Spatial spillover and the socio-ecological determinants of diabetes-related mortality across US counties.

The spatial structure of diabetes-related mortality in US counties is evident from previous studies. However, it is not clear if spatial variation in diabetes-related mortality is associated with spatial variation in socioecological factors. We analyze the spatial spillover effect of changes in socioeconomic gradients (education, employment, household income), retail food environments, and access to health care, on diabetes-related mortality rates across the United States. Seven-year aggregates of multiple cause mortality data from the CDC WONDER compressed mortality database were merged with several sources of county-level data to examine mortality clusters, factors associated with the clusters, and spatial spillover effects in 3109 continuous US counties. The results suggest that high diabetes-related mortality cluster counties are located throughout the Southern Plains, Southeastern, and Appalachian regions. Lower socioeconomic status, a high density of fast food restaurants, a lack of access to grocery stores, a high proportion of Blacks, and low physical activity characterize high diabetes-related mortality rates clusters. The impacts from improvements in socioeconomic gradients and the retail food environment in neighboring counties spill over, and reduce the diabetes-related mortality rate in a particular county. This result implies that improvements in socioeconomic status and access to healthy food would significantly reduce diabetes-related mortality rates in contiguous US counties.