Adults with type 2 diabetes have been shown to have a reduced life expectancy compared with adults without diabetes, particularly due to higher risk of fatal cardiovascular events.^{1, 2} Physical activity (PA) may reduce cardiovascular mortality and risk factors for complications among persons with diabetes, such as poor glycemic control, hypertension, overweight and obesity, and dyslipidemia.^{3, 4} The 2018 Physical Activity Guidelines for Americans (referred to as ‘guidelines’ hereafter) recommend that persons with chronic health conditions such as diabetes engage in aerobic and strength training PA, trying to meet recommendations if they are able ⁵ with potential exceptions and modifications as needed.⁶ However, despite the potential health benefits of PA, adults with diabetes are less likely to be physically active than those without diabetes.^{7, 8} In 2015 only 31% of adults with diabetes in the United States (US) met aerobic PA recommendations, 13% met strength training, and 9% met both aerobic and strength training recommendations.⁹

Rural (non-metropolitan) communities in the US experience higher prevalence of diabetes^{10, 11} and of diabetes related mortality than metropolitan communities.¹² Rural communities in general also lag in meeting PA guidance with only 38% of adults in nonmetro counties meeting aerobic guidelines compared to 50% in large central and fringe metro counties.¹³ However, it is not known how this manifests among adults with diabetes. Therefore, the aim of this study is to assess prevalence of meeting PA guidelines during leisure time among adults with and without diabetes according to urban/rural county of residence.

Characteristics of the study population by self-report of physician-diagnosed diabetes are shown in Table 1. Compared with adults without diabetes, those with diabetes were older, more likely to be male, less likely to be non-Hispanic white, and had lower education levels and incomes. Those reporting diabetes were also more likely to live in non-metro areas, and less likely to report recommended levels of aerobic PA (28.8% vs 49.0%; p<0.001), muscle-strengthening PA (15.3% vs. 32.4%; p<0.001), or both (9.4% vs. 25.8%; p<0.001). In supplemental analysis (data not shown), prevalence of meeting aerobic, strength, or both guidelines did not differ significantly between 2020 and 2022 among those with diabetes or those without diabetes or among adults of any county metropolitan status.

Age-adjusted prevalence of meeting PA guidelines according to diabetes and metro status is shown in Figure 1. Regardless of diabetes status, age-adjusted prevalence of meeting aerobic, muscle-strengthening, or both PA recommendations differed significantly according to metropolitan status (p<0.001). Among adults with diabetes in non-metro counties, the proportion reporting PA meeting recommended levels were 23.8% for aerobic PA, 10.9% for muscle-strengthening PA, and 6.2% for both activities. By contrast, 42.6% of adults without diabetes in non-metro counties were found to meet the recommended levels for aerobic PA, 23.8% for muscle-strengthening PA, and 18.5% for both activities.

Age-adjusted prevalence ratios comparing the prevalence of meeting physical activity guidelines among adults with and without self-reported diabetes according to metropolitan status are shown in Figure 2. By metropolitan status, age-adjusted prevalence of adults with diabetes meeting aerobic PA recommendations was 20% lower in non-metro counties than in large central metro counties (PR=0.80; 95% CI: 0.68-0.94). The prevalence of adults with diabetes meeting muscle-strengthening recommended PA levels was 31% higher in large fringe metro than in large central metro counties (PR=1.31; 95% CI 1.08-1.60). The prevalence of meeting both guidelines among adults with diabetes was 39% lower among those in non-metro compared to large central metro counties (PR=0.61; 95% CI: 0.43-0.86). Among adults without diabetes, age-adjusted prevalence of meeting aerobic, muscle-strengthening, or both PA recommendations was lower in small/medium metro and non-metro counties compared to large central metro counties.

Multivariable-adjusted prevalence ratios comparing the prevalence of meeting physical activity guidelines among adults with and without self-reported diabetes according to metropolitan status are shown in Figure 3. After additional adjustment for demographic and socioeconomic characteristics, among those with diabetes, only the prevalence of meeting guidance on muscle-strengthening remained significantly higher in large fringe metro compared to large central metro counties (PR=1.27; 95% CI 1.03-1.56). Among those without diabetes, multivariable adjusted prevalence of meeting each recommendation and both remained significantly lower in non-metro and small/medium metro counties compared to large central metro counties.

The results of this study suggest that adults with diabetes are far less likely to meet the current recommendations from the Physical Activity Guidelines for Americans than those without diabetes. Specifically, more than 7 out of 10 adults with diabetes in the US do not meet aerobic PA guidelines, 8 out of 10 do not meet muscle-strengthening guidelines, and 9 out of 10 do not meet the combined PA guidelines. Further, disparities in meeting guidelines were observed among both those with and without diabetes according to metropolitan status, with residents of non-metro and small/medium metro counties generally less likely to meet guidelines compared to large metro counties.

It has been previously demonstrated that adults with diabetes are less likely than those without to engage in PA.^{7, 17, 18} Although there is some evidence that the prevalence of meeting PA recommendations has somewhat increased over the last two decades,¹⁷ the results of the present study suggest a disparity by diabetes status persists. However, changes to the NHIS study design in 2019 do not allow direct comparison of 2020 and 2022 prevalence estimates presented here to NHIS estimates published previously. The Physical Activity Guidelines for Americans generally apply to individuals with type 2 diabetes, with recommendations being the same for adults of all ages.⁶ When comorbidities or age-related disabilities affect the ability to engage in PA, modifications may be needed with the aim of engaging in as much aerobic activity as health status allows.⁶ Further, when comorbidities or disability prevent muscle-strengthening guidelines from being met, activity should focus on functional fitness, balance, and flexibility.⁶ PA has the potential to improve cardiovascular risk factors and reduce adverse outcomes among those with diabetes, reducing the risk of cardiovascular disease, even when it is accompanied by little or no weight loss.⁶ Regular aerobic PA improves glycemic control, resulting in 0.5%-0.7% reductions in Hemoglobin A1C.⁶ Muscle-strengthening activity improves blood pressure, lipid profiles, and insulin sensitivity.⁶ Engaging in both aerobic and muscle strengthening PA may provide more benefit in lowering A1C than either type of exercise alone.^{4, 6} Further benefits of PA among those with diabetes include improvements in mental health and improving quality of life.⁶

Rural disparities in health behaviors, chronic disease, and socioeconomic status have been well documented. For example, diabetes prevalence and mortality are higher in non-metro counties compared to more urban counties.^{10, 11, 12, 19} While diabetes mortality has improved in the US during the past two decades, rural counties have not improved as much as urban counties.^{12, 19} This could be linked to higher rural prevalence of diabetes risk factors and lower prevalence of healthy behaviors. For example, obesity and cigarette smoking are more prevalent in more rural areas compared to urban areas.^{20, 21} Meeting PA guidelines is also less common among the general adult population in rural counties.¹³ The results of this study suggest that lower prevalence of meeting PA guidelines among adults with diabetes in non-metro areas may help to explain their continued higher diabetes mortality and further highlight the potential benefits of expanding rural access to diabetes self-management programs and physical activity amenities to provide opportunities for leisure time physical activity.

Although the results suggest that lower rates of PA among those in rural areas may be at least partly explained by socioeconomic disparities experienced by rural residents, there is also evidence to suggest that rural residents experience different environmental factors that may influence PA compared to urban residents. For example, the lower population density generally associated with rural locations may result in fewer walkable or bikeable destinations. Specifically, Whitfield et al. reported in 2015 that rural residents were less likely to report the presence of walkable places such as retail stores, transit stops, recreational facilities, and places of worship, and more likely to report barriers to walking such as traffic and animals.²² Residents from rural locations are also less likely to report infrastructure to facilitate walking or biking such as sidewalks, trails, or roads with adequate shoulders or bike lanes.²² Access to diabetes management lifestyle intervention programs, which often include PA, may also be less available or a further distance from rural residents with diabetes.²³ Some research also suggests cultural norms may pose a barrier to PA in some rural places, such as Appalachia.²⁴ Finally, higher rural rates of diabetes complications²⁵ that pose significant barriers to PA such as amputations and proliferative retinopathy could also explain observed disparities in PA among rural adults with diabetes.

The results of the current study suggest that adults with diabetes still greatly lag those without diabetes in meeting PA guidelines. Further, disparities in meeting PA guidelines exist according to urban/rural status among both adults with and without diabetes. Among adults with and without diabetes, residence in a non-metro county was significantly associated with lower prevalence of meeting aerobic, strength, or both guidelines compared to residence in a large central metro county, although the association became non-significant among those with diabetes after multivariable adjustment. Encouraging adults with and without diabetes in rural areas to be more physically active using community based,²⁶ telehealth,²⁷ or other culturally tailored approaches for rural populations⁸ may help mitigate disparities in type 2 diabetes incidence as well as diabetes mortality and complications.