title: Urban sprawl, obesity, and cancer mortality in the United States: cross-sectional analysis and methodological challenges.
abstract: BACKGROUND
  Urban sprawl has the potential to influence cancer mortality via direct and indirect effects on obesity, access to health services, physical activity, transportation choices and other correlates of sprawl and urbanization.
  
  
  METHODS
  This paper presents a cross-sectional analysis of associations between urban sprawl and cancer mortality in urban and suburban counties of the United States. This ecological analysis was designed to examine whether urban sprawl is associated with total and obesity-related cancer mortality and to what extent these associations differed in different regions of the US. A major focus of our analyses was to adequately account for spatial heterogeneity in mortality. Therefore, we fit a series of regression models, stratified by gender, successively testing for the presence of spatial heterogeneity. Our resulting models included county level variables related to race, smoking, obesity, access to health services, insurance status, socioeconomic position, and broad geographic region as well as a measure of urban sprawl and several interactions. Our most complex models also included random effects to account for any county-level spatial autocorrelation that remained unexplained by these variables.
  
  
  RESULTS
  Total cancer mortality rates were higher in less sprawling areas and contrary to our initial hypothesis; this was also true of obesity related cancers in six of seven U.S. regions (census divisions) where there were statistically significant associations between the sprawl index and mortality. We also found significant interactions (p < 0.05) between region and urban sprawl for total and obesity related cancer mortality in both sexes. Thus, the association between urban sprawl and cancer mortality differs in different regions of the US.
  
  
  CONCLUSIONS
  Despite higher levels of obesity in more sprawling counties in the US, mortality from obesity related cancer was not greater in such counties. Identification of disparities in cancer mortality within and between geographic regions is an ongoing public health challenge and an opportunity for further analytical work identifying potential causes of these disparities. Future analyses of urban sprawl and health outcomes should consider exploring regional and international variation in associations between sprawl and health.
authors.affiliation: Applied Research Program, Division of Cancer Control and Population Sciences, National Cancer Institute, Bethesda, MD 20892, USA. berrigad@mail.nih.gov.
authors.forename: David
authors.initials: D
authors.lastname: Berrigan
authors.forename: Zaria
authors.initials: Z
authors.lastname: Tatalovich
authors.forename: Linda W
authors.initials: LW
authors.lastname: Pickle
authors.forename: Reid
authors.initials: R
authors.lastname: Ewing
authors.forename: Rachel
authors.initials: R
authors.lastname: Ballard-Barbash
mesh_terms: D003430:Cross-Sectional Studies; D005260:Female; D006801:Humans; D008297:Male; D009026:Mortality / Q000639:trends; D009369:Neoplasms / Q000175:diagnosis* / Q000401:mortality*; D009765:Obesity / Q000175:diagnosis* / Q000401:mortality*; D012307:Risk Factors; D014481:United States / Q000453:epidemiology; D014505:Urban Population / Q000639:trends