Geographical disparities in the impacts of heat on diabetes mortality and the protective role of greenness in Thailand: A nationwide case-crossover analysis.

Diabetes is a major public health problem globally, and heat exposure may be a potential risk factor for death among diabetes. This study examines the association between heat and diabetes mortality in different regions of Thailand and investigates whether heat effects are modified by regional greenness. Daily temperature and daily diabetes deaths data were obtained for 60 provinces of Thailand during 2000-2008. A case-crossover analysis was conducted to quantify the odds of heat-related death among diabetes. Meta-regression was then used to examine potential modification effects of regional greenness (as represented by the Normalized Difference Vegetation Index) on heat-related mortality. A strong association between heat and diabetes mortality was found in Thailand, with important regional variations. Nationally, the pooled odds ratio of diabetes mortality was 1.10 (95% confidence interval (CI): 1.06-1.14) for heat (90th percentile of temperature) and 1.20 (95% CI: 1.10-1.30) for extreme heat (99th percentile of temperature) compared with the minimum mortality temperature, across lag 0-1 days. Central and northeast Thailand were the most vulnerable regions. Regional greenness modified the effects of heat, with lower mortality impacts in areas of higher levels of greenness. In conclusion, heat exposure increases mortality risk in diabetes, with large geographical variations in risk suggesting the need for region-specific public health strategies. Increasing greenness levels may help to reduce the burden of heat on diabetes in Thailand against the backdrop of a warming climate.