Lifestyle and Fitness Policy Update Research

Name That Belt – The South Labeled the “Diabetes Belt”

by Allison Knott

The Southern U.S. and Appalachian regions have received disappointing news in the past month.  The area was deemed the most physically inactive in the United States, and then given a new label: the “diabetes belt.”  The diabetes belt is similar in geographic area to the stroke belt – a label to define an area of the country with a high rate of stroke mortality.

The 2007-2008 Behavioral Risk Factor Surveillance Survey (BRFSS), released from the Centers for Disease Control and Prevention, revealed that the Southern region of the United States is the most physically inactive.  Approximately 29 percent of individuals in this region report no physical activity on a regular basis, outside of what he/she receives at their job.  This is four percentage points higher than the United States average of 25 percent.  The states with the highest rates of inactivity are: Tennessee, Alabama, Kentucky, Louisiana, Mississippi and Oklahoma.

The same CDC survey also points to a diabetes belt throughout the southern portion of the United States.  Similar to the stroke belt, the diabetes belt consists of multiple states with higher than average rates of diabetes.  However, there are some discrepancies: West Virginia is within the diabetes belt, but not the stroke belt and Indiana is in the diabetes belt, but not the stroke belt.  The states defining the diabetes belt are: Alabama, Arkansas, Florida, Georgia, Kentucky, Louisiana, North Carolina, Ohio, Pennsylvania, South Carolina, Tennessee, Texas, Virginia and West Virginia.  The diabetes belt includes 644 counties, each with a higher prevalence of diabetes than the rest of the country, 11.4% and 8.5% respectively.  The physically inactive states overlap with the states in the diabetes belt.  And portions of the diabetes belt overlap with the stroke belt.  Longstanding research indicates that physical inactivity plays an important role in obesity and that obesity is a risk factor for diabetes and stroke.  It makes sense to see that the most physically inactive states would also have a higher prevalence of diabetes and stroke.  Other factors contributing to the increased prevalence include ethnicity, with a higher population of African Americans in the Southern states, as well as an older population.

Many factors play a role in this complex issue.  One is the structure of cities and towns throughout the Southern and Appalachian regions.  As someone who grew up in a small town in Eastern Tennessee, I know all too well the challenges of getting enough physical activity while going about daily living.  Evaluating walk scores of various locations in the South using a website,, reveals that the majority of Southern cities and towns do not fare well.  The Walk Score website uses an algorithm to calculate the score based on the ease of living a “car-lite” lifestyle.  It takes into account the distance to amenities according to the address inputted in the website.  You can find more information on the algorithm here.  For comparison, Boston receives a walk score of 97 out of 100 with an average of 82.  My hometown, Cleveland, Tennessee, receives a walk score of 77 out of 100 with an average of 42.

Although the walk-ability of the town is just one factor in the myriad of contributing factors, one thing is sure, the Southern states are suffering from higher rates of obesity, diabetes, stroke and physical inactivity.  Sara Folta, a Friedman professor who works in the John Hancock Research Center on Physical Activity, Nutrition, and Obesity Prevention, conducts most of her research for the Strong Women-Healthy Hearts program.  The pilot work for the Strong Women-Healthy Hearts program was conducted in Arkansas, which is on the border of the diabetes belt.  She says Arkansas women face many challenges to eating healthy and getting enough physical activity.  When asked about foods available, Sara reports:

“Healthy foods are fairly readily available, even in very rural communities, but they are completely overshadowed by all the other stuff.  There is a strong culture around food and expectations around social events that make it difficult, even if someone is highly motivated, to make healthier choices.”

The physical activity component is also difficult for many individuals living in the Southern and Appalachian regions.  Through the Strong Women-Healthy Hearts research, Sara says:

“It’s a similar situation with physical activity.  The opportunities are there, but the challenges are enormous.  The women in Arkansas told me that you have to be very motivated, because you have to either wake up very early to get out for a walk before the heat and mosquitoes take over, or else you have to actively seek out a comfortable indoor place.  So, the two main problems seem to be the overall structure of the communities and the prevailing social norms and culture.  Both very much work against the type of lifestyle that would help to prevent diabetes.”

The researchers summarizing the CDC survey in the most recent American Journal of Preventive Medicine recommend “culturally appropriate interventions aimed at decreasing obesity and sedentary lifestyle” in the counties defining the diabetes belt.  What works in Boston will probably not work in Tennessee.  The authors also recommend changes on a policy level and hope that by defining the diabetes belt by counties, the policies will reflect the specific needs within each county.  The authors do cite limitations with the study such as recall and social desirability bias due to the limitations of the CDC Behavioral Risk Factor Surveillance System.  They also indicate a limitation on making causal inferences because the BRFSS is a cross-sectional survey.

Policy changes, social construct adjustments and improving modifiable lifestyle factors are important in improving the overall health status of the Southern United States.  My hope is with renewed attention to this problem through news stories and research, the South will begin to work towards the much needed changes in the near future.

Allison Knott has been a registered dietitian since 2008 and was previously employed in a hospital in Georgia.  She is currently pursuing a master of science in Nutrition Communication.  Her passion is to communicate accurate and sound nutrition information to the general public. She also blogs at

The Friedman Sprout is a monthly student run newspaper that aims to serve the student population at the Friedman School of Nutrition Science and Policy, prospective students, and alumni. Our mission is to report on newsworthy information that affects the Friedman community including nutrition research, food policy, internship and volunteer opportunities, as well as school events. Our editorial slant is that of sustainability in food and nutrition.

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