title: Age at diagnosis of diabetes in Appalachia.
abstract: BACKGROUND
  Appalachia is a region of the United States noted for the poverty and poor health outcomes of its residents. Residents of the poorest Appalachian counties have a high prevalence of diabetes and risk factors (obesity, low income, low education, etc.) for type 2 diabetes. However, diabetes prevalence exceeds what these risk factors alone explain. Based on this, the history of poor health outcomes in Appalachia, and personally observed high rates of childhood obesity and lack of concern about prediabetes, we speculated that people in Appalachia with diagnosed diabetes might tend to be diagnosed younger than their non-Appalachian counterparts.
  
  
  METHODS
  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.
  
  
  RESULTS
  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.
  
  
  CONCLUSIONS
  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.
authors.affiliation: Division of Diabetes Translation, Centers for Disease Control and Prevention, Atlanta Georgia, USA. lsb8@cdc.gov.
authors.forename: Lawrence
authors.initials: L
authors.lastname: Barker
authors.forename: Robert
authors.initials: R
authors.lastname: Gerzoff
authors.forename: Richard
authors.initials: R
authors.lastname: Crespo
authors.forename: Molly
authors.initials: M
authors.lastname: Shrewsberry