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Onset of type 1 diabetes mellitus in rural areas of the USA
  1. Mary A M Rogers
  1. Internal Medicine, University of Michigan, Ann Arbor, MI 48109, USA
  1. Correspondence to Dr Mary A M Rogers, Internal Medicine, University of Michigan, Ann Arbor, MI 48109, USA; maryroge{at}


Background In the USA, the epidemiologic features of type 1 diabetes are not well-defined across all 50 states. However, the advent of large nationwide insurance databases enables the investigation of where type 1 diabetes cases occur throughout the country.

Methods An integrated database from a large nationwide health insurer in the USA (Clinformatics Data Mart Database) was used, from 2001 to 2017. The database contained longitudinal information on approximately 77 million people.

Results The incidence of type 1 diabetes was greatest in areas of low population density across the 50 states. Individuals in the lowest population density areas had rates that were 2.28 times (95% CI 2.08 to 2.50) that of persons living in high-density areas. This association was consistent across various measures of rural status (p<0.001 for population density; p<0.001 for per cent rural as defined by the US Census Bureau; p=0.026 for farmland). The association between rural areas and the incidence of type 1 diabetes was evident across all four general regions of the USA.

Conclusions The predilection of type 1 diabetes in rural areas provides clues to potential factors associated with the onset of this autoimmune disease.

  • geography
  • diabetes
  • epidemiology
  • epidemiology of diabetes
  • neighborhood/place

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  • Contributors MAMR designed the study, acquired the data and conducted the data analysis; wrote the article and revised it for publication; and is responsible for the content of this article.

  • Funding This study was funded by the National Institutes of Health (grant UL1TR000433) to the Michigan Institute for Clinical & Health Research.

  • Competing interests None declared.

  • Patient consent for publication Not required.

  • Provenance and peer review Not commissioned; externally peer reviewed.