Supermarket Proximity and Risk of Hypertension, Diabetes, and CKD: A Retrospective Cohort Study

Abstract

Rationale & objective: Living in environments with low access to food may increase the risk of chronic diseases. We investigated the association of household distance to the nearest supermarket (as a measure of food access) with the incidence of hypertension, diabetes, and chronic kidney disease (CKD) in a metropolitan area of the United States.

Study design: Retrospective cohort study.

Setting & participants: 777,994 individuals without hypertension, diabetes, or CKD at baseline within the HealthLNK Data Repository, which contains electronic health records from 7 health care institutions in Chicago, Illinois.

Exposure: Zip code-level average distance between households and nearest supermarket.

Outcome: Incidence of hypertension, diabetes, and CKD based on presence of ICD-9 code and/or blood pressure≥140/90mm Hg, hemoglobin A1c≥6.5%, and eGFR<60mL/min/1.73m², respectively.

Analytical approach: Average distance to nearest supermarket was aggregated from street-level metrics for 56 Chicagoland zip codes. The cumulative incidence of hypertension, diabetes, and CKD from 2007-2012 was calculated for each zip code in patients free of these diseases in 2006. Spatial analysis of food access and disease incidence was performed using bivariate local indicator of spatial association (BiLISA) maps and bivariate local Moran I statistics. The relationship between supermarket access and outcomes was analyzed using logistic regression.

Results: Of 777,994 participants, 408,608 developed hypertension, 51,380 developed diabetes, and 56,365 developed CKD. There was significant spatial overlap between average distance to supermarket and incidence of hypertension and diabetes but not CKD. Zip codes with large average supermarket distances and high incidence of hypertension and diabetes were clustered in southern and western neighborhoods. Models adjusted only for neighborhood factors (zip code-level racial composition, access to vehicles, median income) revealed significant associations between zip code-level average distance to supermarket and chronic disease incidence. Relative to tertile 1 (shortest distance), ORs in tertiles 2 and 3, respectively, were 1.27 (95% CI, 1.23-1.30) and 1.38 (95% CI, 1.33-1.43) for diabetes, 1.03 (95% CI, 1.02-1.05) and 1.04 (95% CI, 1.02-1.06) for hypertension, and 1.18 (95% CI, 1.15-1.21) and 1.33 (95% CI, 1.29-1.37) for CKD. Models adjusted for demographic factors and health insurance showed significant and positive association with greater odds of incident diabetes (tertile 2: 1.29 [95% CI, 1.26-1.33]; tertile 3: 1.35 [95% CI, 1.31-1.39]) but lesser odds of hypertension (tertile 2: 0.95 [95% CI, 0.94-0.97]; tertile 3: 0.91 [95% CI, 0.89-0.92]) and CKD (tertile 2: 0.80 [95% CI, 0.78-0.82]; tertile 3: 0.73 [95% CI, 0.72-0.76]). After adjusting for both neighborhood and individual covariates, supermarket distance remained significantly associated with greater odds of diabetes and lesser odds of hypertension, but there was no significant association with CKD.

Limitations: Unmeasured neighborhood and social confounding variables, zip code-level analysis, and limited individual-level information.

Conclusions: There are significant disparities in supermarket proximity and incidence of hypertension, diabetes, and CKD in Chicago, Illinois. The relationship between supermarket access and chronic disease is largely explained by individual- and neighborhood-level factors.

Keywords: Chronic disease; chronic kidney disease (CKD); diabetes; dietary pattern; electronic health record (EHR); food access; food desert; health disparities; hypertension; kidney function; modifiable risk factor; neighborhood; neighborhood deprivation; nutrition.

Figure 1.

Map of Chicago zip codes with shading showing tertile of average distance to the nearest supermarket. Zip codes with longer supermarket distance have darker shading. Abbreviation: Dist, distance.

Figure 2.

Spatial analysis of supermarket proximity and disease incidence. The upper maps show the geographic distribution of incident hypertension, diabetes, and CKD by Chicago zip codes from 2007–2012. The lower maps show BiLISA cluster maps. High-high zip code clusters reflect zip codes with longer average supermarket distance and higher average incidence of disease. Low-low clusters are those with shorter average supermarket distance and lower average incidence of disease. High-low clusters have longer supermarket distance and lower disease incidence, while low-high clusters indicate the opposite: shorter supermarket distance and higher incidence of disease. Abbreviations: BiLISA, bivariate local indicator of spatial association; CKD, chronic kidney disease.