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Gonçalves Soares A, Santos S, Seyve E, Nedelec R, Puhakka S, Eloranta AM, Mikkonen S, Yuan WL, Lawlor DA, Heron J, Vrijheid M, Lepeule J, Nieuwenhuijsen M, Fossati S, Jaddoe VW, Lakka T, Sebert S, Heude B, Felix JF, Elhakeem A, Timpson NJ. Prenatal Urban Environment and Blood Pressure Trajectories From Childhood to Early Adulthood. JACC. ADVANCES 2024; 3:100808. [PMID: 38939392 PMCID: PMC11198279 DOI: 10.1016/j.jacadv.2023.100808] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 06/28/2023] [Revised: 09/25/2023] [Accepted: 10/23/2023] [Indexed: 06/29/2024]
Abstract
Background Prenatal urban environmental exposures have been associated with blood pressure in children. The dynamic of these associations across childhood and later ages is unknown. Objectives The purpose of this study was to assess associations of prenatal urban environmental exposures with blood pressure trajectories from childhood to early adulthood. Methods Repeated measures of systolic blood pressure (SBP) and diastolic blood pressure (DBP) were collected in up to 7,454 participants from a UK birth cohort. Prenatal urban exposures (n = 43) covered measures of noise, air pollution, built environment, natural spaces, traffic, meteorology, and food environment. An exposome-wide association study approach was used. Linear spline mixed-effects models were used to model associations of each exposure with trajectories of blood pressure. Replication was sought in 4 independent European cohorts (up to 9,261). Results In discovery analyses, higher humidity was associated with a faster increase (mean yearly change in SBP for an interquartile range increase in humidity: 0.29 mm Hg/y, 95% CI: 0.20-0.39) and higher temperature with a slower increase (mean yearly change in SBP per interquartile range increase in temperature: -0.17 mm Hg/y, 95% CI: -0.28 to -0.07) in SBP in childhood. Higher levels of humidity and air pollution were associated with faster increase in DBP in childhood and slower increase in adolescence. There was little evidence of an association of other exposures with change in SBP or DBP. Results for humidity and temperature, but not for air pollution, were replicated in other cohorts. Conclusions Replicated findings suggest that higher prenatal humidity and temperature could modulate blood pressure changes across childhood.
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Affiliation(s)
- Ana Gonçalves Soares
- MRC Integrative Epidemiology Unit, University of Bristol, Bristol, United Kingdom
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, United Kingdom
| | - Susana Santos
- The Generation R Study Group, Erasmus Medical Center, University Medical Center Rotterdam, Rotterdam, The Netherlands
- Department of Pediatrics, Erasmus Medical Center, University Medical Center Rotterdam, Rotterdam, The Netherlands
- EPIUnit - Instituto de Saúde Pública, Universidade do Porto, Porto, Portugal
- Laboratório para a Investigação Integrativa e Translacional em Saúde Populacional (ITR), Universidade do Porto, Porto, Portugal
| | - Emie Seyve
- Inserm, CNRS, Institute for Advanced Biosciences, Grenoble Alpes University, Grenoble, France
- Université Paris Cité and Université Sorbonne Paris Nord, Inserm, INRAE, Center for Research in Epidemiology and StatisticS (CRESS), Paris, France
| | - Rozenn Nedelec
- Faculty of Medicine, Research Unit of Population Health, University of Oulu, Oulu, Finland
| | - Soile Puhakka
- Faculty of Medicine, Research Unit of Population Health, University of Oulu, Oulu, Finland
- Department of Sports and Exercise Medicine, Oulu Deaconess Institute, Oulu, Finland
| | - Aino-Maija Eloranta
- Institute of Public Health and Clinical Nutrition, School of Medicine, University of Eastern Finland, Kuopio, Finland
- Institute of Biomedicine, School of Medicine, University of Eastern Finland, Kuopio, Finland
- Department of Medicine, Endocrinology and Clinical Nutrition, Kuopio University Hospital, Kuopio, Finland
| | - Santtu Mikkonen
- Department of Technical Physics, University of Eastern Finland, Kuopio, Finland
- Department of Environmental and Biological Sciences, University of Eastern Finland, Kuopio, Finland
| | - Wen Lun Yuan
- Université Paris Cité and Université Sorbonne Paris Nord, Inserm, INRAE, Center for Research in Epidemiology and StatisticS (CRESS), Paris, France
- Singapore Institute for Clinical Sciences, Agency for Science, Technology, and Research (A∗STAR), Singapore, Singapore
| | - Deborah A. Lawlor
- MRC Integrative Epidemiology Unit, University of Bristol, Bristol, United Kingdom
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, United Kingdom
| | - Jon Heron
- MRC Integrative Epidemiology Unit, University of Bristol, Bristol, United Kingdom
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, United Kingdom
| | - Martine Vrijheid
- Barcelona Institute for Global Health (ISGlobal), Barcelona, Spain
- Universitat Pompeu Fabra (UPF), Barcelona, Spain
- CIBER Epidemiología y Salud Pública (CIBERESP), Madrid, Spain
| | - Johanna Lepeule
- Inserm, CNRS, Institute for Advanced Biosciences, Grenoble Alpes University, Grenoble, France
| | - Mark Nieuwenhuijsen
- Barcelona Institute for Global Health (ISGlobal), Barcelona, Spain
- Universitat Pompeu Fabra (UPF), Barcelona, Spain
- CIBER Epidemiología y Salud Pública (CIBERESP), Madrid, Spain
| | - Serena Fossati
- Barcelona Institute for Global Health (ISGlobal), Barcelona, Spain
- Universitat Pompeu Fabra (UPF), Barcelona, Spain
- CIBER Epidemiología y Salud Pública (CIBERESP), Madrid, Spain
| | - Vincent W.V. Jaddoe
- The Generation R Study Group, Erasmus Medical Center, University Medical Center Rotterdam, Rotterdam, The Netherlands
- Department of Pediatrics, Erasmus Medical Center, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Timo Lakka
- Institute of Biomedicine, School of Medicine, University of Eastern Finland, Kuopio, Finland
- Department of Clinical Physiology and Nuclear Medicine, Kuopio University Hospital, Kuopio, Finland
- Foundation for Research in Health Exercise and Nutrition, Kuopio Research Institute of Exercise Medicine, Kuopio, Finland
| | - Sylvain Sebert
- Faculty of Medicine, Research Unit of Population Health, University of Oulu, Oulu, Finland
| | - Barbara Heude
- Université Paris Cité and Université Sorbonne Paris Nord, Inserm, INRAE, Center for Research in Epidemiology and StatisticS (CRESS), Paris, France
| | - Janine F. Felix
- The Generation R Study Group, Erasmus Medical Center, University Medical Center Rotterdam, Rotterdam, The Netherlands
- Department of Pediatrics, Erasmus Medical Center, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Ahmed Elhakeem
- MRC Integrative Epidemiology Unit, University of Bristol, Bristol, United Kingdom
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, United Kingdom
| | - Nicholas J. Timpson
- MRC Integrative Epidemiology Unit, University of Bristol, Bristol, United Kingdom
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, United Kingdom
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Sørensen M, Pershagen G, Thacher JD, Lanki T, Wicki B, Röösli M, Vienneau D, Cantuaria ML, Schmidt JH, Aasvang GM, Al-Kindi S, Osborne MT, Wenzel P, Sastre J, Fleming I, Schulz R, Hahad O, Kuntic M, Zielonka J, Sies H, Grune T, Frenis K, Münzel T, Daiber A. Health position paper and redox perspectives - Disease burden by transportation noise. Redox Biol 2024; 69:102995. [PMID: 38142584 PMCID: PMC10788624 DOI: 10.1016/j.redox.2023.102995] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2023] [Revised: 12/07/2023] [Accepted: 12/10/2023] [Indexed: 12/26/2023] Open
Abstract
Transportation noise is a ubiquitous urban exposure. In 2018, the World Health Organization concluded that chronic exposure to road traffic noise is a risk factor for ischemic heart disease. In contrast, they concluded that the quality of evidence for a link to other diseases was very low to moderate. Since then, several studies on the impact of noise on various diseases have been published. Also, studies investigating the mechanistic pathways underlying noise-induced health effects are emerging. We review the current evidence regarding effects of noise on health and the related disease-mechanisms. Several high-quality cohort studies consistently found road traffic noise to be associated with a higher risk of ischemic heart disease, heart failure, diabetes, and all-cause mortality. Furthermore, recent studies have indicated that road traffic and railway noise may increase the risk of diseases not commonly investigated in an environmental noise context, including breast cancer, dementia, and tinnitus. The harmful effects of noise are related to activation of a physiological stress response and nighttime sleep disturbance. Oxidative stress and inflammation downstream of stress hormone signaling and dysregulated circadian rhythms are identified as major disease-relevant pathomechanistic drivers. We discuss the role of reactive oxygen species and present results from antioxidant interventions. Lastly, we provide an overview of oxidative stress markers and adverse redox processes reported for noise-exposed animals and humans. This position paper summarizes all available epidemiological, clinical, and preclinical evidence of transportation noise as an important environmental risk factor for public health and discusses its implications on the population level.
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Affiliation(s)
- Mette Sørensen
- Work, Environment and Cancer, Danish Cancer Institute, Copenhagen, Denmark; Department of Natural Science and Environment, Roskilde University, Denmark.
| | - Göran Pershagen
- Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Jesse Daniel Thacher
- Division of Occupational and Environmental Medicine, Department of Laboratory Medicine, Lund University, Lund, Sweden
| | - Timo Lanki
- Department of Health Security, Finnish Institute for Health and Welfare, Kuopio, Finland; School of Medicine, University of Eastern Finland, Kuopio, Finland; Department of Environmental and Biological Sciences, University of Eastern Finland, Kuopio, Finland
| | - Benedikt Wicki
- Department of Epidemiology and Public Health, Swiss Tropical and Public Health Institute, Allschwil, Switzerland; University of Basel, Basel, Switzerland
| | - Martin Röösli
- Department of Epidemiology and Public Health, Swiss Tropical and Public Health Institute, Allschwil, Switzerland; University of Basel, Basel, Switzerland
| | - Danielle Vienneau
- Department of Epidemiology and Public Health, Swiss Tropical and Public Health Institute, Allschwil, Switzerland; University of Basel, Basel, Switzerland
| | - Manuella Lech Cantuaria
- Work, Environment and Cancer, Danish Cancer Institute, Copenhagen, Denmark; Research Unit for ORL - Head & Neck Surgery and Audiology, Odense University Hospital & University of Southern Denmark, Odense, Denmark
| | - Jesper Hvass Schmidt
- Research Unit for ORL - Head & Neck Surgery and Audiology, Odense University Hospital & University of Southern Denmark, Odense, Denmark
| | - Gunn Marit Aasvang
- Department of Air Quality and Noise, Norwegian Institute of Public Health, Oslo, Norway
| | - Sadeer Al-Kindi
- Department of Medicine, University Hospitals, Harrington Heart & Vascular Institute, Case Western Reserve University, 11100 Euclid Ave, Cleveland, OH, 44106, USA
| | - Michael T Osborne
- Cardiovascular Imaging Research Center, Massachusetts General Hospital, Boston, MA, USA; Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Philip Wenzel
- Department of Cardiology, Cardiology I, University Medical Center Mainz, Mainz, Germany; German Center for Cardiovascular Research (DZHK), Partner Site Rhine-Main, Mainz, Germany; Center for Thrombosis and Hemostasis, University Medical Center Mainz, Mainz, Germany
| | - Juan Sastre
- Department of Physiology, Faculty of Pharmacy, University of Valencia, Spain
| | - Ingrid Fleming
- Institute for Vascular Signalling, Centre for Molecular Medicine, Goethe University, Frankfurt Am Main, Germany; German Center of Cardiovascular Research (DZHK), Partner Site RheinMain, Frankfurt, Germany
| | - Rainer Schulz
- Institute of Physiology, Faculty of Medicine, Justus-Liebig University, Gießen, 35392, Gießen, Germany
| | - Omar Hahad
- Department of Cardiology, Cardiology I, University Medical Center Mainz, Mainz, Germany; German Center for Cardiovascular Research (DZHK), Partner Site Rhine-Main, Mainz, Germany
| | - Marin Kuntic
- Department of Cardiology, Cardiology I, University Medical Center Mainz, Mainz, Germany; German Center for Cardiovascular Research (DZHK), Partner Site Rhine-Main, Mainz, Germany
| | - Jacek Zielonka
- Department of Biophysics, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Helmut Sies
- Institute for Biochemistry and Molecular Biology I, Faculty of Medicine, Heinrich Heine University Düsseldorf, Düsseldorf, Germany; Leibniz Research Institute for Environmental Medicine, Düsseldorf, Germany
| | - Tilman Grune
- Department of Molecular Toxicology, German Institute of Human Nutrition Potsdam-Rehbruecke, Nuthetal, Germany; DZHK (German Center for Cardiovascular Research), Partner Site Berlin, Berlin, Germany; German Center for Diabetes Research (DZD), München-Neuherberg, Germany
| | - Katie Frenis
- Hematology/Oncology, Boston Children's Hospital and Harvard Medical School, Boston, MA, USA; Stem Cell Program, Boston Children's Hospital, Boston, MA, USA
| | - Thomas Münzel
- Department of Cardiology, Cardiology I, University Medical Center Mainz, Mainz, Germany; German Center for Cardiovascular Research (DZHK), Partner Site Rhine-Main, Mainz, Germany; Center for Thrombosis and Hemostasis, University Medical Center Mainz, Mainz, Germany
| | - Andreas Daiber
- Department of Cardiology, Cardiology I, University Medical Center Mainz, Mainz, Germany; German Center for Cardiovascular Research (DZHK), Partner Site Rhine-Main, Mainz, Germany; Center for Thrombosis and Hemostasis, University Medical Center Mainz, Mainz, Germany.
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Bolte G, Moebus S, Fehr R. [Urban Epidemiology as an Integrative Approach to Sustainable and Healthy Urban Development]. DAS GESUNDHEITSWESEN 2023; 85:S287-S295. [PMID: 37972600 DOI: 10.1055/a-2156-4305] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2023]
Abstract
Understanding the complex relationships between the physical and social environment and health in urban areas is essential for the development of appropriate measures of health promotion, disease prevention, and health protection. This article aims to characterize the comparatively new approach of urban epidemiology with its relevance for research and practice of urban health. Research in urban epidemiology provides important data and methodological foundations for integrated reporting, health impact assessments, and evaluation of interventions. Current challenges and solutions are outlined and initial recommendations for research, practice, and education and training are presented for discussion. Methods and findings of urban epidemiology can contribute in many ways to health-promoting, sustainable urban development.
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Affiliation(s)
- Gabriele Bolte
- Institut für Public Health und Pflegeforschung, Abt. Sozialepidemiologie, Universität Bremen, Bremen, Germany
| | - Susanne Moebus
- Institute for Urban Public Health, Universitätsmedizin Essen, Universität Duisburg-Essen, Essen, Germany
| | - Rainer Fehr
- Sustainable Environmental Health Sciences, Medizinische Fakultät OWL, Universität Bielefeld, Bielefeld, Germany
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Münzel T, Sørensen M, Hahad O, Nieuwenhuijsen M, Daiber A. The contribution of the exposome to the burden of cardiovascular disease. Nat Rev Cardiol 2023; 20:651-669. [PMID: 37165157 DOI: 10.1038/s41569-023-00873-3] [Citation(s) in RCA: 31] [Impact Index Per Article: 31.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/27/2023] [Indexed: 05/12/2023]
Abstract
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.
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Affiliation(s)
- Thomas Münzel
- Department of Cardiology, Cardiology I, University Medical Center of the Johannes Gutenberg-University, Mainz, Germany.
- German Center for Cardiovascular Research (DZHK), Partner Site Rhine-Main, Mainz, Germany.
| | - Mette Sørensen
- Danish Cancer Society, Copenhagen, Denmark
- Department of Natural Science and Environment, Roskilde University, Roskilde, Denmark
| | - Omar Hahad
- Department of Cardiology, Cardiology I, University Medical Center of the Johannes Gutenberg-University, Mainz, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Rhine-Main, Mainz, Germany
| | - Mark Nieuwenhuijsen
- Institute for Global Health (ISGlobal), Barcelona Biomedical Research Park (PRBB), Barcelona, Spain
- Department of Experimental and Health Sciences, Universitat Pompeu Fabra (UPF), PRBB building (Mar Campus), Barcelona, Spain
- CIBER Epidemiología y Salud Pública (CIBERESP), Instituto de Salud Carlos III, Madrid, Spain
| | - Andreas Daiber
- Department of Cardiology, Cardiology I, University Medical Center of the Johannes Gutenberg-University, Mainz, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Rhine-Main, Mainz, Germany
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Elhakeem A, Hughes RA, Tilling K, Cousminer DL, Jackowski SA, Cole TJ, Kwong ASF, Li Z, Grant SFA, Baxter-Jones ADG, Zemel BS, Lawlor DA. Using linear and natural cubic splines, SITAR, and latent trajectory models to characterise nonlinear longitudinal growth trajectories in cohort studies. BMC Med Res Methodol 2022; 22:68. [PMID: 35291947 PMCID: PMC8925070 DOI: 10.1186/s12874-022-01542-8] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2021] [Accepted: 02/11/2022] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Longitudinal data analysis can improve our understanding of the influences on health trajectories across the life-course. There are a variety of statistical models which can be used, and their fitting and interpretation can be complex, particularly where there is a nonlinear trajectory. Our aim was to provide an accessible guide along with applied examples to using four sophisticated modelling procedures for describing nonlinear growth trajectories. METHODS This expository paper provides an illustrative guide to summarising nonlinear growth trajectories for repeatedly measured continuous outcomes using (i) linear spline and (ii) natural cubic spline linear mixed-effects (LME) models, (iii) Super Imposition by Translation and Rotation (SITAR) nonlinear mixed effects models, and (iv) latent trajectory models. The underlying model for each approach, their similarities and differences, and their advantages and disadvantages are described. Their application and correct interpretation of their results is illustrated by analysing repeated bone mass measures to characterise bone growth patterns and their sex differences in three cohort studies from the UK, USA, and Canada comprising 8500 individuals and 37,000 measurements from ages 5-40 years. Recommendations for choosing a modelling approach are provided along with a discussion and signposting on further modelling extensions for analysing trajectory exposures and outcomes, and multiple cohorts. RESULTS Linear and natural cubic spline LME models and SITAR provided similar summary of the mean bone growth trajectory and growth velocity, and the sex differences in growth patterns. Growth velocity (in grams/year) peaked during adolescence, and peaked earlier in females than males e.g., mean age at peak bone mineral content accrual from multicohort SITAR models was 12.2 years in females and 13.9 years in males. Latent trajectory models (with trajectory shapes estimated using a natural cubic spline) identified up to four subgroups of individuals with distinct trajectories throughout adolescence. CONCLUSIONS LME models with linear and natural cubic splines, SITAR, and latent trajectory models are useful for describing nonlinear growth trajectories, and these methods can be adapted for other complex traits. Choice of method depends on the research aims, complexity of the trajectory, and available data. Scripts and synthetic datasets are provided for readers to replicate trajectory modelling and visualisation using the R statistical computing software.
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Affiliation(s)
- Ahmed Elhakeem
- MRC Integrative Epidemiology Unit at the University of Bristol, Bristol, UK.
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK.
| | - Rachael A Hughes
- MRC Integrative Epidemiology Unit at the University of Bristol, Bristol, UK
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Kate Tilling
- MRC Integrative Epidemiology Unit at the University of Bristol, Bristol, UK
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Diana L Cousminer
- Division of Human Genetics, Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Department of Genetics, University of Pennsylvania, Philadelphia, PA, USA
- Center for Spatial and Functional Genomics, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Stefan A Jackowski
- College of Kinesiology, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
- Children's Hospital of Eastern Ontario Research Institute, Ottawa, Ontario, Canada
| | - Tim J Cole
- UCL Great Ormond Street Institute of Child Health, London, UK
| | - Alex S F Kwong
- MRC Integrative Epidemiology Unit at the University of Bristol, Bristol, UK
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
- Division of Psychiatry, Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - Zheyuan Li
- School of Mathematics and Statistics, Henan University, Kaifeng, Henan, China
- Department of Statistics and Actuarial Sciences, Simon Fraser University, Burnaby, BC, Canada
| | - Struan F A Grant
- Division of Human Genetics, Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Department of Genetics, University of Pennsylvania, Philadelphia, PA, USA
- Center for Spatial and Functional Genomics, Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
- Division of Endocrinology and Diabetes, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | | | - Babette S Zemel
- Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
- Division of Gastroenterology, Hepatology and Nutrition, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Deborah A Lawlor
- MRC Integrative Epidemiology Unit at the University of Bristol, Bristol, UK
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
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