The substantial links between cardiovascular and planetary health, including their common drivers, has been discussed previously [14,15,16]. A Lancet Commission report has recently referred to the shared origins of the epidemics of obesity, malnutrition, and climate change as a syndemic and noted the importance of these to human health and survival [16] A “systems approach” is needed to tackle and understand complex interactions. The interconnectedness of these systems may need to be contextualized and understood before providing solutions. Not doing so may accelerate environmental degradation, perpetuate and worsen inequities, and result in myriad health consequences. Figure 1, presents a socio-ecological-infrastructural systems framework, with key provisioning systems of food, energy, water, and waste management [6, 7]. While essential for human living, many provisioning systems are intricately linked and dependent on fossil fuels, generating exposures and risks, such as air pollution. The same provisioning systems are also vulnerable to climate related disasters and may result in acute health risks related to food scarcity, power outages, destruction of housing, lack of water, and paralysis of transportation during a climate-related disaster. By 2050, global demand for food, water, and energy will sharply rise. We will discuss food, water and waste systems that sit at the cross hairs of climate change induced health effects.

Urban provisioning systems (shown by icons surrounding the City graphic) are decisive for sustainability and health transformation in cities by shaping resource use, impacting exposures and determining health outcomes. (Reprinted with permission from: Rajagopalan S, et al. Circulation. 2024 Apr 9;149(15):e1067-e1089, with permission from the American Heart Association) [17]

Climate is a major determinant of air quality and vice versa [18]. The effects of air pollution are attributable to its complex chemistry and size, which are determined by their sources and atmospheric conditions [19,20,21,22,23,24]. Recent studies have established that particulate matter with a diameter of less than 2.5 µm (PM2.5) plus ozone are responsible for 8.4 million excess deaths/year with exposure to PM2.5 reducing the global life expectancy by 2.9 years [25, 26]. The ultimate solution to solving air pollution is to shift from fossil fuel to renewable green energy sources. The rate of shift has been substantially slowed with the US cancellation of green energy initiatives, exiting from the Paris agreement, and an explicit reversal of policy decisions to accelerate clean transportation. Although current estimates are unavailable, these measures will undoubtedly have a chilling impact on air pollution levels, which are already increasing owing to the increase in landscape fires in the US and Canada.

Although not without initial cost, the gradual elimination of fossil fuel utilization and reducing the associated anthropogenic air pollution has been shown to have immediate impact on health outcomes [27]. It has been shown that much of the economic benefit that comes from decarbonization is driven by reductions in air pollution related health costs [28]. More than half of the immediate health impact of air pollution reduction may relate to reduction in cardiovascular mortality and reduced hospitalizations [12]. The impact on susceptible populations, particularly racial minorities and the socially disadvantaged that contribute disproportionately to cost of care, may indeed be quite substantive. Furthermore, there are several potential synergies that may result from decarbonization [29]. These include: (1) Adoption of public or active forms of travel together with electrification of transportation, yielding reduced noise pollution and increased physical activity; (2) decarbonization in the agricultural sector will lead to reductions in cardiovascular disease due to increased intake of locally sourced and sustainable plant-based ingredients; (3) the prevalence of important risk factors, such as hypertension, obesity, and T2D, will decrease due to reductions in chemical exposures due to elimination of petroleum-based products.

Landscape fires include wildfire disasters, prescribed burning, agricultural burning, and deforestation fires [30]. All can have substantial impacts on human health and well-being through exposure to heat, emissions, and altered ecosystem functioning (e.g., biodiversity, water quality, etc.). The global burden attributable to landscape fire smoke between 2000–19, has been estimated at 1.53 million all-cause deaths per year, including 0.45 million cardiovascular deaths and 0.22 million respiratory deaths [31]. Over 90% of all attributable deaths were in low-income and middle-income countries. Climate change has increased the frequency of dust storms, with wildfires and heat waves often occurring together. Several reviews have covered the expanding number of studies and meta-analysis that have linked LFS with acute myocardial infarction, stroke, and hospitalizations [32,33,34]. Reducing the short- and longer-term health harms associated with LFS requires reducing the genesis of these episodes. The use of prescribed burning involves complex trade-offs between the risks and benefits of smoke exposure, which will vary according to topography, fire history, vegetation, along with population distribution and vulnerability [30]. The greatest opportunity for reducing the large global burden of disease of LFS lies with changing the management of agricultural burning and tropical deforestation fires. For example, nonburning alternatives to agricultural waste management have the potential to substantially reduce pollution, store carbon, and generate income [35].

Both low and high temperatures contribute to cardiovascular morbidity and mortality [36, 37]. Globally, ~ 5 million deaths were attributable to NOT per year, accounting for 9.43% of all deaths; 8.52% were cold-related and 0.91% were heat-related [3]. A substantial proportion of this is related to cardiovascular events. The mechanisms related to heat induced CVD relate to increased hemodynamic demand, dehydration, inflammation, heightened thrombosis, and increased sympathetic tone. Meta-analyses also confirm that atherosclerotic cardiovascular disease is the leading cause of death with NOT [3, 14]. In the large multi-city collaborative (MCC) network involving 567 cities from 27 countries, the relationship between temperatures and ischemic heart disease events was non-linear [38]. The pooled RRs of death associated with extreme heat (99th percentile vs MMT) in this study from ischemic heart disease, stroke, and heart failure were 1.07 (95% CI, 1.04–1.10), 1.10 (95% CI, 1.06–1.15), and 1.12 (95% CI, 1.05–1.19), respectively. The concept of “climate penalty” refers to the enhanced formation of secondary pollutants, such as ground-level ozone, with rising temperatures and altered meteorologic conditions caused by climate change. The link between cardiovascular mortality and ozone levels has been clearly established [39,40,41]. A time-series study in 2017 examined the 2-way effect modifications of higher air temperature and pollution in 8 European cities. On days with higher air temperature, air pollution had a stronger association on total and cardiovascular disease related mortality [42]. Similarly, a greater risk of heat-related CVD mortality is observed in low-middle-income countries (LMICs) compared to upper-middle-income countries and high-income-countries (HICs). These countries often experience high summer temperatures and intense heatwaves, exacerbating vulnerability due to inadequate infrastructure, such as a lack of electricity, air conditioners, and efficient healthcare services during heatwaves [43]. Many of the most frequently prescribed medications, such as anticholinergics, antihypertensives, antiarrhythmics, antianginals, diuretics, antidepressants, insulin, and certain analgesics, have heat-related risks, including reduced effectiveness and adverse side effects, such as decreased sweating [37]. To reduce urban heat island effects, cities can adopt a range of nature-based, architectural, and policy-driven interventions. These include expanding tree cover, installing green roofs, using reflective building materials, promoting permeable and cool pavements, and incorporating water features [44]. Smart urban planning—like designing shaded streets, improving ventilation corridors, and enhancing energy efficiency—also plays a vital role. These strategies not only lower ambient temperatures but also improve air quality, reduce noise, and promote physical activity by creating more walkable environments. The cardiometabolic benefits are significant: lower heat exposure reduces cardiovascular strain and dehydration risk; better air quality reduces inflammation and vascular injury; and greener, cooler urban spaces encourage physical activity and social cohesion, all of which support healthier blood pressure, glucose regulation, and mental well-being.

About 11 million premature deaths, mostly due to ASCVD, are annually linked to unhealthy diets [45]. In 2018, a total of 14.1 million (95% UI: 13.8, 14.4 million) estimated new T2D cases, or 70.3% (95% UI: 68.8–71.8%) of the total, were estimated to be due to suboptimal intake of the 11 dietary factors [46]. Excess intake of six harmful dietary factors jointly (refined rice and wheat, processed meats, unprocessed red meat, sugar sweetened beverages, potatoes, fruit juice) contributed a larger proportion of the total global diet-attributable burden (60.8%) than insufficient intake of five protective dietary factors (whole grains, yogurt, fruits, non-starchy vegetables, nuts and seeds; 39.2%) [47]. Factors that ultimately lead to increased consumption of harmful foods are complex and encompass not only availability and quality of food, but also the policies, economic forces, and environmental factors that influence food production, distribution, and access. A 2019 Lancet commission report emphasized the urgent need to transform our global food system to achieve sustainable development and climate goals and advocated for a shift towards healthy, plant-based diets, and sustainability [48].

Policy changes and incentives can reverse the impact on current food practices. Federal policies that incentivize the food supply chain to increase supply and decrease cost of nutritious foods, taxing sugar sweetened beverages, innovative food system policies directed at private retailers, and discourage unhealthy foods with default healthy choices (e.g., no SSBs in children’s meals, smaller portion sizes, whole grain rather than refined grains in breads/rolls) would be effective [49].

The water supplies of many urban areas of the United States and across the globe face incursion from ubiquitous chemical and trace metal exposures. The latter includes lead, nickel, cadmium and arsenic, which are all associated with cardiometabolic disease [12, 50]. The recent explosion of metals such as cadmium and nickel in batteries, plastics and plastic-related chemicals such as phthalates and legacy chemicals, including bisphenol A (BPA), bisphenol S, per- and polyfluoroalkyl substance (PFAS) have already penetrated water systems [51, 52]. Most urban water management systems in the United States do not purify chemicals and metals and thus, these concerns demand the transformation of urban water systems from source to use [44]. Data from the National Health and Nutrition Examination Survey demonstrate the ubiquity of PFAS exposure [53]. Recent evidence suggests strong evidence linking a variety of PFAS with cardiovascular outcomes [53].

The role of solid waste management in achieving sustainable development is emphasized in several international development agendas [54]. Uncollected and untreated waste has environmental impact, including methane emissions, air pollution, and land/water contamination with chemicals that potentiate CVD [12]. The decomposition of biodegradable waste under anaerobic conditions contributes to about 18% of global methane emissions [55]. Open waste burning and dumping is common in many urban cities of the Global South [56]. These practices almost always affect marginalized social groups near the disposal sites. An integrated approach to waste and water that emphasizes improving all stages, including procurement, treatment, transfer/sorting, and disposal must be grounded on sustainability [57].