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Yu Y, Chen R, Li Z, Luo K, Taylor MP, Hao C, Chen Q, Zhou Y, Kuang H, Hu G, Chen X, Li H, Dong C, Dong GH. Associations of urinary zinc exposure with blood lipid profiles and dyslipidemia: Mediating effect of serum uric acid. THE SCIENCE OF THE TOTAL ENVIRONMENT 2024; 912:168951. [PMID: 38042193 DOI: 10.1016/j.scitotenv.2023.168951] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/16/2023] [Revised: 11/25/2023] [Accepted: 11/25/2023] [Indexed: 12/04/2023]
Abstract
The relationship between zinc (Zn) exposure and abnormal blood lipids including dyslipidemia is contentious. Serum uric acid (SUA) has been reported to be correlated to both Zn exposure and dyslipidemia. The underlying mechanisms of Zn exposure associated with blood lipids and the mediating effects of SUA remain unclear. Therefore, this study analyzed the data from Chinese 2110 adults (mean age: 59.0 years old) in rural areas across China to explore the associations of Zn exposure with blood lipid profiles and dyslipidemia, and to further estimate the mediating effects of SUA in these relationships. The study data showed that urinary Zn was associated with increased levels of blood lipid components triglyceride (TG) and low-density lipoprotein cholesterol (LDL-C). Moreover, an increased risk of dyslipidemia was observed in the study participants who had higher urinary Zn levels. Compared with the first quartile, the fourth quartile of urinary Zn concentration corresponded to the increase of TG (β = 0.20, 95 % CI: 0.12, 0.28), LDL-C (β = 0.06, 95 % CI: 0.01, 0.10) and dyslipidemia risk (OR = 2.16, 95 % CI: 1.50, 3.10), respectively. Elevated urinary Zn was also associated with higher levels of SUA and hyperuricemia risk. The SUA levels were positively related to total cholesterol (TC), TG, LDL-C levels and dyslipidemia risk. Mediation analyses revealed that SUA mediated 31.75 %, 46.16 % and 19.25 % of the associations of urinary Zn with TG, LDL-C levels and dyslipidemia risk, respectively. The subgroup and sensitivity analyses confirmed the positive associations between urinary Zn and blood lipid profiles and the mediating effect of SUA. The national population-based study further enhanced our understanding of the associations between Zn exposure and blood lipid profiles and mediating effect of SUA among generally healthy, middle-aged, and elderly individuals.
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Affiliation(s)
- Yunjiang Yu
- State Environmental Protection Key Laboratory of Environmental Pollution Health Risk Assessment, South China Institute of Environmental Sciences, Ministry of Ecology and Environment, Guangzhou 510655, China.
| | - Runan Chen
- State Environmental Protection Key Laboratory of Environmental Pollution Health Risk Assessment, South China Institute of Environmental Sciences, Ministry of Ecology and Environment, Guangzhou 510655, China
| | - Zhenchi Li
- State Environmental Protection Key Laboratory of Environmental Pollution Health Risk Assessment, South China Institute of Environmental Sciences, Ministry of Ecology and Environment, Guangzhou 510655, China
| | - Kai Luo
- Department of Epidemiology and Population Health, Albert Einstein College of Medicine, New York 10461, USA
| | - Mark Patrick Taylor
- Environment Protection Authority Victoria, Centre for Applied Sciences, Melbourne, Victoria 3085, Australia
| | - Chaojie Hao
- State Environmental Protection Key Laboratory of Environmental Pollution Health Risk Assessment, South China Institute of Environmental Sciences, Ministry of Ecology and Environment, Guangzhou 510655, China
| | - Qian Chen
- Ministry of Education-Shanghai Key Laboratory of Children's Environmental Health, Xin Hua Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200092, China
| | - Yang Zhou
- State Environmental Protection Key Laboratory of Environmental Pollution Health Risk Assessment, South China Institute of Environmental Sciences, Ministry of Ecology and Environment, Guangzhou 510655, China
| | - Hongxuan Kuang
- State Environmental Protection Key Laboratory of Environmental Pollution Health Risk Assessment, South China Institute of Environmental Sciences, Ministry of Ecology and Environment, Guangzhou 510655, China
| | - Guocheng Hu
- State Environmental Protection Key Laboratory of Environmental Pollution Health Risk Assessment, South China Institute of Environmental Sciences, Ministry of Ecology and Environment, Guangzhou 510655, China
| | - Xichao Chen
- State Environmental Protection Key Laboratory of Environmental Pollution Health Risk Assessment, South China Institute of Environmental Sciences, Ministry of Ecology and Environment, Guangzhou 510655, China
| | - Hongyan Li
- State Environmental Protection Key Laboratory of Environmental Pollution Health Risk Assessment, South China Institute of Environmental Sciences, Ministry of Ecology and Environment, Guangzhou 510655, China
| | - Chenyin Dong
- State Environmental Protection Key Laboratory of Environmental Pollution Health Risk Assessment, South China Institute of Environmental Sciences, Ministry of Ecology and Environment, Guangzhou 510655, China.
| | - Guang-Hui Dong
- Guangdong Provincial Engineering Technology Research Center of Environmental Pollution and Health Risk Assessment, Department of Occupational and Environmental Health, School of Public Health, Sun Yat-sen University, Guangzhou 510080, China.
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Gunasekara TDKSC, Herath C, De Silva PMCS, Jayasundara N. Exploring the Utility of Urinary Creatinine Adjustment for KIM-1, NGAL, and Cystatin C for the Assessment of Kidney Function: Insights from the C-KidnEES Cohort. CHILDREN (BASEL, SWITZERLAND) 2023; 11:15. [PMID: 38255329 PMCID: PMC10814906 DOI: 10.3390/children11010015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Revised: 10/21/2023] [Accepted: 10/26/2023] [Indexed: 01/24/2024]
Abstract
Normalization of urinary biomarkers of kidney injury is a common practice in clinical and research settings to account for variations in urine concentration, and urinary creatinine is often used as a reference. However, to date, there is no consensus on the adjustment of urinary biomarkers with creatinine, and both absolute and creatinine-adjusted biomarker levels are adopted for making interpretations of kidney health. Hence, the present study aimed to investigate the associations of urinary creatinine with three widely used kidney injury biomarkers, KIM-1, NGAL, and cystatin C, to validate the applicability of urinary creatinine as a reference for normalization. A cross-sectional study was performed with 2100 students, 10-18 years of age in the Children's Kidney Environmental Exposure Study (C-KidnEES) cohort established in Sri Lanka. As identified in linear regression analyses, normalization of urinary KIM-1, NGAL, and Cys-C to urinary creatinine did not result in significant under-adjustment or over-adjustment to the absolute urinary concentrations, giving no specific rationale for creatinine adjustment. Hence, absolute urinary concentrations of the above biomarkers can be adopted for the characterization of subclinical kidney injury in adolescents in community studies where early morning urine sampling is practiced. However, for spot urine samples, consideration of both absolute and creatinine-adjusted biomarker levels would be a better approach.
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Affiliation(s)
| | - Chula Herath
- Department of Nephrology, Sri Jayewardenepura General Hospital, Colombo 10100, Sri Lanka;
| | | | - Nishad Jayasundara
- Nicholas School of the Environment, Duke University, Durham, NC 27708, USA;
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Wang Z, Dou Y, Guo W, Lin Y, Jiang Y, Jiang T, Qin R, Lv H, Lu Q, Jin G, Ma H, Hu Z, Liu H, Du J. Association between prenatal exposure to trace elements mixture and visual acuity in infants: A prospective birth cohort study. CHEMOSPHERE 2023; 333:138905. [PMID: 37187369 DOI: 10.1016/j.chemosphere.2023.138905] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Revised: 05/06/2023] [Accepted: 05/08/2023] [Indexed: 05/17/2023]
Abstract
BACKGROUND Prenatal environmental factors may affect the development of the offspring and can bring long lasting consequences to the offspring's health. To date, only few studies have reported inconclusive association between prenatal single trace element exposure and visual acuity, and no studies have investigated the association between prenatal exposure to trace elements mixture and visual acuity in infants. METHODS In the prospective cohort study, grating acuity in infants (12 ± 1 months) was measured by Teller Acuity Cards II. Concentrations of 20 trace elements in maternal urine samples collected in early-trimester were measured by Inductively Coupled Plasma Mass Spectrometry. Elastic net regression (ENET) was applied to select important trace elements. Nonlinear associations of the trace elements levels with abnormal grating were explored using the restricted cubic spline (RCS) method. The associations between selected individual elements and abnormal grating acuity were further appraised using the logistic regression model. Then Bayesian Kernel Machine Regression (BKMR) was used to estimate the joint effects of mixture and interactions between trace elements combining with NLinteraction. RESULTS Of 932 mother-infant pairs, 70 infants had abnormal grating acuity. The ENET model produced 8 trace elements with non-zero coefficients, including cadmium, manganese, molybdenum, nickel, rubidium, antimony, tin and titanium. RCS analyses identified no nonlinear associations of the 8 elements with abnormal grating acuity. The single-exposure analyses using logistic regression revealed that prenatal molybdenum exposure possessed a significantly positive association with abnormal grating acuity (odds ratio [OR]: 1.44 per IQR increase, 95% confidence interval [CI]: 1.05, 1.96; P = 0.023), while prenatal nickel exposure presented with a significantly inverse association with abnormal grating acuity (OR: 0.64 per IQR increase, 95% CI: 0.45, 0.89; P = 0.009). Similar effects were also observed in BKMR models. Moreover, the BKMR models and NLinteraction method identified potential interaction between molybdenum and nickel. CONCLUSIONS We established that prenatal exposure to high concentration of molybdenum and low concentration of nickel was associated with the increased risk of abnormal visual acuity. Potential interaction may exist between molybdenum and nickel on abnormal visual acuity.
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Affiliation(s)
- Zijin Wang
- Department of Ophthalmology, The First Affiliated Hospital with Nanjing Medical University, Nanjing, 210029, China; State Key Laboratory of Reproductive Medicine, Nanjing Medical University, Nanjing, 211166, Jiangsu, China; Department of Epidemiology, Center for Global Health, School of Public Health, Nanjing Medical University, Nanjing, 211166, Jiangsu, China
| | - Yuanyan Dou
- State Key Laboratory of Reproductive Medicine, Nanjing Medical University, Nanjing, 211166, Jiangsu, China; Department of Epidemiology, Center for Global Health, School of Public Health, Nanjing Medical University, Nanjing, 211166, Jiangsu, China
| | - Wenhui Guo
- State Key Laboratory of Reproductive Medicine, Nanjing Medical University, Nanjing, 211166, Jiangsu, China; Department of Epidemiology, Center for Global Health, School of Public Health, Nanjing Medical University, Nanjing, 211166, Jiangsu, China
| | - Yuan Lin
- State Key Laboratory of Reproductive Medicine, Nanjing Medical University, Nanjing, 211166, Jiangsu, China; Department of Epidemiology, Center for Global Health, School of Public Health, Nanjing Medical University, Nanjing, 211166, Jiangsu, China; Department of Maternal, Child and Adolescent Health, School of Public Health, Nanjing Medical University, Nanjing, 211166, Jiangsu, China; State Key Laboratory of Reproductive Medicine (Suzhou Centre), The Affiliated Suzhou Hospital of Nanjing Medical University, Suzhou Municipal Hospital, Gusu School, Nanjing Medical University, Suzhou, 215002, Jiangsu, China
| | - Yangqian Jiang
- State Key Laboratory of Reproductive Medicine, Nanjing Medical University, Nanjing, 211166, Jiangsu, China; Department of Epidemiology, Center for Global Health, School of Public Health, Nanjing Medical University, Nanjing, 211166, Jiangsu, China; Department of Maternal, Child and Adolescent Health, School of Public Health, Nanjing Medical University, Nanjing, 211166, Jiangsu, China
| | - Tao Jiang
- State Key Laboratory of Reproductive Medicine, Nanjing Medical University, Nanjing, 211166, Jiangsu, China; Department of Epidemiology, Center for Global Health, School of Public Health, Nanjing Medical University, Nanjing, 211166, Jiangsu, China; Department of Biostatistics, School of Public Health, Nanjing Medical University, Nanjing, 211166, Jiangsu, China
| | - Rui Qin
- State Key Laboratory of Reproductive Medicine, Nanjing Medical University, Nanjing, 211166, Jiangsu, China; Department of Epidemiology, Center for Global Health, School of Public Health, Nanjing Medical University, Nanjing, 211166, Jiangsu, China
| | - Hong Lv
- State Key Laboratory of Reproductive Medicine, Nanjing Medical University, Nanjing, 211166, Jiangsu, China; Department of Epidemiology, Center for Global Health, School of Public Health, Nanjing Medical University, Nanjing, 211166, Jiangsu, China; State Key Laboratory of Reproductive Medicine (Suzhou Centre), The Affiliated Suzhou Hospital of Nanjing Medical University, Suzhou Municipal Hospital, Gusu School, Nanjing Medical University, Suzhou, 215002, Jiangsu, China
| | - Qun Lu
- State Key Laboratory of Reproductive Medicine, Nanjing Medical University, Nanjing, 211166, Jiangsu, China; Department of Maternal, Child and Adolescent Health, School of Public Health, Nanjing Medical University, Nanjing, 211166, Jiangsu, China
| | - Guangfu Jin
- State Key Laboratory of Reproductive Medicine, Nanjing Medical University, Nanjing, 211166, Jiangsu, China; Department of Epidemiology, Center for Global Health, School of Public Health, Nanjing Medical University, Nanjing, 211166, Jiangsu, China; State Key Laboratory of Reproductive Medicine (Suzhou Centre), The Affiliated Suzhou Hospital of Nanjing Medical University, Suzhou Municipal Hospital, Gusu School, Nanjing Medical University, Suzhou, 215002, Jiangsu, China
| | - Hongxia Ma
- State Key Laboratory of Reproductive Medicine, Nanjing Medical University, Nanjing, 211166, Jiangsu, China; Department of Epidemiology, Center for Global Health, School of Public Health, Nanjing Medical University, Nanjing, 211166, Jiangsu, China; State Key Laboratory of Reproductive Medicine (Suzhou Centre), The Affiliated Suzhou Hospital of Nanjing Medical University, Suzhou Municipal Hospital, Gusu School, Nanjing Medical University, Suzhou, 215002, Jiangsu, China
| | - Zhibin Hu
- State Key Laboratory of Reproductive Medicine, Nanjing Medical University, Nanjing, 211166, Jiangsu, China; Department of Epidemiology, Center for Global Health, School of Public Health, Nanjing Medical University, Nanjing, 211166, Jiangsu, China; State Key Laboratory of Reproductive Medicine (Suzhou Centre), The Affiliated Suzhou Hospital of Nanjing Medical University, Suzhou Municipal Hospital, Gusu School, Nanjing Medical University, Suzhou, 215002, Jiangsu, China.
| | - Hu Liu
- Department of Ophthalmology, The First Affiliated Hospital with Nanjing Medical University, Nanjing, 210029, China.
| | - Jiangbo Du
- State Key Laboratory of Reproductive Medicine, Nanjing Medical University, Nanjing, 211166, Jiangsu, China; Department of Epidemiology, Center for Global Health, School of Public Health, Nanjing Medical University, Nanjing, 211166, Jiangsu, China; State Key Laboratory of Reproductive Medicine (Suzhou Centre), The Affiliated Suzhou Hospital of Nanjing Medical University, Suzhou Municipal Hospital, Gusu School, Nanjing Medical University, Suzhou, 215002, Jiangsu, China.
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Liu Y, Yu L, Zhu M, Lin W, Liu Y, Li M, Zhang Y, Ji H, Wang J. Associations of exposure to multiple metals with blood pressure and hypertension: A cross-sectional study in Chinese preschool children. CHEMOSPHERE 2022; 307:135985. [PMID: 35964715 DOI: 10.1016/j.chemosphere.2022.135985] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/16/2022] [Revised: 08/01/2022] [Accepted: 08/05/2022] [Indexed: 06/15/2023]
Abstract
Exposure to metals might be a risk factor for hypertension, which contributes largely to the global burden of disease and mortality. However, relevant epidemiological studies of associations between metals exposure with hypertension among preschoolers are limited. This study aimed to explore the associations of urine metals with blood pressure and hypertension among Chinese preschoolers. A total of 1220 eligible participants who had urine metals measurement, blood pressure measurements, and relevant covariates were included in this cross-sectional study. Urine concentrations of metals were measured by inductively coupled plasma mass spectrometer. The single and multiple metals regression models were used to investigate the associations of urine metal with blood pressure and the risk of hypertension after adjusting for potential confounders. We observed urine concentrations of chromium, iron, and barium were negatively associated with levels of systolic blood pressure, diastolic blood pressure and the risk of hypertension in the single metal model (all P-FDR adjustment <0.05). Significant associations of urine chromium concentrations with systolic blood pressure, diastolic blood pressure and the risk of hypertension were found in the multi-metal model (β or OR (95% confidence interval) was -3.07 (-5.12, -1.02), -2.25 (-4.29, -0.22), and 0.51 (0.26, 0.97) for 3rd quartile, compared with 1st quartile, respectively). The same association was found for barium concentrations in the multi-metal model, while none of the associations among iron quartiles was significant. In addition, urine chromium, iron and barium may have joint effects on systolic blood pressure, diastolic blood pressure and hypertension. Children's age and body mass index could modify the associations of chromium, iron, and barium concentrations with blood pressure. Our findings suggested that exposure to chromium, iron, and barium was inversely associated with blood pressure and hypertension among preschool children. These findings need further validation in prospective studies.
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Affiliation(s)
- Yanli Liu
- Department of Preventive Medicine, School of Public Health and Management, Hubei University of Medicine, Shiyan, Hubei, China; Department of Endocrinology, Renmin Hospital, Hubei University of Medicine, Shiyan, 44200, China
| | - Lili Yu
- Dianjiang Traditional Chinese Medical Hospital, Chongqing, China; Center for Environment and Health in Water Source Area of South-to-North Water Diversion, Hubei University of Medicine, 30 Renmin South Road, Shiyan, 442000, Hubei, China
| | - Meiqin Zhu
- Center for Environment and Health in Water Source Area of South-to-North Water Diversion, Hubei University of Medicine, 30 Renmin South Road, Shiyan, 442000, Hubei, China
| | - Wei Lin
- Center for Environment and Health in Water Source Area of South-to-North Water Diversion, Hubei University of Medicine, 30 Renmin South Road, Shiyan, 442000, Hubei, China
| | - Yang Liu
- Center for Environment and Health in Water Source Area of South-to-North Water Diversion, Hubei University of Medicine, 30 Renmin South Road, Shiyan, 442000, Hubei, China
| | - Mingzhu Li
- Center for Environment and Health in Water Source Area of South-to-North Water Diversion, Hubei University of Medicine, 30 Renmin South Road, Shiyan, 442000, Hubei, China
| | - Yao Zhang
- Department of Preventive Medicine, School of Public Health and Management, Hubei University of Medicine, Shiyan, Hubei, China; Center for Environment and Health in Water Source Area of South-to-North Water Diversion, Hubei University of Medicine, 30 Renmin South Road, Shiyan, 442000, Hubei, China
| | - Hongxian Ji
- Department of Child Health, Shiyan Maternal and Child Health Hospital, Shiyan, 44200, China
| | - Jing Wang
- Department of Endocrinology, Renmin Hospital, Hubei University of Medicine, Shiyan, 44200, China; Center for Environment and Health in Water Source Area of South-to-North Water Diversion, Hubei University of Medicine, 30 Renmin South Road, Shiyan, 442000, Hubei, China.
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Lozano M, Murcia M, Soler-Blasco R, Casas M, Zubero B, Riutort-Mayol G, Gil F, Olmedo P, Grimalt JO, Amorós R, Lertxundi A, Vrijheid M, Ballester F, Llop S. Exposure to metals and metalloids among pregnant women from Spain: Levels and associated factors. CHEMOSPHERE 2022; 286:131809. [PMID: 34388877 DOI: 10.1016/j.chemosphere.2021.131809] [Citation(s) in RCA: 28] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Revised: 08/02/2021] [Accepted: 08/03/2021] [Indexed: 06/13/2023]
Abstract
BACKGROUND Humans are regularly exposed to metals and metalloids present in air, water, food, soil and domestic materials. Most of them can cross the placental barrier and cause adverse impacts on the developing foetus. OBJECTIVES To describe the prenatal concentrations of metals and metalloids and to study the associated sociodemographic, environmental and dietary factors in pregnant Spanish women. METHODS Subjects were 1346 pregnant women of the INMA Project, for whom the following metals arsenic (As), cadmium (Cd), cobalt (Co), copper (Cu), molybdenum (Mo), nickel (Ni), lead (Pb), antimony (Sb), selenium (Se), thallium (Tl) and zinc (Zn) were determined in urine, at both the first and the third trimesters of gestation. Sociodemographic, dietary and environmental information was collected through questionnaires during pregnancy. Multiple linear mixed models were built in order to study the association between each metal and metalloid concentrations and the sociodemographic, environmental and dietary factors. RESULTS The most detected compounds were As, Co, Mo, Sb, Se and Zn at both trimesters. Zn was the element found in the highest concentrations at both trimesters and Tl was detected in the lowest concentrations. We observed significant associations between As, Cd, Cu, Sb, Tl and Zn concentrations and working situation, social class and age. Seafood, meat, fruits, nuts, vegetables and alcohol intake affected the levels of all the metals but Cd and Cu. Proximity to industrial areas, fields and air pollution were related to all metals except Cd, Sb and Se. CONCLUSIONS This is the first large prospective longitudinal study on the exposure to metals and metalloids during pregnancy and associated factors to include several cohorts in Spain. The present study shows that some modifiable lifestyles, food intakes and environmental factors could be associated with prenatal exposure to metal(loid)s, which may be considered in further studies to assess their relationship with neonatal health outcomes.
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Affiliation(s)
- Manuel Lozano
- Preventive Medicine and Public Health, Food Sciences, Toxicology and Forensic Medicine Department, Universitat de València, Valencia, Spain; Epidemiology and Environmental Health Joint Research Unit, FISABIO-Universitat Jaume I-Universitat de València, Valencia, Spain.
| | - Mario Murcia
- Epidemiology and Environmental Health Joint Research Unit, FISABIO-Universitat Jaume I-Universitat de València, Valencia, Spain; Spanish Consortium for Research on Epidemiology and Public Health (CIBERESP), Madrid, Spain; Servicio de Análisis de Sistemas de Información Sanitaria, Conselleria de Sanitat, Generalitat Valenciana, Valencia, Spain
| | - Raquel Soler-Blasco
- Epidemiology and Environmental Health Joint Research Unit, FISABIO-Universitat Jaume I-Universitat de València, Valencia, Spain
| | - Maribel Casas
- Spanish Consortium for Research on Epidemiology and Public Health (CIBERESP), Madrid, Spain; ISGlobal, Barcelona, Spain; Universitat Pompeu Fabra, Barcelona, Spain
| | - Begotxu Zubero
- Preventive Medicine and Public Health Department, University of Basque Country, UPV/EHU, Leioa, Bizkaia, Spain; Health Research Institute, Biodonostia, San Sebastian, Gipuzkoa, Spain
| | - Gabriel Riutort-Mayol
- Foundation for the Promotion of Health and Biomedical Research in the Valencian Region, FISABIO-Public Health, Spain
| | - Fernando Gil
- Department of Legal Medicine and Toxicology, School of Medicine, University of Granada, Spain
| | - Pablo Olmedo
- Department of Legal Medicine and Toxicology, School of Medicine, University of Granada, Spain
| | - Joan O Grimalt
- Institute of Environmental Assessment and Water Research (IDAEA-CSIC), Barcelona, Catalonia, Spain
| | - Rubén Amorós
- Epidemiology and Environmental Health Joint Research Unit, FISABIO-Universitat Jaume I-Universitat de València, Valencia, Spain
| | - Aitana Lertxundi
- Spanish Consortium for Research on Epidemiology and Public Health (CIBERESP), Madrid, Spain; Preventive Medicine and Public Health Department, University of Basque Country, UPV/EHU, Leioa, Bizkaia, Spain; Health Research Institute, Biodonostia, San Sebastian, Gipuzkoa, Spain
| | - Martine Vrijheid
- Spanish Consortium for Research on Epidemiology and Public Health (CIBERESP), Madrid, Spain; ISGlobal, Barcelona, Spain; Universitat Pompeu Fabra, Barcelona, Spain
| | - Ferran Ballester
- Epidemiology and Environmental Health Joint Research Unit, FISABIO-Universitat Jaume I-Universitat de València, Valencia, Spain; Spanish Consortium for Research on Epidemiology and Public Health (CIBERESP), Madrid, Spain; Department of Nursing, Universitat de València, Valencia, Spain
| | - Sabrina Llop
- Epidemiology and Environmental Health Joint Research Unit, FISABIO-Universitat Jaume I-Universitat de València, Valencia, Spain; Spanish Consortium for Research on Epidemiology and Public Health (CIBERESP), Madrid, Spain
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