NUTRITION AND OVERWEIGHT CONCERNS IN RURAL AREAS: A LITERATURE REVIEW
by Tom Tai-Seale and Coleman Chandler
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:
Pertinent to this discussion are the following terms:
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
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
and obesity is found throughout the
Table 1. Selected Comparison Studies of Prevalence of Obesity and Overweight between Rural and Urban Children and Adolescents.
Obesity and Overweight Comparison
Prevalence of obesity was 3 to 9% higher among rural children.
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.
and 1,000 urban school children from
The odds of being obese were 50% higher for rural children.
Fifth graders in three rural counties participated.
Forty percent were overweight.
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
Rural American-Indian fifth graders (N~2000) participated.
One third of the students were overweight.
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
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
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
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
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:
Structural causes of obesity include the following:
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
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
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.
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
Satcher, D. The Surgeon
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Chapter Suggested Citation
Tai-Seale, T., and
[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.