This Seminar reviews COPD with an emphasis on recent advances in epidemiology, pathophysiology, imaging, diagnosis, and treatment.

Integrating Environment and Aging Research: Opportunities for Synergy and Acceleration

Despite significant overlaps in mission, the fields of environmental health sciences and aging biology are just beginning to intersect. It is increasingly clear that genetics alone does not predict an individual’s neurological aging and sensitivity to disease. Accordingly, aging neuroscience is a growing area of mutual interest within environmental health sciences. The impetus for this review came from a workshop hosted by the National Academies of Sciences, Engineering, and Medicine in June of 2020, which focused on integrating the science of aging and environmental health research. It is critical to bridge disciplines with multidisciplinary collaborations across toxicology, comparative biology, epidemiology to understand the impacts of environmental toxicant exposures and age-related outcomes. This scoping review aims to highlight overlaps and gaps in existing knowledge and identify essential research initiatives. It begins with an overview of aging biology and biomarkers, followed by examples of synergy with environmental health sciences. New areas for synergistic research and policy development are also discussed. Technological advances including next-generation sequencing and other-omics tools now offer new opportunities, including exposomic research, to integrate aging biomarkers into environmental health assessments and bridge disciplinary gaps. This is necessary to advance a more complete mechanistic understanding of how life-time exposures to toxicants and other physical and social stressors alter biological aging. New cumulative risk frameworks in environmental health sciences acknowledge that exposures and other external stressors can accumulate across the life course and the advancement of new biomarkers of exposure and response grounded in aging biology can support increased understanding of population vulnerability. Identifying the role of environmental stressors, broadly defined, on aging biology and neuroscience can similarly advance opportunities for intervention and translational research. Several areas of growing research interest include expanding exposomics and use of multi-omics, the microbiome as a mediator of environmental stressors, toxicant mixtures and neurobiology, and the role of structural and historical marginalization and racism in shaping persistent disparities in population aging and outcomes. Integrated foundational and translational aging biology research in environmental health sciences is needed to improve policy, reduce disparities, and enhance the quality of life for older individuals.

Stroke Genetics: Turning Discoveries into Clinical Applications

The field of medical and population genetics in stroke is moving at a rapid pace and has led to unanticipated opportunities for discovery and clinical applications. Genome-wide association studies have highlighted the role of specific pathways relevant to etiologically defined subtypes of stroke and to stroke as a whole. They have further offered starting points for the exploration of novel pathways and pharmacological strategies in experimental systems. Mendelian randomization studies continue to provide insights in the causal relationships between exposures and outcomes and have become a useful tool for predicting the efficacy and side effects of drugs. Additional applications that have emerged from recent discoveries include risk prediction based on polygenic risk scores and pharmacogenomics. Among the topics currently moving into focus is the genetics of stroke outcome. While still at its infancy, this field is expected to boost the development of neuroprotective agents. We provide a brief overview on recent progress in these areas.

Statistical methods for mediation analysis in the era of high-throughput genomics: Current successes and future challenges

Mediation analysis investigates the intermediate mechanism through which an exposure exerts its influence on the outcome of interest. Mediation analysis is becoming increasingly popular in high-throughput genomics studies where a common goal is to identify molecular-level traits, such as gene expression or methylation, which actively mediate the genetic or environmental effects on the outcome. Mediation analysis in genomics studies is particularly challenging, however, thanks to the large number of potential mediators measured in these studies as well as the composite null nature of the mediation effect hypothesis. Indeed, while the standard univariate and multivariate mediation methods have been well-established for analyzing one or multiple mediators, they are not well-suited for genomics studies with a large number of mediators and often yield conservative p-values and limited power. Consequently, over the past few years many new high-dimensional mediation methods have been developed for analyzing the large number of potential mediators collected in high-throughput genomics studies. In this work, we present a thorough review of these important recent methodological advances in high-dimensional mediation analysis. Specifically, we describe in detail more than ten high-dimensional mediation methods, focusing on their motivations, basic modeling ideas, specific modeling assumptions, practical successes, methodological limitations, as well as future directions. We hope our review will serve as a useful guidance for statisticians and computational biologists who develop methods of high-dimensional mediation analysis as well as for analysts who apply mediation methods to high-throughput genomics studies.

The Association of Toxoplasma gondii IgG and Cardiovascular Biomarkers

Background: Toxoplasma gondii (T. gondii) is a protozoan parasite with high prevalence worldwide. More than 40 million individuals in the United States carry this parasite. T. gondii infection causes toxoplasmosis, which is the leading cause of death associated with foodborne diseases in the United States. T. gondii infects humans through different routes, and it is capable of invading a wide range of tissues in the human body following the infection. Methods: The main objective of this study was to investigate the prevalence of T. gondii among adults in the United States and its association with cardiovascular health using data from the National Health and Nutrition Examination Survey (NHANES 2009-2010). Considering the limitation of studies investigating the relationship between T. gondii and cardiovascular biomarkers, this study was focused on assessing the association of T. gondii to nine cardiovascular biomarkers. First, those biomarkers were investigated individually using several statistical tests and models. Second, we developed an overall cardiovascular biomarker index (OCBI) from eight critical biomarkers to better explain the T. gondii potential cumulative effect on the cardiovascular system. These analyses were adjusted for demographic, behavioral, and anthropometric factors. Results:T. gondii IgG antibody-positive participants had significantly higher systolic blood pressure (p = 0.0022), triglycerides (p = 0.0399), C-reactive protein (p = 0.0422), gamma glutamyl transferase (p = 0.0400), and fasting glucose (p = 0.0213) than the negative participants. In addition, the positive participants had significantly lower high-density lipoprotein cholesterol (p = 0.0431) than the negative participants. Adjusting for age, T. gondii positive had a significant negative association with high-density lipoprotein cholesterol (p = 0.0026) and a significant positive association with low-density lipoprotein cholesterol (p = 0.0179), triglycerides (p = 0.0154), and gamma glutamyl transferase (p = 0.0026). With the exception of the low-density lipoprotein, these associations remained statistically significant when adjusting for demographic, behavioral, and anthropometric factors. These results potentially indicate the role of T. gondii in driving cardiovascular-related biomarkers toward dysfunction. The analysis also revealed a significant difference in the OCBI among positive and negative participants (p = 0.0020), with the (cumulative) odds of positive participants having a higher level of OCBI being 0.71 times lower than the odds for negative participants (OR = 0.29). Conclusions: Positive T. gondii IgG antibody was significantly associated with adverse effects on cardiovascular-related biomarkers, including systolic blood pressure, low-density lipoprotein cholesterol, high-density lipoprotein cholesterol, triglycerides, and gamma glutamyl transferase. T. gondii-positive individuals were more likely to have a lower cardiovascular biomarkers index than the negative individuals. Finally, the prevalence of toxoplasmosis among U.S. adults was associated with demographic characteristics including age, ethnicity, country of birth, and occupation.

Adopting a "Compound" Exposome Approach in Environmental Aging Biomarker Research: A Call to Action for Advancing Racial Health Equity

BACKGROUND

In June 2020, the National Academies of Sciences, Engineering, and Medicine hosted a virtual workshop focused on integrating the science of aging and environmental health research. The concurrent COVID-19 pandemic and national attention on racism exposed shortcomings in the environmental research field's conceptualization and methodological use of race, which have subsequently hindered the ability of research to address racial health disparities. By the workshop's conclusion, the authors deduced that the utility of environmental aging biomarkers-aging biomarkers shown to be specifically influenced by environmental exposures-would be greatly diminished if these biomarkers are developed absent of considerations of broader societal factors-like structural racism-that impinge on racial health equity.

OBJECTIVES

The authors reached a post-workshop consensus recommendation: To advance racial health equity, a "compound" exposome approach should be widely adopted in environmental aging biomarker research. We present this recommendation here.

DISCUSSION

The authors believe that without explicit considerations of racial health equity, people in most need of the benefits afforded by a better understanding of the relationships between exposures and aging will be the least likely to receive them because biomarkers may not encompass cumulative impacts from their unique social and environmental stressors. Employing an exposome approach that allows for more comprehensive exposure-disease pathway characterization across broad domains, including the social exposome and neighborhood factors, is the first step. Exposome-centered study designs must then be supported with efforts aimed at increasing the recruitment and retention of racially diverse study populations and researchers and further "compounded" with strategies directed at improving the use and interpretation of race throughout the publication and dissemination process. This compound exposome approach maximizes the ability of our science to identify environmental aging biomarkers that explicate racial disparities in health and best positions the environmental research community to contribute to the elimination of racial health disparities. https://doi.org/10.1289/EHP8392.