County-level contextual factors associated with diabetes incidence in the United States

Solveig A. Cunningham, Shivani A. Patel, Gloria L. Beckles, Linda S. Geiss, Neil Mehta, Hui Xie, Giuseppina Imperatore

Research output: Contribution to journalArticlepeer-review

15 Scopus citations


Purpose: Health and administrative systems are facing spatial clustering in chronic diseases such as diabetes. This study explores how geographic distribution of diabetes in the United States is associated with socioeconomic and built environment characteristics and health-relevant policies. Methods: We compiled nationally representative county-level data from multiple data sources. We standardized characteristics to a mean = 0 and a SD = 1 and modeled county-level age-adjusted diagnosed diabetes incidence in 2013 using 2-level hierarchical linear regression. Results: Incidence of age-standardized diagnosed diabetes in 2013 varied across U.S. counties (n = 3109), ranging from 310 to 2190 new cases/100,000, with an average of 856.4/100,000. Socioeconomic and health-related characteristics explained ∼42% of the variation in diabetes incidence across counties. After accounting for other characteristics, counties with higher unemployment, higher poverty, and longer commutes had higher incidence rates than counties with lower levels. Counties with more exercise opportunities, access to healthy food, and primary care physicians had fewer diabetes cases. Conclusions: Features of the socioeconomic and built environment were associated with diabetes incidence; identifying the salient modifiable features of counties can inform targeted policies to reduce diabetes incidence.

Original languageEnglish (US)
Pages (from-to)20-25.e2
JournalAnnals of Epidemiology
Issue number1
StatePublished - Jan 2018
Externally publishedYes


  • Built environment
  • Diabetes
  • Disease incidence
  • Geographic variation
  • Health disparities
  • Social determinants of health

ASJC Scopus subject areas

  • Epidemiology


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