Rural Americans Have Higher Rates of Heart Disease, Driven by Poverty and Food Insecurity, Study Finds

Health policy experts at Beth Israel Deaconess Medical Center (BIDMC) reveal in a new report that adults living in rural areas of the United States face significantly higher rates of heart disease and related health problems than their urban counterparts—and that these health gaps are largely driven by social and economic conditions, not just lifestyle factors or access to care.

“Cardiovascular death rates are significantly higher in rural America, due in part to limited access to care caused by a weakening health care infrastructure—rural hospital closures, a shrinking number of primary care clinicians, and gaps in insurance coverage, particularly in states that haven’t expanded Medicaid,” said corresponding author Rishi K. Wadhera, MD, MPP, MPhil., associate director of the Richard A. and Susan F. Smith Center for Outcomes Research at BIDMC. “Recent data has shown a concerning rise in cardiovascular mortality among young rural adults and understanding what’s driving these patterns is critical to informing the steps clinicians, health systems, and policymakers need to take to improve heart health in rural communities.”

Wadhera and colleagues first used the 2022 National Health Interview Survey to evaluate the prevalence of four cardiometabolic risk factors (high blood pressure, high cholesterol, obesity and diabetes) in the United States and to see how the burden of these conditions differed across rural, small-town, and urban communities.

Analyzing data that included over 27,000 U.S. adults aged 20 and older, the researchers found that rural Americans were more likely to be older and white than people who live in small towns or cities; they are also more likely to have high blood pressure, high cholesterol, obesity and diabetes compared to those in cities. Rates of coronary heart disease were also higher in rural areas, though stroke rates were similar. The differences were most striking among younger adults aged 20 to 39, where rural residents were 44 percent more likely to have high blood pressure, 54 percent more likely to be obese, and more than twice as likely to have diabetes compared to their urban peers.

“The finding that rural-urban cardiovascular health disparities were largest among young adults is alarming, particularly against the backdrop of rapidly worsening cardiovascular health in this population,” said Wadhera. “The onset of cardiometabolic risk factors at an early age increases the risk of life-threatening cardiovascular events later in life.”

Next the team attempted to determine how lifestyle factors, access to healthcare, and social risk factors contribute to the rural-urban disparities. While rural adults were more likely to smoke and get less exercise, those factors alone didn’t explain the differences. Even after accounting for health care access—such as insurance coverage and having a regular doctor—the rural-urban health gaps remained. But when researchers factored in social conditions like poverty, low education levels, food insecurity, and lack of home ownership, most of the differences in hypertension, diabetes, and heart disease disappeared, though disparities in obesity remained.

“Our findings bolster a large body of evidence that has demonstrated social risk factors are strongly linked to cardiovascular health outcomes,” Wadhera said. “Poverty itself has been shown to independently erode cardiovascular health; as such economic development initiatives and educational programs should be prioritized in rural areas experiencing the highest levels of social disadvantage.”

Co-authors included Michael Liu, MD, Lucas X. Marinacci, MD of BIDMC; and Karen Joynt-Maddox, MD, MPH of Washington University, St. Louis.

This study was supported by a grant from the NIH/National Heart, Lung, and Blood Institute (R01HL174549) and the American Heart Association Established Investigator Award (24EIA1258487).

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 this study, and personal fees from Abbott and Chamber Cardio, outside the submitted work. No other disclosures were reported.