Age at diagnosis of diabetes in Appalachia

We used data from the Behavioral Risk Factor Surveillance System (2006-2008). We compared age at diagnosis among counties by Appalachian Regional Commission-defined level of economic development. To account for risk differences, we constructed a model for average age at diagnosis of diabetes, adjusting for county economic development, obesity, income, sedentary lifestyle, and other covariates.After adjustment for risk factors for diabetes, people in distressed or at-risk counties (the least economically developed) had their diabetes diagnosed two to three years younger than comparable people in non-Appalachian counties. No significant differences between non-Appalachian counties and Appalachian counties at higher levels of economic development remained after adjusting.People in distressed and at-risk counties have poor access to care, and are unlikely to develop diabetes at the same age as their non-Appalachian counterparts but be diagnosed sooner. Therefore, people in distressed and at-risk counties are likely developing diabetes at younger ages. We recommend that steps to reduce health disparities between the poorest Appalachian counties and non-Appalachian counties be considered.The Appalachian region of the United States extends from southern New York to northern Mississippi [1] (Figure 1). Appalachia includes all of West Virginia and parts of Alabama, Georgia, Kentucky, Maryland, Mississippi, New York, North Carolina, Ohio, Pennsylvania, South Carolina, Tennessee, and Virginia. Approximately 42% of Appalachia's population of 24 million people is rural, compared to 20% of the national population [1]. In 2000, Appalachia's population was 88% non-Hispanic white, as compared with about 70% for the rest of the United States [2].Appalachia was slow to develop large urban centers, due in part to rough terrain and a shortage of roads and navigable rivers. In the early days of westward expansion, settlers of the mountainous, often steep-sloped terrain in parts of Appala