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Elucidating the environmental risk factors for rheumatic diseases: An umbrella review of meta-analyses

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Belbasis L1, Dosis V1, Evangelou E1,2. Int J Rheum Dis. 2018 Aug;21(8):1514-1524. doi: 10.1111/1756-185X.13356.


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1 Department of Hygiene and Epidemiology, University of Ioannina Medical School, Ioannina, Greece.

2 Department of Epidemiology and Biostatistics, School of Public Health, Imperial College London, London, UK.


AIMS: Although rheumatic diseases constitute a leading cause of disability, the environmental risk factors for these diseases are not clarified. In the present study, we aim to systematically appraise the epidemiological credibility of the environmental risk factors for rheumatic diseases.

METHODS: We systematically searched PubMed to capture meta-analyses of observational studies on environmental risk factors for the most prevalent rheumatic diseases. For each association, we estimated the summary effect size estimate, the 95% confidence and prediction intervals, and the I2 metric. We further examined the presence of small-study effects and excess significance bias.

RESULTS: Overall, we identified 30 eligible papers describing 42 associations. Thirty-three associations were statistically significant at P < 0.05, whereas 13 of them were statistically significant at P < 1 × 10-6 . Thirty-two associations had large or very large between-study heterogeneity. In 12 associations, evidence of small-study effects and/or excess significance bias was found. Six risk factors (nine associations) presented convincing or highly suggestive evidence of association: smoking and pack-years of smoking for rheumatoid arthritis; BMI (per 5 kg/m2 increase) for gout and hip osteoarthritis; alcohol consumption for gout; BMI (overweight vs lean, obese vs lean), knee injury and participation in heavy work for knee osteoarthritis.

CONCLUSION: Our umbrella review indicated that a narrow range of risk factors has been examined for rheumatic diseases. Current evidence strongly supports that smoking, obesity, alcohol consumption, knee injury, and work activities are associated with risk for at least one rheumatic disease.