Urban-rural disparity in heatwave effects on diabetes mortality in eastern China: A case-crossover analysis in 2016-2019

Diabetics are sensitive to high ambient temperature due to impaired thermoregulation. However, available evidence on the impact of prolonged high temperature (i.e., heatwave) on diabetes deaths is limited and whether urban and rural areas differ in heatwave vulnerability remains unknown so far. A time-stratified case-crossover analysis was em-ployed to estimate the association between heatwaves and diabetes deaths in 1486 districts (509 urban and 977 rural areas) of eastern China (Jiangsu Province), 2016-2019. For each decedent, residential heatwave exposure was mea-sured by matching daily mean temperatures to the geocoded residential address. We adopted nine-tiered heatwave definitions incorporating intensity and duration. Stratified analyses by decedents' characteristics (gender, age, and ed-ucation) were also conducted. During the study period, there were 18,685 deaths from diabetes (urban proportion: 36.95 %, p-value for urban-rural difference < 0.05). Heatwaves were associated with an increased risk of diabetes deaths, with greater and longer-lasting effects in rural areas than urban areas [e.g., rural odds ratio (OR): 1.19 (95 % confidence interval (CI): 1.14, 1.25) vs. urban OR: 1.09 (95 % CI: 1.05, 1.12)]. Risk of diabetes deaths increased with the intensity of heatwaves in rural areas (p-value for trend <0.01), but not in urban areas. Stratified analyses in rural areas suggested that females and less-educated people were more vulnerable to heatwave-related diabetes deaths. Our findings revealed the urban-rural disparity in the risk of diabetes deaths associated with heatwaves. Rural diabetics should be made aware of the increased death risk posed by heatwaves in the context of warming climate.