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Shen Y, Jin H, Guo F, Zhang W, Fu H, Jin M, Chen G. Association of Magnesium, Iron, Copper, and Zinc Levels with the Prevalence of Behavior Problems in Children and Adolescents. Biol Trace Elem Res 2024:10.1007/s12011-024-04098-4. [PMID: 38388752 DOI: 10.1007/s12011-024-04098-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2023] [Accepted: 02/07/2024] [Indexed: 02/24/2024]
Abstract
Magnesium (Mg), iron (Fe), copper (Cu), and zinc (Zn) are indispensable elements in children's growth and development. However, epidemiological evidence regarding essential elements and their mixed exposure to behavior problems remains in its infancy. The objective of the present study was to evaluate the association between essential elements and the manifestation of behavior problems, with an additional focus on the implications of their mixture. An electronic medical records review was performed among 4122 subjects aged 6-18 years who underwent examinations at Children's Hospital, Zhejiang University School of Medicine, between January 2019 and July 2022. The concentrations of essential elements were measured by atomic absorption spectrometry, and behavior problems were assessed by using the Conners' Parent Rating Scale (CPRS). A total of 895 (21.7%) children and adolescents were identified as having behavior problems. For single exposure, inversely linear dose-response relationships were identified between continuous Mg and Zn levels and the prevalence of behavior problems, and the prevalence ratios (PRs) in the categorical lowest tertile were 1.28 (95% confidence interval, CI: 1.07-1.54) for Mg and 1.31 (95% CI: 1.05-1.63) for Zn compared to the highest tertile. For mixture exposure, an inverse association between essential elements and behavior problems was also found, mainly contributed by Mg (posterior inclusion probability, PIP = 0.854). Whole blood levels of Mg and Zn were significantly inversely associated with behavior problems. The findings highlight the pivotal role of essential elements in behavior problems and emphasize the importance of maintaining adequate levels of essential elements during children's maturation.
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Affiliation(s)
- Ying Shen
- Department of Child Health Care, Children's Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, 310005, China
| | - Huyi Jin
- Department of Public Health, and Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, 310058, China
| | - Fanjia Guo
- Department of Public Health, and Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, 310058, China
- Department of Environmental Health, Zhejiang Provincial Center for Disease Control and Prevention, Hangzhou, 310051, China
| | - Wanting Zhang
- Department of Public Health, and Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, 310058, China
- Jiaxing Center for Disease Control and Prevention, Jiaxing, 314000, China
| | - Hao Fu
- Department of Public Health, and Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, 310058, China
| | - Mingjuan Jin
- Department of Public Health, and Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, 310058, China.
| | - Guangdi Chen
- Department of Public Health, and Department of Reproductive Endocrinology, Women's Hospital, Zhejiang University School of Medicine, Hangzhou, 310058, China.
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Li YQ, Zhang ST, Ke NY, Fang YC, Hu WL, Li GA, Huang F, Zhou YF. The impact of multiple metals exposure on the risk of developing proliferative diabetic retinopathy in Anhui, China: a case-control study. Environ Sci Pollut Res Int 2023; 30:112132-112143. [PMID: 37831242 DOI: 10.1007/s11356-023-30294-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Accepted: 10/02/2023] [Indexed: 10/14/2023]
Abstract
Through multiple different pathways, the environmental multiple metals make their ways to the human bodies, where they induce different levels of the oxidative stress response. This study further investigated the impact of multiple-metal exposure on the risk of developing proliferative diabetic retinopathy (PDR). We designed a case-control study with type 2 diabetic patients (T2D), in which the case group was the proliferative diabetic retinopathy group (PDR group), while the control group was the non-diabetic retinopathy group (NDR group). Graphite furnace atomic absorption spectrometry (GFAAS) and inductively coupled plasma optical emission spectrometry (ICP-OES) were used to detect the metal levels in our participants' urine samples. The least absolute shrinkage and selection operator (LASSO) regression approach was used to include these representative trace elements in a multiple exposure model. Following that, logistic regression models and Bayesian kernel machine regression (BKMR) models were used to describe the effect of different elements and also analyze their combined effect. In the single-element model, we discovered that lithium (Li), cadmium (Cd), and strontium (Sr) were all positively related to PDR. The multiple-exposure model revealed a positive relationship between Li and PDR risk, with a maximum quartile OR of 2.80 (95% CI: 1.10-7.16). The BKMR model also revealed that selenium (Se) might act as a protective agent, whereas magnesium (Mg), Li, and Cd may raise the risk of PDR. In conclusion, our study not only revealed an association between exposure to multiple metals and PDR risk but it also implied that urine samples might be a useful tool to assess PDR risk.
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Affiliation(s)
- Yan-Qing Li
- Department of Ophthalmology, First Affiliated Hospital of Anhui Medical University, No.218, Jixi Road, Shushan District, Hefei, Anhui, China
| | - Si-Tian Zhang
- Department of Ophthalmology, First Affiliated Hospital of Anhui Medical University, No.218, Jixi Road, Shushan District, Hefei, Anhui, China
| | - Nai-Yu Ke
- Department of First Clinical Medical College, Anhui Medical University, 81 Meishan Road, Hefei, Anhui, China
| | - Yan-Cheng Fang
- Department of Ophthalmology, First Affiliated Hospital of Anhui Medical University, No.218, Jixi Road, Shushan District, Hefei, Anhui, China
| | - Wen-Lei Hu
- Department of Epidemiology and Biostatistics, School of Public Health, Anhui Medical University, 81 Meishan Road, Hefei, Anhui, China
| | - Guo-Ao Li
- Department of Epidemiology and Biostatistics, School of Public Health, Anhui Medical University, 81 Meishan Road, Hefei, Anhui, China
| | - Fen Huang
- Department of Epidemiology and Biostatistics, School of Public Health, Anhui Medical University, 81 Meishan Road, Hefei, Anhui, China
| | - Yan-Feng Zhou
- Department of Ophthalmology, First Affiliated Hospital of Anhui Medical University, No.218, Jixi Road, Shushan District, Hefei, Anhui, China.
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Wang T, Xu F, Lin X, Lv Y, Zhang X, Cheng W, Wang L, Wang M, Zhang M, Xia T, Qian S, Tang M, Yang W, Zhang Y, Zhang D, Hu A, Zhao Q. Co-exposure to iron, copper, zinc, selenium and titanium is associated with the prevention of gastric precancerous lesions. Biometals 2023; 36:1141-1156. [PMID: 37351758 DOI: 10.1007/s10534-023-00509-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2023] [Accepted: 05/08/2023] [Indexed: 06/24/2023]
Abstract
Gastric cancer is the third leading cause of cancer death, and gastric precancerous lesions (GPLs) are an important stage in the transformation of normal gastric mucosa to gastric cancer. Matched for age and sex, a total of 316 subjects were eventually included from our prospective observation population (including 1007 patients with GPLs and 762 normal controls), and a questionnaire survey was conducted. In total, 10 plasma elements (iron, copper, zinc, selenium, rubidium, strontium, titanium, aluminum, vanadium and arsenic) were measured by applying inductively coupled plasma‒mass spectrometry (ICP‒MS). A multivariate conditional logistic regression model and Bayesian kernel logistic regression model (BKMR) were used to analyze the association between plasma element concentrations and GPLs. In the multimetal model, plasma titanium concentrations were significantly and positively associated with the prevalence of GPLs, with a fourth-quartile OR of 11.56 ([95% CI]: [2.78-48.13]). Plasma selenium and copper were negatively correlated with GPLs, with the highest quartiles of selenium and copper having an OR of 0.03 ([95% CI]: [0.01-0.15]; P < 0.001) and 0.24 ([95% CI]: [0.07-0.82]), respectively. In the BKMR model, there was a significant negative combined correlation of five metals on GPLs: iron, copper, zinc, selenium, and titanium. The results of this study showed that plasma concentrations of selenium and copper were negatively correlated with GPLs, while plasma concentrations of titanium were positively correlated with GPLs, and the combined action of the five elements was negatively correlated with GPLs.
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Affiliation(s)
- Tingting Wang
- Department of Nutrition and Food Hygiene, School of Public Health, Anhui Medical University, Hefei, China
| | - Fang Xu
- Department of Nutrition and Food Hygiene, School of Public Health, Anhui Medical University, Hefei, China
| | - Xiao Lin
- Department of Nutrition and Food Hygiene, School of Public Health, Anhui Medical University, Hefei, China
| | - Yaning Lv
- Anhui Province, Hefei Customs Technology Center, Hefei, China
| | - Xiaohui Zhang
- Department of Nutrition and Food Hygiene, School of Public Health, Anhui Medical University, Hefei, China
| | - Wenli Cheng
- Department of Nutrition and Food Hygiene, School of Public Health, Anhui Medical University, Hefei, China
| | - Li Wang
- Department of Nutrition and Food Hygiene, School of Public Health, Anhui Medical University, Hefei, China
| | - Min Wang
- Department of Nutrition and Food Hygiene, School of Public Health, Anhui Medical University, Hefei, China
| | - Meng Zhang
- Department of Nutrition and Food Hygiene, School of Public Health, Anhui Medical University, Hefei, China
| | - Tao Xia
- Department of Gastroenterology, Anhui Province, Lujiang County People's Hospital, Hefei, China
| | - Shiqing Qian
- Department of Pathology, Anhui Province, Lujiang County People's Hospital, Hefei, China
| | - Min Tang
- Department of Nutrition and Food Hygiene, School of Public Health, Anhui Medical University, Hefei, China
| | - Wanshui Yang
- Department of Nutrition and Food Hygiene, School of Public Health, Anhui Medical University, Hefei, China
| | - Ying Zhang
- Department of Gastroenterology and Hepatology, Anhui Province, Tongling Municipal Hospital, Tongling, China.
| | - Daoming Zhang
- Department of Gastroenterology, Anhui Province, Lujiang County People's Hospital, Hefei, China.
| | - Anla Hu
- Department of Nutrition and Food Hygiene, School of Public Health, Anhui Medical University, Hefei, China.
| | - Qihong Zhao
- Department of Nutrition and Food Hygiene, School of Public Health, Anhui Medical University, Hefei, China.
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Li YQ, Wang Q, Liu R, Li GA, He JL, Huang F, Zhou YF. Associations of exposure to multiple metals with the risk of age-related cataract in Anhui, China: a case-control study. Environ Sci Pollut Res Int 2023; 30:4680-4693. [PMID: 35972654 DOI: 10.1007/s11356-022-22494-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/05/2022] [Accepted: 08/08/2022] [Indexed: 06/15/2023]
Abstract
It's well-known that multiple metal elements can lead to the change of oxidative stress response levels in vivo. However, their relationship with age-related cataract (ARC) had not been well studied. We designed a case-control study including 210 individuals with ARC and 210 matched control group. The metal levels in their urine specimens were measured using graphite furnace atomic absorption spectrometry (GFAAS) and inductively coupled plasma optical emission spectrometry (ICP-OES). Least Absolute Shrinkage and Selection Operator (LASSO) regression was used to select representative metals into the multi-element model and reduce dimension. Multivariate logic analysis and Bayesian kernel machine regression (BKMR) were subsequently used to explore the association of ARC risk with multiple metal elements. We found that magnesium (Mg), chromium (Cr), arsenic (As), manganese (Mn), and selenium (Se) were positively associated with ARC in the single-element model. The multiple exposure model indicated a positive association between Mg and As, in which the OR in their highest quartile were 3.32 (95% CI: 1.24-8.89) and 7.09 (95% CI: 2.56-19.63). The BKMR model also showed the effect of As increased monotonically with its increasing concentration, and high levels of Mg and As had a significant positive effect on ARC risk. In conclusion, we found that exposure to multiple metals was associated with increased ARC risk. Further research is needed to verify these findings in the future.
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Affiliation(s)
- Yan-Qing Li
- Department of Ophthalmology, First Affiliated Hospital of Anhui Medical University, No.218, Jixi Road, Shushan District, Hefei, 230022, Anhui, China
| | - Qian Wang
- Department of Ophthalmology, First Affiliated Hospital of Anhui Medical University, No.218, Jixi Road, Shushan District, Hefei, 230022, Anhui, China
| | - Ran Liu
- Department of Ophthalmology, First Affiliated Hospital of Anhui Medical University, No.218, Jixi Road, Shushan District, Hefei, 230022, Anhui, China
| | - Guo-Ao Li
- Department of Epidemiology and Biostatistics, School of Public Health, Anhui Medical University, 81 Meishan Road, Hefei, Anhui, China
| | - Jia-Liu He
- Department of Epidemiology and Biostatistics, School of Public Health, Anhui Medical University, 81 Meishan Road, Hefei, Anhui, China
| | - Fen Huang
- Department of Epidemiology and Biostatistics, School of Public Health, Anhui Medical University, 81 Meishan Road, Hefei, Anhui, China
| | - Yan-Feng Zhou
- Department of Ophthalmology, First Affiliated Hospital of Anhui Medical University, No.218, Jixi Road, Shushan District, Hefei, 230022, Anhui, China.
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Guo F, Lin Y, Meng L, Peng L, Zhang H, Zhang X, Jin M, Wang J, Zhang Y, Tang M, Chen K. Association of copper exposure with prevalence of chronic kidney disease in older adults. Clin Nutr 2022; 41:2720-2728. [PMID: 36368257 DOI: 10.1016/j.clnu.2022.10.016] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2022] [Revised: 08/21/2022] [Accepted: 10/20/2022] [Indexed: 01/27/2023]
Abstract
BACKGROUND & AIMS Metal exposure is suspected to be associated with the risk of chronic kidney disease (CKD). Copper (Cu) is an essential yet toxic trace element in humans. Epidemiological evidence on the association of Cu exposure with CKD remains inconsistent. This study aims to investigate the association of blood Cu and its co-exposure to other metals with CKD. METHODS A cross-sectional study was conducted among 3285 older participants in Zhejiang, China. The whole blood levels of Cu as well as other 10 metals were measured using the inductively coupled plasma mass spectrometry (ICP-MS). CKD events were defined as the presence of albuminuria or estimated glomerular filtration rate (eGFR) < 60 mL/min/1.73 m2. Multivariable logistic regression and linear regression models were applied to assess the association of Cu with kidney function. The Bayesian kernel machine regression (BKMR) was used to examine the association of metal interactions with CKD. RESULTS In logistic models, we found a dose-dependent positive association between blood Cu and the prevalence of CKD. Compared to the lowest quartile of blood Cu, the odds ratio (OR) of CKD in the highest quartile was 1.65 (95% confidence interval, CI: 1.25, 2.17), and the β of eGFR was -1.74 (95% CI: -3.15, -0.34) after adjusting for multiple covariates. The positive linear dose-response association was found between blood Cu and the OR of CKD, and negative linear association was found between Cu and the β of eGFR. The positive association between blood Cu and CKD risk was stronger at lower level of manganese (Mn) in the BKMR model. CONCLUSION The whole blood level of Cu was remarkably associated with the risk of CKD and showed positive dose-response relationships in the older Chinese population. The toxicity of Cu on kidney function could be antagonized by the exposure of Mn. These findings shed new light on the potential role of Cu in kidney health.
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Affiliation(s)
- Fanjia Guo
- Department of Public Health, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310058, China
| | - Yaoyao Lin
- Department of Public Health, Fourth Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310058, China
| | - Lin Meng
- Department of Public Health, Fourth Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310058, China
| | - Lihe Peng
- Physical and Chemical Laboratory, Center for Disease Control and Prevention, Jiashan County, Jiaxing, Zhejiang Province, 314100, China
| | - Huafang Zhang
- Department of Nursing, The Fourth Affiliated Hospital, Zhejiang University School of Medicine, Yiwu 322000, China
| | - Xue Zhang
- Physical and Chemical Laboratory, Center for Disease Control and Prevention, Jiashan County, Jiaxing, Zhejiang Province, 314100, China
| | - Mingjuan Jin
- Department of Public Health, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310058, China
| | - Jianbing Wang
- Department of Public Health, National Clinical Research Center for Child Health of Children's Hospital, Zhejiang University School of Medicine, Hangzhou 310058, China
| | - Yongming Zhang
- The Fourth Affiliated Hospital, Zhejiang University School of Medicine, Yiwu 322000, China.
| | - Mengling Tang
- Department of Public Health, Fourth Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310058, China.
| | - Kun Chen
- Department of Public Health, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310058, China.
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Hu MJ, Wang S, Zhang Q, He JL, Zhao HH, Hu WL, Huang F. Associations between environmental exposure to polybrominated diphenyl ethers and nodular goiter risk: A case-control study. Environ Res 2022; 212:113345. [PMID: 35469855 DOI: 10.1016/j.envres.2022.113345] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/18/2022] [Revised: 04/18/2022] [Accepted: 04/18/2022] [Indexed: 06/14/2023]
Abstract
Polybrominated diphenyl ethers (PBDEs) are widespread and persistent environmental contaminants, but their association with nodular goiter (NG) remains unknown. The present case-control study of 179 NG cases and 358 matched normal controls aimed to investigate the association between PBDEs and risk of NG. The plasma concentrations of 8 PBDEs congeners (BDE-28, -47, -99, -100, -153, -154, -183, and -209) were determined by gas chromatograph-mass spectrometer. Conditional logistic regression model was used to evaluate the odds ratio (OR) and 95% confidence interval (CI) for the association between each PBDEs congener and NG. Bayesian kernel machine regression (BKMR) was used to evaluate the association between overall levels of 8 PBDEs mixture and NG. The results of logistic model suggested that increased risk of NG was associated with elevated concentrations of all PBDEs congeners, except for BDE-209. In BKMR model, the risk of NG increased with the increase in overall exposure level of 8 PBDEs mixture. Compared to when all PBDEs mixture were at their median value, the risk of exposure-response function for NG increased by 0.34 units when all PBDEs were at their 75th percentile. In women, the results showed similar trends after additional adjustment for age at menarche and menopausal status. These findings provide novel epidemiological evidence for the prevention of NG. However, larger prospective studies are required to address the associations between PBDEs exposure and NG risk.
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Affiliation(s)
- Ming-Jun Hu
- Department of Epidemiology and Biostatistics, School of Public Health, Anhui Medical University, Hefei, Anhui, 230032, China
| | - Sheng Wang
- The Center for Scientific Research of Anhui Medical University, Hefei, Anhui, 230032, China
| | - Qian Zhang
- Department of Epidemiology and Health Statistics, School of Public Health, Fujian Medical University, Fuzhou, Fujian, 350122, China
| | - Jia-Liu He
- Department of Epidemiology and Biostatistics, School of Public Health, Anhui Medical University, Hefei, Anhui, 230032, China
| | - Huan-Huan Zhao
- Department of Epidemiology and Biostatistics, School of Public Health, Anhui Medical University, Hefei, Anhui, 230032, China
| | - Wen-Lei Hu
- Department of Epidemiology and Biostatistics, School of Public Health, Anhui Medical University, Hefei, Anhui, 230032, China
| | - Fen Huang
- Department of Epidemiology and Biostatistics, School of Public Health, Anhui Medical University, Hefei, Anhui, 230032, China; Key Laboratory for Environmental Toxicology of Anhui Higher Education Institutes, Anhui Medical University, Hefei, Anhui, 230032, China.
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Zhong Q, Wu HB, Niu QS, Jia PP, Qin QR, Wang XD, He JL, Yang WJ, Huang F. Exposure to multiple metals and the risk of hypertension in adults: A prospective cohort study in a local area on the Yangtze River, China. Environ Int 2021; 153:106538. [PMID: 33839551 DOI: 10.1016/j.envint.2021.106538] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Revised: 02/28/2021] [Accepted: 03/19/2021] [Indexed: 06/12/2023]
Abstract
BACKGROUND Exposure to multiple metals is recognized as a common and real scenario in daily life. However, limited prospective studies have assessed associations between multiple metals exposure and hypertension. METHODS In total, 2625 adults in a local area on the Yangtze River were investigated at baseline from 2014 to 2015 and followed up in 2019. We measured baseline urine levels of 22 metals and used multivariate logistic analysis and Bayesian kernel machine regression (BKMR) to explore associations between multiple metals exposure and the risk of hypertension. RESULTS A total of 385 individuals (29.6%) were diagnosed with hypertension. Five metals (cadmium, copper, magnesium, molybdenum and zinc) were positively associated with hypertension in single-metal models. Cadmium and zinc remained significantly positive associations after adjusting for these five metals, with the odds ratio (OR) in the highest quartiles of 1.49 (95% CI: 1.01, 2.21; p-trend = 0.05) and 1.60 (95% CI: 1.08, 2.38; p-trend = 0.02), respectively. BKMR analysis showed a significant joint effect of multiple metals on hypertension when the concentrations of five metals were at or above their 55th percentile compared with their median values. A potential interaction between cadmium and zinc in increasing the risk of hypertension was observed with the ORint of 1.41 (95%CI: 1.05, 1.89). CONCLUSIONS We identified the joint effect of multiple metals on hypertension and observed a significant interaction between cadmium and zinc. Further cohort studies are needed to clarify the health effects of multiple metals exposure in a larger population.
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Affiliation(s)
- Qi Zhong
- Department of Epidemiology and Biostatistics, School of Public Health, Anhui Medical University, 81 Meishan Road, Hefei, Anhui, China
| | - Hua-Bing Wu
- Department of Epidemiology and Biostatistics, School of Public Health, Anhui Medical University, 81 Meishan Road, Hefei, Anhui, China
| | - Qin-Shan Niu
- Department of Epidemiology and Biostatistics, School of Public Health, Anhui Medical University, 81 Meishan Road, Hefei, Anhui, China
| | - Ping-Ping Jia
- JC School of Public Health and Primary Care, The Chinese University of Hong Kong, Hong Kong
| | - Qi-Rong Qin
- Ma(,)anshan Center for Disease Control and Provention, Ma(,)anshan, Anhui, China
| | - Xiao-Dong Wang
- Yian Center for Disease Control and Provention, Tongling, Anhui, China
| | - Jia-Liu He
- Department of Epidemiology and Biostatistics, School of Public Health, Anhui Medical University, 81 Meishan Road, Hefei, Anhui, China
| | - Wan-Jun Yang
- Department of Epidemiology and Biostatistics, School of Public Health, Anhui Medical University, 81 Meishan Road, Hefei, Anhui, China
| | - Fen Huang
- Department of Epidemiology and Biostatistics, School of Public Health, Anhui Medical University, 81 Meishan Road, Hefei, Anhui, China.
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