The role of liver enzymes in the association between ozone exposure and diabetes risk: a cross-sectional study of Zhuang adults in China.

Background : Growing evidence has demonstrated the role of ambient air pollutants in driving diabetes incidence. However, epidemiological evidence linking ozone (O 3 ) exposure to diabetes risk has been scarcely studied in Zhuang adults in China. We aimed to investigate the associations of long-term exposure to O 3 with diabetes prevalence and fasting plasma glucose (FPG) and estimate the mediating role of liver enzymes in Zhuang adults. Methods : We recruited 13 843 ethnic minority adults during 2018-2019 based on a cross-sectional study covering nine districts/counties in Guangxi. Generalized linear mixed models were implemented to estimate the relationships between O 3 exposure and diabetes prevalence and FPG. Mediation effect models were constructed to investigate the roles of liver enzymes in the associations of O 3 exposure with diabetes prevalence and FPG. Subgroup analyses were conducted to identify potential effect modifications. Results : Long-term exposure to O 3 was positively associated with diabetes prevalence and FPG levels in Zhuang adults, with an excess risk of 7.32% (95% confidence interval [CI]: 2.56%, 12.30%) and an increase of 0.047 mmol L -1 (95% CI: 0.032, 0.063) for diabetes prevalence and FPG levels, respectively, for each interquartile range (IQR, 1.18 μg m -3 ) increment in O 3 concentrations. Alanine aminotransferase (ALT) significantly mediated 8.10% and 29.89% of the associations of O 3 with FPG and diabetes prevalence, respectively, and the corresponding mediation proportions of alkaline phosphatase (ALP) were 8.48% and 30.00%. Greater adverse effects were observed in females, obese subjects, people with a low education level, rural residents, non-clean fuel users, and people with a history of stroke and hypertension in the associations of O 3 exposure with diabetes prevalence and/or FPG levels (all P values for interaction < 0.05). Conclusion : Long-term exposure to O 3 is related to an increased risk of diabetes, which is partially mediated by liver enzymes in Chinese Zhuang adults. Promoting clean air policies and reducing exposure to environmental pollutants should be a priority for public health policies geared toward preventing diabetes.