Cooking fuel and the risk of pregnancy-induced hypertension in Lanzhou, China: A birth cohort study
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ISSN 0101-2061 (Print)
Food Science and Technology ISSN 1678-457X (Online)
DOI: https://doi.org/10.1590/fst.38320
Cooking fuel and the risk of pregnancy-induced hypertension in Lanzhou, China:
A birth cohort study
Lanlan Li1#, Yang Bai1#, Baolin Wang1#, Yucheng Ren1, Wei Dai1, Jianwei Tan1, Weihu Yang1, Zhuming Wu1 ,
Yaguang Hu1*
Abstract
Background: The relationship between the solid fuels and the occurrence of pregnancy-induced hypertension (PIH) is
inconclusive. Methods: A birth cohort study of 10,452 pregnant women without chronic hypertension was conducted from
2010 to 2012 at the Gansu Provincial Maternity and Child Care Hospital in Lanzhou, China. Multivariable logistic regression
models were used to assess the relationship. Results: Compared to pregnant women using gas as cooking fuel, pregnant women
using coal (OR=2.55, 95% CI: 1.85-3.51)and biomass (OR=3.58, 95% CI: 2.29-5.60) were associated with an increased risk of
PIH, gestational hypertension (biomass: OR=3.38, 95% CI: 1.68-6.80), and preeclampsia (coal: OR=2.89, 95% CI: 1.98-4.21;
biomass: OR=3.38, 95% CI: 1.95-5.84).The relationship between cooking fuel and PIH is modified by maternal age(pCooking fuel and the risk of PIH
history, medical condition and medication use, lifestyle factors, during pregnancy (yes or no), folate intake during pregnancy
occupational exposures, and residential history. The majority of (yes or no), multiple births (yes or no), and ventilation (yes or
the participated women (84%) were interviewed within 3 days no) were analyzed. Additional adjustments, such as history of
after delivery, while others were interviewed within 2 days before PIH, family history of PIH, maternal diabetes, maternal renal
delivery. Information on maternal complications was got from disease before pregnancy and progeny gender, didn’t result in
the medical records. The final sample was 10,452 after exclusion maternal changes observed in pregnant women and were not
of women who delivered still birth (n=53) and who had chronic included in the final models. All analyses were performed using
hypertension (n=37). All study procedures were approved by SAS, version 9.4(SAS Institute Inc., Cary, NC, USA).
the human investigation committees at the Gansu Provincial
Maternity and Child Care Hospital and Yale University.
3 Results
Information regarding cooking fuel used in current and each
past residence was collected, including the duration of stay in 3.1 Pregnant women with PIH showed different
each residence (date from move in and move out), the type of characteristic compared with normotensive pregnant women
fuel used for cooking in each residence (gas, electromagnetic,
coal, biomass and others), ventilation during cooking, and the 568(5.43%) were diagnosed with PIH, in which 180 cases
most common way of cooking (deep fried, pan fried, braised, (31.69%) were GH, 377 (66.37%) were PE, and 11(1.94%) were
steaming, simmer, and other) before and during pregnancy. eclampsia. Among those PE cases, 148 (39.26%) were M-PE,
229(60.74%) were S-PE. Compared to normotensive women,
PIH cases included GH, PE and eclampsia. GH was defined as women with PIH were more likely to be older, less educated, less
hypertension (blood pressure≥140/90 mmHg) and no proteinuria family income, higher unemployment during pregnancy, multipara,
was measured twice at a 6h interval after 20 weeks of gestation. higher pre-pregnancy BMI and GWG, and have history of PIH,
PE was defined as hypertension with proteinuria (≥300mg per family history of PIH, maternal diabetes, maternal renal disease
24 hour) or proteinuria of at least 1+ on dipstick test after 20 before pregnancy, less folate intake during pregnancy, multiple
weeks of gestation. PE was further classified as mild PE (M-PE),
births, and poor cooking ventilation (Table 1). There were no
severe PE (S-PE), early-onset PE (EOPE), and late-onset PE
significant differences in exposure to smoking during pregnancy
(LOPE). M-PE was diagnosed as hypertension (≥140/90 mmHg
and progeny gender between women with and without PIH.
andLi et al.
Table 1. Distribution of selected characteristics of the study population.
Normotensive(n=9884) PIH(n=568)
Characteristics P value
n % n %
Maternal age (years)Cooking fuel and the risk of PIH
Table 2. Distribution of selected characteristics of the study population by cooking fuel types.
Gas (n=8182) Electromagnetic (n=197) Coal (n=506) Biomass (n=173) Other (n=1394)
Characteristics P value
N % n % n % n % n %
Maternal age (years)Li et al.
Table 3. Associations of cooking fuel types with risk of PIH.
PIH(n=568) GH (n=180) (Pre)-eclampsia (n=388)
Cooking fuel types Term (n)
No. OR(95% CI) No. OR(95% CI) No. OR(95% CI)
Gas 7837 345 1.00(ref) 117 1.00(ref) 228 1.00(ref)
Electromagnetic 187 10 1.24(0.64-2.41) 5 1.71(0.68-4.30) 5 0.98(0.39-2.44)
Coal 433 73 2.55(1.85-3.51) 17 1.71(0.95-3.06) 56 2.98(2.06-4.31)
Biomass 137 36 3.58(2.29-5.60) 12 3.38(1.68-6.80) 24 3.64(2.14-6.19)
Note: adjusted for maternal age, education, monthly income, maternal employment during pregnancy, parity, BMI, GWG, smoking (active and passive smoking), folate intake during
pregnancy, multiple births, and ventilation.
S-PE (OR=3.23, 95% CI: 2.06-5.06). No significant correlations observed between cooking fuel and maternal age (Interaction
were also observed for electromagnetic stoves (Table 4). PCooking fuel and the risk of PIH
using gas for cooking, using coal (normal, OR=3.16, 95% CI: SO2 during the first trimester, and NOx, PM2.5, PM10, and SO2
2.01-4.95; overweight, OR=3.22, 95% CI: 1.14-9.04), and biomass during gestational weeks 1-20 were associated with higher risk
(normal, OR=3.31, 95% CI: 1.67-6.57; overweight, OR=4.11, of GH. (Zhu et al., 2017) However, Savitz et al. (2015) conducted
95% CI: 1.17-14.42) were also significantly associated with the a study in New York City involving 268,601 women (PE 11,166,
risk of PIH. Also, increased risk of PIH was associated with GH 5,834 and 17,000 PIH) and suggested a lack of evidence of
using coal among women who had less (OR=6.02, 95% CI: a positive association between PM2.5 or NO2 and PIH. Lee et al.
1.78-20.35) or more GWG (OR=5.27, 95% CI: 2.39-11.61), as (2013) reported PM2.5 exposure (per IQR increase) during first
well as insufficient (OR=4.88, 95% CI: 1.01-23.58) or excessive trimester was associated with GH (OR=1.11, 95% CI: 1.00-1.23)
biomass (OR=3.71, 95% CI: 1.37-10.04). Using coal or biomass1 but not for PM10 in Pittsburgh, Pennsylvania. Whereas Jin L
was significantly associated with the risk of PIH for primipara et al (Huang et al., 2015) conducted a cohort study in China
(coal, OR=3.20, 95% CI: 1.99-5.16; biomass, OR=5.19, 95% CI: that included 8745 women (333 PIH, 127 GH and 206 PE) and
2.64-10.22) and single birth (coal, OR=3.43, 95% CI: 2.35-5.02; observed a 10% increase for the risk of GH (OR=1.10, 95%
biomass, OR=3.97, 95% CI: 2.28-6.90). CI: 1.00, 1.21) during the first 12 gestational weeks after PM10
exposure (per 10μg/m-3 increase) and S-PE during the first 20
gestational weeks was associated with PM10 (OR=1.14, 95%
4 Discussion
CI: 1.01, 1.30 per 10μg/m-3 increase). Pedersen et al. (2017) in
A few studies have estimated the association between Denmark conduct a study including 72,745(PE 1880 and PIH
types of cooking fuels and the risk of PIH, and the results were 2430) pregnancies study subjects and found that a 10-µg/m3
inconsistent.(Wylie et al., 2015; Agrawal & Yamamoto, 2015) In increase in NO2 exposure during first trimester was associated
India, Wylie et al. (2015) conduct a study including 1369 (212 with increased risk of PE (OR=1.07, 95% CI: 1.01-1.14) and PIH
hypertension at delivery) subjects and found that compared (OR = 1.07, 95% CI: 1.01-1.13). A random-effect meta-analysis
to women cooking with gas, 14.6% of women using wood and of ambient air pollution and pregnancy-induced hypertensive
19.6% women using gas as their primary fuel met criteria for disorders also suggested that a 10 µg/m3 increase in NO2 was
hypertension at delivery (P=0.057), but using wood fuel was not associated with PIH (OR=1.23, 95% CI: 1.04-1.41).(Pedersen
significantly associated with hypertension (adjusted prevalence et al., 2014) Hampel et al. (2011) found negative short-term
ratio 0.76[95% CI 0.49, 1.17]). They speculate that this effect NO2 effects on systolic blood pressure in pregnant women. A
may be related to the combustion by-products of biomass fuels, nationwide time –series analysis in China reported a short-term
which are quite similar to tobacco and cigarette smoking during increase in ambient SO2 concentration may induce deaths from
pregnancy was associated with a significantly reduced risk for hypertension disease (Wang et al., 2018).
PE (OR=0.51, 95% CI: 0.37-0.63) have been reported in meta-
The exact mechanisms of IAP exposure from solid fuels on
analysis.(Castles et al., 1999) Agrawal S et al(2015) conducted PIH occurrence are not well understood. The basic pathological
a large-scale cross-sectional nationally representative of adult and physiological changes of PIH are systemic small blood
women in India including 39,657 women (456 preeclampsia/ vessels spasm, endothelial injury and ischemia. PM exposure is
eclampsia), and suggested that women living in households associated with systemic inflammation, endothelial dysfunction,
using biomass and solid fuels were associated with an increased and oxidative stress.(Becker et al., 2005; Bind et al., 2012;
risk of preeclampsia/eclampsia symptoms compared to women Ghio et al., 2000; Huang et al., 2012) PM inhalation induces
living in households using cleaner fuels (OR=2.21, 95% CI: 1.26- inflammatory responses mediated in the lung and systemically
3.87), even after controlling potentially confounding factors. through toll-like receptor 4/nicotinamide adenine dinucleotide
Consistent with the study, we also observed that using coal phosphate (TLR4/NADPH) oxidase-dependent mechanisms,
or biomass was associated with significantly increased risk of which promotes endothelial dysfunction. (Kampfrath et al.,
PE. This study suggested that biomass and coal exposure were 2011) Pulmonary exposure to PM leads to activation of lung
associated with S-PE, biomass exposure also was associated with autonomic nervous system (ANS) arcs mediated, then cause ANS
M-PE. While no study evaluated M-PE and S-PE separately in imbalance, leading to vasoconstriction, endothelial dysfunction,
relation to solid fuels. We found that maternal age, pre-pregnancy hypertension.(Chin, 2015) Routledge et al. (2006) found that
BMI, GWG, parity, and multiple births modified the association SO2 exposure can induce oxidative stress, and elevate markers
between cooking fuels and risk of PIH. Studies reported that of inflammation.
pre-pregnancy BMI and GWG were significantly associated with
the risk of PIH (Shao et al., 2017; Stüber et al., 2015). There were several limitations in the present study. The
information on household heating source was not obtained in
The combustion byproducts of solid fuel are a complex our study. The type of fuels of household heating was relevant
mixture of particulate and gaseous species such as particulate to family income and education, therefore we adjusted the
matter (PM), polycyclic aromatic hydrocarbons, heavy metals, potential confounding in our models. The large participants of
carbon monoxide (CO), nitrogen dioxide (NO2), sulfur dioxide our study were came from urban areas where was concentrated
(SO2), ozone (O3) and so on. (Zhang & Smith, 2007) Previous heating. Whether participants in our study were the primary
studies have suggested that particulate exposure was associated person in charge of food preparation, time spent in kitchen,
with PIH (Zhu et al., 2017; Savitz et al., 2015; Lee et al., 2013; number of meals cooked per day, and time for indoor activities
Huang et al., 2015) but inconsistent. A large retrospective cohort were not collected in the study, which might result in exposure
study from 2008 to 2010 in United States, including 206,054 misclassification. However, the exposure misclassification would
women with 6074 GH, found that exposure to NOx, PM2.5, and likely be negligible. Lack of indoor air pollution monitoring
6 6/8 Food Sci. Technol, Campinas, Ahead of Print, 2021Li et al.
restricted us to explore the association between the amount of Exposure-Related Human Activity Patterns Survey (CEERHAPS). Applied
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