The role of liver enzymes in the association between ozone exposure and diabetes risk: a cross-sectional study of Zhuang adults in China.

: Growing evidence has demonstrated the role of ambient air pollutants in driving diabetes incidence. However, epidemiological evidence linking ozone (O) exposure to diabetes risk has been scarcely studied in Zhuang adults in China. We aimed to investigate the associations of long-term exposure to O with diabetes prevalence and fasting plasma glucose (FPG) and estimate the mediating role of liver enzymes in Zhuang adults. : We recruited 13 843 ethnic minority adults during 2018-2019 based on a cross-sectional study covering nine districts/counties in Guangxi. Generalized linear mixed models were implemented to estimate the relationships between O exposure and diabetes prevalence and FPG. Mediation effect models were constructed to investigate the roles of liver enzymes in the associations of O exposure with diabetes prevalence and FPG. Subgroup analyses were conducted to identify potential effect modifications. : Long-term exposure to O was positively associated with diabetes prevalence and FPG levels in Zhuang adults, with an excess risk of 7.32% (95% confidence interval [CI]: 2.56%, 12.30%) and an increase of 0.047 mmol L (95% CI: 0.032, 0.063) for diabetes prevalence and FPG levels, respectively, for each interquartile range (IQR, 1.18 μg m) increment in O concentrations. Alanine aminotransferase (ALT) significantly mediated 8.10% and 29.89% of the associations of O with FPG and diabetes prevalence, respectively, and the corresponding mediation proportions of alkaline phosphatase (ALP) were 8.48% and 30.00%. Greater adverse effects were observed in females, obese subjects, people with a low education level, rural residents, non-clean fuel users, and people with a history of stroke and hypertension in the associations of O exposure with diabetes prevalence and/or FPG levels (all values for interaction < 0.05). : Long-term exposure to O is related to an increased risk of diabetes, which is partially mediated by liver enzymes in Chinese Zhuang adults. Promoting clean air policies and reducing exposure to environmental pollutants should be a priority for public health policies geared toward preventing diabetes.