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OBJECTIVE To examine changes in and the relationships between diabetes management and rural and urban residence. RESEARCH DESIGN AND METHODS Using National Health and Nutrition Examination Survey (1999–2018) data from 6,372 adults aged ≥18 years with self-reported diagnosed diabetes, we examined poor ABCS: A1C &amp;gt;9% (&amp;gt;75 mmol/mol), Blood pressure (BP) ≥140/90 mmHg, Cholesterol (non-HDL) ≥160 mg/dL (≥4.1 mmol/L), and current Smoking. We compared odds of urban versus rural residents (census tract population size ≥2,500 considered urban, otherwise rural) having poor ABCS across time (1999–2006, 2007–2012, and 2013–2018), overall and by sociodemographic and clinical characteristics. RESULTS During 1999–2018, the proportion of U.S. adults with diabetes residing in rural areas ranged between 15% and 19.5%. In 1999–2006, there were no statistically significant rural-urban differences in poor ABCS. However, from 1999–2006 to 2013–2018, there were greater improvements for urban adults with diabetes than for rural for BP ≥140/90 mmHg (relative odds ratio [OR] 0.8, 95% CI 0.6–0.9) and non-HDL ≥160 mg/dL (≥4.1 mmol/L) (relative OR 0.45, 0.4–0.5). These differences remained statistically significant after adjustment for race/ethnicity, education, poverty levels, and clinical characteristics. Yet, over the 1999–2018 time period, minority race/ethnicity, lower education attainment, poverty, and lack of health insurance coverage were factors associated with poorer A, B, C, or S in urban adults compared with their rural counterparts. CONCLUSIONS Over two decades, rural U.S. adults with diabetes have had less improvement in BP and cholesterol control. In addition, rural-urban differences exist across sociodemographic groups, suggesting that efforts to narrow this divide may need to address both socioeconomic and clinical aspects of care.

Differences in U.S. Rural-Urban Trends in Diabetes ABCS, 1999–2018