County-Level Food Environment Indices and Diabetes Burden in the United States: An Ecological Cross-Sectional Study

Authors

DOI:

https://doi.org/10.5195/ijms.2023.3560

Keywords:

Diabetes, Public Health, Food insecurity, Prevalence, Incidence

Abstract

Background: Diabetes remains a major public health challenge in the United States, and structural food environments may contribute to geographic differences in diabetes burden. However, national county-level evidence comparing alternative Retail Food Environment Indices (RFEI) in relation to diabetes prevalence and incidence remains limited. We examined associations between county-level retail food environment indices and diabetes prevalence and incidence in the United States.

Methods: This ecological cross-sectional study used county-level data from the 2021 CDC Diabetes Surveillance System and the USDA Food Environment Atlas. A total of 2,951 U.S. counties with complete data were included. Primary exposures were the RFEI and expanded variants (RFEI1 and RFEI2), which quantify the relative balance of less healthy and healthier food outlet categories. Primary outcomes were age-adjusted diabetes prevalence and incidence. Pearson correlation coefficients and multivariable linear regression models assessed associations after adjustment for demographic, socioeconomic, behavioral, and food-access covariates. Model diagnostics and sensitivity analyses were performed.

Results: Higher RFEI values were weakly correlated with diabetes prevalence (r = 0.18) and incidence (r = 0.17). Similar positive correlations were observed for RFEI1 and RFEI2. In adjusted models, RFEI remained significantly associated with diabetes prevalence (β = 0.01, 95% CI 0.00-0.02, p = .004) and incidence (β = 0.07, 95% CI 0.04-0.09, p < .001). Associations were modest.

Conclusion: Poorer county-level retail food environments were statistically associated with higher diabetes prevalence and incidence. However, effect sizes were small, and findings should be interpreted as hypothesis-generating county-level associations rather than evidence of individual-level risk or causality.

References

1. Centers for Disease Control and Prevention. National Diabetes Statistics Report. CDC; 2024 [cited 2025 May 22]. Available from: https://www.cdc.gov/diabetes/php/data-research/index.html

2. American Diabetes Association. Diabetes statistics. ADA; 2024 [2025 May 22]. Available from: https://diabetes.org/about-diabetes/statistics/about-diabetes

3. Centers for Disease Control and Prevention. United States Diabetes Surveillance System. CDC; 2024 [cited 2025 May 22]. Available from: https://gis.cdc.gov/grasp/diabetes/diabetesatlas-surveillance.html

4. Wagenknecht LE, Lawrence JM, Isom S, Divers J, Imperatore G, Pihoker C, et al. Trends in incidence of youth-onset type 1 and type 2 diabetes in the USA, 2002–18: results from the population-based SEARCH for Diabetes in Youth study. Lancet Diabetes Endocrinol. 2023;11(4):242-50.

5. American Heart Association. Diabetes risk factors. AHA; 2024 [cited 2025 May 22]. Available from: https://www.heart.org/en/health-topics/diabetes/understand-your-risk-for-diabetes

6. World Health Organization. Diabetes. WHO; 2024 [cited 2025 May 22]. Available from: https://www.who.int/news-room/fact-sheets/detail/diabetes

7. Ismail L, Materwala H, Al Kaabi J. Association of risk factors with type 2 diabetes: a systematic review. Comput Struct Biotechnol J. 2021;19:1759-85.

8. County Health Rankings & Roadmaps. Food Environment Index [Internet]. University of Wisconsin Population Health Institute; 2025 [cited 2025 May 21]. Available from: https://www.countyhealthrankings.org/health-data/community-conditions/health-infrastructure/health promotion-and-harm-reduction/food-environment-index

9. Rideout K, Mah CL, Minaker L. Food environments: an introduction for public health practice. Vancouver (BC): National Collaborating Centre for Environmental Health; 2015.

10. Downs SM, Ahmed S, Fanzo J, Herforth A. Food environment typology: advancing an expanded definition, framework, and methodological approach for improved characterization of wild, cultivated, and built food environments toward sustainable diets. Foods. 2020;9(4):532.

11. United States Department of Agriculture Economic Research Service. Food security in the U.S.: key statistics and graphics. USDA; 2024 [cited 2025 May 21]. Available from: https://www.ers.usda.gov/topics/food-nutrition-assistance/food-security-in-the-us/key-statistics-graphics

12. Parker ED, Lin J, Mahoney T, Ume N, Yang G, Gabbay RA, et al. Economic costs of diabetes in the U.S. in 2022. Diabetes Care. 2024;47(1):26-43.

13. United States Department of Agriculture Economic Research Service. Characteristics and influential factors of food deserts. USDA; 2009 [cited 2025 May 21]. Available from: https://www.ers.usda.gov/publications/pub-details/?pubid=45017

14. Walker RE, Keane CR, Burke JG. Disparities and access to healthy food in the United States: a review of food deserts literature. Health Place. 2010;16(5):876-84.

15. Pineda E, Stockton J, Mindell JS. The Retail Food Environment Index and its association with dietary patterns, body mass index, and socioeconomic position: a multilevel assessment in Mexico. PLOS Glob Public Health. 2024;4(10):e0003819.

16. Glover B, Mao L, Hu Y, Zhang J. Enhancing the Retail Food Environment Index (RFEI) with neighborhood commuting patterns: a hybrid human-environment measure. Int J Environ Res Public Health. 2022;19(17):10798.

17. United States Department of Agriculture Economic Research Service. Food Environment Atlas: data access and documentation downloads. USDA; 2024 [cited 2025 May 21]. Available from: https://www.ers.usda.gov/data-products/food-environment-atlas/data-access-and-documentation-downloads.

18. Opendatasoft. Counties - United States of America. Opendatasoft; 2024 [cited 2025 May 22]. Available from: https://public.opendatasoft.com/explore/dataset/georef-united-states-of-america-county.

19. von Elm E, Altman DG, Egger M, Pocock SJ, Gøtzsche PC, Vandenbroucke JP; STROBE Initiative. The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies. J Clin Epidemiol. 2008;61(4):344-9.

20. Franco M, Diez Roux AV, Glass TA, Caballero B, Brancati FL. Neighborhood characteristics and availability of healthy foods in Baltimore. Am J Prev Med. 2008;35(6):561-7.

21. Zenk SN, Lachance LL, Schulz AJ, Mentz G, Kannan S, Ridella W. Neighborhood retail food environment and fruit and vegetable intake in a multiethnic urban population. Am J Health Promot. 2009;23(4):255-64.

22. Levi R, Bleich SN, Seligman HK. Food insecurity and diabetes: overview of intersections and potential dual solutions. Diabetes Care. 2023;46(9):1599-1608.

23. Liese AD, Weis KE, Pluto D, Smith E, Lawson A. Food store types, availability, and cost of foods in a rural environment. J Am Diet Assoc. 2007;107(11):1916-23.

24. Morland K, Wing S, Diez Roux A, Poole C. Neighborhood characteristics associated with the location of food stores and food service places. Am J Prev Med. 2002;22(1):23-9.

25. Popkin BM, Adair LS, Ng SW. Global nutrition transition and the pandemic of obesity in developing countries. Nutr Rev. 2012;70(1):3-21.

26. Malik VS, Willett WC, Hu FB. Global obesity: trends, risk factors and policy implications. Nat Rev Endocrinol. 2013;9(1):13-27.

27. Drewnowski A, Specter SE. Poverty and obesity: the role of energy density and energy costs. Am J Clin Nutr. 2004;79(1):6-16.

Downloads

Published

2026-09-14

How to Cite

Nammi, J., & Pasala, R. (2026). County-Level Food Environment Indices and Diabetes Burden in the United States: An Ecological Cross-Sectional Study. International Journal of Medical Students, 74–81. https://doi.org/10.5195/ijms.2023.3560

Issue

Forthcoming

Section

Original Article

License

Copyright (c) 2026 Jeevan Nammi, Roshini Pasala

Creative Commons License

This work is licensed under a Creative Commons Attribution 4.0 International License.

  1. The Author retains copyright in the Work, where the term “Work” shall include all digital objects that may result in subsequent electronic publication or distribution.
  2. Upon acceptance of the Work, the author shall grant to the Publisher the right of first publication of the Work.
  3. The Author shall grant to the Publisher and its agents the nonexclusive perpetual right and license to publish, archive, and make accessible the Work in whole or in part in all forms of media now or hereafter known under a Creative Commons Attribution 4.0 International License or its equivalent, which, for the avoidance of doubt, allows others to copy, distribute, and transmit the Work under the following conditions:
    1. Attribution—other users must attribute the Work in the manner specified by the author as indicated on the journal Web site; with the understanding that the above condition can be waived with permission from the Author and that where the Work or any of its elements is in the public domain under applicable law, that status is in no way affected by the license.
    2. The Author is able to enter into separate, additional contractual arrangements for the nonexclusive distribution of the journal's published version of the Work (e.g., post it to an institutional repository or publish it in a book), as long as there is provided in the document an acknowledgment of its initial publication in this journal.
    3. Authors are permitted and encouraged to post online a prepublication manuscript (but not the Publisher’s final formatted PDF version of the Work) in institutional repositories or on their Websites prior to and during the submission process, as it can lead to productive exchanges, as well as earlier and greater citation of published work. Any such posting made before acceptance and publication of the Work shall be updated upon publication to include a reference to the Publisher-assigned DOI (Digital Object Identifier) and a link to the online abstract for the final published Work in the Journal.
    4. Upon Publisher’s request, the Author agrees to furnish promptly to Publisher, at the Author’s own expense, written evidence of the permissions, licenses, and consents for use of third-party material included within the Work, except as determined by Publisher to be covered by the principles of Fair Use.
    5. The Author represents and warrants that:
      1. the Work is the Author’s original work;
      2. the Author has not transferred, and will not transfer, exclusive rights in the Work to any third party;
      3. the Work is not pending review or under consideration by another publisher;
      4. the Work has not previously been published;
      5. the Work contains no misrepresentation or infringement of the Work or property of other authors or third parties; and
      6. the Work contains no libel, invasion of privacy, or other unlawful matter.
    6. The Author agrees to indemnify and hold Publisher harmless from the Author’s breach of the representations and warranties contained in Paragraph 6 above, as well as any claim or proceeding relating to Publisher’s use and publication of any content contained in the Work, including third-party content.

Enforcement of copyright

The IJMS takes the protection of copyright very seriously.

If the IJMS discovers that you have used its copyright materials in contravention of the license above, the IJMS may bring legal proceedings against you seeking reparation and an injunction to stop you using those materials. You could also be ordered to pay legal costs.

If you become aware of any use of the IJMS' copyright materials that contravenes or may contravene the license above, please report this by email to contact@ijms.org

 

Infringing material

If you become aware of any material on the website that you believe infringes your or any other person's copyright, please report this by email to contact@ijms.org