Unmasking spatial disparities and survival bias in the United States diabetes prevalence: A multilevel analysis of individual and ecological determinants using the 2024 behavioral risk factor surveillance system.
7 affiliations
- 1Endocrinology and Metabolism Research Center, Endocrinology and Metabolism Clinical Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran.
- 2Liver and Pancreatobiliary Diseases Research Center, Digestive Diseases Research Institute, Tehran University of Medical Sciences, Tehran, Iran.
- 3Western University of Health Sciences, College of Osteopathic Medicine of the Pacific, Pomona, California, USA.
- 4University of California, Irvine, School of Medicine, Irvine, California, USA.
- 5Department of Clinical Psychology, School of Behavioral Sciences and Mental Health (Tehran Institute of Psychiatry), Iran University of Medical Sciences, Tehran, Iran.
- 6Research Center for Chronic Inflammatory Diseases, Tehran University of Medical Sciences, Tehran, Iran.
- 7Digestive Oncology Research Center, Digestive Diseases Research Institute, Tehran University of Medical Sciences, Tehran, Iran.
Abstract
Diabetes prevalence varies across the United States, but individual versus state-level contributions remain unclear. We examined these predictors and survival bias. Using 2024 data from 406,782 adults in the United States Behavioral Risk Factor Surveillance System, we fitted multilevel logistic models for individual and state-level covariates. Age-stratified analyses tested survival bias. Individual obesity was the strongest predictor (OR = 2.33; 95% CI: 2.28, 2.38). Asian adults exhibited the highest risk (OR = 2.05; 95% CI: 1.91, 2.20), followed by Black (OR = 1.76) and Hispanic adults (OR = 1.54). State-level obesity independently predicted diabetes (OR = 1.38 per 10-point increase; 95% CI: 1.17, 1.63), explaining 57% of between-state variance. Individual obesity effects attenuated in higher-obesity states. Inverse associations for smoking (OR = 0.89; 95% CI: 0.86, 0.92) and binge drinking (OR = 0.62; 95% CI: 0.60, 0.65) were null in young adults but strengthened with age. State-level context independently elevates diabetes risk. Asian Americans face disproportionately high risk, supporting lower body mass index screening thresholds. Apparent protective effects of smoking and binge drinking reflect survival bias.
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BibTeX
@article{imani2026unmasking,
title = {{Unmasking spatial disparities and survival bias in the United States diabetes prevalence: A multilevel analysis of individual and ecological determinants using the 2024 behavioral risk factor surveillance system.}},
author = {Masoud Imani and Seyedshayan Shojaei and Kimia Heidari and Mohammad Javad Shabani and Hamid Mohsenabadi and Bagher Larijani and Mohammad Reza Mohajeri-Tehrani and Amir Kasaeian},
journal = {Preventive medicine reports},
year = {2026},
month = oct,
doi = {10.1016/j.pmedr.2026.103688},
url = {https://europepmc.org/article/MED/42999737},
note = {CC BY},
}
RIS
TY - JOUR
TI - Unmasking spatial disparities and survival bias in the United States diabetes prevalence: A multilevel analysis of individual and ecological determinants using the 2024 behavioral risk factor surveillance system.
AU - Masoud Imani
AU - Seyedshayan Shojaei
AU - Kimia Heidari
AU - Mohammad Javad Shabani
AU - Hamid Mohsenabadi
AU - Bagher Larijani
AU - Mohammad Reza Mohajeri-Tehrani
AU - Amir Kasaeian
PY - 2026
DA - 2026/10/28
JO - Preventive medicine reports
DO - 10.1016/j.pmedr.2026.103688
UR - https://europepmc.org/article/MED/42999737
AB - Diabetes prevalence varies across the United States, but individual versus state-level contributions remain unclear. We examined these predictors and survival bias. Using 2024 data from 406,782 adults in the United States Behavioral Risk Factor Surveillance System, we fitted multilevel logistic models for individual and state-level covariates. Age-stratified analyses tested survival bias. Individual obesity was the strongest predictor (OR = 2.33; 95% CI: 2.28, 2.38). Asian adults exhibited the highest risk (OR = 2.05; 95% CI: 1.91, 2.20), followed by Black (OR = 1.76) and Hispanic adults (OR = 1.54). State-level obesity independently predicted diabetes (OR = 1.38 per 10-point increase; 95% CI: 1.17, 1.63), explaining 57% of between-state variance. Individual obesity effects attenuated in higher-obesity states. Inverse associations for smoking (OR = 0.89; 95% CI: 0.86, 0.92) and binge drinking (OR = 0.62; 95% CI: 0.60, 0.65) were null in young adults but strengthened with age. State-level context independently elevates diabetes risk. Asian Americans face disproportionately high risk, supporting lower body mass index screening thresholds. Apparent protective effects of smoking and binge drinking reflect survival bias.
SN - 2211-3355
ER -