Assessing county-level determinants of diabetes in the United States (2003–2012)

Justin M. Feldman, David C. Lee, Priscilla Lopez, Pasquale E. Rummo, Annemarie G. Hirsch, April P. Carson, Leslie A. McClure, Brian Elbel, Lorna E. Thorpe

Research output: Contribution to journalArticlepeer-review


Using data from the United States Behavioral Risk Factor Surveillance System (2003–2012; N = 3,397,124 adults), we estimated associations between prevalent diabetes and four county-level exposures (fast food restaurant density, convenience store density, unemployment, active commuting). All associations confirmed our a priori hypotheses in conventional multilevel analyses that pooled across years. In contrast, using a random-effects within-between model, we found weak, ambiguous evidence that within-county changes in exposures were associated with within-county change in odds of diabetes. Decomposition revealed that the pooled associations were largely driven by time-invariant, between-county factors that may be more susceptible to confounding versus within-county associations.

Original languageEnglish (US)
Article number102324
JournalHealth and Place
StatePublished - May 2020


  • Built environment
  • Diabetes
  • Multilevel modeling

ASJC Scopus subject areas

  • Health(social science)
  • Sociology and Political Science
  • Life-span and Life-course Studies


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