According to the International Diabetes Federation in the year 2011, diabetes mellitus (DM) affects at least 366 million people worldwide, and that number is expected to reach 566 million by the year 2030. Over 99% of all diabetes cases represent type 2 DM with most of these projected to occur in low- to middle-income countries. Technology innovations, globalization with its free movement of food and services, seismic shifts in agrarian practices, and nutritional transition to freely available high-caloric diets have irrevocably altered energy expenditures during work and leisure. These and other factors are helping to foster the continued epidemiological transition occurring across the globe. Scientific effort over the last few decades has focused primarily on components of urbanization such as inactivity and dietary factors. More recent observations have provided additional links between exposure to environmental factors in air/water and propensity to chronic diseases (1). This issue is of importance given the extraordinary confluence of high levels of airborne and water pollutants in urbanized environments. Multiple studies in China, India, and other rapidly urbanizing economies demonstrate a steep gradient in urban–rural prevalence.
This review will summarize recent evidence on how outdoor air pollution may represent an underappreciated yet critical linkage between urbanization and the emergence of cardiometabolic diseases, with a focus on type 2 DM. We define cardiometabolic disease as the confluence of cardiovascular disease and type 2 DM in recognition of the fact that the milieu of diabetes fundamentally alters the pathophysiology of coronary, cerebrovascular, and peripheral arterial disease. Thus, alteration in susceptibility to DM automatically increases the likelihood of cardiovascular disease. Indoor air pollution is not discussed owing to the paucity of data. It should be noted that our current understanding of air pollution–mediated cardiometabolic disease is derived from outdoor air pollution studies, with there being no good reasons to believe that the dose-response relationship to indoor air pollution will be any different. An understanding of potentially reversible environmental factors responsible for this rapid burgeoning of cardiometabolic disorders among developing nations is crucial in order to devise a societal response that is proportionate and adequate (2). In this review, the association between air pollution and type 2 DM is discussed unless this distinction cannot be made in the cited study (typically health registry data sets).