Mortality burden of protein-energy malnutrition associated with ambient temperature in China: a nationwide case-crossover study

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Title:Mortality burden of protein-energy malnutrition associated with ambient temperature in China: a nationwide case-crossover study

Author(s):Yulin Zhuo, Jiangmei Liu, Jianxiong Hu, Jinlei Qi, Guanhao He, Peng Yin, Tao Liu, Yingyin Liu, Yi Lin, Mengen Guo, Fengrui Jing, Ziqiang Lin, Jinling You, Wenjun Ma, Maigeng Zhou

‌Journal Name, Year, Volume(Issue): Page range:The American Journal of Clinical Nutrition, 2025, 122(2): 441-449

DOI:10.1016/j.ajcnut.2025.06.002

Abstract:

Background: In the context of global warming, the health effects of non-optimum temperatures have attracted increasing attention. Studies have shown that high temperatures increase risk of hospitalization for protein-energy malnutrition (PEM), yet the impact of non-optimum temperatures on PEM mortality is unknown.

Objectives: This study aims to quantitatively assess risk and burden of PEM-related mortality associated with short-term temperature exposure across 31 provinces in China.

Methods: We collected mortality and meteorological data from 1 January, 2013, to 31 December, 2022, in 31 provinces of mainland China. Based on time-stratified case-crossover design, we integrated logistic model with distributed lag nonlinear model to assess the association between non-optimum temperatures and PEM-related mortality. Subgroup analyses were performed by age, sex, type of PEM, and province to identify vulnerable populations.

Results: A total of 197,406 PEM-related deaths were recorded during 2013-2022. The exposure-response curves were inversely J-shaped with higher effect for low temperature than high temperature. Nationally, we estimated that 17.03% [95% empirical confidence intervals (eCI): 14.59%, 19.17%] of PEM mortality was attributable to non-optimum temperatures. Subgroup analyses suggested that the attributable fraction of PEM mortality resulting from non-optimum temperatures was more prominent in males (17.69%; 95% eCI: 13.57%, 21.48%), the older adults ≥65 y (17.44%; 95% eCI: 14.84%, 19.80%), and non-severe PEM (17.45%; 95% eCI: 14.30%, 20.56%). In terms of spatial disparities, the top provinces with higher AFs were Anhui (27.63%; 95% eCI: 20.31%, 33.80%), Xinjiang (22.73%; 95% eCI: -0.14%, 39.55%), and Hubei (22.05%; 95% eCI: 12.36%, 29.87%).

Conclusions: Findings from this nationwide study suggest that both heat and cold are associated with increased risks and burden of PEM-related deaths. These findings underscore the necessity of targeted interventions to reduce the PEM-related mortality burden associated with ambient temperature.

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