Publications by authors named "Marta Cirach"

78 Publications

Associations between green/blue spaces and mental health across 18 countries.

Sci Rep 2021 Apr 26;11(1):8903. Epub 2021 Apr 26.

European Centre for Environment and Human Health, University of Exeter Medical School, Exeter, UK.

Living near, recreating in, and feeling psychologically connected to, the natural world are all associated with better mental health, but many exposure-related questions remain. Using data from an 18-country survey (n = 16,307) we explored associations between multiple measures of mental health (positive well-being, mental distress, depression/anxiety medication use) and: (a) exposures (residential/recreational visits) to different natural settings (green/inland-blue/coastal-blue spaces); and (b) nature connectedness, across season and country. People who lived in greener/coastal neighbourhoods reported higher positive well-being, but this association largely disappeared when recreational visits were controlled for. Frequency of recreational visits to green, inland-blue, and coastal-blue spaces in the last 4 weeks were all positively associated with positive well-being and negatively associated with mental distress. Associations with green space visits were relatively consistent across seasons and countries but associations with blue space visits showed greater heterogeneity. Nature connectedness was also positively associated with positive well-being and negatively associated with mental distress and was, along with green space visits, associated with a lower likelihood of using medication for depression. By contrast inland-blue space visits were associated with a greater likelihood of using anxiety medication. Results highlight the benefits of multi-exposure, multi-response, multi-country studies in exploring complexity in nature-health associations.
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http://dx.doi.org/10.1038/s41598-021-87675-0DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8076244PMC
April 2021

Ambient air pollution and the development of overweight and obesity in children: a large longitudinal study.

Int J Obes (Lond) 2021 May 24;45(5):1124-1132. Epub 2021 Feb 24.

ISGlobal, Barcelona, Spain.

Background: Ambient air pollution may play a role in childhood obesity development, but evidence is scarce, and the modifying role of socioeconomic status (SES) is unclear. We aimed to examine the association between exposure to air pollution during early childhood and subsequent risk of developing overweight and obesity, and to evaluate whether SES is a modifier of this association.

Methods: This longitudinal study included 416,955 children identified as normal weight between 2-5 years old and registered in an electronic primary healthcare record between 2006 and 2016 in Catalonia (Spain). Children were followed-up until they developed overweight or obesity, reached 15 years of age, died, transferred out, or end of study period (31/12/2018). Overweight and obesity were defined following the WHO reference obtained from height and weight measures. We estimated annual residential census levels of nitrogen dioxide (NO) and particulate matter <10 μm (PM), <2.5 μm (PM), and 2.5-10 μm (PM) at study entry. We estimated the risk of developing overweight and obesity per interquartile range increase in air pollution exposure with Cox proportional hazard models.

Results: A total of 142,590 (34.2%) children developed overweight or obesity. Increased exposure to NO, PM, and PM was associated with a 2-3% increased risk of developing overweight and obesity (hazard ratio [HR] per 21.8 μg/m NO = 1.03 [95% CI: 1.02-1.04]; HR per 6.4 μg/m PM = 1.02 [95% CI: 1.02-1.03]; HR per 4.6 µg/m PM = 1.02, [95% CI: 1.01-1.02]). For all air pollutants, associations were stronger among children living in most compared to least deprived areas.

Conclusions: This study suggests that early life exposure to air pollution may be associated with a small increase in the risk of developing overweight and obesity in childhood, and that this association may be exacerbated in the most deprived areas. Even these small associations are of potential global health importance because air pollution exposure is widespread and the long-term health consequences of childhood obesity are clear.
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http://dx.doi.org/10.1038/s41366-021-00783-9DOI Listing
May 2021

Premature mortality due to air pollution in European cities: a health impact assessment.

Lancet Planet Health 2021 03 19;5(3):e121-e134. Epub 2021 Jan 19.

Institute for Global Health (ISGlobal), Barcelona, Spain; Department of Experimental and Health Sciences, Universitat Pompeu Fabra, Barcelona, Spain; CIBER Epidemiología y Salud Pública (CIBERESP), Madrid, Spain. Electronic address:

Background: Ambient air pollution is a major environmental cause of morbidity and mortality worldwide. Cities are generally hotspots for air pollution and disease. However, the exact extent of the health effects of air pollution at the city level is still largely unknown. We aimed to estimate the proportion of annual preventable deaths due to air pollution in almost 1000 cities in Europe.

Methods: We did a quantitative health impact assessment for the year 2015 to estimate the effect of air pollution exposure (PM and NO) on natural-cause mortality for adult residents (aged ≥20 years) in 969 cities and 47 greater cities in Europe. We retrieved the cities and greater cities from the Urban Audit 2018 dataset and did the analysis at a 250 m grid cell level for 2015 data based on the global human settlement layer residential population. We estimated the annual premature mortality burden preventable if the WHO recommended values (ie, 10 μg/m for PM and 40 μg/m for NO) were achieved and if air pollution concentrations were reduced to the lowest values measured in 2015 in European cities (ie, 3·7 μg/m for PM and 3·5 μg/m for NO). We clustered and ranked the cities on the basis of population and age-standardised mortality burden associated with air pollution exposure. In addition, we did several uncertainty and sensitivity analyses to test the robustness of our estimates.

Findings: Compliance with WHO air pollution guidelines could prevent 51 213 (95% CI 34 036-68 682) deaths per year for PM exposure and 900 (0-2476) deaths per year for NO exposure. The reduction of air pollution to the lowest measured concentrations could prevent 124 729 (83 332-166 535) deaths per year for PM exposure and 79 435 (0-215 165) deaths per year for NO exposure. A great variability in the preventable mortality burden was observed by city, ranging from 0 to 202 deaths per 100 000 population for PM and from 0 to 73 deaths for NO per 100 000 population when the lowest measured concentrations were considered. The highest PM mortality burden was estimated for cities in the Po Valley (northern Italy), Poland, and Czech Republic. The highest NO mortality burden was estimated for large cities and capital cities in western and southern Europe. Sensitivity analyses showed that the results were particularly sensitive to the choice of the exposure response function, but less so to the choice of baseline mortality values and exposure assessment method.

Interpretation: A considerable proportion of premature deaths in European cities could be avoided annually by lowering air pollution concentrations, particularly below WHO guidelines. The mortality burden varied considerably between European cities, indicating where policy actions are more urgently needed to reduce air pollution and achieve sustainable, liveable, and healthy communities. Current guidelines should be revised and air pollution concentrations should be reduced further to achieve greater protection of health in cities.

Funding: Spanish Ministry of Science and Innovation, Internal ISGlobal fund.
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http://dx.doi.org/10.1016/S2542-5196(20)30272-2DOI Listing
March 2021

Residential urban greenspace and hypertension: A comparative study in two European cities.

Environ Res 2020 12 16;191:110032. Epub 2020 Aug 16.

ISGlobal, 08003, Barcelona, Spain; Universitat Pompeu Fabra (UPF), 08003, Barcelona, Spain; CIBER Epidemiología y Salud Pública (CIBERESP), 28029, Madrid, Spain. Electronic address:

Background: Living in green areas has been associated with several health benefits; however, the available evidence on such benefits for hypertension is still limited. This study aimed to investigate and compare the association between residential exposure to greenspace and hypertension in Barcelona, Spain and Brussels, Belgium.

Methods: This cross-sectional study was based on data from the 2016 Barcelona Health Interview Survey (HIS) (n = 3400) and the 2013 Belgian HIS (n = 2335). Both surveys were harmonized in terms of outcomes, confounders and exposure assessment. Residential exposure to greenspace was characterized as 1) surrounding greenspace (normalized difference vegetation index (NDVI) and modified soil-adjusted vegetation index 2 (MSAVI2)) across buffers of 100 m, 300 m, and 500 m; 2) surrounding green space across 300 m and 500 m buffers; and 3) Euclidean distance to the nearest green space. Our outcome was self-reported hypertension. We developed logistic regression models to evaluate the city-specific association between each greenspace measure and hypertension, adjusting for relevant covariates.

Results: One interquartile range (IQR) increase in residential distance to the nearest green space was associated with higher risk of hypertension in Barcelona [odds ratio (OR): 1.15; 95%CI 1.03-1.29 (IQR: 262.2)], but not in Brussels [OR: 0.95; 95%CI 0.77-1.17 (IQR: 215.2)]. Stratified analyses suggested stronger associations in older participants (≥65 years) for both cities. Findings for residential surrounding green space and greenspace were not conclusive. However, in Brussels, we found protective associations in older participants for both residential surrounding greenspace metrics [NDVI 300 m buffer OR: 0.51; 95%CI 0.32-0.81 (IQR: 0.21) and MSAVI2 300 m buffer OR: 0.51; 95%CI 0.32-0.83 (IQR: 0.18)]. We did not find any indication for the modification of our evaluated associations by sex and education level.

Conclusion: Our study suggests that living closer to greenspace could be associated with lower risk of hypertension, particularly in older age. Future research is needed to replicate our findings in other settings and shed light on potential underlying mechanism(s).
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http://dx.doi.org/10.1016/j.envres.2020.110032DOI Listing
December 2020

Residential Surrounding Greenspace and Mental Health in Three Spanish Areas.

Int J Environ Res Public Health 2020 08 5;17(16). Epub 2020 Aug 5.

Barcelona Institute for Global Health (ISGlobal), 08003 Barcelona, Spain.

Exposure to greenspace has been related to improved mental health, but the available evidence is limited and findings are heterogeneous across different areas. We aimed to evaluate the associations between residential exposure to greenspace and specific psychopathological and psychosomatic symptoms related to mental health among mothers from a Spanish birth cohort. Our study was based on data from 1171 women participating in two follow-ups of a population-based cohort in Valencia, Sabadell, and Gipuzkoa (2004-2012). For each participant, residential surrounding greenspace was estimated as the average of the satellite-based Normalized Difference Vegetation Index (NDVI) across different buffers around the residential address at the time of delivery and at the 4-year follow-up. The Symptom Checklist 90 Revised (SCL-90-R) was applied to characterize mental health at the 4-year follow-up. We developed mixed-effects logistic regression models controlled for relevant covariates to evaluate the associations. Higher residential surrounding greenspace was associated with a lower risk of somatization and anxiety symptoms. For General Severity Index (GSI), obsessive-compulsive, interpersonal sensitivity, depression, hostility, phobic anxiety, paranoid ideation, and psychoticism symptoms, we generally observed protective associations, but none attained statistical significance. Findings from this study suggested a potential positive impactof greenspace on mental health.
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http://dx.doi.org/10.3390/ijerph17165670DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7460179PMC
August 2020

Early life exposure to air pollution, green spaces and built environment, and body mass index growth trajectories during the first 5 years of life: A large longitudinal study.

Environ Pollut 2020 Nov 28;266(Pt 3):115266. Epub 2020 Jul 28.

ISGlobal, Barcelona, Spain; Spanish Consortium for Research on Epidemiology and Public Health (CIBERESP), Spain; Universitat Pompeu Fabra, Barcelona, Spain. Electronic address:

Urban environments are characterized by multiple exposures that may influence body mass index (BMI) growth in early life. Previous studies are few, with inconsistent results and no evaluation of simultaneous exposures. Thus, this study aimed to assess the associations between exposure to air pollution, green spaces and built environment characteristics, and BMI growth trajectories from 0 to 5 years. This longitudinal study used data from an electronic primary care health record database in Catalonia (Spain), including 79,992 children born between January 01, 2011 and December 31, 2012 in urban areas and followed until 5 years of age. Height and weight were measured frequently during childhood and BMI (kg/m) was calculated. Urban exposures were estimated at census tract level and included: air pollution (nitrogen dioxide (NO), particulate matter <10 μm (PM) and <2.5 μm (PM), green spaces (Normalized Difference Vegetation Index (NDVI) and % green space) and built environment (population density, street connectivity, land use mix, walkability index). Individual BMI trajectories were estimated using linear spline multilevel models with several knot points. In single exposure models, NO PM PM and population density were associated with small increases in BMI growth (e.g. β per IQR PM increase = 0.023 kg/m, 95%CI: 0.013, 0.033), and NDVI, % of green spaces and land use mix with small reductions in BMI growth (e.g. β per IQR % green spaces increase = -0.015 kg/m 95%CI: -0.026, -0.005). These associations were strongest during the first two months of life. In multiple exposure models, most associations were attenuated, with only those for PM and land use mix remaining statistically significant. This large longitudinal study suggests that early life exposure to air pollution, green space and built environment characteristics may be associated with small changes in BMI growth trajectories during the first years of life, and that it is important to account for multiple exposures in urban settings.
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http://dx.doi.org/10.1016/j.envpol.2020.115266DOI Listing
November 2020

Prenatal air pollution exposure and growth and cardio-metabolic risk in preschoolers.

Environ Int 2020 05 16;138:105619. Epub 2020 Mar 16.

ISGlobal, Barcelona, Spain; Universitat Pompeu Fabra (UPF), Barcelona, Spain; CIBER Epidemiología y Salud Pública (CIBERESP), Spain.

Objectives: We investigated the association between outdoor air pollutants exposure in the first trimester of pregnancy, and growth and cardio-metabolic risk at four years of age, and evaluated the mediating role of birth weight.

Methods: We included mother-child pairs (N = 1,724) from the Spanish INMA birth cohort established in 2003-2008. First trimester of pregnancy nitrogen dioxide (NO) and fine particles (PM) exposure levels were estimated. Height, weight, waist circumference, blood pressure, and lipids were measured at four years of age. Body mass index (BMI) trajectories from birth to four years were identified.

Results: Increased PM exposure in the first trimester of pregnancy was associated with decreased z-scores of weight (zWeight) and BMI (zBMI) (zWeight change per interquartile range increase in PM exposure = -0.12; 95% CI: -0.23, -0.01; zBMI change = -0.12; 95% CI: -0.23, -0.01). Higher NO and PM exposure was associated to a reduced risk of being in a trajectory with accelerated BMI gain, compared to children with the average trajectory. Birth weight partially mediated the association between PM and zWeight and zBMI. PM and NO were not associated with the other cardio-metabolic risk factors.

Conclusions: This comprehensive study of many growth and cardio-metabolic risk related outcomes suggests that air pollution exposure during pregnancy may be associated with delays in physical growth in the early years after birth. These findings imply that pregnancy exposure to air pollutants has a lasting effect on growth after birth and require follow-up at later child ages.
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http://dx.doi.org/10.1016/j.envint.2020.105619DOI Listing
May 2020

Impact of urban environmental exposures on cognitive performance and brain structure of healthy individuals at risk for Alzheimer's dementia.

Environ Int 2020 05 6;138:105546. Epub 2020 Mar 6.

Barcelonaβeta Brain Research Center (BBRC), Pasqual Maragall Foundation, Barcelona, Spain; CIBER Fragilidad y Envejecimiento Saludable (CIBERFES), Madrid, Spain; IMIM (Hospital del Mar Medical Research Institute), Barcelona, Spain; Universitat Pompeu Fabra (UPF), Barcelona, Spain. Electronic address:

Background: Air quality might contribute to incidence of dementia-related disorders, including Alzheimer's dementia (AD). The aim of our study is to evaluate the effect of urban environmental exposures (including exposure to air pollution, noise and green space) on cognitive performance and brain structure of cognitively unimpaired individuals at risk for AD.

Participants And Methods: The ALFA (ALzheimer and FAmilies) study is a prospective cohort of middle-age, cognitively unimpaired subjects, many of them offspring of AD patients. Cognitive performance was measured by the administration of episodic memory and executive function tests (N = 958). Structural brain imaging was performed in a subsample of participants to obtain morphological information of brain areas, specially focused on cortical thickness, known to be affected by AD (N = 228). Land Use Regression models were used to estimate residential exposure to air pollutants. The daily average noise level at the street nearest to each participant's residential address was obtained from noise maps. For each participant residential green exposure indicators, such as surrounding greenness or amount of green, were generated. General linear models were conducted to assess the association between environmental exposures, cognitive performance and brain structure in a cross-sectional analysis.

Results: No significant associations were observed between urban environmental exposures and the cognitive composite (p > 0.1). Higher exposure to air pollutants, but not noise, was associated with lower cortical thickness in brain regions known to be affected by AD, especially NO (β = -16.4; p = 0.05) and PM (β = -5.34; p = 0.05). On the other hand, increasing greenness indicators was associated with greater thickness in these same areas (β = 0.08; p = 0.03).

Conclusion: In cognitively unimpaired adults with increased risk for AD, increased exposure to air pollution was suggested to be associated with greater global atrophy and reduced volume and thickness in specific brain areas known to be affected in AD, thus suggesting a potential link between environmental exposures and cerebral vulnerability to AD. Although more research in the field is needed, air pollution reduction is crucial for decreasing the burden of age-related disorders.
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http://dx.doi.org/10.1016/j.envint.2020.105546DOI Listing
May 2020

Green spaces, excess weight and obesity in Spain.

Int J Hyg Environ Health 2020 01 1;223(1):45-55. Epub 2019 Nov 1.

ISGlobal, Barcelona, Spain; Universitat Pompeu Fabra (UPF), Barcelona, Spain; CIBER Epidemiología y Salud Pública (CIBERESP), Madrid, Spain; Municipal Institute of Medical Research (IMIM-Hospital del Mar), Barcelona, Spain.

Background: The epidemiological evidence on green spaces and obesity is inconsistent.

Objectives: To study the association of access to green spaces and surrounding greenness with obesity in Spain.

Methods: We enrolled 2354 individuals 20-85 years from urban areas of seven provinces of Spain between 2008-13. Subjects were randomly selected population controls of the MCC-Spain case-control study. We geocoded current residences and defined exposures in a buffer of 300 m around them: i) access to green space, identified using Urban Atlas, and ii) levels of surrounding greenness, measured by the Normalized Difference Vegetation Index. We examined excess weight/obesity as binary outcomes based on body mass index and waist-hip ratio. We examined effect modification by genetic factors, sex and individual socio-economic status and mediation by physical activity and concentrations of PM and NO. To assess potential effect modification by genetic factors, we used a polygenic risk score based on obesity polymorphisms detected in genome-wide association studies. We used logistic mixed-effects models with a random effect for catchment area adjusted for potential confounders.

Results: Access to green space was associated with a reduced risk of excess weight/obesity after adjusting for confounders [excess weight: OR (95%CI) = 0.82 (0.63, 1.07), p-value = 0.143; abdominal obesity: OR (95%CI) = 0.68 (0.45, 1.01), p-value = 0.057]. In the stratified analysis, this association was only observed in women. Associations between surrounding greenness and excess weight/obesity were null or modest based on a 1 IQR increase in NDVI [excess weight: OR (95%CI) = 0.99 (0.88, 1.11), p-value = 0.875; abdominal obesity: OR (95%CI) = 0.91 (0.79, 1.05), p-value = 0.186]. The observed associations were not mediated by physical activity or air pollution.

Discussion: Access to green space may be associated with decreased risk of excess weight/obesity among women in Spain. Mechanisms explaining this association remain unclear.
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http://dx.doi.org/10.1016/j.ijheh.2019.10.007DOI Listing
January 2020

Exploring mechanisms underlying the relationship between the natural outdoor environment and health and well-being - Results from the PHENOTYPE project.

Environ Int 2020 01 31;134:105173. Epub 2019 Oct 31.

ISGlobal, Centre for Research in Environmental Epidemiology (CREAL), Barcelona, Spain; Universitat Pompeu Fabra (UPF), Barcelona, Spain; CIBER Epidemiología y Salud Pública (CIBERESP), Madrid, Spain.

Background: Despite the large number of studies on beneficial effects of the natural outdoor environment (NOE) on health, the underlying mechanisms are not fully understood.

Objective: This study explored the relations between amount, quality, use and experience of the NOE; and physical activity, social contacts and mental well-being.

Methods: In this cross-sectional study, data on GIS-derived measures of residential surrounding greenness (NDVI), NOE within 300 m, and audit data on quality of the streetscape were combined with questionnaire data from 3947 adults in four European cities. These included time spent in NOE (use); and perceived greenness, and satisfaction with and importance given to the NOE (experience). Physical activity, social contacts and mental health were selected as key outcome indicators. Descriptive and multilevel analyses were conducted both on pooled data and for individual cities.

Results: More minutes spent in the NOE were associated with more minutes of physical activity, a higher frequency of social contacts with neighbors, and better mental well-being. Perceived greenness, satisfaction with and importance of the NOE, were other strong predictors of the outcomes, while GIS measures of NOE and streetscape quality were not. We found clear differences between the four cities.

Conclusions: Use and experience of the natural outdoor environment are important predictors for beneficial effects of the natural outdoor environment and health. Future research should focus more on these aspects to further increase our understanding of these mechanisms, and needs to take the local context into account.
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http://dx.doi.org/10.1016/j.envint.2019.105173DOI Listing
January 2020

Association of residential air pollution, noise, and greenspace with initial ischemic stroke severity.

Environ Res 2019 12 5;179(Pt A):108725. Epub 2019 Sep 5.

Department of Epidemiology, Brown University School of Public Health, Providence, RI 02912, USA. Electronic address:

Background And Purpose: A number of environmental risk factors of acute ischemic stroke have been identified, but few studies have evaluated the influence of the outdoor environment on stroke severity. We assessed the association of residential ambient fine particulate matter air pollution (PM), noise, and surrounding greenspace with initial stroke severity.

Methods: We obtained data on patients hospitalized with acute ischemic stroke from a hospital-based prospective stroke register (2005-2014) in Barcelona. We estimated residential PM based on an established land use regression model, greenspace as the average satellite-based Normalized Difference Vegetation Index (NDVI) within a 300 m buffer of the residence, and daily (Lday), evening (Levening), night (Lnight) and average noise (Lden) level at the street nearest to the residential address using municipal noise models. Stroke severity was assessed at the time of hospital presentation using the National Institute of Health Stroke Scale (NIHSS).We used logistic regression and binomial models to evaluate the associations of PM greenspace, and noise with initial stroke severity adjusting for potential confounders.

Results: Among 2761 patients, higher residential surrounding greenspace was associated with lower risk of severe stroke (OR for NIHSS>5, 0.75; 95% CI: 0.60-0.95), while, living in areas with higher Lden was associated with a higher risk of severe stroke (OR, 1.30; 95% CI: 1.02-1.65). PM was not associated with initial stroke severity.

Conclusions: In an urban setting, surrounding greenspace and traffic noise at home are associated with initial stroke severity, suggesting an important influence of the built environment on the global burden of ischemic stroke.
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http://dx.doi.org/10.1016/j.envres.2019.108725DOI Listing
December 2019

Effects of prenatal exposure to particulate matter air pollution on corpus callosum and behavioral problems in children.

Environ Res 2019 11 7;178:108734. Epub 2019 Sep 7.

ISGLOBAL, Centre for Research in Environmental Epidemiology (CREAL), Barcelona, Spain; Pompeu Fabra University, Barcelona, Catalonia, Spain; Consortium for Biomedical Research in Epidemiology and Public Health (CIBERESP), Madrid, Spain; Institut Hospital del Mar d'Investigacions Mèdiques-Parc de Salut Mar, Barcelona, Catalonia, Spain.

Objective: Air pollution (AP) may affect neurodevelopment, but studies about the effects of AP on the growing human brain are still scarce. We aimed to investigate the effects of prenatal exposure to AP on lateral ventricles (LV) and corpus callosum (CC) volumes in children and to determine whether the induced brain changes are associated with behavioral problems.

Methods: Among the children recruited through a set of representative schools of the city of Barcelona, (Spain) in the Brain Development and Air Pollution Ultrafine Particles in School Children (BREATHE) study, 186 typically developing participants aged 8-12 years underwent brain MRI on the same 1.5 T MR unit over a 1.5-year period (October 2012-April 2014). Brain volumes were derived from structural MRI scans using automated tissue segmentation. Behavioral problems were assessed using the Strengths and Difficulties Questionnaire (SDQ) and the criteria of the Attention Deficit Hyperactivity Disorder DSM-IV list. Prenatal fine particle (PM) levels were retrospectively estimated at the mothers' residential addresses during pregnancy with land use regression (LUR) models. To determine whether brain structures might be affected by prenatal PM exposure, linear regression models were run and adjusted for age, sex, intracranial volume (ICV), maternal education, home socioeconomic vulnerability index, birthweight and mothers' smoking status during pregnancy. To test for associations between brain changes and behavioral outcomes, negative binomial regressions were performed and adjusted for age, sex, ICV.

Results: Prenatal PM levels ranged from 11.8 to 39.5 μg/m during the third trimester of pregnancy. An interquartile range increase in PM level (7 μg/m) was significantly linked to a decrease in the body CC volume (mm) (β = -53.7, 95%CI [-92.0, -15.5] corresponding to a 5% decrease of the mean body CC volume) independently of ICV, age, sex, maternal education, socioeconomic vulnerability index at home, birthweight and mothers' smoking status during the third trimester of pregnancy. A 50 mm decrease in the body CC was associated with a significant higher hyperactivity subscore (Rate Ratio (RR) = 1.09, 95%CI [1.01, 1.17) independently of age, sex and ICV. The statistical significance of these results did not survive to False Discovery Rate correction for multiple comparisons.

Conclusions: Prenatal exposure to PM may be associated with CC volume decrease in children. The consequences might be an increase in behavioral problems.
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http://dx.doi.org/10.1016/j.envres.2019.108734DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6892268PMC
November 2019

Changing the urban design of cities for health: The superblock model.

Environ Int 2020 01 9;134:105132. Epub 2019 Sep 9.

ISGlobal, Barcelona, Spain; Universitat Pompeu Fabra (UPF), Barcelona, Spain; CIBER Epidemiología y Salud Pública (CIBERESP), Madrid, Spain. Electronic address:

Background: Car-dependent city planning has resulted in high levels of environmental pollution, sedentary lifestyles and increased vulnerability to the effects of climate change. The Barcelona Superblock model is an innovative urban and transport planning strategy that aims to reclaim public space for people, reduce motorized transport, promote sustainable mobility and active lifestyles, provide urban greening and mitigate effects of climate change. We estimated the health impacts of implementing this urban model across Barcelona.

Methods: We carried out a quantitative health impact assessment (HIA) study for Barcelona residents ≥20 years (N = 1,301,827) on the projected Superblock area level (N = 503), following the comparative risk assessment methodology. We 1) estimated expected changes in (a) transport-related physical activity (PA), (b) air pollution (NO), (c) road traffic noise, (d) green space, and (e) reduction of the urban heat island (UHI) effect through heat reductions; 2) scaled available risk estimates; and 3) calculated attributable health impact fractions. Estimated endpoints were preventable premature mortality, changes in life expectancy and economic impacts.

Results: We estimated that 667 premature deaths (95% CI: 235-1,098) could be prevented annually through implementing the 503 Superblocks. The greatest number of preventable deaths could be attributed to reductions in NO (291, 95% PI: 0-838), followed by noise (163, 95% CI: 83-246), heat (117, 95% CI: 101-137), and green space development (60, 95% CI: 0-119). Increased PA for an estimated 65,000 persons shifting car/motorcycle trips to public and active transport resulted in 36 preventable deaths (95% CI: 26-50). The Superblocks were estimated to result in an average increase in life expectancy for the Barcelona adult population of almost 200 days (95% CI: 99-297), and result in an annual economic impact of 1.7 billion EUR (95% CI: 0.6-2.8).

Discussion: The Barcelona Superblocks were estimated to help reduce harmful environmental exposures (i.e. air pollution, noise, and heat) while simultaneously increase PA levels and access to green space, and thereby provide substantial health benefits. For an equitable distribution of health benefits, the Superblocks should be implemented consistently across the entire city. Similar health benefits are expected for other cities that face similar challenges of environmental pollution, climate change vulnerability and low PA levels, by adopting the Barcelona Superblock model.
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http://dx.doi.org/10.1016/j.envint.2019.105132DOI Listing
January 2020

Outdoor air pollution and the burden of childhood asthma across Europe.

Eur Respir J 2019 10 31;54(4). Epub 2019 Oct 31.

ISGlobal, Centre for Research in Environmental Epidemiology (CREAL), Barcelona, Spain.

Background: Emerging evidence suggests that air pollution may contribute to childhood asthma development. We estimated the burden of incident childhood asthma that may be attributable to outdoor nitrogen dioxide (NO), particulate matter ≤2.5 µm in diameter (PM) and black carbon (BC) in Europe.

Methods: We combined country-level childhood incidence rates and pooled exposure-response functions with childhood (age 1-14 years) population counts, and exposure estimates at 1 540 386 1 km×1 km cells, across 18 European countries and 63 442 419 children. Annual average pollutant concentrations were obtained from a validated and harmonised European land-use regression model. We investigated two exposure reduction scenarios. For the first, we used recommended annual World Health Organization (WHO) air quality guideline values. For the second, we used the minimum air pollution levels recorded across 41 studies in the underlying meta-analysis.

Results: NO ranged from 1.4 to 70.0 µg·m, with a mean of 11.8 µg·m. PM ranged from 2.0 to 41.1 µg·m, with a mean of 11.6 µg·m. BC ranged from 0.003 to 3.7×10 m, with a mean of 1.0×10 m. Compliance with the NO and PM WHO guidelines was estimated to prevent 2434 (0.4%) and 66 567 (11%) incident cases, respectively. Meeting the minimum air pollution levels for NO (1.5 µg·m), PM (0.4 µg·m) and BC (0.4×10 m) was estimated to prevent 135 257 (23%), 191 883 (33%) and 89 191 (15%) incident cases, respectively.

Conclusions: A significant proportion of childhood asthma cases may be attributable to outdoor air pollution and these cases could be prevented. Our estimates underline an urgent need to reduce children's exposure to air pollution.
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http://dx.doi.org/10.1183/13993003.02194-2018DOI Listing
October 2019

Dog ownership, the natural outdoor environment and health: a cross-sectional study.

BMJ Open 2019 05 27;9(5):e023000. Epub 2019 May 27.

Instituto de Salud Global Barcelona, Barcelona, Spain.

Objectives: Dog owners walking their dog in natural outdoor environments (NOE) may benefit from the physical activity facilitated by dog walking and from time spent in nature. However, it is unclear whether dog owners receive additional health benefits associated with having access to NOE above the physical activity benefit of walking with their dog. We investigated associations between dog ownership, walking, time spent in NOE and health and whether these associations differed among those with good and poor access to NOE and those living in green and less green areas.

Design: Cross-sectional study.

Setting: The Positive Health Effects of the Natural Outdoor Environment in Typical Populations in Different Regions in Europe project.

Participants: n=3586 adults from Barcelona (Spain), Doetinchem (the Netherlands), Kaunas (Lithuania) and Stoke-on-Trent (UK).

Data Collection And Analysis: We calculated access to NOE with land maps and residential surrounding greenness with satellite data. Leisure time walking, time spent in NOE and general and mental health status were measured using validated questionnaires. Associations were estimated using multilevel analysis with a random intercept defined at the neighbourhood level.

Results: Dog ownership was associated with higher rates of leisure time walking and time spending in NOE (OR 2.17, 95% CI 1.86 to 2.54 and 2.37, 95% CI 2.02 to 2.79, respectively). These associations were stronger in those living within 300 m of a NOE and in greener areas. No consistent associations were found between dog ownership and perceived general or mental health status.

Conclusions: Compared with non-dog owners, dog owners walked more and spent more time in NOE, especially those living within 300 m of a NOE and in greener areas. The health implications of these relationships should be further investigated. In a largely physically inactive society, dog walking in NOE may be a simple way of promoting physical activity and health.
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http://dx.doi.org/10.1136/bmjopen-2018-023000DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6549751PMC
May 2019

Low Childhood Nature Exposure is Associated with Worse Mental Health in Adulthood.

Int J Environ Res Public Health 2019 05 22;16(10). Epub 2019 May 22.

Barcelona Institute for Global Health (ISGlobal), Doctor Aiguader 88, 08003 Barcelona, Spain.

Exposure to natural outdoor environments (NOE) is associated with health benefits; however, evidence on the impact of NOE exposure during childhood on mental health (MH) and vitality in adulthood is scarce. This study was based on questionnaire data collected from 3585 participants, aged 18-75, in the PHENOTYPE project (2013) in four European cities. Mixed models were used to investigate associations between childhood NOE exposure and (i) MH; (ii) vitality (perceived level of energy and fatigue); and (iii) potential mediation by perceived amount, use, satisfaction, importance of NOE, and residential surrounding greenness, using pooled and city-level data. Adults with low levels of childhood NOE exposure had, when compared to adults with high levels of childhood NOE exposure, significantly worse mental health (coef. -4.13; 95% CI -5.52, -2.74). Childhood NOE exposure was not associated with vitality. Low levels of childhood NOE exposure were associated with lower importance of NOE (OR 0.81; 95% CI 0.66, 0.98) in adulthood. The association with perceived amount of NOE differed between cities. We found no evidence for mediation. Childhood NOE exposure might be associated with mental well-being in adulthood. Further studies are needed to confirm these findings and to identify mechanisms underlying long-term benefits of childhood NOE exposure.
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http://dx.doi.org/10.3390/ijerph16101809DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6572245PMC
May 2019

Association between Early Life Exposure to Air Pollution and Working Memory and Attention.

Environ Health Perspect 2019 05;127(5):57002

ISGlobal (Barcelona Institute for Global Health), Barcelona, Catalonia, Spain.

Background: Although previous studies have reported negative associations between exposure to air pollution and cognition, studies of the effects of prenatal and postnatal exposures in early childhood have been limited.

Objectives: We sought to assess the role exposure to fine particulate matter ([Formula: see text]) during different prenatal and postnatal windows may play in children's cognitive development at school age.

Methods: Within the Brain Development and Air Pollution Ultrafine Particles in School Children (BREATHE) Project, we estimated residential [Formula: see text] exposures by land use regression for the prenatal period and first seven postnatal years of 2,221 children from Barcelona, Spain. The participants ([Formula: see text]) completed computerized tests assessing working memory, attentiveness, and conflict network during four visits in 2012–2013. We used linear mixed effects and distributed lag models to assess the period of exposure to [Formula: see text] in association with cognitive development.

Results: Inverse associations were identified between [Formula: see text] exposure during the fifth and sixth postnatal years and working memory, with boys showing much higher vulnerability. Regarding attention functions, exposure to higher [Formula: see text] levels during the prenatal period and from the fourth postnatal year were associated with a reduction in conflict network performance, though we found no association with attentiveness. The overall estimated cumulative effect of a [Formula: see text] increase in [Formula: see text] resulted in a reduction in the working memory [Formula: see text] score of [Formula: see text] [95% confidence interval (CI): [Formula: see text], [Formula: see text]] points and an increase in the conflict attentional network of 11.31 (95% CI: 6.05, 16.57) milliseconds, indicating a poorer performance.

Conclusions: Early life exposure to [Formula: see text] was associated with a reduction in fundamental cognitive abilities, including working memory and conflict attentional network. https://doi.org/10.1289/EHP3169.
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http://dx.doi.org/10.1289/EHP3169DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6791117PMC
May 2019

Ambient air pollution and overweight and obesity in school-aged children in Barcelona, Spain.

Environ Int 2019 04 28;125:58-64. Epub 2019 Jan 28.

ISGlobal, Barcelona Institute for Global Health, Spain; Universitat Pompeu Fabra (UPF), Barcelona, Spain; CIBER Epidemiología y Salud Pública (CIBERESP), Barcelona, Spain. Electronic address:

Background: Ambient air pollution may increase the risk of overweight and obesity in children. However, available evidence is still scarce and has mainly focused on ambient air pollution exposure occurring at home without considering the school environment. The aim of this study is to assess whether exposure to ambient air pollution at home and school is associated with overweight and obesity in primary school children.

Methods: We studied 2660 children aged 7-10 years during 2012 in Barcelona. Child weight and height were measured and age- and sex-specific z-scores for body mass index (zBMI) were calculated using the WHO growth reference 2007. Overweight and obesity were defined using the same reference. Land use regression models were used to estimate levels of nitrogen dioxide (NO), particulate matter <2.5 μm (PM), <10 μm (PM) and coarse (PM) at home. Outdoor levels of NO, PM, elemental carbon (EC), and ultrafine particles (UFP) were measured in the schoolyard. Multilevel mixed linear and ordered logistic models were used to assess the association between ambient air pollution (continuous per interquartile range (IQR) increase and categorical with tertile cutoffs) and zBMI (continuous and ordinal: normal, overweight, obese), after adjusting for socio-demographic characteristics.

Results: An IQR increase in PM-home (5.6 μg/m) was associated with a 10% increase in the odds of being overweight or obese (odds ratio (OR) = 1.10; 95% CI = 1.00, 1.22). Children exposed to the highest tertile of UFP-school (>27,346 particles/cm) had a 30% higher odds of being overweight or obese (OR = 1.30; 95%CI = 1.03, 1.64) compared to the lowest tertile of UFP exposure. We also observed that exposure to NO, PM or EC at schools was associated with higher odds of overweight or obese at medium compared to low levels of exposure. Home and school exposures did not show any significant associations with zBMI (except PM-school comparing tertile 2 vs tertile 1) but were similar in direction.

Conclusions: This study suggests that exposure to ambient air pollution, especially at school, is associated with childhood risk for overweight and obesity. A cautious interpretation is warranted because associations were not always linear and because school and home air pollution measurements were not directly comparable.
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http://dx.doi.org/10.1016/j.envint.2019.01.048DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6380992PMC
April 2019

Air Pollution, Noise, Blue Space, and Green Space and Premature Mortality in Barcelona: A Mega Cohort.

Int J Environ Res Public Health 2018 10 30;15(11). Epub 2018 Oct 30.

ISGlobal, 08003 Barcelona, Spain.

: Cities often experience high air pollution and noise levels and lack of natural outdoor environments, which may be detrimental to health. The aim of this study was to evaluate the effects of air pollution, noise, and blue and green space on premature all-cause mortality in Barcelona using a mega cohort approach. : Both men and women of 18 years and above registered on 1 January 2010 by the Sistema d'Informació pel Desenvolupament de la Investigació en Atenció Primària (SIDIAP) and living in the city of Barcelona were included in the cohort and followed up until 31 December 2014 or until death ( = 2,939,067 person years). The exposure assessment was conducted at the census tract level ( = 1061). We assigned exposure to long term ambient levels of nitrogen dioxides (NO₂), nitrogen oxides (NO), particulate matter with aerodynamic diameter less than 2.5 µm (PM), between 2.5 µm and 10 µm (PM, i.e., coarse particulate matter), less than 10 µm (PM) and PM light absorption (hereafter referred to as PM absorbance) based on land use regressions models. Normalized Difference Vegetation Index (NDVI) was assigned based on remote sensing data, percentage green space and blue space were calculated based on land use maps and modelled road traffic noise was available through the strategic noise map for Barcelona. : In this large prospective study ( = 792,649) in an urban area, we found a decreased risk of all-cause mortality with an increase in green space measured as NDVI (hazard ratio (HR) = 0.92, 95% CI 0.89⁻0.97 per 0.1) and increased risks of mortality with an increase in exposure to blue space (HR = 1.04, 95% CI 1.01⁻1.06 per 1%), NO₂ (HR = 1.01, 95% CI 1.00⁻1.02 per 5 ug/m³) but no risk with noise (HR = 1.00, 95% CI 0.98⁻1.02 per 5 dB(A)). The increased risks appeared to be more pronounced in the more deprived areas. Results for NDVI, and to a lesser extent NO₂, remained most consistent after mutual adjustment for other exposures. The NDVI estimate was a little attenuated when NO₂ was included in the model. The study had some limitations including e.g., the assessment of air pollution, noise, green space and socioeconomic status (SES) on census tract level rather than individual level and residual confounding. : This large study provides new insights on the relationship between green and blue space, noise and air pollution and premature all-cause mortality.
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http://dx.doi.org/10.3390/ijerph15112405DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6265844PMC
October 2018

Socioeconomic inequalities in urban and transport planning related exposures and mortality: A health impact assessment study for Bradford, UK.

Environ Int 2018 12 20;121(Pt 1):931-941. Epub 2018 Oct 20.

ISGlobal, Barcelona, Spain; Universitat Pompeu Fabra (UPF), Barcelona, Spain; CIBER Epidemiología y Salud Pública (CIBERESP), Madrid, Spain. Electronic address:

Background: Cities have unique geographic, environmental and sociocultural characteristics that influence the health status of their citizens. Identification and modification of these characteristics may help to promote healthier cities.

Objective: We estimated premature mortality impacts of breaching international exposure guidelines for physical activity (PA), air pollution, noise and access to green space for Bradford (UK) adult residents (n = 393,091).

Methods: We applied the Urban and TranspOrt Planning Health Impact Assessment (UTOPHIA) methodology and estimated mortality, life expectancy (LE) and economic impacts of non-compliance with recommended exposure levels. We also investigated the distribution of the mortality burden among the population, focusing on socioeconomic position (SEP) as defined by deprivation status and ethnicity.

Results: We estimated that annually almost 10% of premature mortality (i.e. 375 deaths, 95% CI: 276-474) in Bradford is attributable to non-compliance with recommended exposure levels. Non-compliance was also estimated to result in over 300 days of LE lost (95% CI: 238-432), which translated in economic losses of over £50,000 per person (95% CI: 38,518-69,991). 90% of the premature mortality impact resulted from insufficient PA performance. Air and noise pollution and the lack of green space had smaller impacts (i.e. 48 deaths). Residents of lower SEP neighborhoods had the highest risks for adverse exposure and premature death. A larger number of deaths (i.e. 253 and 145, respectively) could be prevented by reducing air and noise pollution levels well below the guidelines.

Discussion: Current urban and transport planning related exposures result in a considerable health burden that is unequally distributed among the Bradford population. Improvements in urban and transport planning practices including the reduction of motor traffic and the promotion of active transport together with greening of the district, particularly in areas of lower SEP, are promising strategies to increase PA performance and reduce harmful environmental exposures.
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http://dx.doi.org/10.1016/j.envint.2018.10.017DOI Listing
December 2018

Childhood leukaemia risk and residential proximity to busy roads.

Environ Int 2018 12 18;121(Pt 1):332-339. Epub 2018 Sep 18.

Cancer and Environmental Epidemiology Unit, National Epidemiology Centre, Carlos III Health Institute, Madrid, Spain; Centre for Biomedical Research in Epidemiology & Public Health (CIBER Epidemiología y Salud Pública - CIBERESP), Spain. Electronic address:

Background: Current evidence suggests that childhood leukaemia can be associated with residential traffic exposure; nevertheless, more results are needed to support this conclusion.

Objectives: To ascertain the possible effects of residential proximity to road traffic on childhood leukaemia, taking into account traffic density, road proximity and the type of leukaemia (acute lymphoid leukaemia or acute myeloid leukaemia).

Methods: We conducted a population-based case-control study of childhood leukaemia in Spain, covering the period 1990-2011. It included 1061 incidence cases gathered from the Spanish National Childhood Cancer Registry and those Autonomous Regions with 100% coverage, and 6447 controls, individually matched by year of birth, sex and autonomous region of residence. Distances were computed from the respective participant's residential locations to the different types of roads and four different buffers. Using logistic regression, odds ratios (ORs) and 95% confidence intervals (95%CIs), were calculated for four different categories of distance to roads.

Results: Cases of childhood leukaemia had more than three-fold increased odds of living at <50 m of the busiest motorways compared to controls (OR = 2.90; 95%CI = 1.30-6.49). The estimates for acute lymphoid leukaemia (ALL) were slightly higher (OR = 2.95; 95%CI = 1.22-7.14), while estimates for cases with the same address at birth and at diagnosis were lower (OR = 2.40; 95%CI = 0.70-8.30).

Conclusions: Our study agrees with the literature and furnishes some evidence that living near a busy motorway could be a risk factor for childhood leukaemia.
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http://dx.doi.org/10.1016/j.envint.2018.08.056DOI Listing
December 2018

Residential proximity to green spaces and breast cancer risk: The multicase-control study in Spain (MCC-Spain).

Int J Hyg Environ Health 2018 09 1;221(8):1097-1106. Epub 2018 Aug 1.

ISGlobal, Barcelona, Spain; Universitat Pompeu Fabra (UPF), Barcelona, Catalonia, Spain; CIBER Epidemiología y Salud Pública (CIBERESP), Madrid, Spain.

Background: Breast cancer is the main cause of cancer mortality among women. Green spaces have been recently associated with reduced cancer mortality among women. Mechanisms explaining the beneficial effect of green spaces include increased levels of physical activity and reduced exposure to air pollution, which have been both associated with cancer development.

Objectives: To investigate the associations between presence of urban green areas, presence of agricultural areas and surrounding greenness and risk of breast cancer, and to assess whether these associations are mediated by physical activity and/or air pollution levels.

Methods: We geocoded the current residence of 1129 breast cancer cases and 1619 controls recruited between 2008 and 2013 in ten provinces of Spain, as part of the MCC-Spain study. We assigned different indicators of exposure to green spaces in a buffer of 300 m, and in nested buffers of 100 m and 500 m around the residence: presence of urban green areas according to Urban Atlas, presence of agricultural areas according to CORINE Land Cover 2006, and surrounding greenness according to the average of the Normalized Difference Vegetation Index. We used logistic mixed-effects regression models with a random effect for hospital adjusting for potential confounders. We explored the effect of several potential effect modifiers. We assessed mediation effect by physical activity and levels of air pollution.

Results: Presence of urban green areas was associated with reduced risk of breast cancer after adjusting for age, socio-economic status at individual and at area level, education, and number of children [OR (95%CI) = 0.65 (0.49-0.86)]. There was evidence of a linear trend between distance to urban green areas and risk of breast cancer. On the contrary, presence of agricultural areas and surrounding greenness were associated with increased risk of breast cancer [adjusted OR (95%CI) = 1.33 (1.07-1.65) and adjusted OR (95%CI) = 1.27 (0.92-1.77), respectively]. None of the associations observed were mediated by levels of physical activity or levels or air pollution.

Conclusions: The association between green spaces and risk of breast cancer is dependent on land-use. The confirmation of these results in other settings and the study of potential mechanisms for the associations observed are needed to advance the understanding on the potential effects of green spaces on health.
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http://dx.doi.org/10.1016/j.ijheh.2018.07.014DOI Listing
September 2018

The Urban Exposome during Pregnancy and Its Socioeconomic Determinants.

Environ Health Perspect 2018 07 17;126(7):077005. Epub 2018 Jul 17.

ISGlobal, Barcelona, Spain

Background: The urban exposome is the set of environmental factors that are experienced in the outdoor urban environment and that may influence child development.

Objective: The authors' goal was to describe the urban exposome among European pregnant women and understand its socioeconomic determinants.

Methods: Using geographic information systems, remote sensing and spatio-temporal modeling we estimated exposure during pregnancy to 28 environmental indicators in almost 30,000 women from six population-based birth cohorts, in nine urban areas from across Europe. Exposures included meteorological factors, air pollutants, traffic noise, traffic indicators, natural space, the built environment, public transport, facilities, and walkability. Socioeconomic position (SEP), assessed at both the area and individual level, was related to the exposome through an exposome-wide association study and principal component (PC) analysis.

Results: Mean±standard deviation (SD) NO levels ranged from 13.6±5.1 μg/m (in Heraklion, Crete) to 43.2±11 μg/m (in Sabadell, Spain), mean±SD walkability score ranged from 0.22±0.04 (Kaunas, Lithuania) to 0.32±0.07 (Valencia, Spain) and mean±SD Normalized Difference Vegetation Index ranged from 0.21±0.05 in Heraklion to 0.51±0.1 in Oslo, Norway. Four PCs explained more than half of variation in the urban exposome. There was considerable heterogeneity in social patterning of the urban exposome across cities. For example, high-SEP (based on family education) women lived in greener, less noisy, and less polluted areas in Bradford, UK (0.39 higher PC1 score, 95% confidence interval (CI): 0.31, 0.47), but the reverse was observed in Oslo (-0.57 PC1 score, 95% CI: -0.73, -0.41). For most cities, effects were stronger when SEP was assessed at the area level: In Bradford, women living in high SEP areas had a 1.34 higher average PC1 score (95% CI: 1.21, 1.48).

Conclusions: The urban exposome showed considerable variability across Europe. Pregnant women of low SEP were exposed to higher levels of environmental hazards in some cities, but not others, which may contribute to inequities in child health and development. https://doi.org/10.1289/EHP2862.
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http://dx.doi.org/10.1289/EHP2862DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6108870PMC
July 2018

Long-term exposure to residential green and blue spaces and anxiety and depression in adults: A cross-sectional study.

Environ Res 2018 04 19;162:231-239. Epub 2018 Jan 19.

ISGlobal, Barcelona, Spain; Universitat Pompeu Fabra (UPF), Barcelona, Spain; CIBER Epidemiología y Salud Pública (CIBERESP), Barcelona, Spain.

Background: Although exposure to natural outdoor environments has been consistently associated with improved perceived general health, available evidence on a protective association between this exposure and specific mental health disorders such as depression and anxiety is still limited.

Objective: The aim of this study was to evaluate the effects of long-term exposure to residential green and blue spaces on anxiety and depression and intake of related medication. Additionally, we aimed to explore potential mediators and effect modifiers of this association.

Methods: The study was based on an existing adult cohort (ALFA - Alzheimer and Families) and includes 958 adult participants from Barcelona recruited in 2013-2014. For each participant residential green and blue exposure indicators [surrounding greenness (NDVI), amount of green (land-cover) and access to major green spaces and blue spaces] were generated for different buffers (100m, 300m and 500m). Participants reported their history of doctor-diagnosed anxiety and depressive disorders and intake of related medication. Logistic regression models were applied to assess the corresponding associations.

Results: Increasing surrounding greenness was associated with reduced odds of self-reported history of benzodiazepines [e.g. Odds ratio - OR (95%CI) = 0.62 (0.43, 0.89) for 1-interquartile range (IQR) increase in NDVI in a 300m buffer] and access to major green spaces was associated with self-reported history of depression [OR (95%CI) = 0.18 (0.06, 0.58)]. No statistically significant associations were observed with blue spaces. Air pollution (between 0.8% and 29.6%) and noise (between 2.2% and 5.3%) mediated a proportion of the associations observed, whereas physical activity and social support played a minor role.

Conclusion: Our findings suggest a potential protective role of green spaces on mental health (depression and anxiety) in adults, but further studies, especially longitudinal studies, are needed to provide further evidence of these benefits and of the mediation role of exposures like air pollution and noise.
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http://dx.doi.org/10.1016/j.envres.2018.01.012DOI Listing
April 2018

Short-term exposure to traffic-related air pollution and ischemic stroke onset in Barcelona, Spain.

Environ Res 2018 04 5;162:160-165. Epub 2018 Jan 5.

Hospital del Mar Medical Research Institute, Barcelona, Spain. Electronic address:

Objective: To assess the relationship between short-term exposure to outdoor ambient air pollutants (fine particulate matter [PM] and black carbon [BC]), ischemic stroke (IS) and its different subtypes, and the potential modifying effect of neighborhood greenspace and noise.

Methods: This time-stratified case-crossover study was based on IS and transient ischemic attacks (TIA) recorded in a hospital-based prospective stroke register (BASICMAR 2005-2014) in Barcelona (Catalonia, Spain). Daily and hourly pollutant concentrations and meteorological data were obtained from monitoring stations in the city. Time-lags (from previous 72h to acute stroke onset) were analyzed. Greenness and noise were determined from the Normalized Difference Vegetation Index (NDVI) and daily average noise level at the street nearest to residential address, respectively.

Results: The 2742 cases with known onset date and time, living in the study area, were analyzed. After adjusting for temperature, no statistically significant association between pollutants exposure and overall stroke risk was found. In subtype analysis, an association was detected between BC exposure at 24-47h (odds ratio, 1.251; 95% confidence interval [CI], 1.001-1.552; P = 0.042) and 48-72h (1.211; 95% CI, 0.988-1.484; P = 0.065) time-lag prior to stroke onset and large-artery atherosclerosis subtype. No clear modifying effect of greenness or noise was observed.

Conclusions: Overall, no association was found between PM and BC exposure and acute IS risk. By stroke subtype, large-artery atherosclerotic stroke could be triggered by daily increases in BC, a diesel fuel-related pollutant in the study area.
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http://dx.doi.org/10.1016/j.envres.2017.12.024DOI Listing
April 2018

Estimated effects of air pollution and space-time-activity on cardiopulmonary outcomes in healthy adults: A repeated measures study.

Environ Int 2018 02 30;111:247-259. Epub 2017 Dec 30.

Barcelona Institute for Global Health (ISGlobal-CREAL), Barcelona, Spain. Electronic address:

Background: Exposure to air pollution is known to affect both short and long-term outcomes of the cardiopulmonary system; however, findings on short-term outcomes have been inconsistent and often from isolated and long-term rather than coexisting and short-term exposures, and among susceptible/unhealthy rather than healthy populations.

Aims: We aimed to investigate separately the annual, daily and daily space-time-activity-weighted effect of ambient air pollution, as well as confounding or modification by other environmental (including noise) or space-time-activity (including total daily physical activity) exposures, on cardiopulmonary outcomes in healthy adults.

Methods: Participants (N=57: 54% female) had indicators of cardiopulmonary outcomes [blood pressure (BP), pulse (HR) and heart rate variability (HRV {SDNN}), and lung function (spirometry {FEV, FVC, SUM})] measured on four different mornings (at least five days apart) in a clinical setting between 2011 and 2014. Spatiotemporal ESCAPE-LUR models were used to estimate daily and annual air pollution exposures (including PM, PM, but not Ozone {derived from closest station}) at participant residential and occupational addresses. Participants' time-activity diaries indicated time spent at either address to allow daily space-time-activity-weighted estimates, and capture total daily physical activity (total-PA {as metabolic-equivalents-of-task, METs}), in the three days preceding health measurements. Multivariate-adjusted linear mixed-effects models (using either annual or daily estimates) were adjusted for possible environmental confounders or mediators including levels of ambient noise and greenness. Causal mediation analysis was also performed separately considering these factors as well as total-PA. All presented models are controlled by age, height, sex and season.

Results: An increase in 5μg/m of daily space-time-activity-weighted PM exposure was statistically significantly associated with a 4.1% reduction in total heart rate variability (SDNN; p=0.01), and remained robust after adjusting for suspected confounders [except for occupational-address noise (β=-2.7, p=0.20)]. An increase in 10ppb of annual mean Ozone concentration at the residential address was statistically significantly associated with an increase in diastolic BP of 6.4mmHg (p<0.01), which lost statistical significance when substituted with daily space-time-activity-weighted estimates. As for pulmonary function, an increase in 10μg/m of annual mean PM concentration at the residential address was significantly associated with a 0.3% reduction in FVC (p<0.01) and a 0.5% reduction in SUM (p<0.04), for which again significance was lost when substituted for daily space-time-activity-weighted estimates These associations with pulmonary function remained robust after adjusting for suspected confounders, including annual Ozone, as well as total-PA and bioaerosol (pollen and fungal spore) levels (but not residential-neighborhood greenness {β=-0.22, p=0.09; β=-0.34, p=0.15, respectively}). Multilevel mediation analysis indicated that the proportion mediated as a direct effect on cardiopulmonary outcomes by suspected confounders (including total-PA, residential-neighborhood greenness, and occupational-address noise level) from primary exposures (including PM, PM, and O) was not statistically significant.

Conclusion: Our findings suggest that increased daily space-time-activity-weighted PM exposure levels significantly adversely affect cardiac autonomic modulation (as reduced total HRV) among healthy adults. Additionally, increased annual levels at the residential address of Ozone and PM significantly increase diastolic blood pressure and reduce lung function, respectively, among healthy adults. These associations typically remained robust when adjusting for suspected confounders. Occupational-address noise and residential-neighborhood greenness levels, however, were seen as mediators of cardiovascular and pulmonary outcomes, respectively. Total daily physical activity was not seen as a mediator of any of the studied outcomes, which supports the promotion of active mobility within cities.
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http://dx.doi.org/10.1016/j.envint.2017.11.024DOI Listing
February 2018

Land use regression models for the oxidative potential of fine particles (PM) in five European areas.

Environ Res 2018 01 12;160:247-255. Epub 2017 Oct 12.

MRC-PHE Centre for Environment and Health, Environmental Research Group (ERG), King's College London, London, United Kingdom.

Oxidative potential (OP) of particulate matter (PM) is proposed as a biologically-relevant exposure metric for studies of air pollution and health. We aimed to evaluate the spatial variability of the OP of measured PM using ascorbate (AA) and (reduced) glutathione (GSH), and develop land use regression (LUR) models to explain this spatial variability. We estimated annual average values (m) of OP and OP for five areas (Basel, CH; Catalonia, ES; London-Oxford, UK (no OP); the Netherlands; and Turin, IT) using PM filters. OP and OP LUR models were developed using all monitoring sites, separately for each area and combined-areas. The same variables were then used in repeated sub-sampling of monitoring sites to test sensitivity of variable selection; new variables were offered where variables were excluded (p > .1). On average, measurements of OP and OP were moderately correlated (maximum Pearson's maximum Pearson's R = = .7) with PM and other metrics (PMabsorbance, NO, Cu, Fe). HOV (hold-out validation) R for OP models was .21, .58, .45, .53, and .13 for Basel, Catalonia, London-Oxford, the Netherlands and Turin respectively. For OP, the only model achieving at least moderate performance was for the Netherlands (R = .31). Combined models for OP and OP were largely explained by study area with weak local predictors of intra-area contrasts; we therefore do not endorse them for use in epidemiologic studies. Given the moderate correlation of OP with other pollutants, the three reasonably performing LUR models for OP could be used independently of other pollutant metrics in epidemiological studies.
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http://dx.doi.org/10.1016/j.envres.2017.10.002DOI Listing
January 2018

Living Close to Natural Outdoor Environments in Four European Cities: Adults' Contact with the Environments and Physical Activity.

Int J Environ Res Public Health 2017 09 30;14(10). Epub 2017 Sep 30.

Centre for Research in Environmental Epidemiology (CREAL), ISGlobal, 08003 Barcelona, Spain.

This study investigated whether residential availability of natural outdoor environments (NOE) was associated with contact with NOE, overall physical activity and physical activity in NOE, in four different European cities using objective measures. A nested cross-sectional study was conducted in Barcelona (Spain); Stoke-on-Trent (United Kingdom); Doetinchem (The Netherlands); and Kaunas (Lithuania). Smartphones were used to collect information on the location and physical activity (overall and NOE) of around 100 residents of each city over seven days. We used Geographic Information Systems (GIS) to determine residential NOE availability (presence/absence of NOE within 300 m buffer from residence), contact with NOE (time spent in NOE), overall PA (total physical activity), NOE PA (total physical activity in NOE). Potential effect modifiers were investigated. Participants spent around 40 min in NOE and 80 min doing overall PA daily, of which 11% was in NOE. Having residential NOE availability was consistently linked with higher NOE contact during weekdays, but not to overall PA. Having residential NOE availability was related to NOE PA, especially for our Barcelona participants, people that lived in a city with low NOE availability.
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http://dx.doi.org/10.3390/ijerph14101162DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5664663PMC
September 2017

Natural outdoor environments and mental health: Stress as a possible mechanism.

Environ Res 2017 11 19;159:629-638. Epub 2017 Sep 19.

ISGlobal, Centre for Research in Environmental Epidemiology (CREAL), Barcelona, Spain; Universitat Pompeu Fabra (UPF), Barcelona, Spain; CIBER Epidemiología y Salud Pública (CIBERESP), Barcelona, Spain. Electronic address:

Introduction: Better mental health has been associated with exposure to natural outdoor environments (NOE). However, comprehensive studies including several indicators of exposure and outcomes, potential effect modifiers and mediators are scarce.

Objectives: We used novel, objective measures to explore the relationships between exposure to NOE (i.e. residential availability and contact) and different indicators of mental health, and possible modifiers and mediators.

Methods: A nested cross-sectional study was conducted in: Barcelona, Spain; Stoke-on-Trent, United Kingdom; Doetinchem, Netherlands; Kaunas, Lithuania. Participants' exposure to NOE (including both surrounding greenness and green and/or blue spaces) was measured in terms of (a) amount in their residential environment (using Geographical Information Systems) and (b) their contact with NOE (using smartphone data collected over seven days). Self-reported information was collected for mental health (psychological wellbeing, sleep quality, vitality, and somatisation), and potential effect modifiers (gender, age, education level, and city) and mediators (perceived stress and social contacts), with additional objective NOE physical activity (potential mediator) derived from smartphone accelerometers.

Results: Analysis of data from 406 participants showed no statistically significant associations linking mental health and residential NOE exposure. However, NOE contact, especially surrounding greenness, was statistically significantly tied to better mental health. There were indications that these relationships were stronger for males, younger people, low-medium educated, and Doetinchem residents. Perceived stress was a mediator of most associations, and physical activity and social contacts were not.

Conclusions: Our findings indicate that contact with NOE benefits mental health. Our results also suggest that having contact with NOE that can facilitate stress reduction could be particularly beneficial.
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http://dx.doi.org/10.1016/j.envres.2017.08.048DOI Listing
November 2017

Impact of commuting exposure to traffic-related air pollution on cognitive development in children walking to school.

Environ Pollut 2017 Dec 25;231(Pt 1):837-844. Epub 2017 Sep 25.

ISGlobal, Centre for Research in Environmental Epidemiology (CREAL), Barcelona, Catalonia, Spain; Pompeu Fabra University, Barcelona, Catalonia, Spain; Consortium for Biomedical Research in Epidemiology and Public Health (CIBERESP), Madrid, Spain; Institut Hospital del Mar d'Investigacions Mèdiques-Parc de Salut Mar, Barcelona, Catalonia, Spain.

A few studies have found associations between the exposure to traffic-related air pollution at school and/or home and cognitive development. The impact on cognitive development of the exposure to air pollutants during commuting has not been explored. We aimed to assess the role of the exposure to traffic-related air pollutants during walking commute to school on cognitive development of children. We performed a longitudinal study of children (n = 1,234, aged 7-10 y) from 39 schools in Barcelona (Catalonia, Spain) who commuted by foot to school. Children were tested four times during a 12-month follow-up to characterize their developmental trajectories of working memory (d' of the three-back numbers test) and inattentiveness (hit reaction time standard error of the Attention Network Test). Average particulate matter ≤2.5 μm (PM), Black Carbon (BC) and NO concentrations were estimated using Land Use Regression for the shortest walking route to school. Differences in cognitive growth were evaluated by linear mixed effects models with age-by-pollutant interaction terms. Exposure to PM and BC from the commutes by foot was associated with a reduction in the growth of working memory (an interquartile range increase in PM and BC concentrations decreased the annual growth of working memory by 5.4 (95% CI [-10.2, -0.6]) and 4.6 (95% CI [-9.0, -0.1]) points, respectively). The findings for NO were not conclusive and none of the pollutants were associated with inattentiveness. Efforts should be made to implement pedestrian school pathways through low traffic streets in order to increase security and minimize children's exposure to air pollutants.
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http://dx.doi.org/10.1016/j.envpol.2017.08.075DOI Listing
December 2017