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Diabetes Disparities: Where You Live Impacts Long-Term Health

Study finds diabetics in rural areas, poor neighborhoods fare worse

woman using a diabetes testing kit

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For adult living with diabetes, where you live may influence your chances of avoiding long-term complications including cardiovascular, kidney and eye disease, according to a new study led by researchers at the Mayo Clinic.

Appearing in JAMA Network Open, the neighborhood-by-neighborhood analysis of nearly 32,000 diabetics across three states found disparities in how likely they were to achieve “optimal care” based on five benchmarks known as “the composite D5 metric.”

“Adult patients with diabetes in areas that were more socioeconomically deprived and rural were significantly less likely to attain the D5 metric of optimal diabetes care compared with patients who lived in less deprived and urban areas,” the study concluded.

What was measured

The “D5 metric” is a measure that was developed and is tracked by Minnesota Community Measures and is used by health care organizations and health care practices in Minnesota. It consists of five benchmarks that, when achieved, are recognized as providing diabetes patients with the optimal chance of avoiding long-term complications.

The benchmarks are:

  • Glycemic control. Maintaining stable blood glucose levels as measured by keeping hemoglobin A1c levels at below 8 percent.
  • Blood pressure. Keeping systolic blood pressure at below 140mm Hg and diastolic blood pressure at below 90mm Hg.
  • Cholesterol. Taking prescribed statins to control lipids, commonly known as cholesterol.
  • Aspirin. Using aspirin if ischemic heart disease (caused by narrowed heart arteries) is present.
  • Tobacco free. Patient does not use tobacco products.

Key findings

The study included nearly 32,000 adults (ages 18 to 75) with diabetes who were receiving care from 75 practices across Minnesota, Iowa and Wisconsin. While 4 in 10 diabetics achieved all five of the benchmarks, the results weren’t evenly distributed across rural and urban areas or socioeconomic neighborhoods, according to study coauthor Rozalina McCoy, M.D., an associate professor of medicine in Mayo Clinic’s Division of Community Internal Medicine, Geriatrics and Palliative Care.


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“We found significant differences in the rates of D5 attainment both by rurality and deprivation,” she said.  

Specifically, they found:

  • While 43 percent of diabetics in urban areas achieved D5 benchmarks, only 38 percent did so in rural areas.
  • In the most affluent neighborhoods, 44 percent of diabetics achieved D5 benchmarks, while just 34 percent did so in the least affluent neighborhoods.
  • Nearly 42 percent of white diabetics achieved D5 benchmarks, while just over 34 percent of Black and other racial and ethnic minority groups did so.

What the study means for you

McCoy says that anyone living with diabetes should have access to a trusted health care provider who can help them meet the D5 metrics safely.

“It is important to work closely with their health care providers to optimize blood glucose, blood pressure and cholesterol management; not smoke or use other tobacco products; and take aspirin if they have existing heart disease,” she said.

Communication is key. Patients should tell their health care provider if they can afford and tolerate their medications, and discuss any other barriers to diabetes care, she said.

“There are resources available to help people living with diabetes afford medications and testing supplies, and to live well with their diabetes. Pharmacists, certified diabetes care and education specialists, community health workers, community paramedics and social workers are all integral parts of the health care team and can help people living with diabetes,” McCoy said.

For older adults with diabetes, McCoy suggests they select a Medicare Advantage or Part D plan that covers the medications they need to manage their diabetes. She also cautions them to be particularly watchful of experiencing hypoglycemia (low blood sugar) or hypotension (low blood pressure).  

“Older people are particularly susceptible to both, and both are dangerous. If they are, they need to tell their health care provider so their regimens can be changed. It is important for blood glucose and blood pressure to be in a safe range, not too high or too low,” McCoy said.

Peter Urban is a contributing writer and editor who focuses on health news. Urban spent two decades working as a correspondent in Washington, D.C., for daily newspapers in Connecticut, Massachusetts, Ohio, California and Arkansas, including a stint as Washington bureau chief for the Las Vegas Review-Journal. His freelance work has appeared in Scientific American, Bloomberg Government and CTNewsJunkie.com.