PFOS Exposure and Diabetes Burden in Selected Chinese Provinces: A Spatiotemporal and Demographic Assessment

Perfluorooctanesulfonic acid (PFOS) has been associated with diabetes risk, but its contribution to population burden remains poorly quantified. This study combined a meta-analysis of the association between PFOS exposure and diabetes with province-specific serum PFOS concentrations, diabetes prevalence rates, and demographic data to estimate the diabetes burden attributable to PFOS in nine Chinese provinces from 2012 to 2018. To avoid overestimation for this common outcome, odds ratios (ORs) were converted to relative risks (RRs) within a comparative risk assessment framework. The pooled association indicated increased diabetes risk with PFOS exposure, with an OR of 1.18 (95% CI: 1.04, 1.35) per doubling of PFOS concentration. In 2018, PFOS exposure was associated with an estimated 10.81 million diabetes cases, accounting for 22.1% of total diabetes cases in the study regions. Burden was highest in Guangdong, Jiangsu, and Shandong and remained consistently positive under alternative counterfactual and effect-size scenarios. Men bore more than twice the attributable burden of women, and burden peaked among adults aged 50-54 years. Converting ORs to RRs reduced mean PAF estimates from 25.96% to 21.77%, indicating that direct use of ORs would overestimate attributable burden. These findings identify PFOS as a substantial contributor to diabetes burden in industrialized regions of China and support targeted mitigation in highly exposed regions and vulnerable populations.