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. 2025 Jun 10;25(1):2163.
doi: 10.1186/s12889-025-23380-1.

Exposure-response relationship of household air pollution on body mass index among women in rural areas of Guatemala, India, Peru and Rwanda: household air pollution intervention network trial

Adolphe Ndikubwimana  1 , William Checkley  2 , Yunyun Chen  3 , Thomas Clasen  4 , Carmen Lucía Contreras  5 , Anaite Diaz-Artiga  5 , Ephrem Dusabimana  6 , Lisa de Las Fuentes  7 , Shirin Jabbarzadeh  3 , Michael Johnson  8 , Egide Kalisa  9 , Patrick Karakwende  10 , Miles Kirby  11 , Amy E Lovvorn  4 , John P McCracken  5   12 , Florien Ndagijimana  6 , Theoneste Ntakirutimana  10 , Jean Dieu Ntivuguruzwa  6 , Jennifer L Peel  13 , Ajay Pillarisetti  14 , Victor G Dávila-Román  7 , Ghislaine Rosa  15 , Sarada S Garg  16 , Lisa Thompson  4 , Lance A Waller  3 , Jiantong Wang  3 , Maggie L Clark  13 , Bonnie N Young  13 ; HAPIN investigators
Affiliations

Exposure-response relationship of household air pollution on body mass index among women in rural areas of Guatemala, India, Peru and Rwanda: household air pollution intervention network trial

Adolphe Ndikubwimana et al. BMC Public Health. .

Abstract

Background: Household air pollution from burning biomass materials, the main cooking fuel in low- and middle-income countries, may be linked to metabolic dysfunction. We assessed cross-sectional associations between household air pollution and body mass index (BMI), expecting to see increased BMI with higher pollution concentrations.

Methods: We analyzed data from 414 women aged 40 to 79 years who resided in the households using biomass fuel and were enrolled in the multi-country Household Air Pollution Intervention Network (HAPIN) Trial. We explored associations of 24-h average personal exposure to fine particulate matter (PM2.5), black carbon (BC), and carbon monoxide (CO) with BMI through single pollutant linear and logistic models adjusted for potential confounders (i.e., age, socioeconomic indicators, education, dietary diversity, secondhand smoke exposure, alcohol and grain consumption).Sensitivity analyses explored air pollutants as quartiles, and other variables as potential confounders, such as physical activity, enrollment site, and dietary items. We examined effect modification of research site on the associations.

Results: We observed mixed evidence of associations between household air pollution and BMI in linear regression. There was no association with BMI and PM₂.₅ (1-unit increase in log-transformed PM₂.₅ estimate 0.02 kg/m2 [95% CI: -0.51, 0.54]) or CO (1-unit increase in log-transformed CO estimate 0.42 kg/m2 [95% CI -0.31, 1.14]). However, a 1-unit increase in log-transformed BC showed an association in the opposite direction as hypothesized (BC estimate -0.59 kg/m2 [95% CI -1.17, -0.003]). Using logistic regression models, we found that only CO significantly increased the odds of overweight/obesity: a 1-unit increase in log-transformed CO led to an odds ratio of 1.66 (95% CI: 1.10, 2.51). Effect modification showed inverse association between BC exposure and BMI in Peru.

Conclusions: Evidence suggests a significant association between CO exposure and increased odds of being overweight/obese, whereas impacts of PM2.5 and BC on BMI had null or inverse effects.

Keywords: BMI; Biomass cookstove; Indoor air pollution; Low-and middle-income countries.

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Conflict of interest statement

Declarations. Ethics approval and consent to participate: This study was conducted in accordance with the principles of the Declaration of Helsinki ( https://www.wma.net/policies-post/wma-declaration-of-helsinki/ ). The study protocol has been reviewed and approved by institutional review boards (IRBs) or Ethics Committees at Emory University (00089799), Johns Hopkins University (00007403), Sri Ramachandra Institute of Higher Education and Research (IEC-N1/16/JUL/54/49) and the Indian Council of Medical Research – Health Ministry Screening Committee (5/8/4–30/(Env)/Indo-US/2016-NCD-I), Universidad del Valle de Guatemala (146–08-2016/11–2016) and Guatemalan Ministry of Health National Ethics Committee (11–2016), A.B. PRISMA, the London School of Hygiene and Tropical Medicine (11664–5) and the Rwandan National Ethics Committee (No.357/RNEC/2018), and Washington University of St. Louis (201611159). The HAPIN trial has been registered with ClinicalTrials.gov (Identifier NCT029446282) on October 26, 2016. However, it is a randomized control trial (RCT) not a clinical trial. And all participants provided informed consent prior to participation in the study. Consent for publication: Not applicable. Competing interests: The authors declare no competing interests.

Figures

Fig. 1
Fig. 1
Box-and-whisker plots of baseline BMI by research site (n=414). The central line in each box represents the median, the boxes represent the interquartile range (IQR), and the whiskers extend to 1.5 times the IQR. Outliers beyond the whiskers are shown as individual points. The red dashed line represents the cutoff for overweight/obesity at 25.0
See this image and copyright information in PMC

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