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Background: Environmental parameters, including built and sociodemographic environments, can impact diabetes control (DC). Indeed, epidemiological studies have associated specific environmental factors with DC; however, the impact of multidimensional environmental status has not been assessed. Methods: The Environmental Quality Index (EQI) is a comprehensive quantitative metric that captures five environmental domains. DC was defined as the proportion of adults aged 20+ years with a previous diabetes diagnosis, high fasting blood glucose, and/or elevated hemoglobin A1c (HbA1c) who currently do not have high fasting blood glucose or elevated HbA1c. We conducted county-level analyses of age-adjusted DC prevalence rates for 2004-2012 in association with EQI for 2006-2010 and domain-specific indices using random intercept multilevel linear regression models clustered by state and controlled for county-level rates of obesity and physical inactivity. Analyses were stratified by rural-urban strata and results are reported as prevalence rate differences (PRD) with 95% confidence intervals (CIs) comparing highest quintile/worst environmental quality to lowest quintile/best environmental quality. Findings: The association of DC with cumulative environmental quality is negative after controlling for obesity and leisure time physical inactivity for all counties (PRD -0.32,95% CI:-0.38,-0.27). This suggests that rates of DC worsen as environmental quality declines. While overall environmental quality exerts effects on DC that vary across the rural-urban spectrum, poor sociodemographic and built environmental factors are associated with decreased DC nationally. Interpretation: These data suggest that improvements in environmental quality mediated by larger scale policy and practice interventions may improve glycemic control and reduce the morbidity and mortality arising from hyperglycemia. Funding Statement: This work was supported by the National Institutes of Health [P30 DK092949 to JSJ (via the Chicago Center for Diabetes Translational Research), P30 ES027792 (ChicAgo Center on Health and EnvironmenT), and R01 ES028879 (to RMS)], the American Diabetes Association [1-17-JDF-033 to RMS], and the U.S. Environmental Protection Agency [EP-17-D-000063 to JSJ]. A.K.K. supported in part by an appointment to the Internship/Research Participation Program at Office of Research and Development (Center for Public Health & Environmental Assessment), U.S. Environmental Protection Agency, administered by the Oak Ridge Institute for Science and Education through an interagency agreement between the U.S. Department of Energy and the U.S. Environmental Protection Agency. Declaration of Interests: The authors do not have any conflicts of interest pertinent to this manuscript. |
