WHO Environmental Noise Guidelines for the European Region: A Systematic Review on Environmental Noise and Cardiovascular and Metabolic Effects: A Summary

Abstract

To update the current state of evidence and assess its quality, we conducted a systematic review on the effects of environmental noise exposure on the cardio-metabolic systems as input for the new WHO environmental noise guidelines for the European Region. We identified 600 references relating to studies on effects of noise from road, rail and air traffic, and wind turbines on the cardio-metabolic system, published between January 2000 and August 2015. Only 61 studies, investigating different end points, included information enabling estimation of exposure response relationships. These studies were used for meta-analyses, and assessments of the quality of evidence using the Grading of Recommendations Assessment, Development and Evaluation (GRADE). A majority of the studies concerned traffic noise and hypertension, but most were cross-sectional and suffering from a high risk of bias. The most comprehensive evidence was available for road traffic noise and Ischeamic Heart Diseases (IHD). Combining the results of 7 longitudinal studies revealed a Relative Risk (RR) of 1.08 (95% CI: 1.01-1.15) per 10 dB (LDEN) for the association between road traffic noise and the incidence of IHD. We rated the quality of this evidence as high. Only a few studies reported on the association between transportation noise and stroke, diabetes, and/or obesity. The quality of evidence for these associations was rated from moderate to very low, depending on transportation noise source and outcome. For a comprehensive assessment of the impact of noise exposure on the cardiovascular and metabolic system, we need more and better quality evidence, primarily based on longitudinal studies.

Full text

Int. J. Environ. Res. Public Health 2018, 15, 379; doi:10.3390/ijerph15020379 www.mdpi.com/journal/ijerph
Review
WHO Environmental Noise Guidelines for the
European Region: A Systematic Review on
Environmental Noise and Cardiovascular and
Metabolic Effects: A Summary
Elise van Kempen 1,*, Maribel Casas 2, Göran Pershagen 3 and Maria Foraster 2,4
1 Dutch National Institute for Public Health and the Environment (RIVM), Centre for Sustainability,
Environment and Health, P.O.-Box 1, 3729BA Bilthoven, The Netherlands
2 Barcelona Institute for Global Health (ISGlobal), 08036 Barcelona, Spain; maribel.casas@isglobal.org (M.C.);
mariafp@gmail.com (M.F.)
3 Institute of Environmental Medicine, Karolinska Institute; SE-171 77 Stockholm, Sweden;
goran.pershagen@ki.se
4 Swiss Tropical and Public Health Institute, University of Basel, 4002 Basel, Switzerland
* Correspondence: elise.van.kempen@rivm.nl; Tel.: +31-302-743-601
Received: 19 October 2017; Accepted: 10 February 2018; Published: 22 February 2018
Abstract: To update the current state of evidence and assess its quality, we conducted a systematic
review on the effects of environmental noise exposure on the cardio-metabolic systems as input for
the new WHO environmental noise guidelines for the European Region. We identified 600
references relating to studies on effects of noise from road, rail and air traffic, and wind turbines on
the cardio-metabolic system, published between January 2000 and August 2015. Only 61 studies,
investigating different end points, included information enabling estimation of exposure response
relationships. These studies were used for meta-analyses, and assessments of the quality of evidence
using the Grading of Recommendations Assessment, Development and Evaluation (GRADE). A
majority of the studies concerned traffic noise and hypertension, but most were cross-sectional and
suffering from a high risk of bias. The most comprehensive evidence was available for road traffic
noise and Ischeamic Heart Diseases (IHD). Combining the results of 7 longitudinal studies revealed
a Relative Risk (RR) of 1.08 (95% CI: 1.01–1.15) per 10 dB (LDEN) for the association between road
traffic noise and the incidence of IHD. We rated the quality of this evidence as high. Only a few
studies reported on the association between transportation noise and stroke, diabetes, and/or
obesity. The quality of evidence for these associations was rated from moderate to very low,
depending on transportation noise source and outcome. For a comprehensive assessment of the
impact of noise exposure on the cardiovascular and metabolic system, we need more and better
quality evidence, primarily based on longitudinal studies.
Keywords: noise exposure; blood pressure; hypertension; ischaemic heart disease; stroke; diabetes;
obesity; meta-analysis
1. Introduction
1.1. Aim
In this paper, we present the main results of a systematic review of the literature dealing with
observational studies on the association between environmental noise exposure and the
cardiovascular and metabolic systems. The aim was to update some of the existing exposure-response

Int. J. Environ. Res. Public Health 2018, 15, 379 2 of 62
relationships, and to evaluate the overall quality of the evidence. The World Health Organisation
(WHO) commissioned this systematic review. Its results form important input for the new
environmental noise guidelines for the European Region. The WHO requires that new guidelines should
be based on the latest scientific knowledge. The complete review can be found in the report published at
the website of RIVM (the Dutch National Institute for Public Health and the Environment) via the
following link: http://www.rivm.nl/en/Documents_and_publications/Scientific/Reports/2017/november/
Cardiovascular_and_metabolic_effects_of_environmental_noise_Systematic_evidence_review_in_t
he_framework_of_the_development_of_the_WHO_environmental_noise_guidelines_for_the_Euro
pean_Region [1].
1.2. Background
During the past decades, several national and international organizations have made
recommendations for protecting human health from the adverse effects of environmental noise
exposure. In the existing guidelines [2–5], the principal noise source of concern was transportation
noise, mainly road and air traffic. The health impact of other noise sources, such as rail traffic and
wind turbines, was not addressed in these guidelines. However, with the ongoing extension of
railway transport facilities, and the substantial growth of wind energy facilities, the number of
studies on the impact of noise from rail traffic noise and on wind turbine noise has increased.
The existing guidelines also contain recommendations that specifically deal with the impact of
noise on the cardiovascular system. The most common explanation for the effects of noise on the
heart and circulatory system, is stress [2,3]. The cardiovascular effects related to noise exposure may
also be the consequence of a decrease in sleep quality, caused by noise exposure during the night,
among other additional or interrelated mechanisms. Such reactions may also affect the metabolic
system.
The most recent environmental noise guidelines from WHO, date back to 2009, and focus on
night-time exposure [3]. Meanwhile, new evidence on the relationship between noise exposure and
cardiovascular effects has accumulated. Hypertension and ischaemic heart disease have been the
main outcomes of concern in observational studies on the impact of noise on the cardiovascular
system. In addition, an increasing amount of studies have recently investigated the impact of noise
on other cardiovascular end-points such as stroke. Furthermore, hypertension is considered as an
important risk factor for other cardiovascular outcomes such as stroke and myocardial infarction.
Amongst the newly published studies there were also several studies dealing with the possible effects
of noise on the metabolic system, in particular with regard to outcomes such as obesity and type 2
diabetes.
In addition, a number of the newly published studies investigated the combined effects of noise
and air pollution. People living close to roads, are exposed not only to traffic noise, but also to air
pollution generated by traffic. Previous studies have shown a relationship between air pollution and
cardiovascular disease [6,7]. Since air pollution and noise from road traffic share the same source,
cardiovascular effects could be attributed to both exposure factors.
The existing environmental noise guidelines also include recommendations that aim to reduce
environmental noise exposure in settings where children spend most of their time. However, none of
these recommendations takes into account the cardiovascular effects of noise on children. It is
possible that people exposed to high levels of noise from an early age, might be at higher risk for
cardiovascular problems later in life. Since the publication of the latest environmental noise
guidelines in 1999, the number of studies investigating the impact of noise on children’s blood
pressure has increased substantially.
2. Materials and Methods
2.1. Evaluation of Existing Reviews
The first step in this systematic review was to identify and select reviews of “sufficient” quality,
that described the impact of exposure to environmental noise from several sources (air, road, rail and

Int. J. Environ. Res. Public Health 2018, 15, 379 3 of 62
wind turbines) on the cardiovascular or metabolic systems, in different settings (at home, at school),
and populations (e.g., adults, children).
After an extended search, we identified 37 reviews evaluating available studies into the impact
of exposure to environmental noise on the cardiovascular or metabolic systems. By means of the
“Measurement tool for the Assessment of Multiple SysTemAtic Reviews” (AMSTAR) [8] we
evaluated their quality, and based on the relevance for this whole systematic review, we selected 15
reviews [9–25]. We carried out the evaluation in duplicate (Elise van Kempen and Maria Foraster,
and then discussed the results afterwards.
It appeared that most of the studies covered by the selected reviews, reported on the impacts of
road and aircraft noise exposure among adults. Nine reviews included one or more meta-analyses,
resulting in more than 13 exposure-response relationships. For most available exposure-response
relations, the reviewers were not able to provide a quality judgement of the individual studies. For a
number of (new) health end-points (e.g., obesity) and/or noise sources (e.g., rail traffic, no reviews or
exposure-response relationships were available.
Following the results of the evaluation of existing reviews, we decided to carry out a new
systematic review on the impact of noise on the cardiovascular and metabolic system in order to
update some of the existing exposure-response relationships, and to assess the quality of the existing
evidence.
2.2. Evaluation of Single Studies
2.2.1. Identification and Selection
We identified observational studies on the impact of noise from air, road, and rail traffic and
wind turbines on the cardiovascular or metabolic systems published from 2000 until October 2014 in
several literature databases (Medline/PubMed, SCOPUS, EMBASE and SCISCEARCH (see Appendix
A for the applied search profiles). To ensure that most of the studies could be identified, we manually
scanned reports and proceedings in the fields of epidemiology, and noise and health. We
supplemented the results of this search with studies that were already identified by means of the 15
reviews, which we evaluated during the first step of this systematic review (see Section 2.1). Overall,
we identified more than 600 publications which were screened in duplicate (Elise van Kempen and
Maria Foraster) using predefined criteria. We selected 61 studies for data-extraction [26–135], where
detailed quantitative information was available on exposure and health outcomes, enabling
estimation of exposure-response relationships. However, conducting a systematic review often takes
a lot of time. While working on this review, new results became publically available. In order to keep
our results more up to date, it was decided to extend our study material with more recent results
beyond the studies that had we already identified for the period 2000–October 2014. However, only
updated and new results of studies published between November 2014 and August 2015, were
included and processed. Consequently, we were able to include the latest results published between
November 2014 and August 2015 of several selected studies: DEBATS [26,46], REGICOR [32,33,43,68],
SDPP [29,34,73,78,91,106], HUBRO [30,66] and DCH [27,38,51–53,63,64,136]. In- and exclusion criteria
were extensively described in the complete systematic review [1].
2.2.2. Data Extraction
From the selected 61 studies (described in 113 records), we extracted the following data via a
structured data extraction form:
• Data on general study characteristics (e.g., study design, study period, study location);
• Population characteristics (sampling of the study population, number of participants, response-
and attrition rate, gender, age;
• Exposure assessment and health outcome assessment, and;
• The results of the study.

Int. J. Environ. Res. Public Health 2018, 15, 379 4 of 62
We carried out the data extraction in duplicate (Elise van Kempen, Maribel Casas and/or Göran
Pershagen) and then discussed the results, with the exception of studies on the impact of wind turbine
noise (n = 3) and studies on the impact of noise on children’s blood pressure. For those studies data,
extraction was carried out by one person only (Elise van Kempen).
In the selected studies we evaluated the risk of bias by means of a checklist developed by the
WHO [137]: (i) information bias due to exposure assessment; (ii) bias due to confounding; (iii) bias
due to selection of participants; (iv) information bias due to non-objective health outcome assessment,
and (v) information bias due to non-blinded health outcome assessment. A protocol of how the
studies were scored on each of these five items can be found in Section 3.3 of the complete evidence
review available via the link specified in Section 1.1. For each study, the evaluation was carried out
independently by two or three reviewers (Elise van Kempen, Maribel Casas and Göran Pershagen).
From the scores on the different items, we calculated a total risk of bias score (see also Appendix B
for an overview of the risk of bias scores per study).
The main effects under investigation were hypertension, IHD, stroke, type 2 diabetes, change in
body mass index (BMI), change in waist circumference, and change in mean blood pressure in
children. In order to make a comparison between the studies, we expressed their results in a uniform
way and calculated the following outcome variables:
• For studies on the impact of noise on hypertension, IHD, stroke or type 2 diabetes, we calculated
the natural logarithm of the Relative Risk (RR) and its variance per 10 dB(A);
• For studies on the impact of noise on children’s blood pressure, we calculated the blood pressure
change (mmHg for a noise level increase of 10 dB(A) and its variance for both systolic and
diastolic blood pressure; and
• For studies on the impact of noise on obesity markers BMI and waist circumference, we
calculated the change in BMI (kg/m2) per noise level increase of 10 dB(A) and its variance, and
the change in waist circumference (cm) per noise level increase of 10 dB(A) and its variance.
To retain the link with the European Noise Directive (END [138], we expressed noise exposure
in LDEN. However, most studies did not report an RR per 10 dB (LDEN). Where noise exposure was
expressed by means of another noise indicator than LDEN (e.g., LAeq,16hr or LAeq,24hr), a conversion to LDEN
was needed. Appendix II of the complete review [1] gives an overview of the conversion rules that
we applied.
2.2.3. Data Aggregation
For data-aggregation, we included only estimates from studies that were well matched,
adjusted, or stratified for at least age and sex. If more than one risk estimate was available for a study,
we used the estimates for men and women separately and for separate age-categories, where possible.
After selecting the study estimates, we calculated a pooled estimate using the STATA-command
METAN to fit a random-effects model [139]. To test consistency of the effect estimates across studies,
we used Cochran’s Q-test [140]. We calculated the I2-statistic to reflect the percentage of between-
study heterogeneity [141,142]. For some outcomes, we were able to investigate how the summary
estimates were affected by sources of heterogeneity. To this end, we carried out a meta-regression
analysis using the STATA-command METAREG [141]. Where meta-regression analyses were not
possible, we carried out sub-group analyses.
When enough study estimates were available, we attempted to give insight in the extent of
publication-bias by means of funnel plots [143]: scatter plots of the studies’ effect estimates (RR per
10 dB) against the inverse of the standard error. Also we applied Egger’s test of publication bias using
the STATA-commands METAFUNNEL and METABIAS [144,145].
2.2.4. Assessment of the Quality of Evidence: GRADE
The WHO required us to assess the quality of the evidence that has been retrieved in this review.
In other words, we had to assess to what extent we were confident that an estimate of an association
between noise and an outcome is likely or unlikely to be changed by further research.

Int. J. Environ. Res. Public Health 2018, 15, 379 5 of 62
To this end, we applied a modified version of the GRADE considerations: a systematic and
explicit approach to making judgements about quality of evidence [146,147]. In summary, for every
outcome, we had to assess the quality of evidence according to several criteria (e.g., study design,
study quality, consistency and precision of the results, directness of the evidence, publication bias,
whether an exposure-response gradient was present, the magnitude of the effect found, and possible
confounding. The scores for the different GRADE criteria are presented in Appendix C to H as well
in Appendices III–VIII of the complete systematic review. How we adapted GRADE for this
systematic review is extensively described in Chapter 10 of the complete evidence review [1]. The
main divergence from GRADE was that the initial level of certainty was rated “high” for cohort and
case-control studies, “low” for cross-sectional studies and “very low” for ecological studies.
Furthermore, we upgraded the evidence if the relative risk was 1.5 or higher, but downgraded if
based on only one study. GRADE has four levels for the quality of evidence, ranging from “very low”
to “high” (see Table 1). The level of the quality of evidence will be linked with the guideline values
and recommendations that WHO will include in their environmental noise guidelines.
Table 1. The levels of quality of evidence of the GRADE system (source: [146,147]).
Quality of
Evidence
Definition
Examples of When This is
the Case
High
Further research is very unlikely to change our confidence
in the estimate of effect
Several high-quality studies
with consistent results
Moderate
Further research is likely to have an important impact on
our confidence in the estimate of effect and may change the
estimate
One high-quality study or
several studies with some
limitations
Low
Further research is very likely to have an important impact
on our confidence in the estimate of effect and is likely to
change the estimate
One or more studies with
severe limitations
Very Low
Any estimate of effect is very uncertain
No direct research evidence
One or more studies with
very severe limitations
3. Results: Main Findings and Weighing the Quality of the Evidence
In this section, for each outcome the main findings of the review and the conclusions of the
weighing of the evidence are presented. The report with the complete findings including the
systematic evaluation of the included studies, and the reasoning behind the weighing of the evidence,
can be found in the complete systematic review [1].
A note for the reader: since we carried out the literature search for this systematic review, new
studies have been published that investigate the associations between transportation noise exposure
and metabolic and cardiovascular disease. Unfortunately, owing to time constraints, we were not
able to carry out a structured and extensive additional search for new studies published in the period
November 2014–March 2017. However, in order to identify at least some of the new studies we were
missing, we carried out a search on SCOPUS in March 2017. For this, we applied the same SCOPUS-
search profile as was used to identify studies for the current review. In an “ideal” systematic review,
we should have included the results of these newly identified studies in the results of the current
review, and where necessary updated our results. However, due to time constraints, we have not yet
been able to systematically evaluate the newly identified studies. Nevertheless, we have decided to
present their results in a narrative way, and attempted to assess how they affect the results of the
current review. The differences in results with these recent studies and earlier reviews are described
in detail for each outcome in the complete systematic review [1].
3.1. Hypertension
We evaluated 40 studies [26,28,30,32,33,35–37,40,43,46,49–51,55–57,60–63,65–68,70,73–78,80–86,88–
92,94–99,101,102,105,106,109,110,112,113,117,118,120,123,126,127,130–135,148] that investigated the

Int. J. Environ. Res. Public Health 2018, 15, 379 6 of 62
impact of noise from air, road, and rail traffic and wind turbines on the risk of hypertension. Appendix
B presents the separate risk of bias tables. Appendix C presents the different GRADE tables
(summarized in Table 2).
Table 2. Noise exposure and the risk of hypertension: summary of findings.
Noise Source
Outcome $
Number of Study
Design (s) *
RR per 10 dB
(95% CI) †
Number of Participants
(Cases)
Quality of
Evidence ‡
Air traffic
Prev
9 CS
1.05 (0.95–1.17)
60,121 (9487)
⊕⊕
Inc
1 CO
1.00 (0.77–1.30)
4721 (1346)
⊕⊕
Road traffic
Prev
26 CS
1.05 (1.02–1.08) **
154,398 (18,957)
⊕
Inc
1 CO
0.97 (0.90–1.05)
32,635 (3145)
⊕⊕
Rail traffic
Prev
5 CS
1.05 (0.88–1.26)
15,850 (2059)
⊕
Inc
1 CO
0.96 (0.88–1.04)
7249 (3145)
⊕⊕
Wind turbine
Prev
3 CS
††
1830 (NR)
⊕
$ Outcome: Prev = prevalence of hypertension, Inc = incidence of hypertension; * CS = cross-sectional study, CO =
cohort study; †: RR = Relative risk per 10 decibel (dB change in noise level and its 95% confidence interval (CI) after
aggregating the results of the evaluated studies. For air, road, –and, rail traffic, noise levels were expressed in LDEN.
For wind turbines, noise levels are expressed in Sound Pressure Levels (SPL); ‡ GRADE Working Group Grades
of Evidence: High quality (⊕⊕⊕⊕): Further research is very unlikely to change our confidence in the estimate of
effect, Moderate Quality (⊕⊕⊕): Further research is likely to have an important impact on our confidence in the
estimate of effect and may change the estimate, Low Quality (⊕⊕): Further research is very likely to have an
important impact on our confidence in the estimate of effect and is likely to change the estimate, Very low quality
(⊕): We are very uncertain about the estimate. ** The estimate for the association between road traffic noise and
the prevalence of hypertension is based on 47 estimates derived from 26 studies. †† We decided not to aggregate
the results of the three studies on the impact of wind turbine noise, since too many parameters were unknown
and/or unclear. NR = Not Reported.
There were positive associations between noise from air, road, or rail traffic and hypertension in
the cross-sectional studies, which formed the largest part (n = 38) of the available evidence (Table 2).
After aggregating the results of 26 studies (comprising 154,398 individuals, including 18,957 cases),
we derived an RR of 1.05 (95% CI: 1.02–1.08) per 10 dB (LDEN) for the association between road traffic
noise and the prevalence of hypertension. The studies were carried out within the range of approximately
20–80 dB (LDEN) [28,30,32,33,35–37,43,49,50,55–57,61,62,66–68,70,75,77,80,82,85,88,89,92,96–
99,109,110,117,118,120,123,126,127,130–132,135,149]. For aircraft noise (nine studies), we estimated an
RR of 1.05 (95% CI 0.95–1.17) per 10 dB (LDEN) (comprising 60,121 residents, including 9487)
[28,40,46,50,61,62,74,83,85,94,95,99,102,105,112,113,150]. For rail traffic noise (five studies), we
derived an RR of 1.05 (95% CI: 0.88–1.26) per 10 dB (LDEN) (comprising of 15,850 individuals, including
2059 cases of hypertension) [28,56,80,82,135]. Although there was evidence for moderate to high
heterogeneity among studies, the meta-regression analyses could not reveal clear sources for this
observed heterogeneity.
Despite the fact that most studies were able to adjust for important confounders, and were able
to ascertain individual exposure levels, we rated the quality of the evidence from the cross-sectional
studies mainly as “very low”. This is, among other reasons, because the response rate in many of the
studies was lower than 60%. Furthermore, most studies ascertained hypertension by means of self-
report only.
In the two evaluated cohort studies that investigated the impact of traffic noise on hypertension,
no increased risks were found of hypertension related to traffic noise exposure [51,63,73,78,91,106].
This is confirmed by a recent meta-analysis, including individual data from six cohort studies on the
association between road traffic noise and the incidence of hypertension [151]. The reason for this
apparent discrepancy in the findings between the cross-sectional and cohort studies is unclear.
Overall, we consider the quality of the evidence supporting an association between traffic noise
exposure and hypertension as “very low”, indicating that any estimate of effect is very uncertain.

Int. J. Environ. Res. Public Health 2018, 15, 379 7 of 62
3.2. Ischaemic Heart Disease
We evaluated 22 studies [28,42,44,45,47,50,52–54,61,62,69,72,75,79,82,83,85,87,90,97–100,103,107,109–
111,115,118,120–125,128–131,135] that investigated the association between exposure to noise from
air, road, and rail traffic and IHD. Appendix B presents the separate risk of bias tables, and Appendix
D presents the different GRADE tables (summarized in Table 3). The majority (n = 11) were of cross-
sectional design.
Table 3. Noise exposure and the risk of IHD: summary of findings.
Noise Source
Outcome $
Number of Study
Design (s) *
RR † per 10 dB
(95% CI)
Participants
(Cases)
Quality of
Evidence ‡
Air traffic
Prev
2 CS
1.07 (0.94–1.23)
14,098 (340)
⊕
Inc
2 ECO
1.09 (1.04–1.15)
9,619,082 (158,977)
⊕
Mort
2 ECO
1.04 (0.97–1.12)
3,897,645 (26,066)
⊕
1 CO
1.04 (0.98–1.11)
4,580,311(15,532)
⊕⊕
Road traffic
Prev
8 CS
1.24 (1.08–1.42)
25,682 (1614)
⊕⊕
Inc
1 ECO
1.12 (0.85–1.48)
262,830 (418)
⊕
3 CO, 4CC
1.08 (1.01–1.15)
67,224 (7033)
⊕⊕⊕⊕
Mort
1 CC, 2 CO
1.05 (0.97–1.13)
532,268 (6884)
⊕⊕⊕
Rail traffic
Prev
4 CS
1.18 (0.82–1.68)
13,241 (283)
⊕
$ Outcome: Prev = prevalence of IHD, Inc = incidence of IHD, Mort = mortality due to IHD; * ECO =
ecological study, CS = cross-sectional study, CC = case-control study, CO = cohort study; †: RR =
Relative Risk per 10 decibel (dB change in noise level, 95% CI = 95% Confidence Interval. For air, road
–and, rail traffic, noise levels are expressed in LDEN.; ‡ GRADE Working Group Grades of Evidence:
High quality (⊕⊕⊕⊕): Further research is very unlikely to change our confidence in the estimate of
effect, Moderate Quality (⊕⊕⊕): Further research is likely to have an important impact on our
confidence in the estimate of effect and may change the estimate, Low Quality (⊕⊕): Further research
is very likely to have an important impact on our confidence in the estimate of effect and is likely to
change the estimate, Very low quality (⊕): We are very uncertain about the estimate; # NR = Not
Reported.
The studies that investigated the impact of air traffic noise found indications of an increased risk
of IHD. Exposure to aircraft noise was associated with the prevalence of IHD, the incidence of IHD, and
mortality due to IHD [28,42,44,45,47,50,62,69,72,83,85,98,99]. Only the association between aircraft
noise and the incidence of IHD was statistically significant. We estimated an RR of 1.09 (95% CI: 1.04–
1.15) per 10 dB (LDEN) after aggregating the results of two studies [42,47] comprising of 9,619,082
participants, including 158,977 incident cases of IHD. Since most studies on the impact of aircraft noise
were of ecological and cross-sectional design (see Table 3), the quality of the evidence from these
studies was mostly rated as “very low”. However, the results of the current review are consistent
with the results of new longitudinal studies, which reported positive associations between aircraft
noise and mortality due to IHD [152,153].
Overall, we rate the quality of the evidence supporting an association between air traffic noise and
IHD as “low”, indicating that further research is very likely to have an important impact on our
confidence in the estimate of effect and is likely to change the estimate.
We found evidence that noise from road traffic is associated with an increased risk of IHD. An
increase in road traffic noise was associated with significant increases in the prevalence of IHD, and
the incidence of IHD. The evidence for a relationship between noise from road traffic and the incidence
of IHD was the most robust. After combining the results of three cohort studies and four case-control
studies [52,53,75,100,107,111,115,118,120–123,125,130,131] (comprising 67,224 participants, including
7033 incident cases of IHD, we found an RR of 1.08 (95% CI: 1.01–1.15) per 10 dB (LDEN) for the
association between road traffic noise and the incidence of IHD within the range of approximately 40–
80 dB LDEN. This means that if road traffic noise levels increase from 40 to 80 dB (LDEN), the RR = 1.36.
We rated the quality of the evidence that comes from these studies to be “high”. Supporting evidence
came from studies on the association between road traffic noise and the prevalence of IHD. We rated

Int. J. Environ. Res. Public Health 2018, 15, 379 8 of 62
the quality of evidence from these studies as low. The results of the current review are strengthened
by the results of several recently published longitudinal studies [152,153].
A visualization of the shape of the association between road traffic noise and the incidence of
IHD, indicated that the risk of IHD increases continuously for road traffic noise levels from about 50
dB (LDEN). This is consistent with the findings of another recent meta-analysis on the association
between road traffic noise and IHD [21]. The WHO guidelines of 1999 stated the following:
“epidemiological studies show that cardiovascular effects occur after long-term exposure to noise
with LAeq,24hr values of 65–70 dB” [2]. In the WHO Night-noise guidelines, published in 2009, a general
threshold of 55 dB (LNight) was recommended for protection of cardiovascular disease [3].
Overall, taking into account all available evidence on the association between road traffic noise
on IHD, we rate the quality of the evidence supporting an association between road traffic noise and
IHD to be “moderate”, indicating that further research is likely to have an important impact on our
confidence in the estimate of effect and may change the estimate. However, for road traffic noise and
the incidence of IHD, the quality of the evidence was rated as high.
Compared with noise from road and air traffic, we found only a few studies that investigated
the impact of noise from rail traffic. These had a cross-sectional design. After aggregating the results
of the studies on the association between rail traffic noise and the prevalence of IHD [28,82,90,135], we
found a non-significant RR of 1.18 per 10 dB (LDEN).
Overall, we rate the quality of the evidence supporting an association between exposure to noise
from rail traffic and IHD to be “very low”, indicating that any estimate of effect is very uncertain.
3.3. Stroke
Compared with the number of studies on the impact of noise on hypertension and IHD,
relatively few studies were available that investigated the impact on stroke (n = 9)
[27,42,44,45,47,50,52,54,61,62,64,69,72,79,83,85,98,99]. Appendix B presents the separate risk of bias
tables, and Appendix E presents the different GRADE tables (summarized in Table 4).
Table 4. Noise exposure and the risk of stroke: summary of findings.
Noise
Source
Outcome $
Number of Study
Design (s) *
RR † per 10 dB (95% CI)
Participants (Cases)
Quality of
Evidence ‡
Air traffic
Prev
2 CS
1.02 (0.80–1.28)
14,098 (151)
⊕
Inc
2 ECO
1.05 (0.96–1.15)
9,619,082 (97,949)
⊕
Mort
2 ECO
1.07 (0.98–1.17)
3,897,645 (12,086)
⊕
1 CO
0.99 (0.94–1.04)
4,580,311 (25,231)
⊕⊕⊕
Road traffic
Prev
2 CS
1.00 (0.91–1.10)
14,098 (151)
⊕
Inc
1 CO
1.14 (1.03–1.25)
51,485 (1881)
⊕⊕⊕
Mort
3 CO
0.87 (0.71–1.06)
581,517 (2634)
⊕⊕⊕
Rail traffic
Prev
1 CS
1.07 (0.92–1.25)
9365 (89)
⊕
$ Outcome: Prev = prevalence of stroke, Inc = incidence of stroke, Mort = mortality due to stroke; *
ECO = ecological study, CS = cross-sectional study, CO = cohort study; †: RR = Relative risk per 10
decibel (dB change in noise level, 95% CI = 95% Confidence Interval. The noise levels are expressed
in LDEN; ‡ GRADE Working Group Grades of Evidence: High quality (⊕⊕⊕⊕): Further research is
very unlikely to change our confidence in the estimate of effect, Moderate Quality (⊕⊕⊕): Further
research is likely to have an important impact on our confidence in the estimate of effect and may
change the estimate, Low Quality (⊕⊕): Further research is very likely to have an important impact
on our confidence in the estimate of effect and is likely to change the estimate, Very low quality (⊕):
We are very uncertain about the estimate.
According to the results of the ecological and cross-sectional studies
[28,42,44,45,50,61,62,69,83,85,98,99] an increase in aircraft noise was associated with an increase in the
prevalence and the incidence of stroke. None of these associations was statistically significant (see Table 4).

Int. J. Environ. Res. Public Health 2018, 15, 379 9 of 62
The observations found for the prevalence and incidence of stroke were supported by the ecological
studies [28,42] on the association between air traffic noise and mortality due to stroke.
No association between air traffic noise exposure and mortality due to stroke was observed in the
evaluated cohort study [72]. This is consistent with the results of new longitudinal studies, which showed
no clear indications of an association between aircraft noise and mortality due to stroke [152,153].
The results of the studies [27,28,50,52,54,61,62,64,79,83,85,98,99] that investigated the impact of
road traffic were not consistent. Only for the association between road traffic noise and the incidence
of stroke, there was a statistically significant RR of 1.14 (95% CI 1.03–1.25) per 10 dB (LDEN). This result
was based on one cohort study [27,52,64], comprising 51,485 participants, including 1,881 incident
cases of stroke.
In the evaluated cross-sectional and ecological studies [27,28,44,45,50,52,54,61,62,64,69,79,83,85,98,99]
on the association between road traffic noise and the prevalence of stroke or mortality due to stroke, no
increased risks of stroke due to road traffic noise were observed. This was not consistent with the
results of recently published longitudinal studies, which showed that an increase in road traffic noise
was statistically significantly associated with an increase in mortality due to stroke [152–154]. As part
of the current review, only one cross-sectional study [28] was evaluated, which investigated the
association between rail traffic noise and the prevalence of stroke.
Overall, we rate the quality of the evidence supporting an association between traffic noise and
stroke to be “low”. This indicates that further research is very likely to have an important impact on
our confidence in the estimate of effect and is likely to change the estimate.
3.4. Diabetes
For the current review, we were able to evaluate seven studies [34,38,60,65,75,76,81,84,86,101]
that investigated the association between environmental noise and the risk of diabetes. Four studies
[28,34,38,75] investigated the possible impact of transportation (air, road, rail traffic noise. Appendix
B presents the separate risk of bias tables, and Appendix F presents the different GRADE tables
(summarized in Table 5).
Table 5. Noise exposure and the risk of diabetes: summary of findings.
Noise Source
Outcome $
Number of Study
Design (s) *
RR † per 10 dB
(95% CI)
Participants
(Cases)
Quality of
Evidence ‡
Air traffic
Prev
1 CS
1.01 (0.78–1.31)
9365 (89)
⊕
Inc
1 CO
0.99 (0.47–2.09)
5156 (159)
⊕⊕
Road traffic
Prev
2 CS
- #
11,460 (242)
⊕
Inc
1 CO
1.08 (1.02–1.14)
57,053 (2752)
⊕⊕⊕
Rail traffic
Prev
1 CS
0.21 (0.05–0.82)
9365 (89)
⊕
Inc
1 CO
0.97 (0.89–1.05)
57,053 (2752)
⊕⊕⊕
Wind turbine
Prev
3 CS
**
1830 (NR)
⊕
$ Outcome: Prev = prevalence of diabetes, Inc = incidence of diabetes; * CS = cross-sectional study, CO
= cohort study; † RR = Relative risk per 10 decibel (dB change in noise level, 95% CI = 95% Confidence
Interval. For air, road –and, rail traffic, noise levels are expressed in LDEN. For wind turbines, noise
levels were expressed in Sound Pressure Levels (SPL); ‡ GRADE Working Group Grades of Evidence:
High quality (⊕⊕⊕⊕): Further research is very unlikely to change our confidence in the estimate of
effect, Moderate Quality (⊕⊕⊕): Further research is likely to have an important impact on our
confidence in the estimate of effect and may change the estimate, Low Quality (⊕⊕): Further research
is very likely to have an important impact on our confidence in the estimate of effect and is likely to
change the estimate, Very low quality (⊕): We are very uncertain about the estimate; # the data from
one cross-sectional study were not included in the table since they were based on a secondary analysis
with important information lacking. ** We decided not to aggregate the results of the three studies on
the impact of wind turbine noise, since too many parameters were unknown and/or unclear; NR =
Not Reported.

Int. J. Environ. Res. Public Health 2018, 15, 379 10 of 62
We found two studies [28,34] that investigated the impact of air traffic noise on the occurrence
of diabetes. In a cross-sectional study [28] on the association between air traffic noise and the
prevalence of diabetes, a non-significant RR of 1.01 per 10 dB (LDEN) was found. In the evaluated cohort
study [34] on the association between air traffic noise and the incidence of diabetes, no increased risk
of diabetes due to air traffic noise was observed (see Table 5).
We found indications that noise from road traffic increases the risk of diabetes. The two evaluated
cross-sectional studies [28,75] showed an increasing but non-significant trend of the prevalence of
diabetes with road traffic noise exposure. In the evaluated cohort study [38], an increase in road traffic
noise was statistically significantly associated with an increase in the incidence of diabetes. An RR of
1.08 (95% CI: 1.02–1.14) per 10 dB (LDEN) across a noise range of approximately 50–70 dB (LDEN) was
estimated.
Remarkably, an increase in rail traffic noise was associated with a decrease in the risk of diabetes
in one cross-sectional study [28] while a cohort study [38] found no statistically significant
association.
Overall, we rate the quality of the evidence supporting an association between traffic noise and
diabetes to be “low”. This indicates that further research is very likely to have an important impact
on our confidence in the estimate of effect and is likely to change the estimate.
3.5. Obesity
The number of evaluated studies that investigated the impact of noise on markers of obesity was
limited to four [34,136,155,156]: one cohort study and three cross-sectional studies. Appendix B
presents the separate risk of bias tables, and Appendix G presents the different GRADE tables
(summarized in Table 6). All the studies showed that an increase in traffic noise was associated with
an increase in obesity markers, although, according to one study, this was present only in certain
subgroups. In the cohort study [34], an increase in aircraft noise of 10 dB (LDEN) was associated with
a significant increase in waist circumference of 3.46 (95% CI: 2.13–4.77) cm during 8 to 10 years of
follow-up (see Table 6). The evidence of traffic noise affecting obesity markers is strengthened by the
results of two recent longitudinal studies [157,158].
Table 6. Noise exposure and the risk of obesity: summary of findings.
Noise
Source
Outcome
Number of Study
Design (s) *
Change per 10 dB
(95% CI) †
Participants
Quality of
Evidence ‡
Air traffic
Change in BMI (kg/m2)
1 CO
0.14 (−0.18–0.45)
5156
⊕⊕
Change in waist
circumference (cm)
1 CO
3.46 (2.13–4.77)
5156
⊕⊕⊕
Road
traffic
Change in BMI (kg/m2)
3 CS
0.03 (−0.10–0.15)
71,431
⊕
Change in waist
circumference (cm)
3 CS
0.17 (−0.06–0.40)
71,431
⊕
Rail traffic
Change in BMI (kg/m2)
2 CS
- **
57,531
⊕
Change in waist
circumference (cm)
2 CS
- **
57,531
⊕⊕
* CS = cross-sectional study, CO = cohort study; † 95% CI = 95% Confidence Interval. Noise levels are
expressed in LDEN; ‡ GRADE Working Group Grades of Evidence: High quality (⊕⊕⊕⊕): Further
research is very unlikely to change our confidence in the estimate of effect, Moderate Quality (⊕⊕⊕
): Further research is likely to have an important impact on our confidence in the estimate of effect
and may change the estimate, Low Quality (⊕⊕): Further research is very likely to have an important
impact on our confidence in the estimate of effect and is likely to change the estimate, Very low quality
(⊕): We are very uncertain about the estimate. ** We decided not to aggregate the results of the
studies on the impact of rail traffic noise, since not all parameters were available to assess a change in
BMI or waist circumference per 10 dB; dB = Decibel, BMI = Body Mass Index.
Overall, we rate the quality of the evidence supporting an association between traffic noise and
markers of obesity, respectively, as “low”. This indicates that further research is very likely to have
an important impact on our confidence in the estimate of effect and is likely to change the estimate.

Int. J. Environ. Res. Public Health 2018, 15, 379 11 of 62
3.6. Blood Pressure in Children
We evaluated eight studies investigating the impact of noise on children’s blood pressure
[31,39,41,48,58,59,71,93,114,119,159]. Appendix B presents the separate risk of bias tables, and
Appendix H presents the different GRADE tables (summarized in Table 7). Seven studies were cross-
sectional; one study reported both the results of cross-sectional and longitudinal analyses. With the
exception of the association between road traffic noise at school and systolic blood pressure, we
observed positive but non-significant associations between exposure to road traffic noise and blood
pressure (see Table 7). No combined exposure-response estimate could be computed from the studies
on the impact of aircraft noise, since no quantitative results were provided in one of the studies.
Table 7. Noise exposure and the impact on children’s blood pressure: summary of findings.
Noise
Source
Setting
Outcome
Number of Study
Design (s) *
Change in Blood Pressure
(mmHg) per 10 dB (95% CI) †
Participants
Quality of
Evidence ‡
Air
traffic
School
Systolic blood
pressure (mmHg)
2 CS
-
2013
⊕
Diastolic blood
pressure (mmHg)
2 CS
-
2013
⊕
Home
Systolic blood
pressure (mmHg)
2 CS
-
2013
⊕
Diastolic blood
pressure (mmHg)
2 CS
-
2013
⊕
Road
traffic
School
Systolic blood
pressure (mmHg)
5 CS
−0.60 (−1.51–0.30)
4520
⊕
Diastolic blood
pressure (mmHg)
5 CS
0.46 (−0.60–1.53)
4520
⊕
Home
Systolic blood
pressure (mmHg)
6 CS
0.08 (−0.48–0.64)
4197
⊕
Diastolic blood
pressure (mmHg)
6 CS
0.47 (−0.30–1.24)
4197
⊕
* CS = Cross-sectional study; † 95% CI: 95% confidence interval. Blood pressure is expressed in
millimeters of mercury (mmHg). Noise levels are expressed in LDEN; ‡ GRADE Working Group Grades
of Evidence: High quality (⊕⊕⊕⊕): Further research is very unlikely to change our confidence in
the estimate of effect, Moderate Quality (⊕⊕⊕): Further research is likely to have an important
impact on our confidence in the estimate of effect and may change the estimate, Low Quality (⊕⊕):
Further research is very likely to have an important impact on our confidence in the estimate of effect
and is likely to change the estimate, Very low quality (⊕): We are very uncertain about the estimate;
mmHg: millimeters of mercury.
Overall, we rate the quality of the evidence supporting an association between traffic noise and
blood pressure in children, as “very low”, indicating that any estimate of effect is very uncertain.
3.7. Wind Turbine Noise
Overall, we evaluated only three cross-sectional studies that investigated the impact of noise
from wind turbines on the cardiovascular and metabolic systems [60,65,76,81,84,86,101]. Important
limitations of these studies were the low response rates (two studies had response rates of less than
60%) and, the fact that in all studies the cardiovascular or metabolic endpoint was ascertained by
questionnaire or interview. In these studies, we observed that an increase in wind turbine noise was
associated with non-significant increases in self-reported hypertension and non-significant decreases
in self-reported cardiovascular disease. For self-reported diabetes, the results appeared inconsistent.
Overall, we rate the quality of the studies supporting an association between exposure from wind
turbine noise and adverse effects in the cardiovascular or metabolic system as “very low”, indicating
that any estimate of effect is very uncertain.

Int. J. Environ. Res. Public Health 2018, 15, 379 12 of 62
4. Discussion
The current review shows that a large number of studies have investigated the impact of noise
on the cardiovascular system, but applying the GRADE, the quality of the evidence is often rated as
relatively low. This does not mean that exposure to noise has no effect on the cardiovascular system,
but encourages further research to improve the quality of the evidence. After all, there is a strong
biological plausibility that noise affects human health. Furthermore, in many of the evaluated studies,
we observed statistically significant associations between noise and cardiovascular endpoints. The
most robust were the effects of road traffic noise in relation to IHD. Combining the results of 7
longitudinal studies, revealed an RR of 1.08 (95% CI: 1.01–1.15) per 10 dB (LDEN) for the association
between road traffic noise and the incidence of IHD. We rated the quality of the evidence from these
longitudinal studies as high. Supporting evidence came from studies on the association between road
traffic noise and the prevalence of IHD.
Several recent reviews have been published on cardiovascular effects of environmental noise
exposure, which are described in detail in the full systematic review [1]. The quantitative results
regarding exposure-response relationships following meta-analyses agree well with our review.
However, most earlier reviews did not include a detailed quality assessment of individual studies.
This review also addressed the possible impact of noise on the metabolic system. In comparison
with the studies on the impact of noise on the cardiovascular system, the number of available studies
was rather limited. The results of these studies were not always consistent. In addition, the quality of
the evidence was rather low. It is therefore, at this moment too early to draw definite conclusions
with regard to the impact of noise on the metabolic system.
5. Conclusions
The results of the current review shows that at this moment, not enough studies of good quality
are available that investigated the impact of noise on the cardiovascular and metabolic system. The
plausibility of an association calls for further efforts with improved research. In order to improve the
quality of the existing evidence, more studies with a cohort or case-control design are needed.
In order to improve the quality of the existing evidence, we also recommend that more well
designed studies on health effects in relation to exposure to wind turbines and rail traffic noise are
set up and carried out.
Acknowledgments: This review has been funded by the World Health Organization Regional Office for Europe,
supported by Swiss Federal Office for the Environment, and the authors’ home institutions. It was delivered as
part of the evidence-base that underpins the Environmental Noise Guidelines for the European Region All rights
in the work, including ownership of the original work and copyright thereof, are vested in WHO, The authors
alone are responsible for the views expressed in this publication and do not necessarily represent the decisions
or the stated policy of the World Health Organization. We would also like to thank Marie-Eve Heroux, Jos
Verbeek, Wolfgang Babisch, Goran Belojević, Alva Wallas and Wendy Vercruijsse for their assistance and advice.
Furthermore, we thank our fellow researchers and colleagues for kindly providing us with additional data and
information on their studies: Christian Maschke (SPANDAU study), Julia Dratva (SAPALDIA study), Mette
Sørensen (DCH study), Oscar Breugelmans (AWACS study), Bente Oftedal and Gunn Marit Aasvang (HUBRO
study), Charlotta Eriksson (SDPP study), Jenny Selander (SHEEP study), Peter Lercher (BBT studies and
ALPNAP study), Toshihito Matsui (Okinawa study), and Ta Yuang Chang (Taiwan study). Their efforts have
improved our work considerably.
Author Contributions: Elise van Kempen and Maria Foraster conducted the study selection. Elise van Kempen,
Maribel Casas, Göran Pershagen, and Maria Foraster conducted the study evaluation. Elise van Kempen,
Maribel Casas and Göran Pershagen conducted the data-extraction and meta-analyses. Elise van Kempen wrote
the paper. All authors read and approved the final manuscript.
Conflicts of Interest: The authors declare no conflict of interest.

Int. J. Environ. Res. Public Health 2018, 15, 379 13 of 62
Appendix A. Applied Search Profiles
In order to identify “Observational studies such as ecological studies, cross-sectional studies,
case control studies or cohort studies involving the association between aircraft and/or rail traffic
noise exposure and hypertension and/or high blood pressure, and/or ischemic heart disease
(including angina pectoris and/or myocardial infarction) in adults published from 2000 until October
2014 with no language restriction”, the following search profiles were applied in:
MEDLINE 1950 to present, MEDLINE In-Process & Other Non-Indexed Citations 20141021
1 ((rail* or aircraft or airport* or air traffic*) adj5 noise.tw. (504)
2 Aircraft/or Airports/or Railroads/(9486)
3 *Transportation/(3419)
4 (rail* or aircraft or airport* or air traffic.tw. (11,558)
5 *Noise/(10,029)
6 Noise, transportation/(1017)
7 exp Blood pressure/(254,113)
8 exp Hypertension/(217,361)
9 Myocardial ischemia/(33,403)
10 exp Cardiovascular diseases/or exp Vascular diseases/or exp Heart diseases/(1,944,605)
11 (hypertension or blood pressure.tw. (445,550)
12 (isch?emic heart disease* or coronary heart disease* or angina pectoris or myocard* infarct*or
cardiovascular disease* or heart disease*).tw. (368,878)
13 (1 or 2 or (3 and 4)) and (1 or 5 or 6) (860)
14 13 and (7 or 8 or 9 or 10 or 11 or 12) (119)
15 14 not child*.ti. (112)
16 limit 15 to yr = 2000 − current (83)
Scopus, 20141022
((TITLE-ABS-KEY((rail* OR aircraft OR airport* OR air-traffic*) W/5 noise) AND (TITLE-ABS-
KEY(hypertension OR blood-pressure OR ischemic-heart-disease* OR coronary-heart-disease* OR angina-
pectoris OR myocard*-infarct* OR cardiovascular-disease* OR heart-disease*)) AND PUBYEAR > 1999)
AND NOT (TITLE(child*))
In order to identify “Observational studies such as ecological studies, cross-sectional studies,
case-control studies or cohort studies involving the association between aircraft and/or rail traffic
and/or road traffic noise exposure and stroke and/or diabetes type II, and/or obesity in adults,
published until October 2014 with no language restriction”, the following search profiles were
applied in:
Medline 20141023 MEDLINE 1950 to present, MEDLINE In-Process & Other Non-Indexed Citations
1 ((rail* or aircraft or airport* or road* or traffic* or automobile* or vehicle*) adj5 noise.tw.(1188)
2 exp *Transportation/(35,715)
3 Aircraft/or Airports/or Railroads/or Motor Vehicles/(12,387)
4 *Noise/(10,039)
5 Noise, transportation/(1023)
6 (1 or 2 or 3) and (1 or 4 or 5) (1774)
7 exp Cerebrovascular disorders/(290,152)
8 exp Diabetes Mellitus/(328,383)
9 exp Obesity/or exp Overweight/or exp Body Mass Index/(208,810)
10 (stroke or cerebrovascular* or cva or brain vascular accident* or brain vascular disorder*).tw. (187,910)
11 (diabetes or obesit* or overweight or bmi or body mass index).tw. (556,663)
12 7 or 8 or 9 or 10 or 11 (1,065,975)
13 6 and 12 (54)
14 13 not child*.ti. (51)

Int. J. Environ. Res. Public Health 2018, 15, 379 14 of 62
15 limit 14 to yr = 2000 − current (47)
Scopus 20141023
((TITLE-ABS-KEY((rail* OR aircraft OR airport* OR road* OR traffic* OR automobile* OR vehicle*) W/1
noise) AND (TITLE-ABS-KEY(stroke OR cerebrovascular OR cva OR brain-vascular OR diabetes OR obesit*
OR overweight OR bmi OR body-mass-index)) AND PUBYEAR > 1999) AND NOT (TITLE(child*))
In order to identify “Observational studies such as ecological studies, cross-sectional studies,
case control studies or cohort studies involving the association between road traffic noise exposure
and hypertension and/or high blood pressure published from 2010 until October 2014 with no
language restriction”, the following search profiles were applied in:
Medline 20141017 MEDLINE 1950 to present, MEDLINE In-Process & Other Non-Indexed Citations
1 ((road* or traffic* or automobile* or vehicle* or motor cycle* or motorcycle* or transport*) adj5
noise.tw.(993)
2 exp *Transportation/(35,698)
3 Motor Vehicles/(2962)
4 *Noise/(10,029)
5 Noise, transportation/(1017)
6 (1 or 2 or 3) and (1 or 4 or 5) (1714)
7 exp Blood pressure/(254,113)
8 exp Hypertension/(217,361)
9 (blood pressure or hypertension).tw. (445,404)
10 6 and (7 or 8 or 9) (134)
11 10 not child*.ti. (120)
12 limit 11 to yr = 2010 − current (46)
PubMed 20141024
((traffic*[ti] OR road*[ti] OR automobile*[ti] OR vehicle*[ti] OR motorcycle*[ti] OR transport*[ti]) AND
noise[ti]
Scopus 20141024
(TITLE-ABS-KEY((rail* OR aircraft OR airport* OR road* OR traffic* OR automobile* OR vehicle*) W/1
noise) AND (TITLE-ABS-KEY(hypertension OR blood-pressure) AND PUBYEAR > 2009 AND NOT
TITLE(child*)
In order to identify “Observational studies such as ecological studies, cross-sectional studies,
case-control studies or cohort studies involving the association between road, rail and air traffic noise
exposure and blood pressure in children published until October 2014 without any language
restriction”, the following search profiles were applied in:
Medline 20141017 MEDLINE 1950 to present, MEDLINE In-Process & Other Non-Indexed Citations
1 ((rail* or aircraft or airport* or road* or traffic or automobile* or vehicle*) adj5 noise.tw. (1185)
2 exp *Transportation/(35,698)
3 Aircraft/or Airports/or Railroads/or Motor Vehicles/(12,379)
4 *Noise/(10,029)
5 Noise, transportation/(1017)
6 (1 or 2 or 3) and (1 or 4 or 5) (1770)
7 exp Blood pressure/(254,113)
8 exp Hypertension/(217,361)
9 (blood pressure or hypertension).tw. (445,404)
10 6 and (7 or 8 or 9) (144)
11 10 and (child* or infant* or adolescent*).mp. (43)

Int. J. Environ. Res. Public Health 2018, 15, 379 15 of 62
Scopus 20141024
TITLE-ABS-KEY((rail* OR aircraft OR airport* OR road* OR traffic* OR automobile* OR vehicle*) W/1 noise
AND TITLE-ABS-KEY(blood-pressure OR hypertension) AND TITLE-ABS-KEY(child* OR infant* OR
adolescent*)
In order to identify “Observational studies such as ecological studies, cross-sectional studies,
case-control studies or cohort studies involving the association between audible noise (greater than
20 Hz) and infrasound and low-frequency noise (less than 20 Hz) from wind turbines or wind farms
and blood pressure and/or cardiovascular disease published from October 2012 until October 2014
without any language restriction”, the following search profiles were applied in:
PubMed 20141024
(((((wind turbine* OR wind farm*[Title/Abstract]))) AND ((noise[MeSH Terms]) OR noise[Title/Abstract])))
AND (((health*[Title/Abstract]) OR blood pressure OR cardiovascular)) 2012–current
Medline 20141027 MEDLINE 1950 to present, MEDLINE In-Process & Other Non-Indexed Citations
1 ((wind adj3 turbine*) or (wind adj3 farm*) or windturbine* or windfarm*).tw. (271)
2 Wind/(2794)
3 Renewable energy/(273)
4 Power Plants/(5234)
5 Electric Power Supplies/(4979)
6 Energy-Generating Resources/(1684)
7 2 and (3 or 4 or 5 or 6) (183)
8 1 or 7 (362)
9 Noise/or Sound/(26,842)
10 (infrasound* or noise or low frequenc*).tw. (131,959)
11 (blood pressure or cardiovascular).tw. (474,959)
12 Blood Pressure/(243,394)
13 Cardiovascular Physiological Phenomena/or Cardiovascular Diseases/or Cardiovascular
System/(129,880)
14 health*.ti. (532,337)
15 8 and (9 or 10) and (11 or 12 or 13 or 14) (19)
16 limit 15 to yr = 2012–current (14)
Scopus 20141027
TITLE-ABS-KEY((wind W/3 turbine*) OR windturbine* OR (wind W/3 farm*) OR windfarm*) AND TITLE-
ABS-KEY(noise OR infrasound* OR low-frequenc*) AND (TITLE-ABS-KEY(blood-pressure OR
cardiovascular*) OR TITLE(health*) OR KEY(health*)) AND PUBYEAR > 2011
Embase and SciSearch:
same search profile used as in Medline.
Appendix B. Risk of Bias
This appendix presents the risk of bias tables. They are presented per exposure outcome
combination. An extensive description and the reasoning behind these tables can be found in
Chapters 4–9 of the complete review.

Int. J. Environ. Res. Public Health 2018, 15, 379 16 of 62
Table A1. Reviewer’s judgement about risk of bias for each of the studies on aircraft noise and
hypertension that were selected for data extraction.
Study [Ref.]
Bias Due to
Exposure
Assessment
Bias Due to
Confounding *
Bias Due to
Selection of
Participants †
Bias Due to
Health
Outcome
Assessment
Bias Due to
Not Blinded
Outcome
Assessment
Total
Risk of
Bias
SDPP [73,78,91,106]
Low
Low
High
Low
Low
Low
HYENA
[50,61,62,83,85,98,99]
Low
Low
High
Low
High
High
SEHS [112]
Low
Low
Low
High
Low
Low
DEBATS-pilot [46]
Low
Low
High
Low
Unclear
High
DEBATS-main [26]
Low
Low
Unclear
Low
Unclear
Unclear
AWACS [28]
Low
Low
High
High
Low
High
Okinawa
[40,102,113]
High
Low
Unclear
Low
Low
High
Knipschild-1
[133,134]
High
High
High
Low
Low
High
SERA [74]
Low
Low
High
Low
Unclear
High
GES-2 [94,95,105]
Low
Low
High
High
Low
High
GES-3 [94,95,105]
Low
Low
High
High
Low
High
SPANDAU
[97,109,110]
Low
Low
Low
High
Low
Low
* In order to score “low”, the study should contain information that can be used to derive effect
estimates that are at least adjusted for age and sex; † In order to score “low” participants had to be
randomly sampled from a known population and the response rate of the study had to be higher than
60% (cross-sectional studies) and attrition rate is less than 20% (follow-up studies).
Table A2. Reviewer’s judgement about risk of bias for each of the studies on road traffic noise and
hypertension that were selected for data extraction.
Study [Ref.]
Bias Due to
Exposure
Assessment
Bias Due to
Confounding *
Bias Due to
Selection of
Participants †
Bias Due to
Health Outcome
Assessment
Bias Due to Not
Blinded Outcome
Assessment
Total
Risk of
Bias
Amsterdam [132]
High
Low
Low
Low
Low
Low
Caerphilly [130,131]
High
High
Low
Low
Low
High
Luebeck [126,127]
High
Low
Low
Low
Unclear
High
BCC3 [118,120,123]
Low
Low
High
High
Low
High
SHEEP [75]
Low
Low
Low
Low
Low
Low
Tokyo [117]
Unclear
Low
Low
High
Unclear
Unclear
StockholmRoad [92]
Low
High
Low
High
Low
High
Groningen [88,89]
Low
Low
High
High
Low
High
PREVEND [88,89]
Low
Low
High
Low
Low
Low
UIT1 [135]
Low
High
Low
High
Unclear
High
SPANDAU [97,109,110]
Low
Low
Low
High
Low
Low
Skane-1 [96]
Low
Low
High
High
Unclear
High
Lerum [80]
Low
Low
Low
High
High
High
Skane-2 [77]
Low
Low
Low
High
Low
Low
BBT-1 (phone [82,135]
Low
Low
Low
High
Unclear
High
BBT-2 (face-to-face [82,135]
Low
Low
Low
High
Unclear
High
HYENA
[50,61,62,83,85,98,99]
Low
Low
High
Low
High
High
KORA [37,49]
Low
Low
Low
Low
Low
Low
Berlin-IV [36,149]
Low
Low
High
Low
Low
Low
Taiwan [35,70]
High
Low
Unclear
High
Unclear
High
REGICOR [32,33,43,68]
Low
Low
Low
Low
Low
Low
Heinz-Nixdorf Recall Study
[67]
Low
Low
Low
Low
Low
Low
Oslo Health Study [30,66]
Low
Low
Low
Low
Low
Low
DCH [51,63]
Low
Low
High
High
Low
High
SAPALDIA-2 [55,57]
Low
Low
Low
High
Low
Low
Roadside [56]
Low
High
High
High
Low
High
ALPNAP [82,90,135]
Low
Low
High
High
Unclear
High
AWACS [28]
Low
Low
High
High
Low
High
* In order to score “low”, the study should contain information that can be used to derive effect
estimates that are at least adjusted for age and sex; † In order to score “low” participants had to be
randomly sampled from a known population and the response rate of the study had to be higher than
60%.

Int. J. Environ. Res. Public Health 2018, 15, 379 17 of 62
Table A3. Reviewer’s judgement about risk of bias for each of the studies on rail traffic noise and
hypertension that were selected for data extraction.
Study [Ref.]
Bias Due to
Exposure
Assessment
Bias Due to
Confounding *
Bias Due to
Selection of
Participants †
Bias Due to
Health Outcome
Assessment
Bias Due to Not
Blinded Outcome
Assessment
Total Risk
of Bias
Lerum [80]
Low
Low
Low
High
High
High
AWACS [28]
Low
Low
High
High
Low
High
Roadside [56]
Low
High
High
High
Low
High
DCH [51,63]
Low
Low
High
High
Low
High
SAPALDIA-2 [55,57]
Unclear
Low
Low
High
Low
High
ALPNAP [82,90,135]
Low
Low
High
High
Unclear
High
BBT-1 [82,135]
Low
Low
Low
High
Unclear
High
BBT-2 [82,135]
Low
Low
Low
High
Unclear
High
* In order to score “low”, the study should contain information that can be used to derive effect
estimates that are at least adjusted for age and sex; † In order to score “low” participants had to be
randomly sampled from a known population and the response rate of the study had to be higher than
60%.
Table A4. Reviewer’s judgement about risk of bias for each of the studies on noise from wind turbines
and hypertension that were selected for data extraction.
Study [Ref.]
Bias Due to
Exposure
Assessment
Bias Due to
Confounding *
Bias Due to
Selection of
Participants †
Bias Due to
Health
Outcome
Assessment
Bias Due to
Not Blinded
Outcome
Assessment
Total
Risk of
Bias
NL-07
[60,65,76,84]
High
Low
High
High
Low
High
SWE-00
[65,81,101]
High
Low
Low
High
Low
High
SWE-05
[65,81,86]
High
Low
High
High
Low
High
* In order to score “low”, the study should contain information that can be used to derive effect
estimates that are at least adjusted for age and sex; † In order to score “low” participants had to be
randomly sampled from a known population and the response rate of the study had to be higher than
60%.
Table A5. Reviewer’s judgement about risk of bias for each of the studies on aircraft noise and IHD
that were selected for data extraction.
Study [Ref.]
Bias Due to
Exposure
Assessment
Bias Due to
Confounding *
Bias Due to
Selection of
Participants †
Bias Due to
Health
Outcome
Assessment
Bias Due to
Not Blinded
Outcome
Assessment
Total
Risk of
Bias
HYENA
[44,45,50,61,62,69,83,
85,98,99]
Low
Low
High
High
High
High
USAairports [47]
High
High
Low
Low
Low
High
SPANDAU
[97,109,110]
Low
High
Low
High
Low
High
LSAS [42]
High
Unclear
Low
Low
Low
High
SNC [72]
Unclear
High
Low
Low
Low
High
AWACS-1 [28]
Low
Low
High
High
Low
High
AWACS-2 [28]
Unclear
High
Low
Low
Low
High
IVEM [124,128,129]
High
High
Low
Low
Low
High
* In order to score “low”, the study should contain information that can be used to derive effect
estimates that are at least adjusted for age, sex, and smoking; † In order to score “low” participants
had to be randomly sampled from a known population and the response rate of the study had to be
higher than 60%. Studies with a purposeful sample also scored “low”.

Int. J. Environ. Res. Public Health 2018, 15, 379 18 of 62
Table A6. Reviewer’s judgement about risk of bias for each of the studies on road traffic noise and
IHD that were selected for data extraction.
Study [Ref.]
Bias Due to
Exposure
Assessment
Bias Due to
Confounding *
Bias Due to
Selection of
Participants †
Bias Due to
Health
Outcome
Assessment
Bias Due to
Not Blinded
Outcome
Assessment
Total
Risk of
Bias
Caerphilly-a
[122,125,130,131]
High
High
Low
Low
Low
High
Caerphilly-b
[111,115,122,125,
130,131]
High
Low
Low
Low
Low
Low
Speedwell-a
[121,122,125,131]
High
High
Low
Low
Low
High
Speedwell-b
[111,115,121,122,
125,131]
High
Low
Low
Low
Low
Low
SPANDAU
[97,109,110]
Low
High
Low
High
Low
High
ALPNAP
[82,90,135]
Low
Low
High
High
Unclear
High
NAROMI
[100,107]
Low
Low
Low
Low
Low
Low
BCC1
[118,120,123]
Low
Low
Low
Low
Low
Low
BCC2
[118,120,123]
Low
Low
Low
Low
Low
Low
BCC3
[118,120,123]
Low
Low
Low
High
High
High
Kaunus-1
[87,103]
High
High
Low
Low
Low
High
BBT-Phone
[82,135]
Low
High
Low
High
Unclear
High
BBT-Face
[82,135]
Low
High
Low
High
Unclear
High
IVEM
[124,128,129]
High
High
Low
Low
Low
High
SHEEP [75]
Low
Low
Low
Low
Low
Low
NCSDC [79]
Low
Low
Low
Low
Low
Low
AWACS1 [28]
Low
Low
High
High
Low
High
HYENA
[44,45,50,61,62,6
9,83,85,98,99]
Low
Low
High
High
High
High
DCH [52,53]
Low
Low
Low
Low
Low
Low
Canada1 [54]
Low
High
Low
Low
Low
Low
* In order to score “low”, the study should contain information that can be used to derive effect
estimates that are at least adjusted for age, sex, and smoking; † In order to score “low”, participants
had to be randomly sampled from a known population and the response rate of the study had to be
higher than 60%. Studies with a purposeful sample also scored “low”.
Table A7. Reviewer’s judgement about risk of bias for each of the studies on rail traffic noise and IHD
that were selected for data extraction.
Study [Ref.]
Bias Due to
Exposure
Assessment
Bias Due to
Confounding *
Bias Due to
Selection of
Participants †
Bias Due to
Health Outcome
Assessment
Bias Due to not
Blinded Outcome
Assessment
Total
Risk of
Bias
BBT-1 [82,135]
Low
High
Low
High
Unclear
High
BBT-2 [82,135]
Low
High
Low
High
Unclear
High
ALPNAP
[82,90,135]
Low
Low
High
High
Unclear
High
AWACS [28]
Low
Low
High
High
Low
High
* In order to score “low”, the study should contain information that can be used to derive effect
estimates that are at least adjusted for age, sex, and smoking; † In order to score “low”, participants
had to be randomly sampled from a known population and the response rate of the study had to be
higher than 60%. Studies with a purposeful sample also scored “low”.

Int. J. Environ. Res. Public Health 2018, 15, 379 19 of 62
Table A8. Risk of bias: reviewer’s judgements about each risk of bias item for each of the six studies
on the association between aircraft noise and stroke that were selected for data extraction.
Study [Ref.]
Bias Due to
Exposure
Assessment
Bias Due to
Confounding *
Bias Due to
Selection of
Participants †
Bias Due to
Health Outcome
Assessment
Bias Due to Not
Blinded
Outcome
Assessment
Total
Risk of
Bias
HYENA
[44,45,50,61,62,69,83,85,98,99]
Low
Low
High
High
High
High
LSAS [42]
High
High
Low
Low
Low
High
SNC [72]
Unclear
High
Low
Low
Low
High
AWACS-1 [28]
Low
Low
High
High
Low
High
AWACS-2 [28]
Unclear
High
Low
Low
Low
High
USAairports [47]
High
High
Low
Low
Low
High
* In order to score “low”, the study should contain information that can be used to derive effect
estimates that are at least adjusted for age, sex, and smoking; † In order to score “low”, participants
had to be randomly sampled from a known population and the response rate of the study had to be
higher than 60%. Studies with a purposeful sample also scored “low”.
Table A9. Reviewer’s judgement about risk of bias for each of the studies on road traffic noise and
stroke that were selected for data-extraction.
Study [Ref.]
Bias Due to
Exposure
Assessment
Bias Due to
Confounding *
Bias Due to
Selection of
Participants †
Bias Due to
Health Outcome
Assessment
Bias Due to Not
Blinded Outcome
Assessment
Total
Risk of
Bias
HYENA
[44,45,50,61,62,69,83,85,98,99]
Low
Low
High
High
High
High
NCSDC [79]
Low
Low
Low
Low
Low
Low
DCH [27,52,64]
Low
Low
Low
Low
Low
Low
AWACS1 [28]
Low
Low
High
High
Low
High
Canada1 [54]
Low
High
Low
Low
Low
Low
* In order to score “low”, the study should contain information that can be used to derive effect
estimates that are at least adjusted for age, sex, and smoking; † In order to score “low” participants
had to be randomly sampled from a known population and the response rate of the study had to be
higher than 60%. Studies with a purposeful sample also scored “low”.
Only the AWACS1 study [28] investigated the impact of rail traffic noise on stroke. See Table A9
for the quality assessment.
Table A10. Reviewer’s judgement on risk of bias in studies on aircraft noise and diabetes.
Study
Bias Due to
Exposure
Assessment
Bias Due to
Confounding *
Bias Due to
Selection of
Participants †
Bias Due to Health
Outcome
Assessment
Bias Due to Not
Blinded Outcome
Assessment
Total Risk
of Bias
SDPP [34]
Low
Low
High
Low
Low
Low
AWACS-1 [28]
Low
Low
High
High
Low
High
* In order to score “low”, the study should contain information that can be used to derive effect
estimates that are at least adjusted for age, sex, and smoking; † In order to score “low” participants
had to be randomly sampled from a known population and the response rate of the study had to be
higher than 60%. Studies with a purposeful sample also scored “low”.
Table A11. Reviewer’s judgement on risk of bias in studies on road traffic noise and diabetes.
Study
Bias Due to
Exposure
Assessment
Bias Due to
Confounding *
Bias Due to
Selection of
Participants †
Bias Due to Health
Outcome
Assessment
Bias Due to Not
Blinded Outcome
Assessment
Total
Risk of
Bias
SHEEP [75]
Low
Low
Low
High
Low
Low
DCH [38]
Low
Low
Low
Low
Low
Low
AWACS1 [28]
Low
Low
High
High
Low
High
* In order to score “low”, the study should contain information that can be used to derive effect
estimates that are at least adjusted for age, sex, and smoking; † In order to score “low” participants
had to be randomly sampled from a known population and the response rate of the study had to be
higher than 60%. Studies with a purposeful sample also scored “low”.

Int. J. Environ. Res. Public Health 2018, 15, 379 20 of 62
Table A4 also presents the results of the evaluation of the quality of the studies that investigated
the association between audible noise (greater than 20 Hz) from wind turbines and self-reported
diabetes [60,65,76,81,84,86,101].
Table A10 also presents the results of the evaluation of the quality of the study that investigated
the association between aircraft noise and obesity [34].
Table A11 also presents the results of the evaluation of the quality of the studies that assessed
railway noise and diabetes: DCH [38], AWACS1 [28].
Table A12 also presents the results of the evaluation of the quality of the two studies that
investigated the association between railway noise and obesity [136,155].
Table A12. Reviewer’s judgement on risk of bias in studies on road traffic noise and obesity.
Study
Bias Due to
Exposure
Assessment
Bias Due to
Confounding *
Bias Due to
Selection of
Participants †
Bias Due to Health
Outcome
Assessment
Bias Due to not
Blinded Outcome
Assessment
Total
Risk of
Bias
HUBRO [30,156]
Low
Low
High
Low
Low
Low
SDPP [155]
Low
Low
High
Low
Low
Low
DCH [136]
Low
Low
High
Low
Low
Low
* In order to score “low”, the study should contain information that can be used to derive effect
estimates that are at least adjusted for age, sex, and smoking; † In order to score “low” participants
had to be randomly sampled from a known population and the response rate of the study had to be
higher than 60%. Studies with a purposeful sample also scored “low”.
Table A13. Risk of bias: reviewer’s judgements on risk of bias in studies on noise and children’s blood
pressure.
Study
Bias Due to
Exposure
Assessment
Bias Due to
Confounding *
Bias Due to
Selection of
Participants †
Bias Due to
Health
Outcome
Assessment
Bias Due to not
Blinded
Outcome
Assessment
Total
Risk of
Bias
RANCH
[58,93]
Unclear
Low
High
Unclear
Unclear
High
ICCBP-a
[114,159]
Low
Low
High
Unclear
Unclear
High
ICCBP-b [114]
Low
Low
High
Unclear
Unclear
High
PIAMA [48]
Unclear
Low
High
Unclear
Low
High
GINIplus
[31,41]
Unclear
Low
High
Unclear
Low
High
LISAplus
[31,41]
Unclear
Low
High
Unclear
Low
High
BELGRADE1
[39]
High
Low
High
Unclear
Unclear
High
REGECOVA
[119]
High
High
Low
Unclear
Unclear
High
USA1 [59,71]
High
High
Low
Unclear
Unclear
High
* In order to score “low” the study should contain information that can be used to derive effect
estimates that are at least adjusted for age and sex. † In order to score “low”, participants had to be
randomly sampled from a known population and the response rate of the study had to be higher than
60%. An additional condition for cohort studies was that the attrition rate had to be at least 20%.
Appendix C. Summary of Findings Tables Dealing with Studies on the Impact of Noise on
Hypertension
This appendix presents the summary of findings tables dealing with the studies on the impact
of noise on hypertension. An extensive description and the reasoning behind these tables can be
found in the complete review in Section 11.1.

Int. J. Environ. Res. Public Health 2018, 15, 379 21 of 62
Table A14. Summary of findings table for the association between aircraft noise exposure and the
prevalence of hypertension.
Question
Does Exposure to Aircraft Noise Increase the Risk of Hypertension
People
Adult population (men and women)
Setting
Residential setting: people living in cities (general population) located around airports in Europe and Japan
Outcome
The prevalence of hypertension
Summary of
findings
RR per 10 dB increase in aircraft
noise level (LDEN)
1.05 (95% CI: 0.95–1.17) per 10 dB
Number of participants
(# evaluated studies)
60,121 (9)
Number of cases
9487
Rating
Adjustment to rating
Quality
assessment
Starting rating
9 cross-sectional studies a
2 (low)
Factors
decreasing
confidence
Risk of bias
Serious b
Downgrading
Inconsistency
Serious c
Downgrading
Indirectness
None d
No downgrading
Imprecision
None e
No downgrading
Publication bias
None f
No downgrading
Factors
increasing
confidence
Strength of
association
Small g
No upgrading
Exposure-response
gradient
Non-significant exposure-
response gradient g
Upgrading
Possible
confounding
No serious bias h
Upgrading
Overall judgement of quality of evidence
0 (low)
a Since only cross-sectional studies were available, we started with a grading of “low” (2); b Methods
used to select the population: In six studies, the participants were randomly selected, taking into
account aircraft noise exposure; three studies were originally not designed to investigate the impact
of aircraft noise exposure, but still participants were randomly selected. In six studies, participants
were probably not aware of the fact that they participated in a study investigating the impact of noise;
for three studies, this was unclear. For one study, it was likely that participants were aware of the fact
that they participated in a study investigating the impact of noise. In six studies, response rates were
below 60%; for two studies, the response rate was unclear and only in one study response rate was
higher than 60%; c Results across studies differed in magnitude and direction of effect estimates (see
Figure 4.1 of the complete review). This was confirmed by the results of the heterogeneity analyses,
demonstrating moderate heterogeneity (I2residual = 72.1%); d The studies assessed population, exposure,
and outcome of interest; e We considered the results to be precise, since the number of participants
and the number of cases was large enough. The 95% confidence interval was sufficiently narrow; f
There was little reason to believe that there is major publication bias or small study bias (see also
Figure 4.2). The Egger test did not provide evidence for small-study effects; g Most studies found that
the risk of hypertension increased when aircraft noise level increased (RR per 10 dB > 1). There was
evidence of a non-significant exposure-response gradient: After aggregating the results of the
evaluated studies, we found a non-significant effect size of 1.05 per 10 dB. The noise range of the
studies under evaluation was 35–75 dB. This means that if air traffic noise level increases from 35 to
75 dB, the RR = 1.22. We found indications for an effect of exposure duration: The effect estimates
turned out to be larger for the sample that lived for a longer period in the same house; h We did not
find evidence that suggests that possible residual confounders or biases would reduce our effect
estimate.

Int. J. Environ. Res. Public Health 2018, 15, 379 22 of 62
Table A15. Summary of findings table for the association between road traffic noise exposure and the
prevalence of hypertension.
Question
Does Exposure to Road Traffic Noise Increase the Risk of Hypertension
People
Adult population (men and women)
Setting
Residential setting: people living several cities in Europe
Outcome
The prevalence of hypertension
Summary of
findings
RR per 10 dB increase in road traffic noise
level (LDEN)
1.05 (95% CI: 1.02–1.08) per 10 dB *
Number of participants (# evaluated studies)
154,398 (26)
Number of cases
18,957
Rating
Adjustment to
rating
Quality
assessment
Starting rating
26 cross-sectional studies a
2 (low)
Factors decreasing
confidence
Risk of bias
Serious b
Downgrading
Inconsistency
Serious c
Downgrading
Indirectness
None d
No downgrading
Imprecision
None e
No downgrading
Publication bias
Small probability of
publication bias f
Downgrading
Factors increasing
confidence
Strength of
association
Small g
No upgrading
Exposure-
response gradient
Evidence of an exposure-
response gradient g
Upgrading
Possible
confounding
No serious bias h
Upgrading
Overall judgement of quality of evidence
1 (very low)
* The estimate was based on 47 effect estimates; a Since only cross-sectional studies were available, we
started with a grading of “low” (2); b In 12 studies, the participants were randomly selected taking
into account exposure to road traffic noise; although the participants of these studies were randomly
selected, 14 studies were originally not designed to investigate the impact of road traffic noise
exposure; In 2 studies it was likely that participants were aware of the fact that they participated in a
study investigating the impact of noise. In 8 studies, the participation rate was below 60%; for 16
studies, the participation rate was larger than 60%; c Results across studies differed in magnitude and
direction of effect estimates (see Figure 4.3 of the complete review). This was confirmed by the results
of the heterogeneity analyses, demonstrating “moderate” heterogeneity (I2residual = 52.4%); d The
evaluated studies assessed population, exposure, and outcome of interest; e We considered the results
to be precise: the number of participants and the number of cases was large enough, and the 95% CI
was sufficiently narrow; f There was reason to believe that there is some publication bias or small
study bias (result of the Egger test provided evidence for small-study effects) (see also Figure 4.4 of
the complete review); g Most studies found that the risk of hypertension increased when road traffic
noise level increased (RR per 10 dB > 1). There was evidence of a significant exposure-response
gradient: After aggregating the results of the evaluated studies, we found a significant effect size of
1.05 per 10 dB. The noise range of the studies under evaluation was 20–85 dB. This means that if road
traffic noise level increases from 20 to 85 dB, the RR = 1.34. We found indications for an effect of
exposure duration: The effect estimates turned out to be larger for the sample that lived for a longer
period in the same house; h We did not find evidence to suggest that possible residual confounders or
biases would reduce our effect estimate.

Int. J. Environ. Res. Public Health 2018, 15, 379 23 of 62
Table A16. Summary of findings table for the association between rail traffic noise exposure and the
prevalence of hypertension.
Question
Does Exposure to Rail Traffic Noise Increase the Risk Of Hypertension
People
Adult population (men and women)
Setting
Residential setting: people living in several cities in Europe
Outcome
The prevalence of hypertension
Summary of
findings
RR per 10 dB increase in rail traffic
noise level (LDEN)
1.05 (95% CI: 0.88–1.26) per 10 dB
Number of participants (# evaluated
studies)
15,850 (5)
Number of cases
2059
Rating
Adjustment to rating
Quality
assessment
Starting rating
5 cross-sectional studies #
2 (low)
Factors
decreasing
confidence
Risk of bias
Serious a
Downgrading
Inconsistency
Serious b
Downgrading
Indirectness
None c
No downgrading
Imprecision
None d
No downgrading
Publication bias
NA e
No downgrading
Factors
increasing
confidence
Strength of association
Small f
No upgrading
Exposure-response
gradient
Evidence of a non-significant
exposure-response gradient f
No upgrading
Possible confounding
No conclusions can be drawn g
No upgrading
Overall judgement of quality of evidence
0 (Very low)
# Since only cross-sectional studies were available, we started with a grading of “low”(2); a In three
studies, the participants were randomly selected taking into account road- and/or rail traffic noise
exposure; although the participants of these studies were randomly selected, two other studies were
originally not designed to investigate the impact of (rail) traffic noise exposure; In one study there is
a chance that the participants were aware that they took part in a study investigating the impact of
noise; in two other studies it is not very likely that participants were aware that they took part in a
study investigating the impact of noise, since they were not originally set up to investigate the impact
of noise. For one study, it was unclear whether participants were aware of taking part in a noise study.
In two studies, response rates were below 60%; b Results across studies differed in the magnitude and
direction of effect estimates (see Figure 4.5 of the complete review). This was confirmed by the results
of the heterogeneity analyses, demonstrating “moderate” heterogeneity (I2residual = 57.6%); c The
evaluated studies assessed population, exposure, and outcome of interest; d We considered the results
to be precise: the number of cases was large enough, and the 95% CI was sufficiently narrow; e Due
to the low number of available effect estimates it was not possible to test for publication bias or small
study bias; f Most studies found that the risk of hypertension increased when rail traffic noise level
increased (RR per 10 dB > 1). There was evidence of a non-significant exposure-response gradient:
After aggregating the results of the evaluated studies, we found a non-significant effect size of 1.05
per 10 dB. The noise range of the studies under evaluation was 30–80 dB (LDEN). This means that if rail
traffic noise level increases from 30 to 80 dB, the RR = 1.28; g We were not able to draw any conclusions
whether possible residual confounders or biases would reduce our effect estimate.

Int. J. Environ. Res. Public Health 2018, 15, 379 24 of 62
Table A17. Summary of findings table for the association between exposure to wind turbines and the
prevalence of hypertension.
Question
Does Exposure to Noise from Wind Turbines Increase the Risk of Hypertension
People
Adult population (men and women)
Setting
Residential setting: people in the neighbourhood of wind turbines in The Netherlands and Sweden
Outcome
The prevalence of hypertension
Summary of
findings
RR per 10 dB increase in wind turbine noise
level (SPL)
-
Number of participants
(# evaluated studies)
1830 (3)
Number of cases
NR
Rating
Adjustment to
rating
Quality
assessment
Starting rating
3 cross-sectional studies #
2 (low)
Factors decreasing
confidence
Risk of bias
Very serious a
Downgrading
Inconsistency
None b
No downgrading
Indirectness
None c
No downgrading
Imprecision
Limited d
Downgrading
Publication bias
NA e
No downgrading
Factors increasing
confidence
Strength of association
NA f
No upgrading
Exposure-response
gradient
NA f
No upgrading
Possible confounding
Serious bias cannot be
ruled out g
No upgrading
Overall judgement of quality of evidence
0 (very low)
# Since only cross-sectional studies were available, we started with a grading of “low” (2); a Methods
used to select the population: response rates were in two of the three studies below 60%. The
participants were randomly selected taking into account the distance between their house and a wind
turbine (park); hypertension was in all cases measured by means of a questionnaire; b Although
results across studies differed in the magnitude of effect estimates (see Figure of the complete review
4.6), all studies found a positive association between exposure to wind turbine noise and the
prevalence of hypertension; c The evaluated studies assessed population, exposure, and outcome of
interest; d We considered the results to be imprecise: we assessed that the number of cases was less
than 200, which is small. The 95% CIs of the separate studies contained values below 0.5 and above
2.0; e Due to the low number of available effect estimates it was not possible to test for publication
bias or small study bias; f We decided not to carry out a meta-analysis; g Although we did not find
evidence to suggest that possible residual confounders or biases would reduce our effect estimate, the
studies were unable to adjust for important confounders.
Table A18. Summary of findings table for the association between aircraft noise exposure and the
incidence of hypertension.
Question
Does Exposure to Aircraft Noise Increase the Risk of Hypertension
People
Adult population (men and women, 35–56 years)
Setting
Residential setting: people living around Stockholm Arlanda airport in Sweden
Outcome
The incidence of hypertension
Summary of
findings
RR per 10 dB increase in aircraft
noise level (LDEN)
1.00 (0.77–1.30) per 10 dB
Number of participants
(# studies)
4712 (1)
Number of cases
1346
Rating
Adjustment to rating
Quality
assessment
Starting rating
1 cohort study #
4 (high)
Factors
decreasing
confidence
Risk of bias
Serious limitations a
Downgrading
Inconsistency
NA b
No downgrading
Indirectness
None c
No downgrading
Imprecision
None d
No downgrading
Publication bias
NA e
No downgrading
Strength of
association
Small f
No upgrading

Int. J. Environ. Res. Public Health 2018, 15, 379 25 of 62
Factors
increasing
confidence
Exposure-response
gradient
No evidence of an exposure-
response gradient f
Nu upgrading
Possible
confounding
Non-residual misclassification of
disease
No upgrading
Overall judgement of quality of evidence
2 (Low) g
# Since a cohort study was available, we started with a grading of “high” (4); a Participants were a
(partly) random selection from people participating in the Stockholm Preventive Programm.
Hypertension was ascertained by both a clinical examination and a questionnaire; although it was not
possible to exactly assess the attrition rate, it was probably > 20%; b Since only one study was
evaluated, this criterion was not applied; c The study assessed population, exposure, and outcome of
interest; d We considered the results to be precise: the sample was sufficiently large, and the 95% CI
was sufficiently narrow; e Since only one study was evaluated, we were not able to test for publication
bias; f We found a non-significant effect size of 1.00 per 10 dB. The noise range of the evaluated study
was 45–65 dB (LDEN); g The overall judgement of the quality of evidence was graded as “moderate”
(3). Since only one study was available, we downgraded the overall level of evidence to “low” (2).
Table A19. Summary of findings table for the association between road traffic noise exposure and the
incidence of hypertension.
Question
Does Exposure to Road Traffic Noise Increase the Risk of Hypertension
People
Adult population (men and women, 50–64 years)
Setting
Residential setting: people living in Aarhus or Copenhagen (Denmark)
Outcome
The incidence of hypertension
Summary of
findings
RR per 10 dB increase in road traffic
noise level (LDEN)
0.97 (0.90–1.05) per 10 dB
Number of participants (# studies)
43,635 (1)
Number of cases
3145
Rating
Adjustment to rating
Quality
assessment
Starting rating
1 cohort study #
4 (high)
Factors
decreasing
confidence
Risk of bias
Serious limitations a
Downgrading
Inconsistency
Na b
No downgrading
Indirectness
None c
No downgrading
Imprecision
None d
No downgrading
Publication bias
NA e
No downgrading
Factors
increasing
confidence
Strength of association
NA f
No upgrading
Exposure-response
gradient
No evidence of exposure-
response gradient f
No upgrading
Possible confounding
None
No upgrading
Overall judgement of quality of evidence
2 (low) g
# Since a cohort study was available, we started with a grading of “high” (4); a Participants were people
participating in the DCH cohort. For this cohort, people living in Aarhus or Copenhagen, aged 50-64
years, and who were cancer-free, were randomly selected and invited. Attrition rate was > 20% after
three years of follow-up time. Hypertension was ascertained by a questionnaire; b Since only one
study was evaluated, this criterion was not applied; c The study assessed population, exposure, and
outcome of interest; d We considered the results to be precise: the sample was sufficiently large, and
the 95% CI was sufficiently narrow; e Since only one study was evaluated, we were not able to test for
publication bias; f We found a non-significant effect size of less than 1.00 per 10 dB; g The overall
judgement of the quality of evidence was graded “moderate”(3). Since only one study was available,
we downgraded the overall level of evidence to “low” (2).

Int. J. Environ. Res. Public Health 2018, 15, 379 26 of 62
Table A20. Summary of findings table for the association between rail traffic noise exposure and the
incidence of hypertension.
Question
Does Exposure to Rail Traffic Noise Increase the Risk of Hypertension
People
Adult population (men and women, 50–64 years)
Setting
Residential setting: people living in Aarhus or Copenhagen (Denmark)
Outcome
The incidence of hypertension
Summary of
findings
RR per 10 dB increase in road traffic noise
level (LDEN)
0.96 (0.88–1.04) per 10 dB
Number of participants (# studies)
7249 (1)
Number of cases
3145
Rating
Adjustment to
rating
Quality
assessment
Starting rating
1 cohort study #
4 (high)
Factors decreasing
confidence
Risk of bias
Serious limitations a
Downgrading
Inconsistency
NA b
No downgrading
Indirectness
None c
No downgrading
Imprecision
None d
No downgrading
Publication bias
NA e
No downgrading
Factors increasing
confidence
Strength of
association
NA f
No upgrading
Exposure-response
gradient
No evidence of an exposure-
response gradient f
No upgrading
Possible
confounding
None
No upgrading
Overall judgement of quality of evidence
2 (low) g
# Since a cohort study was available, we started with a grading of “high” (4); a Participants were people
participating in the DCH cohort. For this cohort, people living in Aarhus or Copenhagen, aged 50–64
years. and who were cancer-free, were randomly selected and invited. Attrition rate was > 20% after
three years of follow-up time. Hypertension was ascertained by a questionnaire; b Since only one
study was evaluated, this criterion was not applied; c The study assessed population, exposure, and
outcome of interest; d We considered the results to be precise: the sample was sufficiently large, and
the 95% CI was sufficiently narrow; e Since only one study was evaluated, we were not able to test for
publication bias; f We found a non-significant effect size of less than 1.00 per 10 dB; g The overall
judgement of the quality of evidence was graded as “moderate”(3). Since only one study was
available, we downgraded the overall level of evidence to “low” (2).

Int. J. Environ. Res. Public Health 2018, 15, 379 27 of 62
Appendix D. Summary of Findings Tables Dealing with Studies on the Impact of Noise on
Ischaemic Heart Disease
This appendix presents the summary of findings tables dealing with the studies on the impact
of noise on IHD. An extensive description and the reasoning behind these tables can be found in the
complete review in Section 11.2.
Table A21. Summary of findings table for the association between aircraft noise exposure and the
prevalence of ischaemic heart disease.
Question
Does Exposure to Aircraft Noise Increase the Risk of IHD
People
Adult population (men and women)
Setting
Residential setting: people living in cities located around airports in Europe
Outcome
The prevalence of IHD
Summary of
findings
RR per 10 dB increase in aircraft noise
level (LDEN)
1.07 (95% CI: 0.94–1.23)
Number of participants (# studies)
14,098 (2)
Number of cases
340
Rating
Adjustment to
rating
Quality
assessment
Starting rating
2 cross-sectional studies #
2 (low)
Factors
decreasing
confidence
Risk of bias
Serious a
Downgrading
Inconsistency
None b
No downgrading
Indirectness
None c
No downgrading
Imprecision
None d
No downgrading
Publication bias
NA e
No downgrading
Factors
increasing
confidence
Strength of association
Small f
No upgrading
Exposure-response
gradient
Evidence of a non- significant
exposure-response gradient f
No upgrading
Possible confounding
No conclusions can be drawn g
No upgrading
Overall judgement of quality of evidence
1 (very low)
# Since only cross-sectional studies were available, we started with a grading of “low” (2); a In both
studies, the population was selected randomly. Response rates were in both studies below 60%. In
the studies, IHD was ascertained by means of a questionnaire only; one of the studies was not able to
adjust for smoking; b Although results across studies differed in the magnitude if effect estimates,
both studies found a positive association between exposure to aircraft noise and the prevalence of
IHD (see Figure 5.1 of the complete review); c The studies assessed population, exposure and outcome
of interest; d We considered the results to be precise: the number of cases was large enough, and the
95% CI was sufficiently narrow; e Due to the low number of available effect estimates, it was not
possible to test for publication bias or small study bias; f Both studies found that the risk of IHD
increased when air traffic noise level increased (RR per 10 dB > 1).There was evidence of a non-
significant exposure-response gradient: After aggregating the results of the evaluated studies, we
found a non-significant effect size of 1.07 per 10 dB. The noise range of the studies under evaluation
was 30–70 dB (LDEN); g We were not able to draw any conclusions whether possible residual
confounders or biases would reduce our effect estimate.

Int. J. Environ. Res. Public Health 2018, 15, 379 28 of 62
Table A22. Summary of findings table for the association between road traffic noise exposure and the
prevalence of ischaemic heart disease.
Question
Does Exposure to Road Traffic Noise Increase the Risk of IHD
People
Adult population (men and women)
Setting
Residential setting: people living several cities in Europe
Outcome
The prevalence of IHD
Summary of
findings
RR per 10 dB increase in road traffic noise
level (LDEN)
1.24 (95% CI: 1.08–1.42) per 10 dB
Number of participants (# studies)
25,682 (8)
Number of cases
1614
Rating
Adjustment to rating
Quality
assessment
Starting rating
8 cross-sectional studies #
2 (low) #
Factors
decreasing
confidence
Risk of bias
Serious a
Downgrading
Inconsistency
Serious b
Downgrading
Indirectness
None c
No downgrading
Imprecision
Minor d
No downgrading
Publication bias
NA e
No downgrading
Factors
increasing
confidence
Strength of association
Large f
Upgrading
Exposure-response
gradient
Evidence of an exposure-
response gradient f
Upgrading
Possible confounding
Possible bias g
No upgrading
Overall judgement of quality of evidence
2 (low)
# Since only cross-sectional studies were available, we started with a grading of “low” (2); a Methods
used to select the population: In 6 studies, the participants were randomly selected taking into account
road traffic noise exposure. The response rates were below 60%. In four of the eight studies. In three
of the included studies, exposure was assessed by noise models incorporated in GIS. The noise models
used were able to estimate the noise levels at individual level. In four of the studies, IHD was
ascertained by means of a questionnaire only; b Results across studies differed only in the magnitude
of effect estimates (see Figure 5.2 of the complete review). This was confirmed by the results of the
heterogeneity analyses, indicating “moderate” heterogeneity (I2residual = 51.4%); c The studies assessed
population, exposure and outcome of interest; d We considered the results to be less precise: the
number of cases was large enough, and although the 95% CI contained values > 1.25, we considered
the sample size as sufficiently large; e Due to the low number of available effect estimates, it was not
possible to test for publication bias or small study bias; f All studies found that the risk of IHD
increased when road traffic noise level increased (RR per 10 dB > 1). There was evidence of a
significant exposure-response gradient: After aggregating the results of the evaluated studies, we
found a significant effect size of 1.24 per 10 dB. The noise range of the studies under evaluation was
30–80 dB. This means that if road traffic noise level increases from 30 to 80 dB, the RR = 2.93; g
Adjustment for smoking and indicators of air pollution were found to be important sources of
heterogeneity.
Table A23. Summary of findings table for the association between rail traffic noise exposure and the
prevalence of ischaemic heart disease.
Question
Does exp$osure to Rail Traffic Noise Increase the Risk of IHD
People
Adult population (men and women)
Setting
Residential setting: people living several cities in Europe
Outcome
The prevalence of IHD
Summary of findings
RR per 10 dB increase in road traffic
noise level (LDEN)
1.18 (95% CI: 0.82–1.68) per 10 dB
Number of participants (# studies)
13,241 (4)
Number of cases
283
Rating
Adjustment to
rating
Quality
assessment
Starting rating
4 cross-sectional studies
2 (low) #
Factors
decreasing
confidence
Risk of bias
Serious a
Downgrading
Inconsistency
Serious b
Downgrading
Indirectness
None c
No
downgrading

Int. J. Environ. Res. Public Health 2018, 15, 379 29 of 62
Imprecision
Minor d
No
downgrading
Publication bias
NA e
No
downgrading
Factors increasing
confidence
Strength of association
Large, but non-significant f
No upgrading
Exposure-response gradient
Evidence of a non-significant
exposure-response gradient f
No upgrading
Possible confounding
No conclusions can be
drawn g
No upgrading
Overall judgement of quality of evidence
0 (very low)
# Since only cross-sectional studies were available, we started with a grading of “low” (2); a Response
rates were in two of the four studies below 60%. In all studies, IHD was ascertained by means of a
questionnaire only; b Results across studies differed in the magnitude and direction of effect estimates
(see Figure 5.7 of the complete review). This was confirmed by the results of the heterogeneity
analyses, indicating “moderate” heterogeneity (I2residual = 57.4%); c The studies assessed population,
exposure and outcome of interest; d We considered the results to be less precise: the 95% CI contained
values > 1.25; however, we considered the sample size to be sufficiently large; e Due to the low number
of available effect estimates, it was not possible to test for publication bias or small study bias; f Most
studies found that the risk of IHD increased when rail traffic noise level increased (RR per 10 dB > 1).
There was evidence of a non-significant exposure-response gradient: After aggregating the results of
the evaluated studies, we found a non-significant effect size of 1.18 per 10 dB. The noise range of the
studies under evaluation was 30–80 dB. This means that if rail traffic noise level increases from 30 to
80 dB, the RR = 2.29; g We were not able to draw any conclusions whether possible residual
confounders or biases would reduce our effect estimate.
Table A24. Summary of findings table for the association between aircraft noise exposure and the
incidence of ischaemic heart disease.
Question
Does Exposure to Aircraft Noise Increase the Risk of IHD
People
Adult population (men and women)
Setting
Residential setting: people living in cities located around airports in the UK and USA
Outcome
The incidence (hospital admissions) of IHD
Summary of
findings
RR per 10 dB increase in aircraft noise level (LDEN)
1.09 (95% CI: 1.04–1.15)
Number of participants (# studies)
9,619,082 (2)
Number of cases
158,977
Rating
Adjustment to rating
Quality
assessment
Starting rating
2 ecological studies
1 (very low) #
Factors decreasing
confidence
Risk of bias
Serious a
Downgrading
Inconsistency
Limited b
No downgrading
Indirectness
None c
No downgrading
Imprecision
None d
No downgrading
Publication bias
NA
No downgrading
Factors increasing
confidence
Strength of
association
Small f
No upgrading
Exposure-response
gradient
Evidence of a
significant exposure-
response gradient f
Upgrading
Possible confounding
No conclusions can
be drawn g
No upgrading
Overall judgement of quality of evidence
1 (very low)
# Since only ecological studies were available, we started with a grading of “very low” (1); a Both
ecological studies worked with a purposeful sample; so randomization and response rate is not an
issue. Studies were not able to adjust for important confounders at individual level. Studies were
unable to apply individual exposure estimates; b Although results across studies differed in the
magnitude of effect estimates, both found a positive association between exposure to aircraft noise
and the incidence of IHD (see Figure 5.1 of the complete review). This was confirmed by the results
of the heterogeneity analyses, indicating “low” heterogeneity (I2residual = 48.4%); c The studies assessed
population, exposure and outcome of interest; d We considered the results to be precise: the number
of participants, as well as the number of cases were much larger than 200, and the 95% CI did not

Int. J. Environ. Res. Public Health 2018, 15, 379 30 of 62
contain values below 0.75 or above 1.25; e Due to the low number of available effect estimates, it was
not possible to test for publication bias or small study bias; f There was evidence of a significant
exposure-response gradient: We found a significant effect size of 1.09 per 10 dB across a noise range
of 45 to ~65 dB, this means that if the aircraft noise level increases from 45 to 65 dB, the RR = 1.19; g
We were not able to draw any conclusions whether possible residual confounders or biases would
reduce our effect estimate.
Table A25. Summary of findings table for the association between road traffic noise exposure and the
incidence of ischaemic heart disease: ecological studies.
Question
Does Exposure to Road Traffic Noise Increase the Risk of IHD
People
Adult population (men and women)
Setting
Residential setting: people living in Kaunas (Lithuania)
Outcome
The incidence of IHD
Summary of
findings
RR per 10 dB increase in road traffic
noise level (LDEN)
1.12 (95% CI: 0.85–1.48) per 10 dB
Number of participants (# studies)
262,830 (1)
Number of cases
418
Rating
Adjustment to rating
Quality
assessment
Starting rating
1 ecological study
1 (very low) #
Factors
decreasing
confidence
Risk of bias
Serious a
Downgrading
Inconsistency
Na b
No downgrading
Indirectness
None c
No downgrading
Imprecision
None d
No downgrading
Publication bias
NA e
Downgrading
Factors
increasing
confidence
Strength of
association
NA f
No upgrading
Exposure-response
gradient
Evidence of non-significant
exposure-response gradient f
No upgrading
Possible
confounding
No conclusions can be drawn g
No upgrading
Overall judgement of quality of evidence
0 (very low) h
# Since only one ecological study was available, we started with a grading of “very low” (1); a
Ecological studies worked with a purposeful sample; so randomization and response rate is not an
issue. The study was not able to adjust for important confounders at individual level, and was unable
to apply individual exposure estimates; b Only one study was evaluated, so inconsistency was not an
issue; c The study assessed population, exposure and outcome of interest; d Although the 95% CI
contained values above 1.25, we considered the results to be precise: the number of participants, as
well as the number of cases were much larger than 200; e Due to the low number of available effect
estimates, it was not possible to test for publication bias or small study bias. However, when
combining this study with the other case-control and cohort studies that investigated the association
between road traffic noise and the incidence of IHD, the number of estimates became large enough to
test for publication bias. The funnel plot (Figure 5.6 of the complete review) was somewhat a-
symmetric, but the Egger test provided only weak evidence for small-study effects; f There was
evidence of a non-significant exposure-response gradient: We found a non-significant effect size of
1.12 per 10 dB across a noise range of 55–75 dB; g We were not able to draw any conclusions whether
possible residual confounders or biases would reduce our effect estimate; h The overall judgement of
the quality of the evidence was “very low”(0). Downgrading of the overall level of evidence, because
only one study was available, made no sense.

Int. J. Environ. Res. Public Health 2018, 15, 379 31 of 62
Table A26. Summary of findings table for the association between road traffic noise exposure and the
incidence of ischaemic heart disease: cohort and case-control studies.
Question
Does Exposure to Road Traffic Noise Increase the Risk of IHD
People
Adult population (men and women)
Setting
Residential setting: people living several cities in Europe
Outcome
The incidence of IHD
Summary of
findings
RR per 10 dB increase in road traffic
noise level (LDEN)
1.08 (95% CI: 1.01–1.15) per 10 dB
Number of participants (# studies)
67,224 (7)
Number of cases
7033
Rating
Adjustment to rating
Quality
assessment
Starting rating
3 cohort studies, 4 case-control
studies
4 (high) #
Factors
decreasing
confidence
Risk of bias
Limited a
No downgrading
Inconsistency
Limited b
No downgrading
Indirectness
None c
No downgrading
Imprecision
None d
No downgrading
Publication bias
Small probability of publication
bias e
Downgrading
Factors
increasing
confidence
Strength of
association
Small f
No upgrading
Exposure-response
gradient
Evidence of an exposure-
response gradient f
Upgrading
Possible
confounding
No conclusions can be drawn g
No upgrading
Overall judgement of quality of evidence
4 (high)
# Since cohort and case-control studies were available, we started with a grading of “high” (4); a In all
the studies, the participants were randomly selected. For six studies, the response rate was higher
than 60%; in all the cohort studies, the loss to follow-up was less than 20%. Methods to assess
exposure: In three of the included studies, exposure was assessed by noise models incorporated in
GIS. The noise models used were able to estimate the noise levels at individual level. In three other
studies, noise exposure assessment was based on noise measurements in the direct living area of the
participant; b Results across studies differed only in the magnitude of effect estimates (see Figure 5.3
of the complete review). The results of the heterogeneity analyses demonstrated no clear evidence for
heterogeneity; c The study assessed population, exposure and outcome of interest; d We considered
the results as precise: The number of participants and cases were much larger than 200, and the 95%
CI did not contain values below 0.75 or above 1.25; e Due to the low number of available effect
estimates, it was not possible to test for publication bias or small study bias. However, when
combining these studies with the ecological study that investigated the association between road
traffic noise and the incidence of IHD, the number of estimates became large enough to test for
publication bias. The funnel plot (Figure 5.6) was somewhat a-symmetric, but the Egger test provided
only weak evidence for small-study effects; f Most studies found that the risk of IHD increased when
road traffic noise level increased (RR per 10 dB > 1). There was evidence of a significant exposure-
response gradient: After aggregating the results of the evaluated studies, we found a significant effect
size of 1.08 per 10 dB. The noise range of the studies under evaluation was 40–80 dB. This means that
if road traffic noise level increases from 40 to 80 dB, the RR = 1.36; g We were not able to draw any
conclusions whether possible residual confounders or biases would reduce our effect estimate.

Int. J. Environ. Res. Public Health 2018, 15, 379 32 of 62
Table A27. Summary of findings table for the association between aircraft noise exposure and
mortality due to ischaemic heart disease: ecological studies.
Question
Does Exposure to Aircraft Noise Increase the Risk of IHD
People
Adult population (men and women)
Setting
Residential setting: people living in cities located around airports in the UK and The Netherlands
Outcome
Mortality due to IHD
Summary of
findings
RR per 10 dB increase in aircraft noise level (LDEN)
1.04 (95% CI: 0.97–1.12)
Number of participants (# studies)
3,897,645 (2)
Number of cases
26,066
Rating
Adjustment to rating
Quality
assessment
Starting rating
2 ecological studies
1 (very low) #
Factors decreasing
confidence
Risk of bias
Serious a
Downgrading
Inconsistency
Limited b
No downgrading
Indirectness
None c
No downgrading
Imprecision
None d
No downgrading
Publication bias
NA e
No downgrading
Factors increasing
confidence
Strength of association
Small f
No upgrading
Exposure-response gradient
Evidence of a non-significant
exposure-response gradient f
No upgrading
Possible confounding
No conclusions can be drawn g
No upgrading
Overall judgement of quality of evidence
0 (very low)
# Since only ecological studies were available, we started with a grading of “very low” (0); a Both
ecological studies worked with a purposeful sample; so randomization and response rate is not an
issue. Studies were not able to adjust for important confounders at individual level. Studies were
unable to apply individual exposure estimates; b Results across studies differed in the magnitude and
direction of effect estimates (see Figure 5.1 of the complete review). This was not confirmed by the
results of the heterogeneity analyses, demonstrating “low” heterogeneity (I2residual = 39.7%); c The
studies assessed population, exposure and outcome of interest; d We considered the results to be
precise: Both the number of participants and cases were much larger than 200; the 95% CI did not
contain values below 0.75 or above 1.25; e Due to the low number of available effect estimates, it was
not possible to test for publication bias or small study bias; f One of the two studies found that the risk
of IHD increased when air traffic noise level increased (RR per 10 dB > 1). There was evidence of a
non-significant exposure-response gradient: After aggregating the results of the evaluated studies,
we found a non-significant effect size of 1.04 per 10 dB. The noise range of the studies under
evaluation was 40–65 dB; g We were not able to draw any conclusions whether possible residual
confounders or biases would reduce our effect estimate.
Table A28. Summary of findings table for the association between aircraft noise exposure and
mortality due to ischaemic heart disease: cohort studies.
Question
Does Exposure to Aircraft Noise Increase the Risk of IHD
People
Adult population (men and women)
Setting
Residential setting: people living in Switzerland
Outcome
Mortality due to IHD
Summary of
findings
RR per 10 dB increase in aircraft noise level (LDEN)
1.04 (95% CI: 0.98–1.11) per 10 dB
Number of participants (# studies)
4,580,311 (1)
Number of cases
15,532
Rating
Adjustment to
rating
Quality
assessment
Starting rating
1 cohort study
4 (high) #
Factors decreasing
confidence
Risk of bias
Serious a
Downgrading
Inconsistency
Na b
No downgrading
Indirectness
None c
No downgrading
Imprecision
None d
No downgrading
Publication bias
NA e
No downgrading
Factors increasing
confidence
Strength of
association
Small f
No upgrading
Exposure-response
gradient
Evidence of a non-significant exposure-
response gradient f
No upgrading
Possible confounding
No conclusions can be drawn g
No upgrading
Overall judgement of quality of evidence
2 (low) h
# Since a cohort study was available, we started with a grading of “high” (4); a Aircraft noise levels
were available at 100 × 100 m grids and the study suffered from a lack of information about important
life style factors; b Only one study was evaluated, so inconsistency was not an issue (see Figure 5.1 of

Int. J. Environ. Res. Public Health 2018, 15, 379 33 of 62
the complete review); c The study assessed population, exposure and outcome of interest. d We
considered the results to be precise: Both the number of participants and cases were much larger than
200. The 95% CI did not contain values below 0.75 or above 1.25; e Due to the low number of available
effect estimates, it was not possible to test for publication bias or small study bias; f There was evidence
of a non-significant exposure-response gradient: We found a non-significant effect size of 1.04 per 10
dB across a noise range of 40 to 60 dB; g We were not able to draw any conclusions whether possible
residual confounders or biases would reduce our effect estimate; h We graded the overall quality of
evidence as “moderate”. Since only one study was available, we downgraded the overall level of
evidence to “low” (2).
Table A29. Summary of findings table for the association between road traffic noise exposure and
mortality due to ischaemic heart disease: cohort and case-control studies.
Question
Does Exposure to Road Traffic Noise Increase the Risk of IHD
People
Adult population (men and women)
Setting
Residential setting: people living several cities in Europe
Outcome
Mortality due to IHD
Summary of
findings
RR per 10 dB increase in road traffic noise level
(LDEN)
1.05 (95% CI: 0.97–1.13) per 10 dB
Number of participants (# studies)
532,268 (3)
Number of cases
6884
Rating
Adjustment to rating
Quality
assessment
Starting rating
1 cohort studies, 2
case-control studies
4 (high) #
Factors decreasing
confidence
Risk of bias
Limited a
Downgrading
Inconsistency
Limited b
No downgrading
Indirectness
None c
No downgrading
Imprecision
None d
No downgrading
Publication bias
NA e
No downgrading
Factors increasing
confidence
Strength of
association
Small f
No upgrading
Exposure-response
gradient
Evidence of a non-
significant exposure-
response gradient f
No upgrading
Possible confounding
No conclusions can
be drawn g
No upgrading
Overall judgement of quality of evidence
3 (moderate)
# Since cohort and case-control studies were available, we started with a grading of “high” (4); a For
the largest of the three studies, there was a possible risk of bias since there were worries with regard
to exposure assessment, and one was not able to adjust for smoking; b Results across studies differed
in the magnitude and direction of effect estimates (see Figure 5.5 of the complete review). This was
not confirmed by the heterogeneity analyses, demonstrating “low” heterogeneity (I2residual = 34.9%); c
The study assessed population, exposure and outcome of interest; d We considered the results to be
precise: Both the number of participants and cases were much larger than 200. The 95% CI did not
contain values below 0.75 or above 1.25; e Due to the low number of available effect estimates, it was
not possible to test for publication bias or small study bias; f Most studies found that the risk of IHD
increased when road traffic noise level increased (RR per 10 dB > 1). There was evidence of a non-
significant exposure-response gradient: After aggregating the results of the evaluated studies, we
found a non-significant effect size of 1.05 per 10 dB. The noise range of the studies under evaluation
was 42–70 dB; g We were not able to draw any conclusions whether possible residual confounders or
biases would reduce our effect estimate.
Appendix E. Summary of Findings Tables Dealing with Studies on the Impact of Noise on
Stroke
This appendix presents the summary of findings tables dealing with the studies on the impact
of noise on stroke. An extensive description and the reasoning behind these tables can be found in
the complete review in Section 11.3.

Int. J. Environ. Res. Public Health 2018, 15, 379 34 of 62
Table A30. Summary of findings table for the association between aircraft noise exposure and the
prevalence of stroke.
Question
Does Exposure to Aircraft Noise Increase the Risk of Stroke
People
Adult population (men and women)
Setting
Residential setting: people living in cities located around airports in Europe and The Netherlands
Outcome
The prevalence of stroke
Summary of
findings
RR per 10 dB increase in aircraft noise level (LDEN)
1.02 (95% CI: 0.80–1.28)
Number of participants (# studies)
14,098 (2)
Number of cases
151
Rating
Adjustment to rating
Quality
assessment
Starting rating
2 cross-sectional
studies #
2 (low)
Factors decreasing
confidence
Risk of bias
Serious a
Downgrading
Inconsistency
Limited b
No downgrading
Indirectness
None c
No downgrading
Imprecision
Serious d
Downgrading
Publication bias
NA e
No downgrading
Factors increasing
confidence
Strength of
association
Small f
No upgrading
Exposure-response
gradient
Evidence of a non-
significant exposure-
response gradient f
No upgrading
Possible confounding
No conclusions can
be drawn g
No upgrading
Overall judgement of quality of evidence
0 (very low)
# Since only cross-sectional studies were available, we started with a grading of “low” (2); a Response
rates were in both studies below 60%. In the studies, stroke was ascertained by means of a
questionnaire only; one of the two studies was not able to adjust for smoking; b Results between
studies differed in the magnitude and direction of effect estimates (see Figure 6.1 of the complete
review). This was not confirmed by the result of the heterogeneity analysis, demonstrating “low”
heterogeneity (I2residual = 0.0%); c The studies assessed population, exposure and outcome of interest; d
We considered the results to be imprecise: The number of cases was smaller than 200, and the 95% CI
was judged as not sufficiently narrow; e Due to the low number of available effect estimates, it was
not possible to test for publication bias or small study bias; f One the two studies found that the risk
of stroke increased when air traffic noise level increased (RR per 10 dB > 1). There was evidence of a
non-significant exposure-response gradient: After aggregating the results of the evaluated studies,
we found a non-significant effect size of 1.02 per 10 dB. The noise range of the studies under
evaluation was 30–75 dB; g We were not able to draw any conclusions whether possible residual
confounders or biases would reduce our effect estimate.
Table A31. Summary of findings table for the association between road traffic noise exposure and the
prevalence of stroke.
Question
Does Exposure to Road Traffic Noise Increase the Risk of Stroke
People
Adult population (men and women)
Setting
Residential setting: people living in cities located around airports in Europe and The Netherlands
Outcome
The prevalence of stroke
Summary of
findings
RR per 10 dB increase in road traffic noise level (LDEN)
1.00 (95% CI: 0.91–1.10) per 10 dB
Number of participants (# studies)
14,098 (2)
Number of cases
151
Rating
Adjustment to rating
Quality
assessment
Starting rating
2 cross-sectional studies #
2 (low)
Factors decreasing
confidence
Risk of bias
Serious a
Downgrading
Inconsistency
Limited b
No downgrading
Indirectness
None c
No downgrading
Imprecision
Serious d
Downgrading
Publication bias
NA e
No downgrading
Factors increasing
confidence
Strength of association
NA f
No upgrading
Exposure-response
gradient
No evidence of an
exposure-response
gradient f
No upgrading

Int. J. Environ. Res. Public Health 2018, 15, 379 35 of 62
Possible confounding
No conclusions can be
drawn g
No upgrading
Overall judgement of quality of evidence
0 (very low)
# Since only cross-sectional studies were available, we started with a grading of “low” (2); a Response
rates were in both studies below 60%. In the studies, stroke was ascertained by means of a
questionnaire only; one of the two studies was not able to adjust for smoking; b Results between
studies differed in the magnitude and direction of effect estimates (see Figure 6.2 of the complete
review). This was not confirmed by the result of the heterogeneity analysis, demonstrating “low”
heterogeneity (I2residual = 0.0%); c The studies assessed population, exposure and outcome of interest; d
We considered the results to be imprecise since the number of cases was smaller than 200. The 95%
CI was judged as sufficiently narrow; e Due to the low number of available effect estimates, it was not
possible to test for publication bias or small study bias; f One the two studies found that the risk of
stroke increased when road traffic noise level increased (RR per 10 dB > 1). There was no evidence of
an exposure-response gradient: After aggregating the results of the evaluated studies, we found a
non-significant effect size of 1.00 per 10 dB. The noise range of the studies under evaluation was 30–
75 dB; g We were not able to draw any conclusions whether possible residual confounders or biases
would reduce our effect estimate.
Table A32. Summary of findings table for the association between rail traffic noise exposure and the
prevalence of stroke.
Question
Does Exposure to Rail Traffic Noise Increase the Risk of Stroke
People
Adult population (men and women)
Setting
Residential setting: people living in cities around airports in The Netherlands
Outcome
The prevalence of stroke
Summary of
findings
RR per 10 dB increase in road traffic noise level (LDEN)
1.07 (95% CI: 0.92–1.25) per 10 dB
Number of participants (# studies)
9365 (1)
Number of cases
89
Rating
Adjustment to rating
Quality
assessment
Starting rating
1 cross-sectional study #
2 (low)
Factors decreasing
confidence
Risk of bias
Serious a
Downgrading
Inconsistency
NA b
No downgrading
Indirectness
None c
No downgrading
Imprecision
Serious d
Downgrading
Publication bias
NA e
No downgrading
Factors increasing
confidence
Strength of association
Small, but non-
significant f
No upgrading
Exposure-response
gradient
Evidence of a non-
significant exposure-
response gradient f
No upgrading
Possible confounding
No conclusions can be
drawn g
No upgrading
Overall judgement of quality of evidence
0 (very low) h
# Since one cross-sectional study was available, we started with a grading of “low” (2); a Response rate
was below 60%, and stroke was ascertained by means of a questionnaire only; b NA; c The study
assessed population, exposure and outcome of interest; d We considered the results to be imprecise:
Although the 95% CI was considered as sufficiently narrow, we considered the number of cases to be
small; e Due to the low number of available effect estimates, it was not possible to test for publication
bias or small study bias; f The evaluated study found that the risk of stroke increased when rail traffic
noise level increased (RR per 10 dB > 1). There was evidence of a non-significant exposure-response
gradient: We found a non-significant effect size of 1.07 per 10 dB. The noise range of the study under
evaluation was 30–65 dB; g We were not able to draw any conclusions whether possible residual
confounders or biases would reduce our effect estimate; h We graded the overall quality of the
evidence to be “very low” (0). Grading the overall judgement of the quality of evidence down with
one level was not considered to be useful. Despite the fact that only one study was available, we did
not downgrade the overall level of evidence. The overall judgement of the quality of evidence was
already judged as “very low”.

Int. J. Environ. Res. Public Health 2018, 15, 379 36 of 62
Table A33. Summary of findings table for the association between aircraft noise exposure and the
incidence of stroke: ecological studies.
Question
Does Exposure to Aircraft Noise Increase the Risk of Stroke
People
Adult population (men and women)
Setting
Residential setting: people living in cities located around airports in the UK and USA
Outcome
The incidence (hospital admissions) of stroke
Summary of
findings
RR per 10 dB increase in aircraft noise level (LDEN)
1.05 (95% CI: 0.96–1.15)
Number of participants (# studies)
9,619,082 (2)
Number of cases
97,949
Rating
Adjustment to rating
Quality
assessment
Starting rating
2 ecological studies
1 (very low)
Factors decreasing
confidence
Risk of bias
Serious a
Downgrading
Inconsistency
Serious b
Downgrading
Indirectness
None c
No downgrading
Imprecision
None d
No downgrading
Publication bias
NA
No downgrading
Factors increasing
confidence
Strength of
association
Small f
No upgrading
Exposure-response
gradient
Evidence of a non-
significant exposure-
response gradient f
No upgrading
Possible confounding
No conclusions can
be drawn g
No upgrading
Overall judgement of quality of evidence
0 (very low)
# Since only ecological studies were available, we started with a grading of “very low” (1); a Both
ecological studies worked with a purposeful sample; so randomization and response rate is not an
issue. Studies were not able to adjust for important confounders at individual level. Studies were
unable to apply individual exposure estimates; b Results between studies differed in the magnitude
and direction of effect estimates (see Figure 6.1 of the complete review). This was confirmed by the
result of the heterogeneity analysis, indicating “strong” heterogeneity (I2residual = 82.7%); c The studies
assessed population, exposure and outcome of interest; d We considered the results to be precise: Both
the number of participants and cases were much larger than 200. The 95% CI did not contain values
below 0.75 or above 1.25; e Due to the low number of available effect estimates, it was not possible to
test for publication bias or small study bias; f One the two studies found that the risk of stroke
increased when air traffic noise level increased (RR per 10 dB > 1). There was evidence of a non-
significant exposure-response gradient: After aggregating the results of the evaluated studies, we
found a non-significant effect size of 1.05 per 10 dB. The noise range of the studies under evaluation
was 40 to approximately 65 dB; g We were not able to draw any conclusions whether possible residual
confounders or biases would reduce our effect estimate.

Int. J. Environ. Res. Public Health 2018, 15, 379 37 of 62
Table A34. Summary of findings table for the association between road traffic noise exposure and the
incidence of stroke.
Question
Does Exposure to Road Traffic Noise Increase the Risk of Stroke
People
Adult population (men and women)
Setting
Residential setting: people living in several cities in Denmark
Outcome
The incidence of stroke
Summary of
findings
RR per 10 dB increase in road traffic noise level
(LDEN)
1.14 (95% CI: 1.03–1.25) per 10 dB
Number of participants (# studies)
51,485 (1)
Number of cases
1,881
Rating
Adjustment to Rating
Quality
assessment
Starting rating
1 cohort study
4 (high)
Factors decreasing
confidence
Risk of bias
Limited a
No downgrading
Inconsistency
NA b
No downgrading
Indirectness
None c
No downgrading
Imprecision
None d
No downgrading
Publication bias
NA e
No downgrading
Factors increasing
confidence
Strength of
association
Small f
No upgrading
Exposure-response
gradient
Evidence of an
exposure-response
gradient f
Upgrading
Possible confounding
No conclusions can
be drawn g
No upgrading
Overall judgement of quality of evidence
3 (moderate) h
# Since one cohort study was available, we started with a grading of ”high” (4); a No limitations in
study design found; b Only one study was evaluated, so inconsistency was not an issue; c The study
assessed population, exposure and outcome of interest; d We considered the results of the study to be
precise: Both the number of participants and cases were much larger than 200. The 95% CI did not
contain values below 0.75 or above 1.25; e The number of available effect estimates was too small to
test for publication bias; f The evaluated study found that the risk of stroke increased when road traffic
noise level increased (RR per 10 dB > 1). There was evidence of a significant exposure-response
gradient: We found a significant effect size of 1.14 per 10 dB. The noise range of the study under
evaluation was approximately 50 to 70 dB. This means that if the road traffic noise level increases
from 50 to 70 dB, the RR = 1.30; g We were not able to draw any conclusions whether possible residual
confounders or biases would reduce our effect estimate; h We graded the overall quality of the
evidence to be “high” (4). Since only one study was available, we downgraded the overall level of
evidence to “moderate” (3).
Table A35. Summary of findings table for the association between aircraft noise exposure and
mortality due to stroke: ecological studies.
Question
Does Exposure to Aircraft Noise Increase the Risk of Stroke
People
Adult population (men and women)
Setting
Residential setting: people living in cities located around airports in the UK and The Netherlands
Outcome
Mortality due to stroke
Summary of
findings
RR per 10 dB increase in aircraft noise level (LDEN)
1.07 (95% CI: 0.98–1.17)
Number of participants (# studies)
3,897,645 (2)
Number of cases
12,086
Rating
Adjustment to
rating
Quality
assessment
Starting rating
2 ecological studies
1 (very low)
Factors decreasing
confidence
Risk of bias
Serious a
Downgrading
Inconsistency
Limited b
No downgrading
Indirectness
None c
No downgrading
Imprecision
None d
No downgrading
Publication bias
NA
No downgrading
Factors increasing
confidence
Strength of
association
Small f
No upgrading
Exposure-response
gradient
Evidence of a non- significant exposure-
response gradient f
No upgrading
Possible confounding
No conclusions can be drawn g
No upgrading
Overall judgement of quality of evidence
0 (very low)

Int. J. Environ. Res. Public Health 2018, 15, 379 38 of 62
# Since we only ecological studies were available, we started with a grading of “very low” (1); a Both
ecological studies worked with a purposeful sample; so randomization and response rate is not an
issue. Studies were not able to adjust for important confounders at individual level. Studies were
unable to apply individual exposure estimates; b Results between studies differed in the magnitude
of effect estimates (see Figure 6.1 of the complete review). The result of the heterogeneity analysis
demonstrated “low” heterogeneity (I2residual = 28.5%); c The studies assessed population, exposure and
outcome of interest; d We considered the results to be precise: Both the number of participants and
cases were much larger than 200. The 95% CI did not contain values below 0.75 or above 1.25; e Due
to the low number of available effect estimates, it was not possible to test for publication bias or small
study bias; f Both studies found that the risk of stroke increased when air traffic noise level increased
(RR per 10 dB > 1). There was evidence of a non-significant exposure-response gradient: After
aggregating the results of the evaluated studies, we found a non-significant effect size of 1.07 per 10
dB. The noise range of the studies under evaluation was approximately 40 to 65 dB. This means that
if the aircraft noise level increases from 40 to 65 dB, the RR = 1.18; g We were not able to draw any
conclusions whether possible residual confounders or biases would reduce our effect estimate.
Table A36. Summary of findings table for the association between aircraft noise exposure and the
mortality due to stroke: cohort studies.
Question
Does Exposure to Air Traffic Noise Increase the Risk of Stroke
People
Adult population (men and women)
Setting
Residential setting: people living in several cities near airports in Switzerland
Outcome
Mortality due to stroke
Summary of
findings
RR per 10 dB increase in air traffic noise level (LDEN)
0.99 (95% CI: 0.94–1.04) per 10 dB
Number of participants (# studies)
4,580,311 (1)
Number of cases
25,231
Rating
Adjustment to
rating
Quality
assessment
Starting rating
1 cohort study
4 (high)
Factors decreasing
confidence
Risk of bias
Limited a
No downgrading
Inconsistency
NA b
No downgrading
Indirectness
None c
No downgrading
Imprecision
None d
No downgrading
Publication bias
NA e
No downgrading
Factors increasing
confidence
Strength of association
NA f
No upgrading
Exposure-response
gradient
No evidence of an exposure-
response gradient f
No upgrading
Possible confounding
No conclusions can be drawn g
No upgrading
Overall judgement of quality of evidence
3 (moderate) g
# Since one cohort study was available, we started with a grading of “high” (4); a No limitations in
study design found; b Only one study was evaluated, so inconsistency was not an issue; c The study
assessed population, exposure and outcome of interest; d We considered the results to be precise: Both
the number of participants and cases were much larger than 200. The 95% CI did not contain values
below 0.75 or above 1.25; e The number of available effect estimates was too small to test for
publication bias; f The evaluated study did not find that the risk of stroke increased when air traffic
noise level increased (RR per 10 dB < 1). There was no evidence of a gradient: We found a non-
significant effect size of 0.99 per 10 dB. The noise range of the study under evaluation was
approximately 40 to 65 dB; g We graded the overall quality of the evidence to be “high”. Since only
one study was available, we downgraded the overall level of evidence “moderate” (3).
Table A37. Summary of findings table for the association between road traffic noise exposure and
mortality due to stroke.
Question
Does Exposure to Road Traffic Noise Increase the Risk of Stroke
People
Adult population (men and women)
Setting
Residential setting: people living in several cities in Denmark, The Netherlands and Canada
Outcome
Mortality due to stroke
Summary of
findings
RR per 10 dB increase in road traffic noise
level (LDEN)
0.87 (95% CI: 0.71–1.06) per 10 dB
Number of participants (# studies)
581,517 (3)
Number of cases
2634

Int. J. Environ. Res. Public Health 2018, 15, 379 39 of 62
Rating
Adjustment to Rating
Quality
assessment
Starting rating
3 cohort studies
4 (high)
Factors decreasing
confidence
Risk of bias
Limited a
No downgrading
Inconsistency
Serious b
Downgrading
Indirectness
None c
No downgrading
Imprecision
Limited d
No downgrading
Publication bias
NA e
No downgrading
Factors increasing
confidence
Strength of
association
NA f
No upgrading
Exposure-response
gradient
No evidence of an exposure-
response gradient f
No upgrading
Possible
confounding
No conclusions can be drawn g
No upgrading
Overall judgement of quality of evidence
3 (moderate)
# Since cohort studies were available, we started with a grading of “high” (4); a No limitations in study
design found; b Results across studies differed in the magnitude and direction of effect estimates (see
also Figure 6.2). This was confirmed by the results of the heterogeneity analysis, demonstrating
“strong” heterogeneity (I2residual = 78.0%); c The study assessed population, exposure and outcome of
interest; d We considered the results to be precise enough: Both the number of participants and cases
were much larger than 200. However, the 95% CI did contain values below 0.75; e The number of
available effect estimates were too small to test for publication bias; f Only one of the evaluated studies
found that the risk of stroke increased when road traffic noise level increased (RR per 10 dB > 1). There
was no evidence of an exposure-response gradient: After aggregating the results of the studies, a non-
significant effect size of 0.87 per 10 dB across a noise range of ~50 to 70 dB was found; g We were not
able to draw any conclusions whether possible residual confounders or biases would reduce our effect
estimate.
Appendix F. Summary of Findings Tables Dealing with Studies on the Impact of Noise on
Diabetes
This appendix presents the summary of findings tables dealing with the studies on the impact
of noise on diabetes. An extensive description and the reasoning behind these tables can be found in
the complete review in Section 11.4.
Table A38. Summary of findings table for the association between aircraft noise exposure and the
prevalence of diabetes.
Question
Does Exposure to Aircraft Noise Increase the Risk of Diabetes
People
Adult population (men and women)
Setting
Residential setting: people living in cities located around airports in The Netherlands
Outcome
The prevalence of diabetes
Summary of
findings
RR per 10 dB increase in aircraft noise level (LDEN)
1.01 (95% CI: 0.78–1.31)
Number of participants (# studies)
9365 (1)
Number of cases
89
Rating
Adjustment to Rating
Quality
assessment
Starting rating
1 cross-sectional
study #
2 (low)
Factors decreasing
confidence
Risk of bias
Serious a
Downgrading
Inconsistency
NA b
No downgrading
Indirectness
None c
No downgrading
Imprecision
Serious d
Downgrading
Publication bias
NA e
No downgrading
Factors increasing
confidence
Strength of association
Small f
No upgrading
Exposure-response
gradient
Evidence of a non-
significant exposure-
response gradient f
No upgrading
Possible confounding
No conclusions can
be drawn g
No upgrading
Overall judgement of quality of evidence
0 (very low) h

Int. J. Environ. Res. Public Health 2018, 15, 379 40 of 62
# Since only one cross-sectional study was available, we started with a grading of “low” (2); a The
response rates was below 60%. Diabetes was ascertained by means of a questionnaire only; the study
was not able to adjust for smoking; b Since only one study is available, this criterion is not applicable;
c The study assessed population, exposure and outcome of interest; d We considered the results to be
imprecise: The number of cases was small, and the 95% CI was not sufficiently narrow; e Since the
results of only one study were available it was not possible to test for publication bias or small study
bias; f The evaluated study found that the risk of diabetes increased when air traffic noise level
increased (RR per 10 dB > 1). There was evidence of a non-significant exposure-response gradient: we
found a non-significant effect size of 1.01 per 10 dB. The noise range of the studies under evaluation
was 30–65 dB. this means that if the air traffic noise level increases from 30 to 65 dB, the RR = 1.04; g
We were not able to draw any conclusions whether possible residual confounders or biases would
reduce our effect estimate; h We graded overall quality of the evidence to be “very low” (0). Despite
the fact that only one study was available, it was not useful to downgrade the overall quality of
evidence.
Table A39. Summary of findings table for the association between road traffic noise exposure and the
prevalence of diabetes.
Question
Does Exposure to Road Traffic Noise Increase the Risk of Diabetes
People
Adult population (men and women)
Setting
Residential setting: people living in cities located around airports in The Netherlands and Stockholm
Outcome
The prevalence of diabetes
Summary of
findings
RR per 10 dB increase in road noise level (LDEN)
NR
Number of participants (# studies)
11,460 (2)
Number of cases
242
Rating
Adjustment to Rating
Quality
assessment
Starting rating
2 cross-sectional
study #
2 (low)
Factors decreasing
confidence
Risk of bias
Serious a
Downgrading
Inconsistency
Limited b
No downgrading
Indirectness
None c
No downgrading
Imprecision
Serious d
Downgrading
Publication bias
NA e
No downgrading
Factors increasing
confidence
Strength of association
NA f
No upgrading
Exposure-response
gradient
NA f
No upgrading
Possible confounding
No conclusions can
be drawn g
No upgrading
Overall judgement of quality of evidence
0 (very low)
# Since only cross-sectional studies were available, we started with a grading of “low” (2); a In one of
the studies, the response rate was below 60%. In the studies, diabetes was ascertained by means of a
questionnaire only; b Results of the studies differed in the magnitude of effect estimates; c The studies
assessed population, exposure and outcome of interest; d We considered the results of the studies to
be imprecise: Although the number of cases was > 200, the 95% CIs of the separate studies were not
sufficiently narrow; e Since the results of only two studies were available it was not possible to test for
publication bias or small study bias; f Both studies found that the risk of diabetes increased when road
traffic noise level increased (RR per 10 dB > 1). A meta-analysis was not carried out; g We were not
able to draw any conclusions whether possible residual confounders or biases would reduce our effect
estimate.
Table A40. Summary of findings table for the association between rail traffic noise exposure and the
prevalence of diabetes.
Question
Does Exposure to Rail Traffic Noise Increase the Risk of Diabetes
People
Adult population (men and women)
Setting
Residential setting: people living in cities located around airports in The Netherlands
Outcome
The prevalence of diabetes
Summary of
findings
RR per 10 dB increase in rail noise level (LDEN)
0.21 (95% CI: 0.05–0.82)
Number of participants (# studies)
9365 (1)

Int. J. Environ. Res. Public Health 2018, 15, 379 41 of 62
Number of cases
89
Rating
Adjustment to Rating
Quality
assessment
Starting rating
1 cross-sectional
study #
2 (low)
Factors decreasing
confidence
Risk of bias
Serious a
Downgrading
Inconsistency
NA b
No downgrading
Indirectness
None c
No downgrading
Imprecision
Serious d
Downgrading
Publication bias
NA e
No downgrading
Factors increasing
confidence
Strength of association
Small f
No upgrading
Exposure-response
gradient
NA f
No upgrading
Possible confounding
No conclusions can
be drawn g
No upgrading
Overall judgement of quality of evidence
0 (very low) h
# Since only one cross-sectional study was available, we started with a grading of “low” (2); a The
response rate was below 60%. Diabetes was ascertained by means of a questionnaire only; b Since only
one study is available, this criterion is not applicable; c The study assessed population, exposure and
outcome of interest; d We considered the results to be imprecise: The number of cases was small, and
the 95% CI was not sufficiently narrow; e Since the results of only one study were available, it was not
possible to test for publication bias or small study bias; f In the evaluated study a health promoting
effect of noise was found; g We were not able to draw any conclusions whether possible residual
confounders or biases would reduce our effect estimate; h We graded the overall quality of the
evidence to be “very low”(0). Despite the fact that only one study was available, it was not useful to
downgrade the overall quality of evidence.
Table A41. Summary of findings table for the association between exposure to noise from wind
turbines and the prevalence of diabetes.
Question
Does Exposure to Noise from Wind Turbines Increase the Risk of Diabetes
People
Adult population (men and women)
Setting
Residential setting: people in the neighbourhood of wind turbines in The Netherlands and Sweden
Outcome
The prevalence of diabetes
Summary of
findings
RR per 10 dB increase in wind turbine noise
level (SPL)
-
Number of participants (# evaluated studies)
1830 (3)
Number of cases
NR
Rating
Adjustment to rating
Quality
assessment
Starting rating
3 cross-sectional studies #
2 (low)
Factors
decreasing
confidence
Risk of bias
Very serious a
Downgrading
Inconsistency
Limited b
No downgrading
Indirectness
None c
No downgrading
Imprecision
Seriousd
Downgrading
Publication bias
NA e
No downgrading
Factors
increasing
confidence
Strength of association
NA f
No upgrading
Exposure-response gradient
NA f
No upgrading
Possible confounding
Serious bias cannot be
ruled out g
No upgrading
Overall judgement of quality of evidence
0 (very low)
# Since only cross-sectional studies were available, we started with a grading of “low” (2); a Methods
used to select the population: response rates were in two of the three studies below 60%. The
participants were randomly selected, taking into account the distance between their house and a wind
turbine (park); diabetes was in all cases measured by means of a questionnaire; b Results across studies
differed in the magnitude and direction of effect estimates (see Figure 7.1 of the complete review); c
The evaluated studies assessed population, exposure, and outcome of interest; d We considered the
results to be imprecise: We assessed that the number of cases is probably lower than 200. The 95% CIs
of the separate studies contained values below 0.5 and above 2.0; e Due to the low number of available
effect estimates it was not possible to test for publication bias or small study bias; f Only one of the
evaluated studies found that We decided not to carry out a meta-analysis; g The studies were unable
to adjust for important confounders.

Int. J. Environ. Res. Public Health 2018, 15, 379 42 of 62
Table A42. Summary of findings table for the association between aircraft noise exposure and the
incidence of diabetes.
Question
Does Exposure to Aircraft Noise Increase the Risk of Diabetes
People
Adult population (men and women)
Setting
Residential setting: people living in Stockholm (Sweden)
Outcome
The incidence of diabetes
Summary of
findings
RR per 10 dB increase in aircraft noise level (LDEN)
0.99 (95% CI: 0.47–2.09)
Number of participants (# studies)
5156 (1)
Number of cases
159
Rating
Adjustment to rating
Quality
assessment
Starting rating
1 cohort #
4 (high)
Factors decreasing
confidence
Risk of bias
Limited a
No downgrading
Inconsistency
NA b
No downgrading
Indirectness
None c
No downgrading
Imprecision
Serious d
Downgrading
Publication bias
NA e
No downgrading
Factors increasing
confidence
Strength of association
NA f
No upgrading
Exposure-response
gradient
No evidence of an
exposure-response
gradient f
No upgrading
Possible confounding
No conclusions can
be drawn g
No upgrading
Overall judgement of quality of evidence
2 (low) h
# Since we have a cohort study, we start at 4 (high evidence; a) The loss-to-follow-up was estimated
as > 20%; b Since only one study is available, this criterion is not applicable; c The study assessed
population, exposure and outcome of interest; d Although the number of cases was large, the 95% CI
was judged as not sufficiently narrow; e Since the results of only one study were available it was not
possible to test for publication bias or small study bias; f The evaluated study found that the risk of
diabetes decreased when air traffic noise level increased (RR per 10 dB < 1). No evidence of an
exposure-response gradient was found: the evaluated study found an non-significant effect size of
0.99 per 10 dB; g We were not able to draw any conclusions whether possible residual confounders or
biases would reduce our effect estimate; h We graded the overall quality of the evidence to be
“moderate” (3). Since only one study was available, we downgraded the overall level of evidence to
“low” (2).
Table A43. Summary of findings table for the association between road traffic noise exposure and the
incidence of diabetes.
Question
Does Exposure to Road Traffic Noise Increase the Risk of Diabetes
People
Adult population (men and women)
Setting
Residential setting: people living in cities in Denmark
Outcome
The incidence of diabetes
Summary of
findings
RR per 10 dB increase in road traffic noise level
(LDEN)
1.08 (95% CI: 1.02–1.14)
Number of participants (# studies)
57,053 (1)
Number of cases
2752
Rating
Adjustment to rating
Quality
assessment
Starting rating
1 cohort #
4 (high)
Factors decreasing
confidence
Risk of bias
Limited a
No downgrading
Inconsistency
NA b
No downgrading
Indirectness
None c
No downgrading
Imprecision
Limited d
No downgrading
Publication bias
NA e
No downgrading
Factors increasing
confidence
Strength of association
Small f
No upgrading
Exposure-response
gradient
Evidence of a
significant exposure-
response gradient f
Upgrading
Possible confounding
No conclusions can
be drawn g
No upgrading
Overall judgement of quality of evidence
3 (moderate) h

Int. J. Environ. Res. Public Health 2018, 15, 379 43 of 62
# Since one cohort study is available, we started with a grading of “high” (4); a The quality of the study
was judged as high; b Since only one study is available, this criterion is not applicable; c The study
assessed population, exposure and outcome of interest; d We considered the results of the study to be
precise: The number of cases was large, and the 95% CI was sufficiently narrow; e Since the results of
only one study were available it was not possible to test for publication bias or small study bias; f The
evaluated study found that the risk of diabetes increased when road traffic noise level increased (RR
per 10 dB < 1). There was evidence of a significant exposure-response gradient: In the evaluated study
a statistically significant RR of 1.08 per 10 dB across the noise range of 50-70 dB was found. This means
that if the road traffic noise level increases from 50 to 70 dB, the RR = 1.17; g We were not able to draw
any conclusions whether possible residual confounders or biases would reduce our effect estimate; h
We graded the overall quality of the evidence to be “high” (4). Since only one study was available,
we downgraded the overall level of evidence to “moderate” (3).
Table A44. Summary of findings table for the association between rail traffic noise exposure and the
incidence of diabetes.
Question
Does Exposure to Rail Traffic Noise Increase the Risk of Diabetes
People
Adult population (men and women)
Setting
Residential setting: people living in cities in Denmark
Outcome
The incidence of diabetes
Summary of
findings
RR per 10 dB increase in aircraft noise level (LDEN)
0.97 (95% CI: 0.89–1.05)
Number of participants (# studies)
57,053 (1)
Number of cases
2752
Rating
Adjustment to rating
Quality
assessment
Starting rating
1 cohort #
4 (high)
Factors decreasing
confidence
Risk of bias
Limited a
No downgrading
Inconsistency
NA b
No downgrading
Indirectness
None c
No downgrading
Imprecision
Limited d
No downgrading
Publication bias
NA e
No downgrading
Factors increasing
confidence
Strength of association
NA f
No upgrading
Exposure-response
gradient
No evidence of an
exposure-response
gradient f
No upgrading
Possible confounding
No conclusions can
be drawn g
No upgrading
Overall judgement of quality of evidence
3 (moderate) h
# Since, a cohort study is available, we started with a grading of “high” (4); a The quality of the study
was judged as high; b Since only one study is available, this criterion is not applicable; c The study
assessed population, exposure and outcome of interest; d We considered the results of the studies as
precise: the number of cases was large, and the 95% CI was judged as sufficiently narrow; e Since the
results of only one study were available it was not possible to test for publication bias or small study
bias; f The evaluated study found that the risk of diabetes decreased when rail traffic noise level
increased (RR per 10 dB < 1). No evidence of an exposure-response gradient was found: the evaluated
study found a non-significant effect size of 0.97 per 10 dB; g We were not able to draw any conclusions
whether possible residual confounders or biases would reduce our effect estimate; h We graded the
overall quality of the evidence to be “high” (4). Since only one study was available, we downgraded
the overall level of evidence to “moderate” (3).

Int. J. Environ. Res. Public Health 2018, 15, 379 44 of 62
Appendix G. Summary of Findings Tables Dealing with Studies on the Impact of Noise on
Obesity
This appendix presents the summary of findings tables dealing with the studies on the impact
of noise on obesity. An extensive description and the reasoning behind these tables can be found in
the complete review in Section 11.5.
Table A45. Summary of findings table for the association between aircraft noise exposure and the
change in Body Mass Index.
Question
Does Exposure to Aircraft Noise Increase the Risk of Obesity
People
Adult population (men and women)
Setting
Residential setting: people living in Stockholm in areas located around the airport
Outcome
Change in BMI (kg/m3)
Summary of
findings
Change in BMI per 10 dB increase in aircraft noise
level (LDEN)
0.14 (95% CI: −0.18–0.45) kg/m2
Number of participants (# studies)
5156 (1)
Number of cases
NR
Rating
Adjustment to rating
Quality
assessment
Starting rating
1 cohort study #
4 (high)
Factors decreasing
confidence
Risk of bias
Limited a
No downgrading
Inconsistency
NA b
No downgrading
Indirectness
None c
No downgrading
Imprecision
Serious d
Downgrading
Publication bias
NA e
No downgrading
Factors increasing
confidence
Strength of association
Small f
No upgrading
Exposure-response
gradient
Evidence of a non-
significant exposure-
response gradient f
No upgrading
Possible confounding
No conclusions can
be drawn g
No upgrading
Overall judgement of quality of evidence
2 (low) #
# Since a cohort study was available, we started with a grading of “high” (4); a The quality of the study
was judged as high; b Since only one study is available, this criterion is not applicable; c The study
assessed population, exposure and outcome of interest; d We considered the results to be imprecise:
The standard deviation of the reported effect size was larger than the mean difference in BMI; e Since
the results of only one study were available, it was not possible to test for publication bias or small
study bias; f In the evaluated study, a harmful effect of noise was found. There was evidence of a non-
significant exposure-response gradient: we found a non-significant effect size of 0.14 kg/m2 per 10 dB.
The noise range of the study under evaluation was 48–65 dB. This means that in case the air traffic
noise level increases from 48 to 65 dB, the BMI increased with 0.24 kg/m2 (this is less than 3–5% change
in BMI, which is considered clinically significant); g We were not able to draw any conclusions whether
possible residual confounders or biases would reduce our effect estimate; h We graded the overall
quality of the evidence to be “moderate” (3). Because only one study was available, we downgraded
the overall quality of evidence to “low” (2).

Int. J. Environ. Res. Public Health 2018, 15, 379 45 of 62
Table A46. Summary of findings table for the association between road traffic noise exposure and the
change in Body Mass Index.
Question
Does Exposure to Road Traffic Noise Increase the Risk of Obesity
People
Adult population (men and women)
Setting
Residential setting: people living in Stockholm in areas located around the airport (Sweden), people
living in Oslo (Norway), People living in Aarhus or Copenhagen (Denmark)
Outcome
Change in BMI (kg/m3)
Summary of
findings
Change in BMI per 10 dB increase in road traffic
noise level (LDEN)
0.03 (95% CI: −0.10–0.15) kg/m2
Number of participants (# studies)
71,431 (3)
Number of cases
NR
Rating
Adjustment to rating
Quality
assessment
Starting rating
3 cross-sectional
studies #
2 (low)
Factors decreasing
confidence
Risk of bias
Limited a
No downgrading
Inconsistency
Serious b
Downgrading
Indirectness
None c
No downgrading
Imprecision
Serious d
Downgrading
Publication bias
NA e
No downgrading
Factors increasing
confidence
Strength of association
Small f
No upgrading
Exposure-response
gradient
Evidence of a non-
significant exposure-
response gradient f
No upgrading
Possible confounding
No conclusions can
be drawn g
No upgrading
Overall judgement of quality of evidence
0 (very low)
# Since only cross-sectional studies were available, we started with a grading of “low” (2); a The quality
of the studies was judged as high; b Results across studies differed in the magnitude and direction of
effect estimate (see Figure 8.1 of the complete review). This was confirmed by the results of the
heterogeneity analysis, demonstrating “strong” heterogeneity (I2residual = 84.4%); c The study assessed
population, exposure and outcome of interest. d We considered the results to be imprecise: The
standard deviation of the reported effect size was larger than the mean difference in BMI; e Since the
number of available estimates was small, it was not possible to test for publication bias or small study
bias; f In one of the evaluated studies, a harmful effect of noise was found. There was evidence of a
non-significant exposure-response gradient: After aggregating the results of the studies, we found a
non-significant effect size of 0.03 kg/m2 per 10 dB. The noise range of the studies under evaluation
was ~40–65 dB. This means that if the road traffic noise level increases from 40 to 65 dB, the BMI
increased with 0.08 kg/m2 (this is probably less than 3–5% change in BMI, which is considered
clinically significant); g We were not able to draw any conclusions whether possible residual
confounders or biases would reduce our effect estimate.

Int. J. Environ. Res. Public Health 2018, 15, 379 46 of 62
Table A47. Summary of findings table for the association between rail traffic noise exposure and the
change in Body Mass Index.
Question
Does Exposure to Rail Traffic Noise Increase the Risk of Obesity
People
Adult population (men and women)
Setting
Residential setting: people living in Stockholm in areas located around the airport (Sweden), and
people living in Aarhus or Copenhagen (Denmark)
Outcome
Change in BMI (kg/m3)
Summary of
findings
Change in BMI per 10 dB increase in rail traffic noise
level (LDEN)
-
Number of participants (# studies)
57,531 (2)
Number of cases
NR
Rating
Adjustment to rating
Quality
assessment
Starting rating
2 cross-sectional
studies #
2 (low)
Factors decreasing
confidence
Risk of bias
Limited a
No downgrading
Inconsistency
Serious b
Downgrading
Indirectness
None c
No downgrading
Imprecision
Limited d
No downgrading
Publication bias
NA e
No downgrading
Factors increasing
confidence
Strength of association
NA f
No upgrading
Exposure-response
gradient
NA f
No upgrading
Possible confounding
No conclusions can
be drawn g
No upgrading
Overall judgement of quality of evidence
1 (very low)
# Since only cross-sectional studies were available, we started with a grading of “low” (2); a The quality
of the studies was judged as high; b Results varied between the studies; c Results across studies differed
in the magnitude of effect estimates. The direction of the effects was consistent; c The study assessed
population, exposure and outcome of interest; d We considered the results to be precise: For both
studies, the standard deviations of the reported effect were smaller than the reported effect size; e
Since the number of available estimates was small, it was not possible to test for publication bias or
small study bias; f Both studies found a harmful effect of rail traffic noise. We decided not to carry out
a meta-analysis; g Residual confounding primarily due to the way exposure was assessed, cannot be
ruled out. For the other factors, we were not able to draw any conclusions whether possible residual
confounders or biases would reduce our effect estimate.
Table A48. Summary of findings table for the association between aircraft noise exposure and the
change in waist circumference.
Question
Does Exposure to Aircraft Noise Increase the Risk of Obesity
People
Adult population (men and women)
Setting
Residential setting: people living in Stockholm in areas located around the airport
Outcome
Change in waist circumference (cm)
Summary of
findings
Change in waist circumference per 10 dB increase in
aircraft noise level (LDEN)
3.46 (95% CI: 2.13–4.77) cm
Number of participants (# studies)
5156 (1)
Number of cases
NR
Rating
Adjustment to rating
Quality
assessment
Starting rating
1 cohort study #
4 (high)
Factors decreasing
confidence
Risk of bias
Limited a
No downgrading
Inconsistency
NA b
No downgrading
Indirectness
None c
No downgrading
Imprecision
Limited d
No downgrading
Publication bias
NA e
No downgrading
Factors increasing
confidence
Strength of association
Large f
Upgrading
Exposure-response
gradient
Evidence of a
significant exposure-
response gradient f
Upgrading
Possible confounding
No conclusions can
be drawn g
No upgrading
Overall judgement of quality of evidence
3 (moderate) h

Int. J. Environ. Res. Public Health 2018, 15, 379 47 of 62
# Since a cohort study was available, we started with a grading of “high” (4); a The quality of the study
was judged as high; b Since only one study is available, this criterion is not applicable; c The study
assessed population, exposure and outcome of interest; d We considered the results of the study to be
precise: The standard deviation of the reported effect size was smaller than the mean difference in
waist circumference; e Since the results of only one study were available, it was not possible to test for
publication bias or small study bias; f The study found a harmful effect of aircraft noise. There was
evidence of a significant exposure-response gradient: we found a significant effect size of 3.46 cm per
10 dB. The noise range of the study under evaluation was 48–65 dB. This means that if the air traffic
noise level increases from 48 to 65 dB, the waist circumference increased more than 5.88 cm; g We were
not able to draw any conclusions whether possible residual confounders or biases would reduce our
effect estimate; h We graded the overall quality of the evidence to be ”high” (4). Because only one
study was available, we downgraded the overall quality of evidence to “moderate” (3).
Table A49. Summary of findings table for the association between road traffic noise exposure and the
change in waist circumference.
Question
Does Exposure to Road Traffic Noise Increase the Risk of Obesity
People
Adult population (men and women)
Setting
Residential setting: people living in Stockholm in areas located around the airport (Sweden), people
living in Oslo (Norway), People living in Aarhus or Copenhagen (Denmark)
Outcome
Change in waist circumference (cm)
Summary of
findings
Change in waist circumference per 10 dB increase in
road traffic noise level (LDEN)
0.17 (95% CI: −0.06–0.40) cm
Number of participants (# studies)
71,431 (3)
Number of cases
NR
Rating
Adjustment to rating
Quality
assessment
Starting rating
3 cross-sectional
studies #
2 (low)
Factors decreasing
confidence
Risk of bias
Limited a
No downgrading
Inconsistency
Serious b
Downgrading
Indirectness
None c
No downgrading
Imprecision
Serious d
No downgrading
Publication bias
NA e
No downgrading
Factors increasing
confidence
Strength of association
Small f
No upgrading
Exposure-response
gradient
Evidence of a non-
significant
exposure-response
gradient f
No upgrading
Possible confounding
No conclusions can
be drawn g
No upgrading
Overall judgement of quality of evidence
1 (very low)
# Since only cross-sectional studies were available, we started with a grading of “low” (2); a The quality
of the studies was judged as high b Results across studies differed in the magnitude and direction of
effect estimate (see Figure 8.1 of the complete review). This was confirmed by the results of the
heterogeneity analysis, demonstrating “strong” heterogeneity (I2residual = 84.4%); c The study assessed
population, exposure and outcome of interest; d We considered the results to be precise enough: The
standard deviation of the reported effect size was smaller than the mean difference in waist
circumference; e Since the number of available estimates was small, it was not possible to test for
publication bias or small study bias; f Two studies found a harmful effect of road traffic noise. There
was evidence of a non- significant exposure-response gradient: After aggregating the results of the
three evaluated studies, we found a non-significant effect size of 0.17 per 10 dB. The noise range of
the study under evaluation was ~40–65 dB. This means that if the road traffic noise level increases
from 40 to 65 dB, the waist circumference increased with 0.43 cm (this is probably less than 3-5%
change in waist circumference, which is considered clinically significant); g Residual confounding
primarily due to the way exposure was assessed cannot be ruled out. For the rest we were not able to
draw any conclusions whether possible residual confounders or biases would reduce our effect
estimate.

Int. J. Environ. Res. Public Health 2018, 15, 379 48 of 62
Table A50. Summary of findings table for the association between rail traffic noise exposure and the
change in waist circumference.
Question
Does Exposure to Rail Traffic Noise Increases the Risk of Obesity
People
Adult population (men and women)
Setting
Residential setting: people living in Stockholm in areas located around the airport (Sweden), and
people living in Aarhus or Copenhagen (Denmark)
Outcome
Change in waist circumference (cm)
Summary of
findings
Change in waist circumference per 10 dB increase in
rail traffic noise level (LDEN)
-
Number of participants (# studies)
57,531 (2)
Number of cases
NR
Rating
Adjustment to rating
Quality
assessment
Starting rating
2 cross-sectional
studies #
2 (low)
Factors decreasing
confidence
Risk of bias
Limited a
No downgrading
Inconsistency
Limited b
No downgrading
Indirectness
None c
No downgrading
Imprecision
Limited d
No downgrading
Publication bias
NA e
No downgrading
Factors increasing
confidence
Strength of association
NA f
No upgrading
Exposure-response
gradient
NA f
No upgrading
Possible confounding
No conclusions can
be drawn g
No upgrading
Overall judgement of quality of evidence
2 (low)
# Since only cross-sectional studies were available, we started with a grading of “low” (2); a The quality
of the studies was judged as high; b Results across studies only differed in magnitude of effect
estimates; c The study assessed population, exposure and outcome of interest; d We considered the
results to be precise: For both studies, the standard deviations of the reported effect were smaller than
the reported effect size; e Since the number of available estimates was small, it was not possible to test
for publication bias or small study bias; f Both studies found a harmful effect of rail traffic noise. We
decided not to carry out a meta-analysis; g We were not able to draw any conclusions whether possible
residual confounders or biases would reduce our effect estimate.
Appendix H. Summary of Findings Tables Dealing with Studies on the Impact of Noise on
Children’s Blood Pressure
This appendix presents the summary of findings tables dealing with the studies on the impact
of noise on children’s blood pressure. An extensive description and the reasoning behind these tables
can be found in the complete review in Section 11.6.

Int. J. Environ. Res. Public Health 2018, 15, 379 49 of 62
Table A51. Summary of findings table for the association between aircraft noise exposure at home
and the change in systolic blood pressure in children.
Question
Does Exposure to Aircraft Noise Affect Blood Pressure
People
Children (boys and girls)
Setting
Residential setting: Children (aged 6–11 years) living in cities around Schiphol Amsterdam airport (The
Netherlands), London Heathrow (United Kingdom) and Kingsford-Smith airport (Australia)
Outcome
Change in systolic blood pressure (mmHg)
Summary of
findings
Change in systolic blood pressure level per 10 dB increase
in aircraft noise level (LDEN)
-
Number of participants (# studies)
2013 (2)
Number of cases
NR
Rating
Adjustment to rating
Quality
assessment
Starting rating
2 cross-sectional studies #
2 (low)
Factors decreasing
confidence
Risk of bias
A lot is unclear a
Downgrading
Inconsistency
Serious b
Downgrading
Indirectness
None c
No downgrading
Imprecision
Serious d
Downgrading
Publication bias
NA e
No downgrading
Factors increasing
confidence
Strength of association
NA f
No upgrading
Exposure-response
gradient
NA f
No upgrading
Possible confounding
No conclusions can be
drawn g
No upgrading
Overall judgement of quality of evidence
0 (very low)
# Since only cross-sectional studies were available, we started with a grading of “low” (2); a The quality
of the studies was judged as low, since response rates in both studies were higher than 60%, and
because of the difficulty to judge the quality of the blood pressure measurements; b One study found
a positive effect; the other found a negative effect (see Figure 9.1 of the complete review); c The studies
assessed population, exposure and outcome of interest; d We considered the results to be imprecise:
The standard deviation of the reported effect size was larger than the mean difference in blood
pressure; e Since the results of only two studies were available it was not possible to test for publication
bias or small study bias; f One of the studies found a harmful effect of noise. It was not possible to
combine the results of both studies. A meta-analysis was not carried out; g We were not able to draw
any conclusions whether possible residual confounders or biases would reduce our effect estimate.
Table A52. Summary of findings table for the association between aircraft noise exposure at home
and the change in diastolic blood pressure in children.
Question
Does Exposure to Aircraft Noise Affect Blood Pressure
People
Children (boys and girls)
Setting
Residential setting: Children (aged 6–11 years) living in cities around Schiphol Amsterdam airport (The
Netherlands), London Heathrow (United Kingdom) and Kingsford-Smith airport (Australia)
Outcome
Change in diastolic blood pressure (mmHg)
Summary
of findings
Change in diastolic blood pressure
level per 10 dB increase in aircraft noise
level (LDEN)
-
Number of participants (# studies)
2013 (2)
Number of cases
NR
Rating
Adjustment to rating
Quality
assessment
Starting rating
2 cross-sectional studies #
2 (low)
Factors
decreasing
confidence
Risk of bias
A lot is unclear a
Downgrading
Inconsistency
Serious b
Downgrading
Indirectness
None c
No downgrading
Imprecision
Serious d
Downgrading
Publication bias
NA e
No downgrading
Factors
increasing
confidence
Strength of association
NA f
No upgrading
Exposure-response
gradient
NA f
No upgrading
Possible confounding
No conclusions can be
drawn g
No upgrading
Overall judgement of quality of evidence
0 (very low)
# Since only cross-sectional studies were available, we started with a grading of “low” (2); a The quality
of the studies was judged as low, since response rates in both studies were higher than 60% and

Int. J. Environ. Res. Public Health 2018, 15, 379 50 of 62
because of the difficulty to judge the quality of the blood pressure measurements; b One study found
a positive effect; the other found a negative effect (see Figure 9.2 of the complete review); c The studies
assessed population, exposure and outcome of interest; d We considered the results to be imprecise:
The standard deviation of the reported effect size was larger than the mean difference in blood
pressure; e Since the results of only two studies were available it was not possible to test for publication
bias or small study bias; f One of the evaluated studies found a harmful effect of noise. It was not
possible to combine the results of both studies. A meta-analysis was not carried out; g We were not
able to draw any conclusions whether possible residual confounders or biases would reduce our effect
estimate.
Table A53. Summary of findings table for the association between aircraft noise exposure at school
and the change in systolic blood pressure in children.
Question
Does Exposure to Aircraft Noise Affect Blood Pressure
People
Children (boys and girls)
Setting
Educational setting: Children (aged 6–11 years) visiting primary schools in cities around Schiphol
Amsterdam airport (The Netherlands), London Heathrow (United Kingdom) and Kingsford-Smith
airport (Australia)
Outcome
Change in systolic blood pressure (mmHg)
Summary of
findings
Change in systolic blood pressure level per 10 dB
increase in aircraft noise level (LDEN)
-
Number of participants (# studies)
2013 (2)
Number of cases
NR
Rating
Adjustment to rating
Quality
assessment
Starting rating
2 cross-sectional
studies #
2 (low)
Factors decreasing
confidence
Risk of bias
A lot is unclear a
Downgrading
Inconsistency
Serious b
Downgrading
Indirectness
None c
No downgrading
Imprecision
Serious d
Downgrading
Publication bias
NA e
No downgrading
Factors increasing
confidence
Strength of association
NA f
No upgrading
Exposure-response
gradient
NA f
No upgrading
Possible confounding
No conclusions can
be drawn g
No upgrading
Overall judgement of quality of evidence
0 (very low)
# Since only cross-sectional studies were available, we started the grading with “low” (2); a The quality
of the studies was judged as low, since response rates in both studies were higher than 60% and
because of the difficulty to judge the quality of the blood pressure measurements; b One study found
a positive effect; the other found a negative effect (see Figure 9.1 of the complete review); c The studies
assessed population, exposure and outcome of interest; d The standard deviation of the reported effect
size was larger than the mean difference in blood pressure; e Since the results of only two studies were
available it was not possible to test for publication bias or small study bias; f It was not possible to
combine the results of both studies. A meta-analysis was not carried out; g We were not able to draw
any conclusions whether possible residual confounders or biases would reduce our effect estimate.

Int. J. Environ. Res. Public Health 2018, 15, 379 51 of 62
Table A54. Summary of findings table for the association between aircraft noise exposure at school
and the change in diastolic blood pressure in children.
Question
Does Exposure to Aircraft Noise Affect Blood Pressure
People
Children (boys and girls)
Setting
Educational setting: Children (aged 6–11 years) visiting primary schools in cities around Schiphol
Amsterdam airport (The Netherlands), London Heathrow (United Kingdom) and Kingsford-Smith
airport (Australia)
Outcome
Change in diastolic blood pressure (mmHg)
Summary of
findings
Change in diastolic blood pressure level per 10 dB
increase in aircraft noise level (LDEN)
-
Number of participants (# studies)
2013 (2)
Number of cases
NR
Rating
Adjustment to rating
Quality
assessment
Starting rating
2 cross-sectional
studies #
2 (low)
Factors decreasing
confidence
Risk of bias
A lot is unclear a
Downgrading
Inconsistency
Serious b
Downgrading
Indirectness
None c
No downgrading
Imprecision
Serious d
Downgrading
Publication bias
NA e
No downgrading
Factors increasing
confidence
Strength of association
NA f
No upgrading
Exposure-response
gradient
NA f
No upgrading
Possible confounding
No conclusions can
be drawn g
No upgrading
Overall judgement of quality of evidence
0 (very low)
# Since only cross-sectional studies were available, we started with a grading of ”low” (2); a The quality
of the studies was judged as low, since response rates in both studies were higher than 60% and
because of the difficulty to judge the quality of the blood pressure measurements; b One study found
a positive effect; the other found a negative effect (see Figure 9.2 of the complete review); c The studies
assessed population, exposure and outcome of interest; d The standard deviation of the reported effect
size was larger than the mean difference in blood pressure; e Since the results of only two studies were
available it was not possible to test for publication bias or small study bias; f It was not possible to
combine the results of both studies. A meta-analysis was not carried out; g We were not able to draw
any conclusions whether possible residual confounders or biases would reduce our effect estimate.
Table A55. Summary of findings table for the association between road traffic noise exposure at home
and the change in systolic blood pressure in children.
Question
Does Exposure to Road Traffic Noise Affect Blood Pressure
People
Children (boys and girls)
Setting
Residential setting: Children (aged 6–11 years) living in cities in The Netherlands, the United Kingdom, Germany,
Croatia, Serbia and the United States of America
Outcome
Change in systolic blood pressure (mmHg)
Summary of
findings
Change in systolic blood pressure level per 10 dB increase
in road traffic noise level (LDEN)
0.08 (95% CI: −0.48–0.64) mmHg
Number of participants (# studies)
4197 (6)
Number of cases
NR
Rating
Adjustment to rating
Quality
assessment
Starting rating
6 cross-sectional studies #
2 (low)
Factors decreasing
confidence
Risk of bias
Serious a
Downgrading
Inconsistency
Serious b
Downgrading
Indirectness
None c
No downgrading
Imprecision
Serious d
Downgrading
Publication bias
NA e
No downgrading
Factors increasing
confidence
Strength of association
NA f
No upgrading
Exposure-response
gradient
Evidence of a non-
significant exposure-
response gradient f
No upgrading
Possible confounding
No conclusions can be
drawn g
No upgrading
Overall judgement of quality of evidence
0 (very low)

Int. J. Environ. Res. Public Health 2018, 15, 379 52 of 62
# Since only cross-sectional studies were available, we started with a grading of “low” (2); a The quality
of the studies was judged as low, since response rates in both studies were higher than 60% and
because of the difficulty to judge the quality of the blood pressure measurements. Also studies were
not always able to adjust for confounding or were able to attribute individual exposure estimates; b
Results across studies differed in the magnitude and direction of effect estimates (see Figure 9.1 of the
complete review). This was not confirmed by the results of the heterogeneity analysis, demonstrating
only “low” heterogeneity (I2residual = 8.9%); c The studies assessed population, exposure and outcome
of interest; d We considered the results to be imprecise: The standard deviation of the reported effect
size was larger than the mean difference in blood pressure; e Since the number of available effect
estimates was less than 10, it was not possible to test for publication bias or small study bias; f Three
of the evaluated studies found a harmful effect of noise. There was evidence of a non-significant
exposure-response gradient: after combining the results of the evaluated studies, we found a non-
significant effect size of 0.08 mmHg per 10 dB. The noise range was ~35–80 dB. This means that if the
road traffic noise level increases from 35 to 80 dB, the blood pressure increased with 0.36 mmHg; g
We were not able to draw any conclusions whether possible residual confounders or biases would
reduce our effect estimate.
Table A56. Summary of findings table for the association between road traffic noise exposure at home
and the change in diastolic blood pressure in children.
Question
Does Exposure to Road Traffic Noise Affect Blood Pressure
People
Children (boys and girls)
Setting
Residential setting: Children (aged 6–11 years) living in cities in The Netherlands, the United
Kingdom, Germany, Croatia, Serbia and the United States of America
Outcome
Change in diastolic blood pressure (mmHg)
Summary of
findings
Change in diastolic blood pressure level per 10 dB
increase in road traffic noise level (LDEN)
0.47 (95% CI: −0.30–1.24) mmHg
Number of participants (# studies)
4197 (6)
Number of cases
NR
Rating
Adjustment to rating
Quality
assessment
Starting rating
6 cross-sectional
studies #
2 (low)
Factors decreasing
confidence
Risk of bias
Serious a
Downgrading
Inconsistency
Serious b
Downgrading
Indirectness
None c
No downgrading
Imprecision
Serious d
Downgrading
Publication bias
NA e
No downgrading
Factors increasing
confidence
Strength of association
NA f
No upgrading
Exposure-response
gradient
Evidence of a non-
significant exposure-
response gradient f
No upgrading
Possible confounding
No conclusions can
be drawn g
No upgrading
Overall judgement of quality of evidence
0 (very low)
# Since only cross-sectional studies were available, we started with a grading of “low” (2); a The quality
of the studies was judged as low, since response rates in both studies were higher than 60%, and
because of the difficulty to judge the quality of the blood pressure measurements. Also studies were
not always able to adjust for confounding or were able to attribute individual exposure estimates; b
Results across studies differed in the magnitude and direction of effect estimates (see Figure 9.2 of the
complete review). This was confirmed by the results of the heterogeneity analysis, demonstrating
“strong” heterogeneity (I2residual = 76.0%); c The studies assessed population, exposure and outcome of
interest; d The results were considered to be imprecise: The standard deviation of the reported effect
size was larger than the mean difference in blood pressure; e Since the number of available effect
estimates was less than 10, it was not possible to test for publication bias or small study bias; f Three
of the evaluated studies found a harmful effect of noise. There was evidence of a non-significant
exposure-response gradient: After combining the results of the evaluated studies we found a non-
significant effect size of 0.47 mmHg per 10 dB. The noise range was ~35–80 dB. This means that if the
road traffic noise level increases from 35 to 80 dB, the blood pressure increased with 2.1 mmHg; g We

Int. J. Environ. Res. Public Health 2018, 15, 379 53 of 62
were not able to draw any conclusions whether possible residual confounders or biases would reduce
our effect estimate.
Table A57. Summary of findings table for the association between road traffic noise exposure at
school and the change in systolic blood pressure in children.
Question
Does Exposure to Road Traffic Noise Affects Blood Pressure
People
Children (boys and girls)
Setting
Educational setting: Children (aged 6–11 years) living in cities in The Netherlands, the United
Kingdom, Croatia, Serbia and the United States of America
Outcome
Change in systolic blood pressure (mmHg)
Summary of
findings
Change in systolic blood pressure level per 10 dB
increase in road traffic noise level (LDEN)
−0.60 (95% CI: −1.51–0.30) mmHg
Number of participants (# studies)
4520 (5)
Number of cases
NR
Rating
Adjustment to rating
Quality
assessment
Starting rating
5 cross-sectional
studies #
2 (low)
Factors decreasing
confidence
Risk of bias
Serious a
Downgrading
Inconsistency
Serious b
Downgrading
Indirectness
None c
No downgrading
Imprecision
Serious d
Downgrading
Publication bias
NA e
No downgrading
Factors increasing
confidence
Strength of association
NA f
No upgrading
Exposure-response
gradient
No evidence of an
exposure-response
gradient f
No upgrading
Possible confounding
No conclusions can
be drawn g
No upgrading
Overall judgement of quality of evidence
0 (very low)
# Since we only cross-sectional studies were available, we started with a grading of “low” (2); a The
quality of the studies was judged as low, since response rates in both studies were higher than 60%
and because of the difficulty to judge the quality of the blood pressure measurements. Also studies
were not always able to adjust for confounding or were able to attribute individual exposure
estimates; b Results across studies differed in the magnitude and direction of effect estimates (see
Figure 9.1 of the complete review). This was confirmed by the results of the heterogeneity analysis,
demonstrating “moderate” heterogeneity (I2residual = 61.6%); c The studies assessed population,
exposure and outcome of interest; d We considered the results to be imprecise: The standard deviation
of the reported effect size was larger than the mean difference in blood pressure; e Since the number
of available effect estimates was less than 10, it was not possible to test for publication bias or small
study bias; f Three studies found a harmful effect. There was no evidence of an exposure-response
gradient: after combining the results of the evaluated studies, we found a non-significant effect size
of −0.60 mmHg per 10 dB; g We were not able to draw any conclusions whether possible residual
confounders or biases would reduce our effect estimate.
Table A58. Summary of findings table for the association between road traffic noise exposure at
school and the change in diastolic blood pressure in children.
Question
Does Exposure to Road Traffic Noise Affect Blood Pressure
People
Children (boys and girls)
Setting
Educational setting: Children (aged 6–11 years) living in cities in The Netherlands, the United Kingdom,
Croatia, Serbia and the United States of America
Outcome
Change in diastolic blood pressure (mmHg)
Summary of
findings
Change in diastolic blood pressure level per 10 dB
increase in road traffic noise level (LDEN)
0.46 (95% CI: −0.60–1.53) mmHg
Number of participants (# studies)
4520 (5)
Number of cases
NR
Rating
Adjustment to
rating
Quality
assessment
Starting rating
5 cross-sectional studies#
2 (low)
Risk of bias
Serious a
Downgrading

Int. J. Environ. Res. Public Health 2018, 15, 379 54 of 62
Factors decreasing
confidence
Inconsistency
Serious b
Downgrading
Indirectness
None c
No downgrading
Imprecision
Serious d
Downgrading
Publication bias
NA e
No downgrading
Factors increasing
confidence
Strength of association
NA f
No upgrading
Exposure-response
gradient
Evidence of a statistically
non-significant exposure-
response gradient f
No upgrading
Possible confounding
No conclusions can be
drawn g
No upgrading
Overall judgement of quality of evidence
0 (very low)
# Since only cross-sectional studies were available, we started with a grading of “low” (2); a The quality
of the studies was judged as low, since response rates in both studies were higher than 60% and
because of the difficulty to judge the quality of the blood pressure measurements. Also studies were
not always able to adjust for confounding or were able to attribute individual exposure estimates; b
Results across studies differed in the magnitude and direction of effect estimates (see Figure 9.1 of the
complete review). This was not confirmed by the results of the heterogeneity analysis, demonstrating
“low” heterogeneity (I2residual = 16.0%); c The studies assessed population, exposure and outcome of
interest; d We considered the results to be imprecise: The standard deviation of the reported effect size
was larger than the mean difference in blood pressure; e Since the number of available effect estimates
was less than 10, it was not possible to test for publication bias or small study bias; f There was
evidence of a statistically non-significant exposure-response gradient: after combining the results of
the evaluated studies, we found a non-significant effect size of 0.46 mmHg per 10 dB. The noise range
was ~35–80 dB. This means that if the road traffic noise level increases from 35 to 80 dB, the blood
pressure increased with 2.1 mmHg; g We were not able to draw any conclusions whether possible
residual confounders or biases would reduce our effect estimate.
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