title: Changes in Disparity in County-Level Diagnosed Diabetes Prevalence and Incidence in the United States, between 2004 and 2012.
abstract: BACKGROUND
  In recent decades, the United States experienced increasing prevalence and incidence of diabetes, accompanied by large disparities in county-level diabetes prevalence and incidence. However, whether these disparities are widening, narrowing, or staying the same has not been studied. We examined changes in disparity among U.S. counties in diagnosed diabetes prevalence and incidence between 2004 and 2012.
  
  
  METHODS
  We used 2004 and 2012 county-level diabetes (type 1 and type 2) prevalence and incidence data, along with demographic, socio-economic, and risk factor data from various sources. To determine whether disparities widened or narrowed over the time period, we used a regression-based β-convergence approach, accounting for spatial autocorrelation. We calculated diabetes prevalence/incidence percentage point (ppt) changes between 2004 and 2012 and modeled these changes as a function of baseline diabetes prevalence/incidence in 2004. Covariates included county-level demographic and, socio-economic data, and known type 2 diabetes risk factors (obesity and leisure-time physical inactivity).
  
  
  RESULTS
  For each county-level ppt increase in diabetes prevalence in 2004 there was an annual average increase of 0.02 ppt (p<0.001) in diabetes prevalence between 2004 and 2012, indicating a widening of disparities. However, after accounting for covariates, diabetes prevalence decreased by an annual average of 0.04 ppt (p<0.001). In contrast, changes in diabetes incidence decreased by an average of 0.04 ppt (unadjusted) and 0.09 ppt (adjusted) for each ppt increase in diabetes incidence in 2004, indicating a narrowing of county-level disparities.
  
  
  CONCLUSIONS
  County-level disparities in diagnosed diabetes prevalence in the United States widened between 2004 and 2012, while disparities in incidence narrowed. Accounting for demographic and, socio-economic characteristics and risk factors for type 2 diabetes narrowed the disparities, suggesting that these factors are strongly associated with changes in disparities. Public health interventions that target modifiable risk factors, such as obesity and physical inactivity, in high burden counties might further reduce disparities in incidence and, over time, in prevalence.
authors.affiliation: Centers for Disease Control and Prevention, Division of Diabetes Translation, Atlanta, Georgia, United States of America.
authors.forename: Sundar S
authors.initials: SS
authors.lastname: Shrestha
authors.affiliation: Centers for Disease Control and Prevention, Division of Diabetes Translation, Atlanta, Georgia, United States of America.
authors.forename: Theodore J
authors.initials: TJ
authors.lastname: Thompson
authors.affiliation: Centers for Disease Control and Prevention, Division of Diabetes Translation, Atlanta, Georgia, United States of America.
authors.forename: Karen A
authors.initials: KA
authors.lastname: Kirtland
authors.affiliation: Centers for Disease Control and Prevention, Division of Diabetes Translation, Atlanta, Georgia, United States of America.
authors.forename: Edward W
authors.initials: EW
authors.lastname: Gregg
authors.affiliation: Centers for Disease Control and Prevention, Division of Diabetes Translation, Atlanta, Georgia, United States of America.
authors.forename: Gloria L
authors.initials: GL
authors.lastname: Beckles
authors.affiliation: Centers for Disease Control and Prevention, Division of Diabetes Translation, Atlanta, Georgia, United States of America.
authors.forename: Elizabeth T
authors.initials: ET
authors.lastname: Luman
authors.affiliation: Centers for Disease Control and Prevention, Division of Diabetes Translation, Atlanta, Georgia, United States of America.
authors.forename: Lawrence E
authors.initials: LE
authors.lastname: Barker
authors.affiliation: Centers for Disease Control and Prevention, Division of Diabetes Translation, Atlanta, Georgia, United States of America.
authors.forename: Linda S
authors.initials: LS
authors.lastname: Geiss
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D003924:Diabetes Mellitus, Type 2 / Q000453:epidemiology*; D005260:Female; D005843:Geography; D015438:Health Behavior; D054624:Health Status Disparities; D054625:Healthcare Disparities / Q000639:trends*; D006801:Humans; D015994:Incidence; D008297:Male; D008875:Middle Aged; D015995:Prevalence; D012307:Risk Factors; D014481:United States / Q000453:epidemiology; D055815:Young Adult