Date of Conferral

4-30-2026

Degree

Ph.D.

School

Health Sciences

Advisor

Howell Sasser

Abstract

Dollar stores are the fastest growing food retail format and are highly concentrated in rural, low-income communities including West Virginia, where diabetes and obesity prevalence rank among the highest in the United States. Although these retailers increase physical access to food, concerns remain about their limited healthier food options and potential contribution to chronic disease disparities. Guided by the socioecological model, this three-manuscript dissertation examined how dollar store density and healthier food availability related to county-level diabetes and obesity prevalence in West Virginia. Manuscript 1 used a cross-sectional ecological design with all 55 West Virginia counties, using data from USDA, CDC, County Health Rankings, and Census sources. The analysis examined the association between dollar store density and diabetes prevalence, adjusting for income, education, provider ratios, and rurality. Manuscript 2 included a statewide stratified comparison of healthier food availability in dollar stores and grocery stores using the Nutrition Environment Measures Survey in Stores and real-time online inventory platforms. Manuscript 3 included the county-level analytic approach with obesity prevalence as the outcome. Dollar store density was not independently associated with diabetes or obesity prevalence after adjustment, although educational attainment was a significant predictor in both models. Grocery stores demonstrated significantly higher healthier food availability than dollar stores. A key social change implication of these findings is that dollar store density may function more as a marker of structural disadvantage than as an independent predictor of chronic disease, helping to inform more effective approaches to improving food access and health equity.

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