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Comment
. 2025 Jun 1;10(6):585-594.
doi: 10.1001/jamacardio.2025.0538.

Cardiovascular Health Among Rural and Urban US Adults-Healthcare, Lifestyle, and Social Factors

Michael Liu  1   2 , Lucas X Marinacci  1 , Karen E Joynt Maddox  3   4 , Rishi K Wadhera  1   2   5
Affiliations
Comment

Cardiovascular Health Among Rural and Urban US Adults-Healthcare, Lifestyle, and Social Factors

Michael Liu et al. JAMA Cardiol. .

Abstract

Importance: Improving cardiovascular health in rural areas is a national priority in the US. However, little is known about the current state of rural cardiovascular health and the underlying drivers of any rural-urban disparities.

Objective: To compare rates of cardiometabolic risk factors and cardiovascular diseases between rural and urban US adults and to evaluate the extent to which health care access, lifestyle factors, and social risk factors contribute to any rural-urban differences.

Design, setting, and participants: This nationally representative cross-sectional study analyzed data from US adults aged 20 years or older residing in rural vs urban areas using the 2022 National Health Interview Survey. Data were analyzed between August 2024 and February 2025.

Exposure: County-level rurality.

Main outcomes and measures: The primary outcomes were age-standardized rates of cardiometabolic risk factors (hypertension, hyperlipidemia, obesity, and diabetes) and cardiovascular diseases (coronary heart disease [CHD] and stroke).

Results: The study population consisted of 27 172 adults, including 4256 adults (14.0%) residing in rural areas, 14 741 (54.8%) in small or medium metropolitan areas, and 8175 (31.2%) in urban areas. Mean (SD) participant age was 49.1 (17.8) years, and 4399 participants (50.8%) were female. Compared with their urban counterparts, rural adults were more likely to smoke, be insufficiently physically active, and have more social risk factors. Age-standardized rates of cardiometabolic risk factors were significantly higher in rural areas, including hypertension (37.1% vs 30.9%; rate ratio [RR], 1.20; 95% CI, 1.13-1.27), hyperlipidemia (29.3% vs 26.7%; RR, 1.10; 95% CI, 1.03-1.18), obesity (41.1% vs 30.0%; RR, 1.37; 95% CI, 1.27-1.47), and diabetes (11.2% vs 9.8%; RR, 1.15; 95% CI, 1.02-1.29). The same pattern was observed for CHD (6.7% vs 4.3%; RR, 1.58; 95% CI, 1.35-1.85), but no differences were observed for stroke. The magnitude of rural-urban disparities was largest among young adults (aged 20-39 years) for hypertension (RR, 1.44; 95% CI, 1.12-1.86), obesity (RR, 1.54; 95% CI, 1.34-1.77), and diabetes (RR, 2.59; 95% CI, 1.54-4.38). Rural-urban disparities in cardiovascular health were not meaningfully attenuated after adjustment for measures of health care access (insurance coverage, usual source of care, and recent health care utilization) and lifestyle factors (smoking and physical activity). However, accounting for social risk factors (poverty, education level, food insecurity, and home ownership) completely attenuated rural-urban disparities in hypertension (adjusted RR [aRR], 0.99; 95% CI, 0.93-1.06), diabetes (aRR, 1.02; 95% CI, 0.90-1.15), and CHD (aRR, 1.08; 95% CI, 0.91-1.29), but only partially attenuated disparities in obesity (aRR, 1.29; 95% CI, 1.20-1.39).

Conclusions and relevance: This national cross-sectional study found substantial rural-urban disparities in cardiometabolic risk factors and cardiovascular diseases, which were largest among younger adults and almost entirely explained by social risk factors. These findings suggest that efforts to improve socioeconomic conditions in rural communities may be critical to address the rural-urban gap in cardiovascular health.

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Conflict of interest statement

Conflict of Interest Disclosure: Dr Marinacci reported grants from the US National Institutes of Health (NIH) during the conduct of the study. Dr Joynt Maddox reported grants from the NIH, serving on the advisory council for the Centene Corporation, and research support from Humana outside the submitted work. Dr Wadhera reported grants from the US National Heart, Lung, and Blood Institute and the American Heart Association during the conduct of the study and personal fees from Abbott and Chamber Cardio outside the submitted work. No other disclosures were reported.

Comment on

References

    1. Cross SH, Mehra MR, Bhatt DL, et al. Rural-urban differences in cardiovascular mortality in the US, 1999-2017. JAMA. 2020;323(18):1852-1854. doi: 10.1001/jama.2020.2047 - DOI - PMC - PubMed
    1. Marinacci LX, Zheng Z, Mein S, Wadhera RK. Rural-urban differences in cardiovascular mortality in the United States, 2010-2022. J Am Coll Cardiol. 2025;85(1):93-97. doi: 10.1016/j.jacc.2024.09.1215 - DOI - PubMed
    1. Harrington RA, Califf RM, Balamurugan A, et al. Call to action: rural health: a Presidential Advisory from the American Heart Association and American Stroke Association. Circulation. 2020;141(10):e615-e644. doi: 10.1161/CIR.0000000000000753 - DOI - PubMed
    1. Mueller JT, McConnell K, Burow PB, Pofahl K, Merdjanoff AA, Farrell J. Impacts of the COVID-19 pandemic on rural America. Proc Natl Acad Sci U S A. 2021;118(1):2019378118. doi: 10.1073/pnas.2019378118 - DOI - PMC - PubMed
    1. Frakt AB. The rural hospital problem. JAMA. 2019;321(23):2271-2272. doi: 10.1001/jama.2019.7377 - DOI - PubMed