Growing numbers of old people on the islands and in countryside regions are struggling to meet escalating bills for heating their homes. They are much worse off than old people in urban areas, with many having to cut back on food, transport and other essentials to stay warm.
The risks to people's health can be "catastrophic", experts warn, leading to thousands of extra deaths. Cold, damp homes can cause hypothermia and make illnesses worse, including arthritis, respiratory and circulatory conditions.
A comprehensive new analysis by Scotland's Rural College (SRUC) reveals myriad linked problems facing some rural areas. Young people are leaving, transport costs are high and affordable housing can be in short supply.
The report by SRUC shows that nearly 60% of over-60s in rural areas are in fuel poverty, compared to 45% in urban areas. "Rural households in which the highest income householder is aged 60-plus are more likely than not to be living in fuel poverty," it concludes.
The highest levels of fuel poverty endured by the old were on the islands: 76% in the Western Isles, 75% in Orkney and 69% in Shetland. This compares to levels of under 40% in Glasgow, Renfrewshire, West Dunbartonshire and elsewhere.
Scottish households are defined as being in fuel poverty when they have to spend more than one-tenth of their income on fuel. Levels of fuel poverty have grown as prices of gas and electricity have increased.
"Fuel poverty is an extremely serious issue in rural areas," said Dr Mandie Currie, who manages Argyll, Lomond and the Islands Energy in Oban, a charity seeking to combat fuel poverty. The problem was underestimated in national studies, she argued.
"The prevalence of older 'hard to heat, hard to treat' dwellings, together with high fuel costs, higher living costs generally, lower average incomes and harsh weather conditions all combine to push people into fuel poverty," she said. "The fact that most of the area is not on the gas grid forces people to rely on more expensive fuels such as electricity and oil.
"Older people in particular are more likely to experience fuel poverty because they often have more limited incomes and because they tend to spend more time at home."
Currie thought the problem was getting worse, despite government interventions. Fuel poverty was "an urgent health issue" that required action to increase incomes, cut fuel costs and improve the energy efficiency of homes, she said.
She was backed by the fuel poverty charity, Energy Action Scotland, which pointed out that people in rural areas had often not benefitted as much from schemes meant to tackle the problems. The Scottish Council for Voluntary Organisations called on policymakers to "demonstrate more recognition of the fact that higher fuel costs hit rural people particularly hard".
According to the editor of SRUC's new report, Dr Sarah Skerratt, rural poverty often remained hidden because it was missed by national policies and measures. "The cost of household heating is just one area of poverty in which there is an imbalance between rural and urban Scotland," she said.
Fuel poverty was often tied to a series of other problems afflicting rural areas, she argued. Food costs were 10-40% higher, more was spent on vehicle fuel and, in almost half of rural local authority areas, 50% of people earning less than £15,000 a year had no access to a car.
"Policies for rural Scotland do not demonstrate the same level of interconnectedness as the issues faced by rural residents," Skerratt contended. "In order to address this we believe there must be an over-arching vision and strategy for rural Scotland."
The report says many more 18-year-olds are leaving the Western Isles, Orkney and Shetland than are arriving. But the net migration of people aged 26 to 30 was often positive.
The report highlights housing shortages faced in some rural areas because not enough new houses are being built. Perth and Kinross is said to be facing an annual shortfall of more than 500 new houses, while Stirling, Highland and Angus have smaller deficits.
Housing charity Shelter Scotland pointed out that housing shortages were generally worse in rural areas, while costs were higher and conditions poorer. "Below the surface of the rural idyll, there are long-term housing crises driving poverty, social exclusion and local tensions," said the charity's Alison Watson.
Rob Gibson, the SNP MSP for Caithness, Sutherland and Ross and convener of the Scottish Parliament's Rural Affairs Committee, called for a "policy revolution" to help local people access local resources. "Affordable land for affordable homes, local control of forests, rivers and inshore waters can all play a part in a vibrant rural future," he said.