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  • Review Article
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The contribution of the exposome to the burden of cardiovascular disease

Nature Reviews Cardiology volume 20, pages 651–669 (2023)Cite this article

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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.

Key points

  • Leading health risk factors, such as hypertension, smoking, overnutrition, diabetes mellitus, air pollution, high BMI and dyslipidaemia, increase the global burden of chronic non-communicable diseases, particularly cardiovascular diseases.

  • Environmental exposures account for up to two-thirds of all chronic non-communicable diseases, and chemical pollution alone is responsible for 16% of global deaths, thereby having greater influence than genetic predisposition; multiple co-exposures cause additive increases in the risk of cardiometabolic disease.

  • The exposome concept was established to investigate the effect of all exposures on endogenous biochemical and functional changes and the association with adverse health outcomes.

  • Harmful exposures can increase health risks and mortality synergistically with age, genetic predisposition and pre-existing chronic diseases.

  • It is challenging to assess exposures and their effects on the internal environment using omics approaches and functional assays, and exposome studies that assess associations between exposure, omics data and health outcomes are rare.

  • Substantial challenges for ongoing and future exposome studies are related to costs, handling of big data and multi-exposure assessment.

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Fig. 1: Global number of deaths and DALYs in 2019 attributable to health risk factors according to cause and sex.
Fig. 2: Colocalization of environmental exposures in Denmark.
Fig. 3: The exposome concept.
Fig. 4: Global deaths and DALYs for different pollutants and age groups.
Fig. 5: Assessment of environmental exposures and lifestyle factors.
Fig. 6: Blood biomarkers of the exposome.

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Acknowledgements

T.M. and A.D. received support from vascular biology research grants from the Boehringer Ingelheim Foundation for the collaborative research group “Novel and neglected cardiovascular risk factors: molecular mechanisms and therapeutics” and through continuous research support from the Foundation Heart of Mainz. M.S. received support from the European Union’s Horizon 2020 Research and Innovation Program under grant agreement No 874753 (REMEDIA). T.M. is a principal investigator and A.D. is a scientist of the DZHK (German Center for Cardiovascular Research), Partner Site Rhine-Main, Mainz, Germany.

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Authors and Affiliations

  1. Department of Cardiology, Cardiology I, University Medical Center of the Johannes Gutenberg-University, Mainz, Germany

    Thomas Münzel, Omar Hahad & Andreas Daiber

  2. German Center for Cardiovascular Research (DZHK), Partner Site Rhine-Main, Mainz, Germany

    Thomas Münzel, Omar Hahad & Andreas Daiber

  3. Danish Cancer Society, Copenhagen, Denmark

    Mette Sørensen

  4. Department of Natural Science and Environment, Roskilde University, Roskilde, Denmark

    Mette Sørensen

  5. Institute for Global Health (ISGlobal), Barcelona Biomedical Research Park (PRBB), Barcelona, Spain

    Mark Nieuwenhuijsen

  6. Department of Experimental and Health Sciences, Universitat Pompeu Fabra (UPF), PRBB building (Mar Campus), Barcelona, Spain

    Mark Nieuwenhuijsen

  7. CIBER Epidemiología y Salud Pública (CIBERESP), Instituto de Salud Carlos III, Madrid, Spain

    Mark Nieuwenhuijsen

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All authors researched data for the article, provided substantial contributions to the discussion of content and wrote the manuscript. T.M., M.S., O.H., M.N. and A.D. reviewed and/or edited the manuscript before submission.

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Related links

Exposome-Explorer: http://exposome-explorer.iarc.fr/

T3DB: www.t3db.ca

The European Human Exposome Network (EHEN): https://www.humanexposome.eu/

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Münzel, T., Sørensen, M., Hahad, O. et al. The contribution of the exposome to the burden of cardiovascular disease. Nat Rev Cardiol 20, 651–669 (2023). https://doi.org/10.1038/s41569-023-00873-3

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