Diabetes Deaths Remain High in Rural US, Among Men and Youth

Miriam E. Tucker

September 13, 2022

There has been a decline in deaths associated with diabetes in urban but not rural areas in the past two decades, with the reduction in diabetes-related mortality mainly seen among women and older patients.

Rural areas, on the other hand, have seen minimal gains and there are trends towards worsening rates of diabetes death among men and patients younger than 55.

As a result, the mortality gap between rural and urban areas has tripled in the past three decades, cardiologist Ofer Kobo, MD, and colleagues report in a short communication published online September 10 in Diabetologia.

"A synchronized effort is required to improve cardiovascular health indices and healthcare access in rural areas and to decrease diabetes-related mortality," say Kobo, Hillel Yaffe Medical Centre, Hadera, Israel, and Keele University, UK, and coauthors.

Significant Male–Female Gap

The findings are from the US Centers for Disease Control and Prevention's Wide-Ranging Online Data for Epidemiologic Research (CDC WONDER) Multiple Cause of Death database for US residents for 1999-2019.

Data were analyzed for 1,572,536 death certificates that list diabetes as the underlying cause, of which 79.8% were in urban counties, and 5,025,745 death certificates with diabetes as a contributing cause of death, of which 79.5% were in urban counties.

In urban areas, the age-adjusted mortality rate of diabetes as underlying and contributing causes of death decreased by 16.7% and 13.5%, respectively, from 1999 to 2019.

But in rural areas, those proportions increased nonsignificantly, by 2.6% and 8.9%, respectively. Rural area residents are at increased risk for diabetes along with higher rates of obesity and metabolic syndrome. Moreover, those individuals are less likely to participate in diabetes self-management education programs and they have higher rates of diabetes-related emergency department use compared with urban residents, the authors say.

"The management of diabetes and its complications requires expertise that may be difficult to access in rural communities. Residents of rural counties are less likely to have usual primary care provided by physicians. Furthermore, there has been a disproportionate closure of hospitals in rural areas," they add.

In both rural and urban areas, the age-adjusted mortality rates of diabetes as underlying and contributing causes of death were higher in males than females. Those rates dropped to a greater degree in females than in males, leaving a significant male-female gap (P trend < .05).

"The fact that male individuals are more likely to be diagnosed with diabetes at an early age may explain the widening male–female diabetes-related mortality gap in both urban and rural areas," Kobo and colleagues say.

Early Onset Type 2 Diabetes More Aggressive

There was a temporal increase in diabetes-associated age-adjusted mortality among people younger than 55 years old that was significantly larger in rural than urban areas, both as underlying (59% vs 14.7%) and contributing causes (65.2% vs 13.8%) (both P trend < .001).

"The increased mortality among the younger adults may be related to the increasing prevalence of type 2 diabetes in adolescents and young adults. Early onset type 2 diabetes is associated with more aggressive disease and higher rates of premature complications," the authors point out.

In contrast, among those older than age 55, there was a large decrease in diabetes-related age-adjusted mortality in urban areas (by –20.6% and –15.6% for underlying and contributing causes, respectively, both P trend < .001), but not in rural areas (–4.8% and +3.7%, respectively).

Overall, American Indian and Black patients had significantly higher diabetes-related age-adjusted mortality rates than Asian and White patients.

However, those rates did drop for both groups — in all areas for American Indians and in urban but not rural areas for Black patients. Those rates also dropped significantly in both urban and rural areas among White patients.

"The role of socioeconomic deprivation and structural racism in the incidence of cardiovascular risk factors, progression of diabetes, and survival rates must also be considered, particularly in American Indian and Black individuals," Kobo and colleagues write.  

They also note that cardiometabolic risk varies across ethnic groups and areas, and "is inextricably linked with social determinants of health, including education, economic resources, psychological stress, and access to preventive healthcare." 

Approaches that could mitigate some of the urban–rural disparity include healthcare equity, expansion of Medicaid, and telemedicine initiatives that extend access to specialty care, they suggest.

However, "the ultimate solutions may lie in economic and policy interventions that broaden our focus from treating disease to preventing it."

The authors have reported no relevant financial relationships.

Diabetologia. Published online September 10, 2022. Abstract

Miriam E. Tucker is a freelance journalist based in the Washington, DC, area. She is a regular contributor to Medscape, with other work appearing in The Washington Post, NPR's Shots blog, and Diabetes Forecast magazine. She is on Twitter: @MiriamETucker.

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