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A new study has found that the rate of rural residents dying from diabetes is increasing, while the rate in urban areas is falling.

Men, ethnic minorities and younger adults in rural areas all had higher diabetes-related mortality rates than their urban counterparts, the study published in Diabetologia found.

Using data from the Centers for Disease Control and Prevention’s (CDC) Wide-Ranging Online Data for Epidemiologic Research (WONDER), the researchers looked at every death in the U.S. between 1999 and 2019 and identified ones where diabetes caused or contributed to the death. Diabetes deaths were disproportionately high in rural counties, the study found.

Researchers found that the age-adjusted mortality rates (AAMR) for diabetes patients in rural areas was higher across all age, sex and ethnicity groups.

The reasons could be many, but that lack of access to healthcare – exacerbated by the closure of rural hospitals – was probably the leading cause, researchers said. But other factors play a role. 

Trends in age-adjusted diabetes-related mortality in the USA 1999–2019, stratified by urbanisation status, per 100,000 population. Diabetes as the underlying cause of death (a); and diabetes as a contributing cause of death (b). (Source: Urban–rural disparities in diabetes-related mortality in the USA 1999–2019
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“There will be clear socioeconomic drivers, with an important intersection with race that may account for major differences in risk factors, the progression of diabetes and survival,” Dr. Mamas A. Mamas of Keele University in Keele, England, said in an email interview. 

Mamas said structural racism also played a role. “It is no surprise that ethnic minorities in rural areas, that are at highest risk of social deprivation, have the worst outcomes.”

Over the two decades, the study found that the mortality rate where diabetes was an underlying factor decreased in urban areas. In rural areas, the mortality rate of diabetes as the underlying cause rose 2.5%, while the mortality rate of diabetes as a contributing factor rose by nearly 9%.

The study also found that the death rate from diabetes increased in men while it decreased in women. Additionally, the study found higher mortality rates in younger adults over the last 20 years compared to the older population. In adults under 55, there was an increase in both rural and urban mortality rates, but the increase was larger in rural areas (more than 59% for underlying cause) than in urban areas (15% for underlying cause).

Ethnic minorities, such as Blacks and Native Americans, living in rural areas also had higher mortality rates. Over the course of the study, mortality rates in Black patients fell by nearly 28% in urban areas. In rural areas, however, the mortality rate for Blacks stayed the same. In both urban and rural areas, the study found, diabetes-related mortality rates were nearly twice as high in Black patients as they were in white ones.

Mamas said one of the reasons for the higher rural mortality rates may be due to the rise of Type 2 diabetes.

“The prevalence of diabetes is increasing worldwide and reflects the growing obesity epidemic driven by increased consumption of processed food and refined sugars and decreased physical activity,” he said. “It is growing more quickly in rural environments and it is intrinsically tied to socioeconomic deprivation and the ability to make healthy lifestyle choices when one is on the breadline.”

Early-onset Type 2 diabetes is associated with a more aggressive disease, he said, and higher rates of complications. Males are more likely to be diagnosed with diabetes at an early age, he said, which may explain the widening gap between the male and female diabetes-related mortality gap.

Mamas said rural residents are also less likely to have participated in diabetes self-management education and had higher rates of diabetes-related visits to the emergency department.

Connecting all of this, he said, was a lack of access to healthcare in rural communities.

“The management of diabetes and its complications requires expertise that may be difficult to access in rural communities,” the study said. “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.”

Addressing the mortality gap, researchers said, would require efforts to improve healthcare access in rural areas.

Telehealth may be one solution, he said. But even that has its limitations.

“Telehealth will definitely improve the ability to provide care to isolated communities and therefore improve outcomes,” he said. “To my mind the bigger challenge will be the upfront costs of setting up such services, particularly given that investment in rural healthcare services is much lower than in urban (areas).”

The study defined rural areas as counties that are located outside Metropolitan Statistical Areas, according to the federal Office of Management and Budget (2013).

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