U.S. Rural Counties Have Higher Death Rates From Diabetes Than More Urbanized Environments

Photo of a man in a harvested corn field representing the study group of this research.

Diabetes requires lifelong care. Accessing that care may be more difficult in some places—especially rural areas—than in others. In addition, people who live in rural areas may be at higher risk for developing diabetes. A new NIMHD-supported study investigated the role of rurality in diabetes and found that U.S. rural counties have higher diabetes mortality rates than urban areas.

Using data from the Centers for Disease Control and Prevention, researchers compared the annual diabetes mortality rate (ADMR) per 100,000 people in 2017-2018 with the rate in 1999-2000. This mortality rate includes deaths where diabetes is listed as one of multiple causes. The researchers attempted to look beyond national mortality trends by examining results based on gender, age group, region of the country, and degree of urbanization.

They classified counties’ degree of urbanization as:

  • Metro (large central metropolitan and large fringe metropolitan).
  • Medium-small (medium metropolitan and small metropolitan).
  • Rural (micropolitan and noncore).

They focused on individuals age 25 and older, because diabetes in those people would more likely be type 2, which accounts for 90% to 95% of all diabetes cases.

This comparison showed that the ADMR was highest in rural areas. The rural death rate did not change between 1999-2000 and 2017-2018. However, in more urbanized counties, the death rate from diabetes fell over the same period, showing that people in rural areas were not experiencing whatever factor accounted for the decrease in more urbanized areas.

The researchers also found differences in ADMR between 1999-2000 and 2017-2018 by gender, age group, and region of the country. Women had lower ADMR whether in metro, medium-small, or rural counties; however, female mortality fell the least in rural counties. Among men, ADMR increased in rural counties but declined or stayed the same elsewhere. Even though ADMR increased among the 25- to 54-year-old group regardless of urbanization, the rate was highest in rural counties. For the older population (age 55 and above), ADMR declined in medium-small and metro counties and did not change in rural counties. ADMR increased in the rural South, remained the same in the rural Midwest and West, and decreased in the rural Northeast.

Even though the data revealed differences in mortality associated with gender, age group, and region of the country, rural health disparities in diabetes were a consistent theme across all groups. The researchers point out that these rural health trends would not be visible in an analysis of national-level data. Large declines in diabetes mortality in recent decades in more urbanized counties have resulted in national-level declines in ADMR, masking the health disparities present in rural counties.

The researchers suggest several possible reasons why people in rural areas may be more likely to die from diabetes. People in rural areas may be more likely to have other medical conditions that could make their diabetes worse. They may have difficulty accessing health care and may not consume as many fruits and vegetables as people in urban areas do. They may also be disproportionately affected by environmental pollution. All of these factors make the ongoing management of diabetes more difficult, especially when changes in treatment are required.

This study contributes knowledge about health disparities related to diabetes death rates in rural counties. The researchers write that further research could show why these disparities exist and support development of ways to improve rural health.


Dugani, S. B., Wood-Wentz, C. M., Mielke, M. M., Bailey, K. R., & Vella, A. (2022). Assessment of disparities in diabetes mortality in adults in U.S. rural vs. nonrural counties, 1999–2018. JAMA Network Open, 5(9), e2232318. https://doi.org/10.1001/jamanetworkopen.2022.32318

Page updated February 27, 2023