Built Environment, Community Safety, and Diabetes in the Deep South: A County Level Geospatial Analysis

Abstract Background/Purpose Diabetes prevalence in the Deep South remains among the highest in the United States. Yet few studies have examined the role of community level determinants, such as poverty, food insecurity, healthcare shortages, and unsafe environments in the geographic clustering of high diabetes burden in counties with higher proportions of racial/ethnic minoritized populations. Methods We conducted an ecological, county-level study of 418 Deep South counties using publicly available data. The outcome was percentage of adults diagnosed with diabetes (2022). Exposures included food insecurity, access to exercise opportunities and parks, firearm mortality, healthcare workforce and insurance indicators, education, broadband access, and racial/ethnic composition (percent non-Hispanic Black, non-Hispanic White, Hispanic). We used descriptive statistics, Pearson correlations, and LISA mapping to identify hotspots and cold spots. Results Average county level diabetes burden was 15.6%. Strong positive correlations were found with physical inactivity ( r = 0.82), obesity ( r = 0.78), poverty ( r = 0.74), firearm fatalities ( r = 0.67), and food insecurity ( r = 0.59). Inverse correlations were observed for broadband access ( r = -0.69), education ( r = -0.59), access to exercise opportunities ( r = -0.42), and primary care physician availability ( r = -0.28). LISA maps showed hotspots concentrated in the Mississippi Delta and parts of Alabama and Louisiana, co-occurring with higher poverty, higher firearm mortality, and higher proportions of non-Hispanic Black residents, while cold spots aligned with counties with stronger infrastructure and healthcare resources. Implications for Public Health Diabetes in the Deep South reflects structural and environmental conditions beyond individual behaviors. Policies that expand health-promoting infrastructure, strengthen healthcare access, reduce food insecurity, and improve community safety are warranted, particularly in hotspot counties with higher proportions of racial/ethnic minoritized populations.