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

Authors

  • Jeevan Nammi MBBS, MPH(C). University of Alabama at Birmingham, Birmingham, Alabama, United States of America
  • Roshini Pasala MBBS. Siddhartha Medical College, Vijayawada, Andhra Pradesh, India

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 both diabetes prevalence and incidence remains limited. we examined the association between these counties 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 diabetes 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 diabetes incidence (β = 0.07, 95% CI 0.04-0.09, p < .001). Although statistically significant, associations were modest.

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

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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. Retrieved from https://ijms.info/IJMS/article/view/3560

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