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J Epidemiol Community Health. 2019 Sep 28. pii: jech-2019-212693. doi: 10.1136/jech-2019-212693. [Epub ahead of print]

Onset of type 1 diabetes mellitus in rural areas of the USA.

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Internal Medicine, University of Michigan, Ann Arbor, MI 48109, USA



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.


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.


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.


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


diabetes; epidemiology; epidemiology of diabetes; geography; neighborhood/place


Conflict of interest statement

Competing interests: None declared.

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