Where You Live Shapes Diabetes Risk: Multilevel Determinants of Type 2 Diabetes in the East South Central United States.

Type 2 diabetes melittus (T2DM) remains a major public health challenge in the United States, particularly in the east south central regions. his study investigated behavioral, socioeconomic, and built environment determinants of county-level diabetes prevalence across Alabama, Kentucky, Mississippi, and Tennessee using linear mixed-effects and Random Forest models. The results indicated that food insecurity (β = 0.057, p < 0.001), smoking (β = 0.151, p < 0.001), poverty (β = 0.027, p < 0.001), the percentage of uninsured individuals (β = 0.072, p < 0.001), and the percentage of Black residents (β = 0.058, p < 0.001) were significantly associated with higher T2DM prevalence. Significant interactions were observed between obesity and physical inactivity (β = 0.0030, p < 0.001), obesity and alcohol consumption (β = - 0.0120, p < 0.001), and obesity and social deprivation (β = - 0.00081, p < 0.001), indicating that the association between obesity and diabetes prevalence varied according to behavioral and socioeconomic conditions. The Random Forest model demonstrated strong predictive performance (R2 = 0.884) and identified binge drinking, the percentage of Black residents, physical inactivity, poverty, obesity, food insecurity, and social deprivation as the most influential predictors. The consistency in findings across both multilevel and machine learning approaches highlights the combined influence of behavioral, socioeconomic, and environmental factors in shaping regional diabetes disparities and underscores the need for targeted public health interventions to reduce diabetes-related health inequities in the U.S. east south regions.