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An analysis of trends in the burden of ischemic stroke caused by air pollution in China between 1990 and 2021

BMC Public Health volume 25, Article number: 1567 (2025) Cite this article

Abstract

Background

This study evaluates the burden of ischemic stroke attributable to air pollution in China from 1990 to 2021, examines gender and age-specific differences, and projects future disease burden trends from 2022 to 2036. By analyzing the impact of air pollution on ischemic stroke, this study aims to provide insights for public health policies and preventive measures.

Methods

Utilizing data from the 2021 Global Burden of Disease (GBD) study, this research examined the ischemic stroke burden associated with air pollution in China. To assess historical trends and project disease burden from 2022 to 2036, Joinpoint regression modeling and decomposition analysis were employed. These methods allow for identifying significant trend changes and disentangling the contributions of various factors.

Results

From 1990 to 2021, China observed a decline in both age-standardized mortality rates (ASMR) and age-standardized disability-adjusted life years (DALY) rates for ischemic stroke attributed to air pollution. However, the decline was slower among men than women, with a higher burden observed in elderly males. Epidemiological transitions, including improved healthcare and lifestyle changes, were the main drivers behind the overall reduction in disease burden. Projections indicate that over the next 15 years, ASMR and age-standardized DALY rates (ASDR) for women will continue to decline, while ASMR for men is expected to rise and ASDR for men will gradually increase before stabilizing.

Conclusion

Elderly males are disproportionately affected by ischemic stroke related to air pollution, highlighting a critical public health issue. To mitigate this burden, it is essential for the government to implement targeted, gender- and age-specific policies aimed at improving air quality, enhancing healthcare access, and promoting preventive measures for vulnerable populations, particularly the elderly and men. These findings underscore the need for integrated strategies to reduce health disparities and address the ongoing challenges posed by air pollution.

Peer Review reports

Introduction

Most strokes are caused by ischemic factors, while those triggered by cerebral hemorrhage are relatively rare [1]. Ischemic stroke is a condition resulting from reduced blood supply to specific areas of the brain due to blocked blood vessels. In 2020, China reported 15.5 million cases of ischemic stroke, representing 86.8% of the total stroke cases [2, 3]. Since 2015, stroke has emerged as the primary cause of both mortality and disability in China. As a prominent chronic non-communicable disease, it presents a substantial threat to the health of Chinese citizens [4]. However, with the continuous changes in China's population structure, risk factors for stroke such as hypertension and hypercholesterolemia are increasing, leading to a rising burden of stroke [4, 5]. Air pollution, as the fifth leading risk factor for death globally, accounts for approximately one-tenth of all global deaths. In China, 14% of the disease burden is attributable to air pollution [6]. Emerging evidence indicates that air pollution is becoming a significant risk factor for ischemic stroke. In recent decades, air pollution levels have steadily increased, and the percentage of stroke-related deaths attributable to this factor has reached 14% [7,8,9].

Previous studies have demonstrated that air pollution, particularly particulate matter (PM), environmental ozone, and nitrogen dioxide, significantly affects the incidence of ischemic stroke. The 2021 GBD study identifies air pollution as a critical risk factor, encompassing both outdoor and indoor sources. Outdoor particulate matter and indoor air pollution from solid fuel combustion are significant contributors. According to the World Health Organization, over 4 million people die annually due to outdoor air pollution, while nearly 91.5 million DALYs are attributed to indoor air pollution [10, 11]. China, as one of the leading countries in ischemic stroke mortality and DALYs associated with environmental particulate matter, continues to grapple with the health burden imposed by air pollution [12]. Notably, gender differences have been identified in previous studies. For example, environmental particulate matter pollution is the primary contributor to ischemic stroke deaths and DALYs for men, while indoor air pollution from solid fuels plays a more significant role for women [13]. This gender disparity underscores the need for gender-specific public health interventions.

Despite these insights, there remains a significant research gap in understanding the evolving burden of ischemic stroke due to air pollution in China, especially from a gender- and age-specific perspective. To address this, we draw upon data from the 2021 GBD study, which focuses on assessing risk factors for various diseases, to thoroughly analyze the trends in ischemic stroke burden attributable to air pollution in China from 1990 to 2021. Our study aims to provide a more comprehensive understanding of the long-term impact of air pollution on ischemic stroke and project the future disease burden, highlighting the need for targeted policy interventions.

Method

Data resources

The data for this research are derived from the 2021 GBD Study. The GBD aims to provide researchers with essential tools for assessing disease burden and risk factors worldwide, playing a crucial role in understanding global health issues, guiding public health policies, and informing resource allocation. For this study, we employed the most recent 2021 GBD database. This database provides comprehensive data on the incidence, prevalence, mortality, and DALY rates for 371 diseases and injuries across 204 countries and regions from 1990 to 2021, with detailed breakdowns by age and gender [14]. Further information can be obtained from the official website: (https://www.healthdata.org/research-analysis/gbd). The GBD data for China have been officially recognized for their reliability and population representativeness. A considerable number of studies that extensively leverage GBD data specific to China have been accepted and published in high-impact research journals [15, 16]. This study involved retrieving data related to the burden of ischemic stroke caused by air pollution in China from the GBD database, forming the core of our research. The data were categorized into 13 age groups (ranging from 25–29 years to 80–84 years, and 85 years and older), and age-standardized rates were computed using the GBD 2021 reference population structure.

Time trend analysis

To analyze the temporal trends in the burden of ischemic stroke attributable to air pollution in China, we utilized the Joinpoint regression model for our trend analysis. The Joinpoint regression model is a widely recognized technique for analyzing time series data that allows for detecting significant changes in trends over time. This method has been widely used in epidemiological studies to identify shifts in disease burden, making it well-suited for understanding the impact of air pollution on ischemic stroke trends. This is a linear model composed of statistical ensembles [17], designed to analyze changes in trends within time series data. It allows for the setting of multiple inflection points, thereby transforming the overall trend into multiple local trends. We determined the mortality and DALY rates of ischemic stroke attributable to air pollution in China between 1990 and 2021, identified the most appropriate model for fitting, and analyzed the trend in the disease burden. This method was chosen due to its ability to detect non-linear trends, which is essential when analyzing health outcomes that are influenced by both gradual changes and abrupt shifts in risk factors, such as air pollution. When the average annual percent change (AAPC) and the annual percent change (APC) exceed zero, it reflects an upward trend; when they are below zero, it indicates a downward trend; and when they equal zero, it points to a stable trend. Statistical significance is attributed to results when the P-value falls below 0.05.

Decomposition analysis

Decomposition analysis is an effective method for revealing patterns and changes in data. This method is particularly useful in disentangling the contributions of multiple factors to an observed trend, making it ideal for analyzing the complex interactions between air pollution, aging, and population growth in relation to ischemic stroke burden. Decomposition analysis was used in this study to assess the distinct contributions of aging, population growth, and epidemiological transitions to the observed trends in mortality and DALYs. Epidemiological changes refer to variations in mortality and complication rates after adjusting for underlying age and population characteristics [18]. The degree of population aging is assessed by analyzing shifts in age structure, while population growth is evaluated based on trends in total population changes. Through decomposition analysis, we evaluate the contribution of each factor to the overall trend and ascertain whether it leads to an increase or decrease in the burden of ischemic stroke caused by air pollution.

Model prediction

For time series analysis and forecasting future values, the Autoregressive Integrated Moving Average (ARIMA) model is a widely adopted technique. The ARIMA model is particularly suited for forecasting health outcomes like ischemic stroke burden, as it can account for both autoregressive (past values) and moving average (random shocks) components in time series data. This makes it an ideal tool for modeling the long-term effects of air pollution, which may exhibit seasonal and cyclic fluctuations. The ARIMA model used in this study includes three autoregressive (AR) parameters, one differencing (I) parameter, and one moving average (MA) parameter, facilitating the accurate representation of trends and seasonal fluctuations in the time series. The parameters of the ARIMA model are typically denoted as (p, d, q) [19], where p = 3 indicates that the model uses the previous three lagged values to explain the data trend; d = 1 means that the data becomes stationary after one order of differencing; and q = 1 indicates that the model incorporates the lagged prediction error to adjust forecasts. During the modeling process, the time series data were first stabilized using the differencing method, and the auto.arima() function selected the most suitable model based on the Akaike Information Criterion (AIC). To assess the normality of the residuals, we subsequently employed Q-Q plots, autocorrelation function (ACF) plots, and partial autocorrelation function (PACF) plots. Finally, the Ljung-Box test was employed to determine if the residual sequence exhibited white noise characteristics, indicating robustness [20].

Result

Temporal trends of the burden of ischemic stroke caused by air pollution in China

Table 1 provides an overview of the disease burden of ischemic stroke attributed to air pollution in China from 1990 to 2021. The ASMR decreased from 35.84 per 100,000 people in 1990 to 19.50 per 100,000 people in 2021 (AAPC = −1.99, P < 0.001). The ASDR decreased from 656.13 per 100,000 people in 1990 to 355.52 per 100,000 people in 2021 (AAPC = −2.02, P < 0.001). Over the period from 1990 to 2021, both the ASDR and ASMR displayed a fluctuating trend, characterized by an initial drop, a subsequent rise, and a final decrease. Meanwhile, the ASMR for females, the ASDR for females, and the ASDR for males all followed this overall trend. However, the ASMR for males showed a different pattern, initially increasing and then decreasing.

Table 1 The ASMR and ASDR for ischemic stroke due to air pollution in China, from 1990 to 2021, along with the AAPC of these rates, are provided separately for each gender
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The burden of ischemic stroke caused by air pollution in China classified by age and gender

Figures 1 and 2 depict the trends in deaths, DALYs, mortality rates, and DALY rates attributable to air pollution-related ischemic stroke across various age groups and genders in 1990 and 2021. The disease burden of ischemic stroke primarily affects individuals aged 70 and older. Relative to 1990, the number of deaths and DALYs increased substantially by 2021 for both genders, with particularly marked growth among the elderly. In 1990, the peak values for male deaths, DALYs for males, and DALYs for females were all observed at the age of 70–74, while the peak for female deaths was at the age of 75–79. However, among those aged 75 and older, the mortality and DALY rates for both genders were elevated in 1990 relative to 2021. In every year examined, the mortality and DALY rates for men were consistently higher than for women within the same age brackets, with the gender gap being more evident among individuals aged 75 and over.

Fig. 1
figure 1

The burden of ischemic stroke deaths and DALYs caused by air pollution in China in 1990 and 2021, by age and gender (A), (B) Number of deaths (C), (D) Number of DALYs

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Fig. 2
figure 2

The burden of ischemic stroke deaths and DALYs rates caused by air pollution in China in 1990 and 2021, by age and gender (A), (B) mortality rate (C), (D) DALYs rate

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Investigating the impact of air pollution on ischemic stroke burden in China through joinpoint regression analysis

Figure 3 presents the Joinpoint regression analysis of the burden of ischemic stroke attributable to air pollution in China from 1990 to 2021. Overall, both the ASMR and the ASDR exhibited a downward trend, although they experienced a slight increase from 1998 to 2004, with APCs of 2.03% and 1.40%, respectively. The ASMR and ASDR trends for Chinese women and men were consistent with the overall pattern. However, for women, the ASMR and ASDR slightly increased from 1997 to 2004, with APCs of 1.33% and 0.77%, respectively, while for men, these rates increased more significantly from 1999 to 2004, with APCs of 3.27% and 2.36%, respectively. The most rapid declines in ASMR and ASDR occurred from 2016 to 2019, with APCs of −8.03% and −7.92%, respectively. For men, the ASMR and ASDR decreased most rapidly from 2015 to 2019, with APCs of −7.44% and −7.18%, respectively. For women, the ASMR declined most significantly from 2004 to 2007, with an APC of −7.03%, while the ASDR declined most significantly from 2016 to 2019, with an APC of −6.71%. Moreover, compared with women, the ASMR and ASDR for men have shown a slower downward trend in the past three years.

Fig. 3
figure 3

Joinpoint regression analysis was applied to assess the ASMR and ASDR associated with ischemic stroke due to air pollution in China between 1990 and 2021. A The analysis encompasses the overall ASMR, as well as the ASMR for females and males. B Additionally, it includes the overall ASDR and the corresponding ASDR for females and males

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Investigation into the drivers of changes in mortality and DALYs associated with ischemic stroke caused by air pollution in China

Figure 4 depicts the contributing factors that have driven changes in deaths and DALYs from ischemic stroke attributable to air pollution in China over the period from 1990 to 2021. For mortality, epidemiological changes have become a significant driving force for the decline in both sexes, with a more pronounced impact on men than on women. Due to population growth, there has been a minor increase in the number of deaths, with both genders experiencing a similar pattern. Aging has resulted in an increase in mortality rates, with a more pronounced rise among men. Furthermore, the factors influencing changes in DALYs and mortality are similar for both sexes. The aggregate impact of these factors, represented by the black dots, contributes to a net decline in the DALY rate for both sexes. This examination reveals the complex dynamics between epidemiological transformations, population expansion, and aging in shaping the trend of ischemic stroke burden caused by air pollution.

Fig. 4
figure 4

The analysis decomposes the changes in DALYs and deaths resulting from ischemic stroke due to air pollution in China from 1990 to 2021, factoring in the contributions of aging (yellow), epidemiological changes (green), and population growth (orange). The black dots signify the total effect of these factors. A Gender-based decomposition of DALYs changes: male and female. B Gender-based decomposition of mortality changes: male and female

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Forecast trends of ASMR and ASDR of ischemic stroke caused by air pollution in China from 2022 to 2036

Figure 5 employs ischemic stroke mortality and DALY rate data spanning from 1990 to 2021 in the ARIMA model to project future trends quantitatively over the subsequent 15 years. Over the next 15 years, it is projected that the ASMR for females will continue to decline, while the ASMR for males will keep rising. The ASDR for females is also expected to continue falling, while for males, it will initially increase slowly and then level off. By 2036, it is projected that the ASMR for females will drop to 8.26 per 100,000 people and the ASDR will fall to 165.10 per 100,000 people. Meanwhile, for males, the ASMR is expected to rise to 46.31 per 100,000 people and the ASDR to 496.84 per 100,000 people.

Fig. 5
figure 5

The projected burden of ischemic stroke in Chinese men and women due to air pollution from 2022 to 2036 (A), (C) ASMR (B), (D) ASDR

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Discussion

Research findings indicate that from 1990 to 2021, the ASMR and ASDR of ischemic stroke attributable to air pollution generally exhibited a downward trend, with AAPC of -1.99% and -2.02%, respectively. However, compared with women, the decline in ASMR and ASDR among men has been slower. The analysis using the Joinpoint regression model indicates that, while the ASMR and ASDR for men and women have varied over the past 32 years, they have consistently decreased over the last decade. Notably, in the past three years, the decline in ASMR and ASDR for men has been slower compared to women. It is important to highlight that the disease burden of ischemic stroke is particularly significant among the elderly, especially among men aged 70 and above. According to the decomposition analysis, epidemiological changes play the leading role in reducing deaths and DALYs from ischemic stroke, while population growth and aging have contributed opposing forces to these trends.The ARIMA model prediction analysis suggests that over the next 15 years, the ASMR and ASDR of ischemic stroke attributable to air pollution among women will continue to decline. In contrast, the ASMR among men will continue to rise, and the ASDR will initially increase slowly before stabilizing. Although the overall disease burden of ischemic stroke attributable to air pollution has shown a downward trend, the disease situation remains severe, particularly for men, especially elderly men.

Joinpoint regression analysis indicates that the ASMR and ASDR of ischemic stroke attributable to air pollution in China have shown a downward trend in recent years, consistent with the overall trend in the disease burden of ischemic stroke [21]. This suggests that the current measures taken by China to improve air quality and reduce pollutant emissions are effective. Evidence from studies suggests that both brief and prolonged exposure to air pollution can heighten the risk of ischemic stroke. The underlying mechanism may involve environmental PM2.5 exposure contributing to the formation of atherosclerosis, which affects both cerebral small vessels and large arteries, thereby increasing the risk of ischemic stroke [8, 9, 22, 23]. Studies have further indicated that ischemic stroke caused by PM2.5 exposure is connected to systemic inflammation and oxidative stress, which elevate reactive oxygen species (ROS) levels and decrease anti-inflammatory capabilities, thus raising the risk of thrombosis [24]. Additionally, PM1 and O3 pollutants are also linked to the occurrence of ischemic stroke. Small rises in air pollution levels are associated with a greater likelihood of developing cerebrovascular diseases. This is because these pollutants can damage the vascular endothelium, activate the sympathetic nervous system, and adversely affect blood circulation [25]. In recent years, with the growing public awareness of air pollution and the continuous improvement of environmental protection laws, various air pollutants have exhibited a decreasing trend annually [26, 27]. While China has achieved remarkable progress in enhancing air quality, the burden of ischemic stroke due to air pollution remains significant, and sustained initiatives are still essential.

Our findings indicate that the impact of air pollution on ischemic stroke is more pronounced among men than women in China, especially during the last decade and for men aged 70 and over.The primary contributor to this burden is PM2.5 from air pollution. Inhaled pollutants can disrupt the homeostasis of the autonomic nervous system (ANS), leading to increased vascular resistance [28]. Studies have shown that when environmental PM2.5 concentrations are between 0 and 35 μg/m3, men exhibit greater sensitivity to fine particulate matter exposure compared to women. Additionally, elderly individuals are more susceptible to PM2.5 exposure than younger populations [29]. Studies have also found that short-term exposure to PM2.5 in older adults is associated with increased cerebral vascular resistance and diminished cerebral blood flow [30]. Therefore, it can be inferred that elderly men are more sensitive to air pollution. Air pollution increases the risk of various diseases in elderly men, including cardiovascular and cerebrovascular diseases, as well as respiratory diseases. Consequently, during periods of high air pollution, elderly men should minimize outdoor activities and actively wear masks to protect their respiratory and cerebrovascular health.

According to our decomposition analysis, the principal force driving the decrease in ischemic stroke mortality and DALY rates is epidemiological change. This indicates that the implementation of air pollution control policies and the reduction of anthropogenic pollutant emissions have significantly improved air quality [26], thereby reducing the disease burden of ischemic stroke. However, with the aging of the population, the cerebral blood flow in elderly individuals will decline, increasing their susceptibility to air pollution and, consequently, the risk of ischemic stroke. This finding is consistent with previous research [29, 30]. Population growth and aging are expected to lead to increases in mortality and DALY rates, necessitating continuous public health interventions that prioritize prevention, early diagnosis, and effective treatment to address this growing concern.

The ARIMA model projects that, over the next 15 years, the ASMR and ASDR of ischemic stroke linked to air pollution will continue to drop among women in China, while among men, these rates are anticipated to rise steadily. These trends suggest an enhanced health awareness among the female population, including healthier lifestyles and improved disease prevention measures. The reduction in the burden on women is a positive development, reflecting the positive impact of improvements in air quality and ischemic stroke management. Differences in health awareness and behavior between men and women may contribute to these divergent trends. For instance, unhealthy habits such as smoking are more prevalent among men. The increased burden suggests that there is a need to enhance public awareness of the health risks posed by air pollution, particularly among the male population, in order to promote healthier lifestyles and stronger environmental protection consciousness. In response to this burden, improving air quality is crucial. The government can strengthen supervision over environmental protection and mobilize all sectors of society to actively participate in atmospheric environment protection, thereby reducing the impact of air pollution on public health, especially for the male population.

However, the ARIMA model relies on several key assumptions that may influence the accuracy of its predictions. First, it assumes that the time series data are stationary, meaning that statistical properties such as mean and variance do not change over time [31]. This assumption could be problematic if the data show long-term trends or abrupt changes in external conditions, such as air pollution control policies or economic shifts. Second, ARIMA assumes that the error terms in the model are normally distributed and independent, but real-world data often contain autocorrelations or external shocks that violate these assumptions [32]. For example, public health crises like the Coronavirus disease 2019 (COVID-19) pandemic or significant policy changes can introduce biases. To address these limitations, we performed sensitivity analyses to test the robustness of our predictions by varying key assumptions and comparing different model specifications. This process ensures that our findings are not overly dependent on any single set of assumptions or external factors.

Social, cultural, and biological factors behind gender and age differences

Evidence suggests that the burden of ischemic stroke attributable to air pollution is disproportionately higher among men, particularly older men. These gender differences can be attributed to a combination of biological and sociocultural factors. Biologically, men are at greater risk for ischemic stroke due to differences in cardiovascular risk factors, such as higher rates of smoking and alcohol consumption [33,34,35]. These factors increase their susceptibility to stroke, especially in the presence of environmental pollutants like PM2.5 [29]. Additionally, older adults, especially men, tend to have a higher prevalence of chronic conditions such as hypertension, diabetes, and atherosclerosis, making them more vulnerable to the adverse effects of air pollution [36,37,38]. Socioculturally, men are more likely to engage in outdoor activities that increase their exposure to air pollution, including occupational exposure, which is often higher in male-dominated industries [39]. Furthermore, older men may have more limited access to healthcare and resources to mitigate the effects of air pollution, such as air purifiers or appropriate medical interventions.

These biological and sociocultural differences explain why men, particularly elderly men, are more severely affected by air pollution than women. The aging process itself exacerbates the risks associated with environmental pollutants due to reduced physiological resilience and the accumulation of chronic health conditions. Therefore, gender and age differences in health outcomes are shaped not only by biological mechanisms but also by broader social determinants, including lifestyle choices, socioeconomic status, and healthcare access [40,41,42].

Public health policy recommendations

The ARIMA model projects that, over the next 15 years, the ASMR and ASDR of ischemic stroke linked to air pollution will continue to drop among women in China, while among men, these rates are anticipated to rise steadily. These trends suggest that public health interventions, particularly those targeting women, may be more effective in raising health awareness and improving health behaviors. The decrease in the disease burden among women can be attributed to increasing health awareness, healthier lifestyles, and more proactive disease prevention measures [43]. However, the rising burden among men calls for intensified health education campaigns specifically targeting male populations, particularly older men.

Our findings underline the need for a more tailored approach to public health interventions. For instance, government policies should prioritize air quality improvements, but with a specific focus on vulnerable populations such as elderly men [44]. Health education campaigns should raise awareness of the risks of air pollution and promote protective measures such as reducing outdoor activities during high pollution periods and wearing masks [45, 46]. Furthermore, policymakers should consider gender-specific interventions that address the unique risks faced by men, particularly in occupational settings, and ensure that healthcare systems are equipped to support elderly individuals with chronic conditions that exacerbate the effects of air pollution.

Limitations and future research directions

Although GBD 2021 employed rigorous algorithms to estimate the data, the study inevitably faces some limitations. Firstly, the GBD 2021 dataset is limited to national-level data and does not provide more detailed information at the provincial or municipal levels. The use of finer-grained classification data would help reveal regional differences more accurately. Secondly, due to challenges in accurately recording deaths caused by ischemic stroke and distinguishing them from other causes, the statistical data on the disease burden of ischemic stroke attributable to air pollution may be underestimated. Thirdly, predictions are based on specific assumptions, while the occurrence of diseases is influenced by multiple unpredictable factors, including population dynamics, environmental conditions, healthcare services, and economic conditions. Therefore, the prediction results may be subject to bias. It is necessary to further refine the ARIMA model to enhance its predictive accuracy.

Conclusion

The burden of ischemic stroke attributable to air pollution in China from 1990 to 2021 has fluctuated but generally shows a downward trend. The disease burden has been consistently decreasing for both men and women. However, over the past three years, the reduction in the ASMR and ASDR among men has been slower compared to women. Air pollution primarily affects older adults and males. Due to population growth, aging, and epidemiological transformations, the mortality rate for ischemic stroke linked to air pollution has increased among Chinese men, while the burden on women has reduced. These gender differences are influenced by biological and sociocultural factors, with men, particularly elderly men, being more vulnerable to the effects of air pollution due to higher exposure levels and pre-existing health conditions. In the next 15 years, the disease burden of ischemic stroke attributable to air pollution among women is expected to continue declining, while that among men is projected to steadily increase overall. This suggests the need for gender-specific interventions and policies that target male populations, particularly the elderly, to reduce their exposure to air pollution and its adverse health effects. To alleviate the burden of ischemic stroke related to air pollution, the Chinese government should formulate effective measures and policies to improve air quality and simultaneously enhance public awareness of the health risks associated with air pollution, particularly for vulnerable groups such as elderly men. Government actions could include stricter regulations on industrial emissions, promoting the use of clean energy, and increasing public health campaigns to educate people about the risks of air pollution and the importance of protective behaviors. Moreover, tailored healthcare programs for high-risk populations, such as early detection and management of stroke risk factors in elderly men, are essential to mitigate the future health burden.

Data availability

All data were retrieved from the online GBD database, which can be accessed at http://ghdx.healthdata.org/gbd-results-tool.

Abbreviations

GBD:

Global Burden of Disease

ASMR:

Age-standardized mortality rates

DALY:

Disability-adjusted life years

ASDR:

Age-standardized DALY rates

PM:

Particulate matter

AAPC:

Average annual percent change

APC:

Annual percent change

ARIMA:

Autoregressive Integrated Moving Average

AR:

Autoregressive

I:

Differencing

MA:

Moving average

AIC:

Akaike Information Criterion

ACF:

Autocorrelation function

PACF:

Partial autocorrelation function

ROS:

Reactive oxygen species

ANS:

Autonomic nervous system

COVID-19:

Coronavirus disease 2019

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Acknowledgements

We extend our gratitude to the numerous individuals who have contributed to the GBD Study 2021 in diverse roles.

Funding

This study was financially supported by the Traditional Chinese Medicine Science and Technology Project of Shandong Province (No. 2021M175), and the Shandong Co-Innovation Center of Classic Traditional Chinese Medicine formula, Shandong University of Tradition Chinese Medicine (No.2019KFY18).

Author information

Authors and Affiliations

  1. Acumox and Tuina Institute, Shandong University of Traditional Chinese Medicine, Jinan, Shandong Province, China

    Zhengfeng Yu, Mingyan Ju, Yuxuan Zhang & Yuying Li

  2. Department of Acupuncture and Moxibustion, Shandong University of Traditional Chinese Medicine Affiliated Hospital, Jinan, China

    Xiuyun Zhang & Ying Yin

  3. Shandong First Medical University Affiliated Hospital for Cervical, Shoulder, Back and Leg Pain, Jinan, Shandong Province, China

    Xiaomei Fu

  4. Shandong First Medical University and Shandong Academy of Medical Sciences, Jinan, Shandong, China

    Xuemin Jia

  5. Bone Biomechanics Engineering Laboratory of Shandong Province, Shandong Medicinal Biotechnology Center (School of Biomedical Sciences), Neck-Shoulder and Lumbocrural Pain Hospital, Shandong First Medical University, and Shandong Academy of Medical Sciences, Jinan, Shandong, China

    Fanjie Liu

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  1. Zhengfeng Yu
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Contributions

Zhengfeng Yu: Formal analysis, Data curation, Writing-Original draft preparation. Xiuyun Zhang: Data curation, Visualization, Writing-Original draft preparation. Xiaomei Fu: Data curation, Writing-Original draft preparation. Xuemin Jia: Results interpretation, Writing-Reviewing and Editing. Mingyan Ju: Results interpretation, Writing-Reviewing and Editing. Yuxuan Zhang: Results interpretation, Writing-Reviewing and Editing. Yuying Li: Results interpretation, Writing-Reviewing and Editing. Ying Yin: Conceptualization, Supervision, Funding acquisition, Writing-Reviewing and Editing. Fanjie Liu: Conceptualization, Supervision, Funding acquisition, Writing-Reviewing and Editing.

Corresponding authors

Correspondence to Ying Yin or Fanjie Liu.

Ethics declarations

Ethics approval and consent to participate

The GBD data used in our analysis was obtained from publicly available websites. No human or animal experiments, observations, or interventions were conducted as part of this study.

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Not applicable.

Competing interests

The authors declare no competing interests.

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Supplementary Information

12889_2025_22287_MOESM1_ESM.docx

Supplementary Material 1: Supplementary Table 1. ASMR and ASDR of ischemic stroke attributable to air pollution in China from 1990 to 2021, stratified by gender.

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Yu, Z., Zhang, X., Fu, X. et al. An analysis of trends in the burden of ischemic stroke caused by air pollution in China between 1990 and 2021. BMC Public Health 25, 1567 (2025). https://doiorg.publicaciones.saludcastillayleon.es/10.1186/s12889-025-22287-1

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ISSN: 1471-2458

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