A national study of the association between food environments and county-level health outcomes

J Rural Health. Winter 2011;27(4):367-79. doi: 10.1111/j.1748-0361.2011.00378.x. Epub 2011 Apr 27.


Purpose: This national, county-level study examines the relationship between food availability and access, and health outcomes (mortality, diabetes, and obesity rates) in both metro and non-metro areas.

Methods: This is a secondary, cross-sectional analysis using Food Environment Atlas and CDC data. Linear regression models estimate relationships between food availability and access variables (direct-to-consumer farm sales, per capita grocery stores, full-service restaurants, fast food restaurants, and convenience stores) with health outcomes. Controls include smoking, race/ethnicity, gender, age, education, poverty, primary care availability, recreational facility availability, and mobility/distance-from-grocery-store.

Findings: Non-metro findings: Lower adjusted mortality rates were associated with more per capita full-service restaurants and grocery stores, and greater per capita direct farm sales. Lower adjusted diabetes rates were associated with a lower per capita supply of fast food restaurants and convenience stores, and more per capita full-service restaurants and grocery stores. Lower adjusted obesity rates were associated with more per capita full-service restaurants and grocery stores. Unexpectedly, obesity rates were positively associated with per capita grocery stores and negatively associated with fast food restaurants. Metro findings: More per capita full-service restaurants, grocery stores, and direct farm sales are associated with positive health outcomes; fast food restaurants and convenience stores are associated with negative health outcomes.

Conclusions: The food access/availability environment is an important determinant of health outcomes in metro and non-metro areas. Future research should focus on more refined specifications that capture variability across non-metro settings.

Publication types

  • Research Support, U.S. Gov't, P.H.S.

MeSH terms

  • Commerce / statistics & numerical data
  • Cross-Sectional Studies
  • Fast Foods
  • Female
  • Food Supply*
  • Health Status Indicators*
  • Humans
  • Male
  • Middle Aged
  • Obesity / epidemiology
  • Regression Analysis
  • Restaurants / statistics & numerical data
  • Rural Health*
  • United States / epidemiology
  • Urban Population