by Tom Tai-Seale and Coleman Chandler





  • Overweight and obesity are one of the 10 “leading health indicators” selected through a process led by an interagency workgroup within the U.S. Department of Health and Human Services.40
  • Nutritional disorders with complications and comorbidities are the ninth most frequent diagnostic category among hospitalized rural elderly Medicare beneficiaries.41
  • Nationally, rural areas have higher self-reported rates of adult obesity than urban areas, but there is considerable variation among men and women across the region.42
  • Diet and activity patterns have been ranked second only to tobacco as the leading “actual causes of death” in the United States, i.e., contributing to the diagnosed condition associated with death.43




The goal of Healthy People 2010’s nutrition and overweight focus area is to promote health and reduce chronic disease associated with diet and weight.1 The problem of obesity and overweight is described as a new epidemic according to the Surgeon General’s recent Call to Action.2 In the last 20 years, the number of American children and adults who are overweight or obese has doubled. Sixty-one percent of American adults are overweight or obese, and 13 percent of children and adolescents are overweight. Traditionally, rural areas have experienced a lower incidence of overweight and obesity due to the increased physical demands characteristic of an agrarian lifestyle. However, this is no longer the case, and rural residents experience an increased prevalence of obesity and overweight compared to their urban counterparts.


The primary objectives addressed in this discussion relate to decreasing the incidence of obesity and improving dietary quality as follows:


  • 19-1. Increase the proportion of adults who are at a healthy weight.
  • 19-2. Reduce the proportion of adults who are obese.
  • 19-3. Reduce the proportion of children and adolescents who are overweight or obese.
  • 19-15. Increase the proportion of children and adolescents aged six to 19 years whose intake of meals and snacks at school contributes to good overall dietary quality.
  • 19-16. Increase the proportion of worksites that offer nutrition or weight management classes or counseling.


Pertinent to this discussion are the following terms:


  • Body Mass Index (BMI) is a popular method used to gauge whether or not a person is overweight. BMI is calculated by dividing a person’s weight (in kilograms) by his or her height (in meters, squared). A healthy weight range is a BMI of 19 to 24.9.44, 45
  • Overweight is defined as exceeding expected, normal, or proper weight; especially exceeding the bodily weight for one’s age, height, and build. An overweight individual has a BMI of 25 up to 29.9.45, 46
  • Obesity is a condition characterized by excessive bodily fat and characterized by a BMI of 30.0 or higher.45, 46




According to the Rural Healthy People 2010 survey, nutrition and overweight tied with cancer for 10th and 11th ranks among the Healthy People 2010 focus areas that were rated as rural health priorities; it was nominated by an average of 22 percent of the four groups of state and rural health respondents.3 There were statistically significant differences among the respondents, as local public health agencies and local rural health centers and clinics were more likely than state agencies or rural hospitals to rate this topic area as a priority. The Northeast and Midwest produced statistically significantly higher percentages of nominations for nutrition and overweight as a priority than did the South and West.


Published studies that assess the health priorities of rural residents are rare, and there is no indication that obesity is considered the most pressing health issue in rural areas. Clearly, however, there is interest in combating the nutrition and obesity problem in the U.S. The diet industry in the United States is a multi-billion dollar business reaching every area; rural physicians publish concerns about rising obesity; and obesity has been classified as a leading health indicator by the Surgeon General, reflecting a major public health concern.2


Prevalence AND DISPARITIES in rural areas


While overweight and obesity is found throughout the United States, the problem may be especially severe in rural areas. Table 1 summarizes relevant studies illustrating obesity and overweight are more prevalent among rural children and adolescents than their urban counterparts.


Children and Adolescents


Table 1. Selected Comparison Studies of Prevalence of Obesity and Overweight between Rural and Urban Children and Adolescents.


Obesity and Overweight Comparison



Michigan (rural northern)

Rural Michigan 4 to 17 year olds (N=993) were compared with state children overall.

Prevalence of obesity was 3 to 9% higher among rural children.

Gauthier, 2000120


Rural 4th graders (N=457) were compared to a national sample.

Rural Iowan children were taller and heavier than the national sample.

Gustafson-Larson and Terry, 1992121


Children in grades 3 through 5 (N=54) were invited to participate.

One-third of rural children were overweight.

Crooks, 200067

North Carolina

1,000 rural and 1,000 urban school children from North Carolina were compared.

The odds of being obese were 50% higher for rural children.

McMurray, 199965

West Virginia

Fifth graders in three rural counties participated.

Forty percent were overweight.

Neal, 2001122

South Carolina

Sixth graders (N=352) in two rural counties were compared to national average. Three-fourths of the students were African American.

Forty-nine percent of the students were obese compared to a national obesity average of 21%.

Felton, et al., 1998123

Central New Mexico

Rural American-Indian fifth graders (N~2000) participated.

One third of the students were overweight.

Davis and Lambert, 2000124

South Texas

Mexican Hispanics ranging in age from 12-17 years old (N=4,375) were compared to national averages.

Forty percent were overweight, and 22% were obese (double the national average).

Lacar, et al., 2000125


While none of the studies reviewed in Table 1 contain nationally representative samples of rural populations, they nevertheless support the notion that childhood and adolescent obesity appears to be worse in rural areas across the United States. This is apparently a reversal of the situation in the United States prior to 1980, when, in general, obesity was more common in children in large metropolitan areas.4, 5




Among adults, national survey data and smaller regional studies6-9 support the view that obesity is more common in rural areas. For adult men, the prevalence of obesity steadily increases with declines in population density¾being lowest in large central metropolitan areas and highest in counties with no city greater than 10,000 residents.2 For adult women, the highest prevalence of obesity is also in rural areas. A national study examining the prevalence of obesity by gender and race (black and white) found that rural white men and women are more likely to be overweight than their urban counterparts, even when controlling for demographics and mediating variables like energy intake and expenditure.28 A similar study of white women also found that obesity is more common in rural areas than in metropolitan areas.47


For black men and women, however, the picture is more complicated. No effect of rural residence is found when controlling for demographics and mediating variables¾save for extremely overweight black men, who are more prevalent in both rural areas and in large cities rather than in mid-sized cities[i].28


Impact of THE CONDITION on mortality


In 14 studies (each having more than 20,000 subjects), it has been shown that obesity is associated with an elevated risk of mortality. Further, studies with fewer subjects usually show the same relationship¾if they are followed long enough.48 Current estimates are that obesity increases the risk of death from all causes about 1.5 fold and from coronary heart disease about two-fold.12-15, 48


Regional differences in obesity-related mortality are also observed. The age-adjusted coronary heart disease death rate in the South is highest in rural areas and second highest (in most years) in the rural Northeast.16


Impact of the condition on morbidity


Obese children suffer more psychosocial dysfunction, hypertension, abnormal cholesterol metabolism, and orthopedic conditions like Blount’s disease and hip problems such as slipped capital femoral epiphysis.17 Excess weight on an adolescent tends to be carried into adulthood,18-21, 49 facilitating the early beginning of atherosclerosis or buildup of fatty tissue in the arteries.22 For both men and women who were overweight as adolescents, the rates of atherosclerosis, diabetes, coronary heart disease, hip fractures, and gout are increased.14


Overweight and obesity increases the risk of a great variety of serious diseases including heart disease; stroke; hypertension; gallbladder disease; cancer of the endometrium, colon, kidney, gallbladder, and postmenopausal breast.23 Overweight and obesity is also associated with high cholesterol, type 2 diabetes, glucose intolerance, menstrual irregularities, pregnancy complications, stress incontinence, and psychosocial disorders.23 Further, the number of chronic medical conditions increases and the quality of life decreases with increasing body mass index.12 It is relatively easy to develop obesity-related health complications. In fact, a weight gain of a mere 11 to 18 pounds over normal doubles the risk of developing type 2 diabetes.50 In one study among women, being overweight by as little as 5 percent increased the risk of developing heart disease by 30 percent.51


The higher rates of obesity in rural areas may be one reason why some studies show that rural areas have higher rates of chronic diseases,52-55 including stroke¾especially among blacks.56 This may be a new trend. Earlier studies show lower rates of coronary heart disease in non-metropolitan areas.57, 58 One recent study, however, does not support this trend.59


Contributor to many other health problems


Overweight and obesity causes lost wages due to illness and places huge burdens on the health care system, requiring more physician visits and nursing care. A health economist calculated that obesity is associated with a 36 percent increase in both inpatient and outpatient hospital spending¾more than either the increase of costs due to smoking or drinking.60 It is estimated that obesity accounts for between 6 to 7 percent of our total health care expenditures and costs our country over $100 billion dollars annually.10, 11


Finally, the overweight bear the brunt of severe social criticism that characterizes them as unhealthy, diseased, emotionally immature, weak, lazy, and impulsive.24 Consequently, they face a wide variety of social problems including stigmatization, discrimination,25 and other negative social outcomes. For example, seven years after determination of obesity in late adolescence, women who were obese had lower rates of marriage, fewer years of completed education, lower family incomes,61 and higher rates of poverty. The authors believe that obesity was a determinate, not a consequence, of these social correlates.62




There is evidence that rural life presents special challenges to maintaining a healthy weight. Among these are cultural and structural limitations in rural areas that may negatively affect both diet and exercise.


Cultural limitations include the following:


  • Higher dietary fat and calorie consumption, and a lower frequency of exercise. Some studies indicate that rural residents in some areas may have a higher fat and calorie intake than the average U.S. citizen.63, 64 A number of studies found that rural school children and particularly African-American girls have a higher fat intake than their urban counterparts[ii].65-68
  • Television watching. Some evidence supports the idea that overweight rural youth may watch more videos and/or play more on the computer than their non-overweight peers.67 Television watching may cause obesity in four ways: youth who watch television may snack more while watching; they may watch more commercials for high calorie and/or high-fat foods and select these over more nutritious foods;69 they may have a lower metabolic rate because of television watching,70 and they may substitute television watching for more energy-consuming activities. The last of these is viewed by some as the strongest cause of obesity.71
  • Failure of education. The over consumption of fat and calories among rural people, to the extent it exists, may be due to a failure of education or to a cultural pattern. There is evidence, for example, that rural residents comply less with dietary recommendations.72 This may reflect a rural preference for reliance on non-professional health advice. Some studies indicate that people in rural environments prefer informal to formal information channels.73 It may also reflect less social support in rural areas for compliance,74 or it may reflect less confidence in the recommendations of rural health professionals.
  • Differential amounts of exercise. Traditionally, rural adults exercised more than their urban counterparts due to the greater proportion of rural residents who were farmers. While farmers may get more exercise than non-farmers in rural areas,75 fewer people are farming, and it is becoming ever more mechanized.


Structural causes of obesity include the following:


  • Lack of nutrition education. Some studies suggest rural caregivers may lack the knowledge necessary to provide good nutrition to children. In a small qualitative study (N=20) designed to investigate barriers to nutritious feeding of toddlers, rural Michigan caregivers lacked knowledge of easy meal planning, the principles of nutrition, cooking skills, and child-appropriate portions; but they also complained of structural limitations¾lack of time and money to prepare nutritious meals.76
  • Access to nutritionists. Rural areas have difficulties attracting nutritionists. In fact, nutritionists score worse than physicians and pharmacists in being willing to work in rural areas¾even when in rural health professional training programs.77 This leaves the task of training rural residents in nutrition to other health professionals. Physicians, however, have little training in behavioral counseling78, 79 and feel ill-prepared to provide diet therapy.80 Further, only about half of physicians feel that good diet and exercise habits are very important for the average person, and even less believe it is their role to educate patients about resources in the community that could help patients with health promotion.81 Regarding other health providers, nurses in rural areas frequently get questions about nutrition but only score average on nutrition tests.82, 83
  • Limited resources. Smaller schools have fewer nutrition services.84
  • Exercise. Rural areas may have fewer physical education classes in schools, fewer sidewalks, and fewer exercise facilities. Hospitals may offer exercise programs, but rural hospitals are much less likely than urban hospitals to have exercise programs, and they are more likely to identify this as an unmet need being affected by a lack of personnel and funds.85




While the recent increase in obesity and its detrimental effects are clear, it is less clear how overweight and obesity can be prevented.2 It is also not clear why rural children and adolescents are often heavier than their urban counterparts.


A fair portion of the disproportionate prevalence of obesity in rural areas is caused by the distinctive demographic composition of rural communities. Rural residents are on average older, less educated, and have a lower income than urban residents; and those who are older, less educated, and have a lower income have greater obesity.26-33


PROPOSED Solutions OR INTERVENTIONS that are feasible in rural communities


According to the Surgeon General, the most effective prevention and treatment strategies for obesity are unknown.2 In addition, the literature contains few long-term studies on the prevention and treatment of obesity and even fewer in rural communities. Thus, it is hard to identify model programs with confidence. Nevertheless, the outlines of a model program can be discerned from the Surgeon General’s recent suggestions for developing a public health response.2 Elements may also be borrowed from programs utilized in urban areas.


In brief, the Surgeon General calls for communication, action, research, and evaluation to address obesity at each of five social settings: family and community, school, health care, media and communications, and worksites. Thus, the best program ensures that there are effective and complimentary interventions at each setting. No such program exists in the literature at the present time.


The Surgeon General’s call for communication is meant to highlight the need to inform, motivate, and empower decision makers in all social settings to prevent and decrease overweight and obesity. The call specifically states that “individual behavior change can only occur in a supportive environment with accessible and affordable healthy food choices and opportunities for regular physical activity.” Thus, model programs cannot focus only on changing the behavior of the obese. Indeed, the Surgeon General makes plain that “actions to reduce overweight and obesity will fail without … [a] multidimensional approach.” To be successful, interventions must consider individual behavior change, group influence, institutional and community influences, and public policy. Few programs at present are so far reaching.


Model programs should also use media and communication to stress healthy dietary choices and the benefits of regular physical activity. The Surgeon General asks that weight-loss programs and goals be truthful and reasonable, that media outlets balance messages that may encourage over-consumption and inactivity with more healthful messages, that healthier eating and physical activity messages be integrated into youth TV programming, that media professionals employ actors of diverse sizes, and that nutrition and exercise scientists be trained in media advocacy. These are reasonable goals for model programs.


The best place to start in preventing obesity is with preventing the development of obesity in young children. Obesity may be more effectively treated in preschool than in elementary school.86 Nutrition authorities assert that a diet that contributes no more than 30 percent of calories from fat and less than 10 percent of calories from saturated fat is safe for children above two years of age.87-90 Though rare, more extreme dietary restrictions may cause harm to children.91, 92


Many interventions designed to prevent or treat obesity in children can be applied across a population, that is, provided to all children. In general, nutritional interventions for all children focus on purchasing foods with less fat content, eliminating excess or added fat in food preparation, using cooking methods that do not add fat, and increasing the amounts of fresh fruits and vegetables. Fat-lowering diet interventions using these techniques at preschools have proven successful.34, 35 One of the keys is to lower fat intake in foods children enjoy eating.93 For example, a school-based intervention that is easy to implement is to substitute good for poor quality snacks in school vending machines. This has proven successful in both metropolitan and rural areas.94


In general, combining fat-lowering school food service programs with enhanced physical activity in physical education classes and classroom-based health education may offer effective interventions to obesity among children. Through these interventions, the fat content of school lunches has been significantly reduced, and the level of school physical activity has been significantly increased in both rural and urban studies.95-98 Recent reviews of the literature also suggest the effectiveness of school-based heart-health programs at improving the health behaviors of students.99, 100 The evidence is mixed as to whether school children make up in other meals the extra fat lost in modified school lunches or compensate for receiving extra activity at school by getting less activity after school.96, 98 Consequently, school-based fat-lowering diets and activity-increasing programs should be accompanied by interventions aimed at families.


A recent review suggests that children are affected by the heart-health habits of their parents and that school-based programs are strengthened when a family component is included.101 For example, fat avoidance of parents is one of the best predictors of fat avoidance in children.102 Further, children have better exercise performance and less obesity when their parents are physically active,103 and families who are involved in organizations or activities that promote activity (e.g., YMCA, YWCA, health clubs, health spas, sports, and Scouts) have children with better physical activity performance scores and less obesity. Young children, however, may not model parental health behavior and require more active interventions.104 While families should work together to reduce childhood obesity through reduced calorie intake and increased physical activity, there is evidence to suggest that obese children may benefit best by programs that involve parents separately in weight-loss counseling.105


School-based, fat-lowering, activity-increasing programs for all students in a class are often not, however, effective in significantly lowering the average body mass index of students in a school. While successfully lowering fat intake and increasing activity, these positive effects may be obscured by the large developmental changes occurring during early school years and by the averaging that occurs in these studies. For school-level weight loss, a long intervention period or more substantive changes may be needed. Nevertheless, such programs help build in students the foundation for life-long health habits. For weight loss among obese children, school-based programs that use behavior modification (setting specific goals, behaviors, and rewards) for reducing fat and calorie content and increasing physical activity, coupled with the provision of special low-calorie school lunches, and social support training for those in the child’s social network (parents, teachers, physical education instructors, peers, food-service personnel, and administrators) have proven successful.106


Beyond school-based programs, community or home-based programs have been successful in reducing child and adolescent obesity. The Children’s Health Project, while developed for children with high LDL in the north Philadelphia suburbs, contains components that seem applicable to rural areas. One such component, the parent-child auto-tutorial (PCAT), consists of a home-based self-instruction program consisting of 10 ‘talking-book’ lessons with audiotape, picture booklet, paper and pencil activities, and a parent manual.36, 37 Children who use the program significantly lower their total fat and saturated fat intake in comparison to controls and do as well as children receiving face-to-face counseling with a dietician.


Nutrition and physical exercise counseling programs that are offered once a week in the community for children at-risk for diabetes and their parents have also shown to improve both exercise and nutrition habits.107


As to adults, the most successful therapy for weight loss and maintenance combines a low calorie diet (800 to 1,500 calories a day) with increased physical activity and behavioral therapy.23 The NIH clinical guidelines for adults state that while reducing fat intake is helpful, this is insufficient for weight loss without a reduction in calories. A low calorie diet achieves about an 8 percent weight loss in six months. The NIH recommends that each low calorie diet should be personally tailored to the patient, and the patient should receive frequent contact with health professionals during weight loss.


The behavioral therapy component of treatment consists of practices designed to help individuals or groups overcome barriers to compliance with dietary and activity recommendations. These include: self-monitoring of eating habits and physical activity, managing stress that triggers dysfunctional eating, eliminating stimuli that lead to overeating, generating solutions to problem behaviors and making plans to implement them, making rewards contingent on good behavior, restructuring thought to set realistic goals and eliminate self-defeating thoughts, and building social support networks.23


Numerous programs have used some or all of the strategies above to achieve weight loss in adults. Some of these have been developed in rural areas, and others may be easy to adapt. Weight-loss programs broadcast over cable television offer promise for overcoming the distance barriers and costs associated with treatment in rural settings and have proven as successful as face-to-face interventions in urban interventions.38 Short programs on network television affiliates that stress simple diet rules have also proven successful. In one study, a behavior modification diet received 15 minutes of air time on Mondays and 5 minutes on Wednesdays and Fridays on a morning show for a month. Each week, a few simple eating rules were emphasized for losing weight, and participants charted their progress at home. Subjects completing the entire program lost an average of 5.6 pounds.108


Correspondence courses may also prove useful in overcoming barriers that hinder meetings in rural areas. Courses modeled on behavior modification techniques have shown that weight loss can be achieved and maintained among those who are active correspondents in metropolitan areas.39 These courses could easily be offered in rural areas. Web-based courses also offer promise for rural areas.


Programs designed to increase fruit and vegetable consumption may also reduce fat and calorie intake. Several community-based efforts have been successful in promoting the habit of eating at least five servings of fruit and vegetables a day.109-111 These can be tried in rural settings. While nutritionists have not generally recommended diet meal replacements, these have been found to reduce and keep weight off in some rural participants.112


Solutions to rural obesity may also require additional involvement of physicians and other health professionals. Many primary health care providers in both rural and urban settings feel ill prepared to give nutrition and physical activity counseling. Continuing nutrition education delivered to rural physicians in rural settings in Wyoming increased both physician knowledge of nutrition and the use of educational materials for nutrition.113 Physicians working in rural southern areas were trained to use a simple dietary assessment device, deliver specific behavior change recommendations, and use a monitoring and reinforcement system to increase dietary compliance.114 A three-session counseling program using small achievable steps designed to improve self-efficacy among low-literacy and low-income patients in the South was successful in a modest lowering of body mass index and in statistically significant improvements in dietary habits in 11 counties throughout largely rural North Carolina.115 Physicians in rural North Carolina have also found that patients may accept a very low-fat diet¾but this has only been shown in a small study with motivated coronary artery disease patients.116


In worksites, the Surgeon General calls for creating opportunities for regular physical activity during the workday, ensuring that healthy foods are available for lunch, establishing or promoting employee membership in fitness facilities, and creating incentives for workers to achieve and maintain healthy body weight. Few rural worksite studies focused on obesity have been published. One study with mostly white male rural energy workers in Texas and Louisiana, who consume a high-fat, low-fiber diet, found that workers know they should eat a healthier diet but lack the efficacy expectations to do it.117 The lack of self-efficacy clearly underlies much of the failure to improve life-style behaviors118 and may be especially important to develop in rural residents. One promising study found that the confidence and intention necessary to lower fat intake can be increased in rural worksites.119




See the Models for Practice section in Volume 1 for a catalog of models.


Summary and Conclusions


It is not clear why living in a rural area increases the odds of being obese and suffering its effects. Certainly, the demographic composition of rural areas accounts for some, perhaps a large portion, of the extra risk. But rural areas also have other challenges: fewer prevention and treatment facilities, further distances to reach them, and perhaps cultural challenges that may vary from place to place.


Given the current state of knowledge, those designing interventions to decrease rural obesity will be hard-put to know where to begin as the list of possible contributing factors is large and perhaps varied from region to region. There is, however, wisdom in starting with basics: improving diet (decreasing fat and calorie intake) and increasing exercise. The Surgeon General’s Call to Action makes it clear that progress can be made at each level of society: from individual to community, school to worksite, and media to health care. Surely, one of the more important steps is to begin coalition formation in each rural community to raise awareness of the problem and to improve resources. It is likely that progress will occur slowly through improvements in infrastructure that can impact rural obesity: nutrition and exercise education, better school lunches, and more exercise sites. Increased emphasis on attracting more public health workers trained in nutrition to rural areas, training rural primary-care givers in effective nutrition and exercise change strategies, and enhancing the rural public’s sense of self-efficacy to make diet and nutrition changes are avenues that may help trim the belts and enhance the health of rural America.




1. U.S. Department of Health and Human Services. Healthy People 2010. 2nd ed. With Understanding and Improving Health and Objectives for Improving Health. 2 vols. Washington, DC: U.S. Government Printing Office, November 2000.


2. Satcher, D. The Surgeon General’s Call to Action to Prevent and Decrease Overweight and Obesity 2001. Washington, DC: U.S. Department of Health and Human Services, 2001.


3. Gamm, L.; Hutchison, L.; Bellamy, G.; et al. Rural healthy people 2010: Identifying rural health priorities and models for practice. Journal of Rural Health, 18(1):9-14, 2002.


4. Dietz, W.H., Jr., and Gortmaker, S.L. Factors within the physical environment associated with childhood obesity. American Journal of Clinical Nutrition 39(4):619-624, 1984.


5. Malina, R.M. Ethnic variation in the prevalence of obesity in North American children and youth. Critical Reviews in Food Science and Nutrition 33(4-5):389-396, 1993.


6. Noel, M.; Hickner, J.; Ettenhofer, T.; et al. The high prevalence of obesity in Michigan primary care practices. An UPRNet study. Upper Peninsula Research Network. Journal of Family Practice 47(1):39-43, 1998.


7. Levin, S.; Mayer-Davis, E.J.; Ainsworth, B.E.; et al. Racial/ethnic health disparities in South Carolina and the role of rural locality and educational attainment. Southern Medical Journal 94(7):711-718, 2001.


8. Greenlund, K.J.; Kiefe, C.I.; Gidding, S.S.; et al. Differences in cardiovascular disease risk factors in black and white young adults: Comparisons among five communities of the CARDIA and the Bogalusa Heart Studies. Coronary artery risk development in young adults. Annals of Epidemiology 8(1):22-30, 1998.


9. Ogunyemi, D.; Hullett, S.; Leeper, J.; et al. Prepregnancy body mass index, weight gain during pregnancy, and perinatal outcome in a rural black population. Journal of Maternal-Fetal Medicine 7(4):190-193, 1998.


10. Wolf, A.M. What is the economic case for treating obesity? Obesity Research 6 (1 Suppl): 2S-7S, 1998.


11. Colditz, G.A. Economic costs of obesity and inactivity. Medicine and Science in Sports and Exercise 31(11 Suppl):S663-667, 1999.


12. Sturm, R., and Wells, K.B. Does obesity contribute as much to morbidity as poverty or smoking? Public Health 115(3):229-235, 2001.


13. Must, A., and Strauss, R.S. Risks and consequences of childhood and adolescent obesity. International Journal of Obesity and Related Metabolic Disorders 23 (2 Suppl):S2-11, 1999.


14. Dietz, W.H. Childhood weight affects adult morbidity and mortality. Journal of Nutrition 128(2 Suppl):411S-414S, 1998.


15. Pi-Sunyer, F.X. Medical hazards of obesity. Annals of Internal Medicine 119(7 Pt 2):655-660, 1993.


16. Ingram, D.D., and Gillum, R.F. Regional and urbanization differentials in coronary heart disease mortality in the United States, 1968-85. Journal of Clinical Epidemiology 42(9):857-868, 1989.


17. Dietz, W.H., Jr. Prevention of childhood obesity. Pediatric Clinics of North America 33(4):823-833, 1986.


18. Guo, S.; Salisbury, S.; Roche, A.F.; et al. Cardiovascular disease risk factors and body composition: A review. Nutrition Research 14(11):1721-1777, 1994.


19. Freedman, D.S.; Shear, C.L.; Burke, G.L.; et al. Persistence of juvenile-onset obesity over eight years: The Bogalusa Heart Study. American Journal of Public Health 77(5):588-592, 1987.


20. Srinivasan, S.R.; Bao, W.; Wattigney, W.A.; et al. Adolescent overweight is associated with adult overweight and related multiple cardiovascular risk factors: The Bogalusa Heart Study. Metabolism 45(2):235-240, 1996.


21. Serdula, M.K.; Ivery, D.; Coates, R.J.; et al. Do obese children become obese adults? A review of the literature. Preventive Medicine 22(2):167-177, 1993.


22. Berenson, G.S.; Wattigney, W.A.; Tracy, R.E.; et al. Atherosclerosis of the aorta and coronary arteries and cardiovascular risk factors in persons aged 6 to 30 years and studied at necropsy (The Bogalusa Heart Study). American Journal of Cardiology 70(1):851-858, 1992.


23. National Institute of Health (NIH), National Heart, Lung, and Blood Institute (NHLBI). Clinical guidelines on the identification, evaluation, and treatment of overweight and obesity in adults. Department of Health and Human Services, Public Health Service (PHS), 1998, xxiii.


24. De Jong, W. The stigma of obesity: The consequences of naive assumptions concerning the cause of physical deviants. Journal of Health and Social Behavior 21:75-87, 1980.


25. Sobal, J., and Devine, C. Social aspects of obesity: Influences, consequences, assessments, and interventions. In: Dalton, S. Overweight and Weight Management: The Health Professional’s Guide to Understanding and Practice. New York, NY: ASPEN Publication, 1997, 289-308.


26. Martikainen, P.T., and Marmot, M.G. Socioeconomic differences in weight gain and determinants and consequences of coronary risk factors. American Journal of Clinical Nutrition 69(4):719-726, 1999.


27. Lantz, P.M.; House, J.S.; Lepkowski, J.M.; et al. Socioeconomic factors, health behaviors, and mortality: Results from a nationally representative prospective study of U.S. adults. Journal of the American Medical Association 279(21):1703-1708, 1998.


28. Sobal, J.; Troiana, R.P.; and Frongillo, E.A., Jr. Rural-urban differences in obesity. Rural Sociology 2(61):289-305, 1996.


29. Desch, C.E.; Smith, T.J.; Breindel, C.L.; et al. Cancer treatment in rural areas. Hospital and Health Services Administration 37(4):449-463, 1992.


30. Crooks, D.L. American children at risk: Poverty and its consequences for children’s health, growth, and school achievement. Yearbook of Physical Anthropology 38:57-86, 1995.


31. Sherry, B.; Springer, D.A.; Connell, F. A.; et al. Short, thin, or obese? Comparing growth indexes of children from high- and low-poverty areas. Journal of the American Dietetic Association 92(9):1092-1095, 1992.


32. Duelberg, S.I. Preventive health behavior among black and white women in urban and rural areas. Social Science and Medicine 34(2):191-198, 1992.


33. Miller, M.K.; Stokes, C.S.; and Clifford, W.B. A comparison of the rural-urban mortality differential for deaths from all causes, cardiovascular disease and cancer. Journal of Rural Health 3(2):23-34, 1987.


34. Williams, C.L.; Bollella, M.C.; Strobino, B.A.; et al. “Healthy-start”: Outcome of an intervention to promote a heart healthy diet in preschool children. Journal of the American College of Nutrition 21(1):62-71, 2002.


35. Spark, A.; Pfau, J.; Nicklas, T.A.; et al. Reducing fat in preschool meals: Description of the foodservice intervention component of Healthy Start. Journal of Nutrition Education 30(3):170-177, 1998.


36. Dixon, L.B.; Tershakovec, A.M.; McKenzie, J.; et al. Diet quality of young children who received nutrition education promoting lower dietary fat. Public Health Nutrition 3(4):411-416, 2000.


37. McKenzie, J.; Dixon, L.B.; Wright, H.S.; et al. Change in nutrient intakes, number of servings, and contributions of total fat from food groups in 4- to 10-year-old children enrolled in a nutrition education study. Journal of the American Dietetic Association 96(9):865-873, 1996.


38. Meyers, A.W.; Graves, T.J.; Whelan, J.P.; et al. An evaluation of a television-delivered behavioral weight loss program: Are the ratings acceptable? Journal of Consulting and Clinical Psychology 64(1):172-178, 1996.


39. Jeffery, R.W., and Gerber, W.M. Group and correspondence treatments for weight reduction used in the multiple risk factor intervention trial. Behavior Therapy 13:24-30, 1982.


40. U.S. Department of Health and Human Services. Leading Health Indicators.



41. Buczko, W. Rural Medicare beneficiaries’ use of rural and urban hospitals. Journal of Rural Health 17:53-58, 2001.


42. Eberhardt, M.S.; Ingram, D.D.; Makuc, D.M.; et al. Urban and Rural Chartbook. Health, United States, 2001. Hyattsville, MD: National Center for Health Statistics, 2001.


43. McGinnis, J.M., and Foege, W.H. Actual causes of death in the United States. Journal of the American Medical Association 270:2207-2212, 1993.


44. Cleveland Clinic. Body Mass Index. 2002. < article/2731.1672>June 13, 2002.


45. Web MD Health. Obesity. 2002. < 2731.1444>June 13, 2002.


46. Mirriam Webster’s Collegiate Dictionary. <>June 13, 2002.


47. Wolfe, W.S.; Sobal, J.; Olson, C.M.; et al. Parity-associated body weight: Modification by sociodemographic and behavioral factors. Obesity Research 5(2):131-141, 1997.


48. Sjostrom, L. Impact of body weight, body composition, and adipose tissue distribution on morbidity and mortality. Obesity: Theory and Therapy, 2nd ed. New York: Raven Press, 1993, 13-41.


49. Mossberg, H.O. 40-year follow-up of overweight children. Lancet 2:491-493, 1989.


50. Ford, E.S.; Williamson, D.F.; and Liu, S. Weight change and diabetes incidence: Findings from a national cohort of U.S. adults. American Journal of Epidemiology 146(3):214-222, 1997.


51.Manson, J.E.; Colditz, G.A.; Stampfer, M.J.; et al. A prospective study of obesity and risk of coronary heart disease in women. New England Journal of Medicine 322(13):882-889, 1990.


52. Ermann, D.A. Rural health care: The future of the hospital. Medical Care Review 47(1):33-73, 1990.


53. Collins, J.G. Prevalence of selected chronic conditions: United States, 1986-88. Vital and Health Statistics Series 10:1-87, 1992.


54. Rowland, D., and Lyons, B. Triple jeopardy: Rural, poor, and uninsured. Health Services Research 23(6):975-1004, 1989.


55. Ingram, D.D., and Gulliman, R.F. The mortality surveillance system and its application to the study of isceh. Proceeding of the Social Statistics American Statistical Association, 324-327, 1987.


56. Gillum, R.F., and Ingram, D.D. Relation between residence in the southeast region of the United States and stroke incidence. The NHANES I Epidemiologic Follow up Study. American Journal of Epidemiology 144(7):665-673, 1996.


57. Sauer, H.I. Geographic patterns in the risk of dying and associated factors ages 35-74 years: United States, 1968-72. Vital and Health Statistics 3(18):1-120, 1980.


58. Kleinman, J.C.; DeGruttola, V.G.; Cohen, B.B.; et al. Regional and urban-suburban differentials in coronary heart disease mortality and risk factor prevalence. Journal of Chronic Diseases 34(1):11-19, 1981.


59. Barnett, E.; Strogatz, D.; Armstrong, D.; et al. Urbanisation and coronary heart disease mortality among African Americans in the U.S. South. Journal of Epidemiology and Community Health 50(3):252-257, 1996.


60. Sturm, R. The effects of obesity, smoking, and drinking on medical problems and costs. Obesity outranks both smoking and drinking in its deleterious effects on health and health costs. Health Affairs (Millwood) 21(2):245-253, 2002.


61. Register, C.A., and Williams, D.R. Wage effects of obesity among young workers. Social Science Quarterly 71(1):130-141, March 1990.


62. Gortmaker, S.L.; Must, A.; Perrin, J.M.; et al. Social and economic consequences of overweight in adolescence and young adulthood. New England Journal of Medicine 329(14):1008-1012, 1993.


63. Lutz, S.; Smallwood, D.; and Blaylock, J. Changes in food consumption and expenditures in American households during the 1980s. Statistical Bulletin 849, USDA-Economic Research Service, 1992.


64. Frank, G.C.; Voors, A.W.; Schilling, P.E.; et al. Dietary studies of rural school children in a cardiovascular survey. Journal of the American Dietetic Association 71(1):31-35, 1977.


65. McMurray, R.G.; Harrell, J.S.; Bangdiwala, S.I.; et al. Cardiovascular disease risk factors and obesity of rural and urban elementary school children. Journal of Rural Health 15(4):365-374, 1999.


66. Steele, M.F., and Spurgeon, J.H. Body size, body form, and nutritional intake of black girls age 9 years living in rural and urban regions of eastern North Carolina. Growth 47(2):207-216, 1983.


67. Crooks, D.L. Food consumption, activity, and overweight among elementary school children in an Appalachian Kentucky community. American Journal of Physical Anthropology 112(2):159-170, 2000.


68. Kumanyika, S. Diet and chronic disease issues for minority populations. Journal of Nutrition Education 22:89-95, 1990.


69. Jeffrey, D.B.; McLellarn, R.W.; and Fox, D.T. The development of children’s eating habits: The role of television commercials. Health Education Quarterly 9(2-3):174-189, 1982.


70. Klesges, R.C.; Shelton, M.L.; and Klesges, L.M. Effects of television on metabolic rate: Potential implications for childhood obesity. Pediatrics 91(2):281-286, 1993.


71. Sylvester, G.P.; Achterberg, C.; and Williams, J. Children’s television and nutrition: Friends or foes? Nutrition Today 30(1):6-15, 1995.


72. Johnson, R.K.; Johnson, D.G.; Wang, M.Q.; et al. Characterizing nutrient intakes of adolescents by sociodemographic factors. Journal of Adolescent Health 15(2):149-154, 1994.


73. Weinert, C., and Long, K.A. Understanding the health care needs of rural families. Family Relations (30):450-455, 1987.


74. Walker, L.O.; Walker, M.L.; and Walker, M.E. Health and well-being of childbearing women in rural and urban contexts. Journal of Rural Health 10(3):168-172, 1994.


75. Pomrehn, P.R.; Wallace, R.B.; and Burmeister, L.F. Ischemic heart disease mortality in Iowa farmers. The influence of life-style. Journal of the American Medical Association 248(9):1073-1076, 1982.


76. Omar, M.A.; Coleman, G.; and Hoerr, S. Healthy eating for rural low-income toddlers: Caregivers’ perceptions. Journal of Community Health Nursing 18(2):93-106, 2001.


77. Leeper, J.; Hullett, S.; and Wang, L. Rural Alabama health professional training consortium: Six-year evaluation results. Family and Community Health 24(2):18-26, 2001.


78. Zimmerman, M., and Kretchmer, N. Isn’t it time to teach nutrition to medical students? American Journal of Clinical Nutrition 58:828-829, 1993.


79. Winick, M. Nutrition education in medical schools. American Journal of Clinical Nutrition 58(6):825-827, 1993.


80. Ammerman, A.S.; DeVellis, R.F.; Carey, T.S.; et al. Physician-based diet counseling for cholesterol reduction: Current practices, determinants, and strategies for improvement. Preventive Medicine 22:96-109, 1993.


81. Wechsler, H.; Levine, S.; Idelson, R.K.; et al. The physician’s role in health promotion revisited¾A survey of primary care practitioners. New England Journal of Medicine 334(15):996-998, 1996.


82. Lindseth, G. Evaluating rural nurses for preparation in implementing nutrition interventions. Journal of Rural Health 6(3):231-245, 1990.


83. Henderson-Sabry, J.; Hedley, M.R.; and Kristine, M.L. A survey of needs and preferences of public health nurses for continuing education in nutrition. Canadian Journal of Public Health 78:51-56, 1987.


84. Heneghan, A.M., and Malakoff, M.E. Availability of school health services for young children. Journal of School Health 67(8):327-332, 1997.


85. Hendryx, M.S. Rural hospital health promotion: Programs, methods, resource limitations. Journal of Community Health 18(4):241-250, 1993.


86. Davis, K., and Christoffel, K.K. Obesity in preschool and school-age children. Treatment early and often may be best. Archives of Pediatrics and Adolescent Medicine 148(12):1257-1261, 1994.


87. Johnson, R.K. Can children follow a fat-modified diet and have adequate nutrient intakes essential for optimal growth and development? Journal of Pediatrics 136(2):143-145, 2000.


88. Ballew, C.; Kuester, S.; Serdula, M.; et al. Nutrient intakes and dietary patterns of young children by fat intakes. Journal of Pediatrics 136:181-187, 2000.


89. Shea, S.; Basch, C.E.; Stein; A.D.; et al. Is there a relationship between dietary fat and stature or growth in children three to five years of age? Pediatrics 92(4):579-586, 1993.


90. Kleinman, R.E.; Finberg, L.F.; Klish, W.J.; et al. Dietary guidelines for children: U.S. recommendations. Journal of Nutrition 126(4 Suppl):1028S-1030S, 1996.


91. Lifshitz, F., and Tarim, O. Considerations about dietary fat restrictions for children. Journal of Nutrition 126(4 Suppl):1031S-1041S, 1996.


92. Vobecky, J.S.; Vobecky, J.; and Normand, L. Risk and benefit of low fat intake in childhood. Annals of Nutrition and Metabolism 39(2):124-133, 1995.


93. Sigman-Grant, M.; Zimmerman, S.; and Kris-Etherton, P.M. Dietary approaches for reducing fat intake of preschool-age children. Pediatrics 91(5):955-960, 1993.


94. Ezell, J.M.; Skinner, J.D.; and Penfield, M.P. Appalachian adolescents’ snack patterns: Morning, afternoon, and evening snacks. Journal of the American Dietetic Association 85(11):1450-1454, 1985.


95. Luepker, R.V.; Perry, C.L.; McKinlay, S.M.; et al. Outcomes of a field to improve children’s dietary patterns and physical activity. Journal of the American Medical Association 10:275, 1996.


96. Donnelly, J.E.; Jacobsen, D.J.; Whatley, J.E.; et al. Nutrition and physical activity program to attenuate obesity and promote physical and metabolic fitness in elementary school children. Obesity Research 4(3):229-243, 1996.


97. Snyder, M.P.; Story, M.; and Trenkner, L.L. Reducing fat and sodium in school lunch programs: The LUNCHPOWER! intervention study. Journal of the American Dietetic Association 92(9):1087-1091, 1992.


98. Simons-Morton, B.G.; Parcel, G.S.; Baranowski, T.; et al. Promoting physical activity and a healthful diet among children: Results of a school-based intervention study. American Journal of Public Health 81(8):986-991, 1991.


99. McArthur, D.B. Heart healthy eating behaviors of children following a school-based intervention: A meta-analysis. Issues in Comprehensive Pediatric Nursing 21(1):35-48, 1998.


100. Nicklas, T.A.; Johnson, C.C.; Webber, L.S.; et al. School-based programs for health-risk reduction. Annals New York Academy of Science 817:208-224, 1997.


101. Nicholson, S.O. The effect of cardiovascular health promotion on health behaviors in elementary school children: An integrative review. Journal of Pediatric Nursing 15(6):343-355, 2000.


102. Zive, M.M.; Frank-Spohrer, G.C.; Sallis, J.F.; et al. Determinants of dietary intake in a sample of white and Mexican-American children. Journal of the American Dietetic Association 98(11):1282-1289, 1998.


103. Pate, R.R., and Ross, J.G. Factors associated with health-related fitness. Journal of Physical Education, Recreation and Dance, 45-48, 1987.


104. Bruhn, J.G., and Parcel, G.S. Preschool health education program (PHEP): An analysis of baseline data. Health Education Quarterly 9(2-3):116-129, 1982.


105. Brownell, K.D.; Kelman, J.H.; and Stunkard, A.J. Treatment of obese children with and without their mothers: Changes in weight and blood pressure. Pediatrics 71(4):515-523, 1983.


106. Brownell, K.D., and Kaye, F.S. A school-based behavior modification, nutrition education, and physical activity program for obese children. American Journal of Clinical Nutrition 35(2):277-283, 1982.


107. McKenzie, S.B.; O’Connell, J.; Smith, L.A.S.; et al. A primary intervention program (pilot study) for Mexican-American children at risk for type 2 diabetes. Diabetes Educator 24(2):180-187, 1998.


108. Frankel, A.R.; Birkimer, J.C.; Brown, J.E.; et al. A behavioral diet on network television. Behavioral Counseling and Community Interventions (3):91-101, 1983.


109. Campbell, M.K.; Reynolds, K.D.; Havas, S.; et al. Stages of change for increasing fruit and vegetable consumption among adults and young adults participating in the national 5-a-day for better health community studies. Health Education and Behavior 26(4):513-534, 1999.


110. Marcus, A.C.; Heimendinger, J.; Wolfe, P.; et al. A randomized trial of a brief intervention to increase fruit and vegetable intake: A replication study among callers to the CIS. Preventive Medicine 33(3):204-216, 2001.


111. Lutz, S.F.; Ammerman, A.S.; Atwood, J.R.; et al. Innovative newsletter interventions improve fruit and vegetable consumption in healthy adults. Journal of the American Dietetic Association 99(6):705-709, 1999.


112. Rothacker, D.Q. Five-year self-management of weight using meal replacements: Comparison with matched controls in rural Wisconsin. Nutrition 16(5):344-348, 2000.


113. Moore, S., and Marlow, R.A. Continuing education in nutrition for rural physicians. Family Medicine 18(2):104-105, 1986.


114. Ammerman, A.S.; DeVellis, B.M.; Haines, P.S.; et al. Nutrition education for cardiovascular disease prevention among low-income populations¾Description and pilot evaluation of a physician-based model. Patient Education and Counseling 19:5-18, 1992.


115. Rosamond, W.D.; Ammerman, A.S.; Holliday, J.L.; et al. Cardiovascular disease risk factor intervention in low-income women: The North Carolina WISEWOMAN project. Preventive Medicine 31(4):370-379, 2000.


116. Franklin, T.L.; Kolasa, K.M.; Griffin, K.; et al. Adherence to very-low-fat diet by a group of cardiac rehabilitation patients in the rural southeastern United States. Archives of Family Medicine 4(6):551-554, 1995.


117. Kuppens, R.; Eriksen, M.P.; Adriaanse, H.P.; et al. Determinants of fat and fiber consumption in American rural energy workers. Preventive Medicine 25(2):212-217, 1996.


118. Gillis, A.J. Determinants of a health-promoting lifestyle: An integrative review. Journal of Advanced Nursing 18(3):345-353, 1993.


119. Fries, E.A.; Ripley, J.S.; Figueiredo, M.I.; et al. Can community organization strategies be used to implement smoking and dietary changes in a rural manufacturing work site? Journal of Rural Health 15(4):413-420, 1999.


120. Gauthier, B.M.; Hickner, J.M.; and Noel, M.M. High prevalence of overweight children in Michigan primary care practices. An UPRNet study. Upper Peninsula Research Network. Journal of Family Practice 49:73-76, 2000.


121. Gustafson-Larson, A.M., and Terry, R.D. Weight-related behaviors and concerns of fourth-grade children. Journal of the American Dietetic Association 92:818-822, 1992.


122. Neal, W.A.; Demerath, E.; Gonzales, E.; et al. Coronary artery risk detection in Appalachian communities (CARDIAC): Preliminary findings. West Virginia Medical Journal 97:102-105, 2001.


123. Felton, G.M.; Pate, R.R.; Parsons, M.A.; et al. Health risk behaviors of rural sixth graders. Research in Nursing and Health 21:475-485, 1998.


124. Davis, S.M., and Lambert, L.C. Body image and weight concerns among Southwestern American Indian preadolescent schoolchildren. Ethnicity and Disease 10:184-194, 2000.


125. Lacar, E.S.; Soto, X.; and Riley, W.J. Adolescent obesity in a low-income Mexican American district in South Texas. Archives of Pediatrics and Adolescent Medicine 154:837-840, 2000.


126. Williamson, D.F. Epidemiologic analysis of weight gain in U.S. adults. Nutrition 7:285-286, 1991.


127. McCoy, H.; Kenney, M.A.; Kirby, A.; et al. Nutrient intakes of female adolescents from eight southern states. Journal of the American Dietetic Association 84:1453-1460, 1984.


Chapter Suggested Citation


Tai-Seale, T., and Chandler, C. (2003). Nutrition and Overweight Concerns in Rural Areas: A Literature Review. Rural Healthy People 2010: A companion document to Healthy People 2010. Volume 2. College Station, TX: The Texas A&M University System Health Science Center, School of Rural Public Health, Southwest Rural Health Research Center.



[i] Some studies, however, do not show increased obesity in rural areas.74 The lack of effect may, however, be due to demographic differences: rural mothers tended to be younger, perhaps before the period of greatest weight gain between the ages of 25 to 34.126


[ii] However, not all studies agree about rural fat intake. In a nationwide food consumption survey of adolescents (N=933), degree of urbanization had no effect on the total amount of fat consumed.72 Further, excess fat intake may or may not translate into excess calorie intake. Rural teenage girls from eight southern states had significantly lower caloric intake than their urban counterparts.127 In instances where the calorie restrictions are severe or nutrient density is very poor for growing children, the higher rates of obesity may simply reflect shorter stature.