{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,9,8]],"date-time":"2026-09-08T05:11:13Z","timestamp":1788844273313,"version":"build-2803163510"},"reference-count":20,"publisher":"BMJ","issue":"12","funder":[{"name":"NIH","award":["Grant UL1TR000433"],"award-info":[{"award-number":["Grant UL1TR000433"]}]}],"content-domain":{"domain":["bmj.com"],"crossmark-restriction":true},"short-container-title":["J Epidemiol Community Health"],"accepted":{"date-parts":[[2019,9,21]]},"published-print":{"date-parts":[[2019,12]]},"abstract":"<jats:sec>\n                  <jats:title>Background<\/jats:title>\n                  <jats:p>In the USA, the epidemiologic features of type 1 diabetes are not well-defined across all 50 states. However, the advent of large nationwide insurance databases enables the investigation of where type 1 diabetes cases occur throughout the country.<\/jats:p>\n               <\/jats:sec>\n               <jats:sec>\n                  <jats:title>Methods<\/jats:title>\n                  <jats:p>An integrated database from a large nationwide health insurer in the USA (Clinformatics Data Mart Database) was used, from 2001 to 2017. The database contained longitudinal information on approximately 77\u2009million people.<\/jats:p>\n               <\/jats:sec>\n               <jats:sec>\n                  <jats:title>Results<\/jats:title>\n                  <jats:p>The incidence of type 1 diabetes was greatest in areas of low population density across the 50 states. Individuals in the lowest population density areas had rates that were 2.28 times (95%\u2009CI 2.08 to 2.50) that of persons living in high-density areas. This association was consistent across various measures of rural status (p&lt;0.001 for population density; p&lt;0.001 for per cent rural as defined by the US Census Bureau; p=0.026 for farmland). The association between rural areas and the incidence of type 1 diabetes was evident across all four general regions of the USA.<\/jats:p>\n               <\/jats:sec>\n               <jats:sec>\n                  <jats:title>Conclusions<\/jats:title>\n                  <jats:p>The predilection of type 1 diabetes in rural areas provides clues to potential factors associated with the onset of this autoimmune disease.<\/jats:p>\n               <\/jats:sec>","DOI":"10.1136\/jech-2019-212693","type":"journal-article","created":{"date-parts":[[2019,9,28]],"date-time":"2019-09-28T17:29:55Z","timestamp":1569691795000},"page":"1136-1138","update-policy":"https:\/\/doi.org\/10.1136\/crossmarkpolicy","source":"Crossref","is-referenced-by-count":13,"title":["Onset of type 1 diabetes mellitus in rural areas of the USA"],"prefix":"10.1136","volume":"73","author":[{"ORCID":"https:\/\/orcid.org\/0000-0001-5519-3223","authenticated-orcid":false,"given":"Mary A M","family":"Rogers","sequence":"first","affiliation":[{"name":"Internal Medicine, University of Michigan, Ann Arbor, MI 48109, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"239","published-online":{"date-parts":[[2019,9,28]]},"reference":[{"key":"2025100302145507000_73.12.1136.1","doi-asserted-by":"crossref","first-page":"69","DOI":"10.1016\/S0140-6736(13)60591-7","article-title":"Type 1 diabetes","volume":"383","author":"Atkinson","year":"2014","journal-title":"The Lancet"},{"key":"2025100302145507000_73.12.1136.2","doi-asserted-by":"crossref","first-page":"2331","DOI":"10.1016\/S0140-6736(16)30582-7","article-title":"Genetic risk factors for type 1 diabetes","volume":"387","author":"Pociot","year":"2016","journal-title":"The Lancet"},{"key":"2025100302145507000_73.12.1136.3","doi-asserted-by":"crossref","first-page":"2340","DOI":"10.1016\/S0140-6736(16)30507-4","article-title":"Environmental risk factors for type 1 diabetes","volume":"387","author":"Rewers","year":"2016","journal-title":"The Lancet"},{"key":"2025100302145507000_73.12.1136.4","doi-asserted-by":"crossref","DOI":"10.1136\/bmj.d35","article-title":"Enterovirus infection and type 1 diabetes mellitus: systematic review and meta-analysis of observational molecular studies","volume":"342","author":"Yeung","year":"2011","journal-title":"BMJ"},{"key":"2025100302145507000_73.12.1136.5","doi-asserted-by":"crossref","first-page":"89","DOI":"10.1007\/s12560-017-9322-4","article-title":"Coxsackievirus B4 as a causative agent of diabetes mellitus type 1: is there a role of inefficiently treated drinking water and sewage in virus spreading?","volume":"10","author":"El-Senousy","year":"2018","journal-title":"Food Environ Virol"},{"key":"2025100302145507000_73.12.1136.6","doi-asserted-by":"crossref","DOI":"10.1186\/s12916-017-0958-6","article-title":"Fluctuations in the incidence of type 1 diabetes in the United States from 2001 to 2015: a longitudinal study","volume":"15","author":"Rogers","year":"2017","journal-title":"BMC Med"},{"key":"2025100302145507000_73.12.1136.7","doi-asserted-by":"publisher","DOI":"10.1146\/annurev.micro.54.1.81"},{"key":"2025100302145507000_73.12.1136.8","doi-asserted-by":"crossref","unstructured":"DeSimone LA , Hamilton PA . 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