title: Spatiotemporal variation in diabetes mortality in China: multilevel evidence from 2006 and 2012.
abstract: BACKGROUND
  Despite previous studies reporting spatial in equality in diabetes prevalence across China, potential geographic variations in diabetes mortality have not been explored.
  
  
  METHODS
  Age and gender stratified annual diabetes mortality counts for 161 counties were extracted from the China Mortality Surveillance System and interrogated using multilevel negative binomial regression. Random slopes were used to investigate spatiotemporal variation and the proportion of variance explained was used to assess the relative importance of geographical region, urbanization, mean temperature, local diabetes prevalence, behavioral risk factors and relevant biomarkers.
  
  
  RESULTS
  Diabetes mortality tended to reduce between 2006 and 2012, though there appeared to be an increase in diabetes mortality in urban (age standardized rate (ASR) 2006-2012: 10.5-13.6) and rural (ASR 10.8-13.0) areas in the Southwest region. A Median Rate Ratio of 1.47, slope variance of 0.006 (SE 0.001) and covariance of 0.268 (SE 0.007) indicated spatiotemporal variation. Fully adjusted models accounted for 37% of this geographical variation, with diabetes mortality higher in the Northwest (RR 2.55, 95% CI 1.74, 3.73) and Northeast (RR 2.68, 95% CI 1.70, 4.21) compared with the South. Diabetes mortality was higher in urbanized areas (RR tertile 3 versus tertile 1 ('RRt3vs1') 1.39, 95% CI 1.17, 1.66), with higher mean body mass index (RRt3vs1 1.46, 95% CI 1.18, 1.80) and with higher average temperatures (RR 1.05 95% CI 1.03, 1.08). Diabetes mortality was lower where consumption of alcohol was excessive (RRt3vs1 0.84, 95% CI 0.72, 0.99). No association was observed with smoking, overconsumption of red meat, high mean sedentary time, systolic blood pressure, cholesterol, and diabetes prevalence.
  
  
  CONCLUSIONS
  Declines in diabetes mortality between 2006 and 2012 have been unequally distributed across China, which may imply differentials in diagnosis, management, and the provision of services that warrant further investigation.
authors.affiliation: National Center for Chronic and Noncommunicable Disease Control and Prevention, Chinese Center for Disease Control and Prevention, 27 Nanwei Road, Xicheng District, Beijing, 100050, China. maigengzhou@126.com.
authors.forename: Maigeng
authors.initials: M
authors.lastname: Zhou
authors.affiliation: School of Science and Health, University of Western Sydney, Sydney, Australia. T.Astell-Burt@uws.edu.au.|School of Geography and Geosciences, University of St Andrews, St Andrews, UK. T.Astell-Burt@uws.edu.au.
authors.forename: Thomas
authors.initials: T
authors.lastname: Astell-Burt
authors.affiliation: National Center for Chronic and Noncommunicable Disease Control and Prevention, Chinese Center for Disease Control and Prevention, 27 Nanwei Road, Xicheng District, Beijing, 100050, China. p.yinpeng@gmail.com.
authors.forename: Peng
authors.initials: P
authors.lastname: Yin
authors.affiliation: School of Health and Society, University of Wollongong, Wollongong, Australia. xfeng@uow.edu.au.
authors.forename: Xiaoqi
authors.initials: X
authors.lastname: Feng
authors.affiliation: School of Science and Health, University of Western Sydney, Sydney, Australia. a.page@uws.edu.au.
authors.forename: Andrew
authors.initials: A
authors.lastname: Page
authors.affiliation: National Center for Chronic and Noncommunicable Disease Control and Prevention, Chinese Center for Disease Control and Prevention, 27 Nanwei Road, Xicheng District, Beijing, 100050, China. liuyunning0723@163.com.
authors.forename: Yunning
authors.initials: Y
authors.lastname: Liu
authors.affiliation: National Center for Chronic and Noncommunicable Disease Control and Prevention, Chinese Center for Disease Control and Prevention, 27 Nanwei Road, Xicheng District, Beijing, 100050, China. 460554914@qq.com.
authors.forename: Jiangmei
authors.initials: J
authors.lastname: Liu
authors.affiliation: National Center for Chronic and Noncommunicable Disease Control and Prevention, Chinese Center for Disease Control and Prevention, 27 Nanwei Road, Xicheng District, Beijing, 100050, China. alexleeliyichong@gmail.com.
authors.forename: Yichong
authors.initials: Y
authors.lastname: Li
authors.affiliation: National Center for Chronic and Noncommunicable Disease Control and Prevention, Chinese Center for Disease Control and Prevention, 27 Nanwei Road, Xicheng District, Beijing, 100050, China. liusw@chinacdc.cn.
authors.forename: Shiwei
authors.initials: S
authors.lastname: Liu
authors.affiliation: National Center for Chronic and Noncommunicable Disease Control and Prevention, Chinese Center for Disease Control and Prevention, 27 Nanwei Road, Xicheng District, Beijing, 100050, China. wlm65@126.com.
authors.forename: Limin
authors.initials: L
authors.lastname: Wang
authors.affiliation: National Center for Chronic and Noncommunicable Disease Control and Prevention, Chinese Center for Disease Control and Prevention, 27 Nanwei Road, Xicheng District, Beijing, 100050, China. wangle_19@aliyun.com.
authors.forename: Lijun
authors.initials: L
authors.lastname: Wang
authors.affiliation: National Center for Chronic and Noncommunicable Disease Control and Prevention, Chinese Center for Disease Control and Prevention, 27 Nanwei Road, Xicheng District, Beijing, 100050, China. linhong@chinawch.org.cn.
authors.forename: Linhong
authors.initials: L
authors.lastname: Wang
mesh_terms: D000328:Adult; D000367:Age Factors; D000368:Aged; D002681:China / Q000453:epidemiology; D003920:Diabetes Mellitus / Q000401:mortality*; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D012307:Risk Factors; D012424:Rural Population / Q000706:statistics & numerical data; D012737:Sex Factors; D012959:Socioeconomic Factors; D062211:Spatio-Temporal Analysis; D014505:Urban Population / Q000706:statistics & numerical data; D055815:Young Adult