Unveiling causal connections: Long-term particulate matter exposure and type 2 diabetes mellitus mortality in Southern China

Evidence of the potential causal links between long-term exposure to particulate matters (PM, i.e., PM₁, PM_2.5, and PM_1–2.5) and T2DM mortality based on large cohorts is limited. In contrast, the existing evidence usually suffers from inherent bias with the traditional association assessment. A prospective cohort of 580,757 participants in the southern region of China were recruited during 2009 and 2015 and followed up through December 2020. PM exposure at each residential address was estimated by linking to the well-established high-resolution simulation dataset. Hazard ratios (HRs) were calculated using time-varying marginal structural Cox models, an established causal inference approach, after adjusting for potential confounders. During follow-up, a total of 717 subjects died from T2DM. For every 1 μg/m³ increase in PM_2.5, the adjusted HRs and 95% confidence interval (CI) for T2DM mortality was 1.036 (1.019–1.053). Similarly, for every 1 μg/m³ increase in PM₁ and PM_1–2.5, the adjusted HRs and 95% CIs were 1.032 (1.003–1.062) and 1.085 (1.054–1.116), respectively. Additionally, we observed a generally more pronounced impact among individuals with lower levels of education or lower residential greenness which as measured by the Normalized Difference Vegetation Index (NDVI). We identified substantial interactions between NDVI and PM₁ (P-interaction = 0.003), NDVI and PM_2.5 (P-interaction = 0.019), as well as education levels and PM₁ (P-interaction = 0.049). The study emphasizes the need to consider environmental and socio-economic factors in strategies to reduce T2DM mortality. We found that PM₁, PM_2.5, and PM_1–2.5 heighten the peril of T2DM mortality, with education and green space exposure roles in modifying it.