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Obesity: Combating a Rural Epidemic
By Thomas D. Rowley
Like most people in the United States these days, rural
Americans are eating more and getting bigger.
In fact, rural data
in the CDC publication, Health, United States,
2001, shows a higher
incidence of obesity among nonmetropolitan men and women than
in their metro counterparts in nearly every region of the country.
While it’s tempting to think that rural residents—by
virtue of their rural lifestyle—are somehow immune to the
dangers of growing larger and unhealthier, the opposite is true.
Meit, Director of the University of Pittsburgh’s
Center for Rural Health Practice thinks that obesity is a nationwide
just think that we in rural areas are a little further along,” Meit
said. “We’re the proverbial canary in the coalmine.
The rural populations are getting more and more obese and facing
the health care challenges that come along with that.” Meit
said that this obesity is going to put more of a strain on rural
health care systems and that it will lead to more illness and
more uncompensated care.
“That’s a recipe for disaster,” he
According to researchers Tom Tai-Seale and Coleman Chandler
in Rural Healthy People 2010, while rural areas traditionally had
lower rates of overweight and obese people because of the physical
demands of farming and other occupations, such is no longer
the case. They cite several studies showing that obesity and being
overweight are more common among rural residents—children,
adolescents, and adults—than
their urban counterparts.
In Bridging the Health Divide: The
Rural Public Health Agenda, by the Center for Rural Health
Practice, Jeff Oxendine and Emily Elman at the Pacific Public
Health Training Center cite research that shows both men and
women in rural areas have higher rates of self-reported obesity
than men and women in other areas.
They note that rural residents
are also more likely to describe their overall health status
as fair/poor than urban residents and that chronic illnesses
are more prevalent in rural areas. (Rural dwellers—adults
also more likely to smoke and rural adults are more likely to drink.)
statistics are part of a larger national concern.
Not only are
we eating too much, we’re eating the wrong things. According
to the CDC, only 25 percent of U.S. adults eat the recommended five
or more servings of fruit and vegetables every day. Fewer kids
(less than 20 percent) eat five a day, while more than 60 percent
eat too much fat. Even more troubling is the fact that the obesity
epidemic threatens our infants and toddlers. According to Susan
Pac of baby-food maker Gerber in a presentation at the U.S. Department
2004 Agricultural Outlook conference, by the tender age of 15 months
the most commonly consumed vegetable is that staple of American
diets, the French fry.
Nor are we exercising. The CDC reports that
despite the proven benefits of physical activity, fewer than
40 percent of American adults get enough physical activity to provide
health benefits. More than a quarter of them are not active at
all in their leisure time. Sadly, lack of exercise is also rampant
among children. Daily participation in high school physical education
classes dropped from 42 percent in 1991 to 29 percent in 1999.
As a result, more than one-third of kids in grades nine through
12 “do not regularly engage in vigorous physical
activity.” Unsettling as all that is, the damage to our health
and economy caused by our expanding national waistline is even more
- Obesity increases the likelihood of type 2 diabetes,
cardiovascular disease, gallbladder disease, sleep apnea, osteoarthritis
and various types of cancer.
- The cost of obesity in dollars
is approximately $120 billion a year.
- The cost in lives
approaches 400,000 a year.
While tobacco use is still the leading cause of preventable death
in the United States, a recent article by CDC researchers in
the Journal of the American Medical Association shows that obesity
is catching up and, if trends continue, will pass tobacco next
year, causing more than 500,000 deaths each year.
Overweight or Obese?
Overweight and obesity can be defined in a number of ways.
And whether a particular person is overweight or obese may
vary according to the definitions used. Body mass index (BMI)
is a popular method used to determine whether someone is at
a healthy weight, overweight or obese. BMI is calculated by
dividing a person’s weight (in kilograms) by his or her
height (in meters squared). BMI is more highly correlated than
any other indicator of height and weight with body fat.
- 19 to 24.9 is considered the healthy weight range
- 25 to 29.9 is considered overweight
- 30 and higher is considered obese
CDC maintains a BMI calculator for adults at http://www.cdc.gov/nccdphp/dnpa/healthyweight/assessing/bmi/adult_BMI/english_bmi_calculator/bmi_calculator.htm
Rural Healthy People 2010 and the Centers for Disease Control
Fortunately, efforts are underway to alert Americans—rural
the need to slim down and get healthy, and to help them get
busy and do it. According to Kristine Sande, the Rural Assistance
Coordinator, the concept of wellness is starting to resonate
with rural communities, especially in terms of controlling
the incidence of obesity and chronic conditions related to it such
as diabetes and cardiovascular disease.
seen this trend while reviewing grants at the Federal and
State levels, in the calls that we get here at RAC and when
the Center for Rural Health staff visited 13 rural communities
around North Dakota this fall,” said
Sande. “I think that this is a topic where there are
all kinds of ways that different groups can work together
to promote healthy living.”
Based on what she’s
seen and heard in the field, Sande listed several ways communities
can help promote wellness. Her list is by no means comprehensive:
can promote healthy living by teaching proper nutrition;
emphasizing the importance of physical activity through
physical education; holding contests that challenge kids to walk;
serving healthy choices for lunch; and limiting the availability
of candy and soda.
- Hospitals and clinics can offer
classes on controlling diabetes and can expand their
cardio/pulmonary rehabilitation areas into workout facilities available
to the community at large.
- County extension offices can
provide healthy-cooking demonstrations and nutrition classes.
can offer support groups for weight management, organize
walking clubs and make church facilities available for
- Local public health departments can provide
fitness screenings for community members.
organizations can start a wellness center or community
garden. For example, Sande said, there is a community gardener
in North Dakota who also works for the local diabetes prevention
program. The gardener invites local Native American youth
to help in the gardens, providing them with physical
activity and making it more likely that the kids will eat healthy
food because they helped raise it.
“I really think there is tremendous opportunity in most communities
for folks to come together around this issue,” Sande said.
Dr. Sylvia Moore, Professor and Director of Medical
Education and Public Health at the University of Wyoming would
likely agree with Sande, pointing to a unique program called “WIN
The program targets rural areas because small
rural communities have a better chance of making things happen,
With efforts in Wyoming, Montana, and Idaho, WIN the
Rockies—now in its
final stages—has two goals: first, to enhance
the well-being of people by improving their attitudes
and behaviors related to food, physical activity
and body image; second, to help build the capacity
of communities to foster and sustain these changes.
Ultimately, the project seeks to reverse the rising
tide of obesity in the three states. The underlying
philosophy is that people are responsible for their
own health and communities can create environments
that foster good health and provide health options.
The idea was to take a holistic look at the problem
“We wanted to look at health as
opposed to weight, look at healthy and pleasurable
eating and at body sizes,” Moore said. “We
wanted to help people accept who they are, instead
of going after an advertising ideal. And we wanted
to put a community focus on it, rather than doing
Begun in 2001, the
program selected six small rural communities—two
in each state. Three received help while three acted
as comparison communities to help measure the success
of the interventions. The program has three components:
pre- and post-intervention surveys in the six communities,
efforts aimed at 50 adults in each community, and
efforts aimed at fifth grade classes in each community.
The efforts varied according to what participants
in each community wanted to do—e.g., walking
programs, classes in healthy eating, physical activity,
and body awareness and appreciation. Each, however,
was designed to meet one or more of the following
- Accept and value all body sizes and shapes and recognize
that everyone can reduce their risk of poor health by adopting
a healthy lifestyle.
- Enjoy physical activity every day.
- Take both pleasure
and control in eating.
In addition, communities received assistance in building walking
paths, purchasing milk machines for schools, obtaining gym equipment
and other improvements to help promote wellness. Project organizers
even brought in experts from the famous Cooper Institute in Dallas,
Texas—founded by cardiovascular surgeon Kenneth
Cooper to advance the understanding of the
relationship between living habits and health—to help set
up community fitness programs. It also brought in a sculptor
to show how beautiful the human body is—in all shapes and
body cast sculptures.
Efforts in the demonstrator
communities have concluded, and comparator communities are now
receiving the educational materials and some
assistance in creating programs. In addition,
results are being evaluated and showing some
mixed success. The incidence of being overweight
in all six communities (even the comparators)
went down, but rates of obesity stayed the same,
as people with the most weight to lose have not
been able to do so. At this point, project organizers
have no real explanation as to why that is the
As for lessons learned, Moore says they found a common thread.
There is a work ethic that keeps rural people from
exercising unless it has a productive purpose.
“People are having a
hard time shifting to activity for activity’s
sake,” Moore says.
in Ho-Chunk Nation
Type 2 diabetes runs high
among members of the Ho-Chunk Nation in rural Wisconsin, even
among the youth. Within the tribe’s six- to 18-year-old population,
obesity—a major risk factor for the
at five times the national rate.
To help reduce
those numbers and the risk of diabetes, the
Ho-Chunk Nation Youth Fitness Program in
Jackson County, Wisconsin, provides at-risk
youth with nutrition counseling and exercise
On the nutrition front, a pediatric
nutritionist performs in-home family assessments and teaches
meal-planning skills. The project focuses
on providing low-fat cooking tips, food substitutes
and advice on eating out.
The exercise portion of the program includes
games, weight training and cardiovascular exercise for older
children along with balance, coordination, agility
and strength work for younger children. Exercise classes
also teach about the effects of exercise on the body.
To help motivate the
kids, they get t-shirts, water bottles and field trips. Participation
is also encouraged through articles in local newspapers.
is a collaboration between the Ho-Chunk Nation Department of Health,
the Ho-Chunk Nation Youth Services Program, the University of Wisconsin-Madison
Pediatric Fitness Clinic and three rural school districts.
For its innovative efforts, the program
received an award from the Pan American Health Organization as
part of the 2002 national celebration of World Health Day.
Workers with HealthWorks
In McKean County, Pennsylvania, employers,
health care providers and insurers are coming together to promote
wellness. The program, known as HealthWorks, is the brainchild
of Zippo Manufacturing, Highmark Blue Cross/Blue Shield, and
Bradford Regional Medical Center. Its aim—once up and running—is
to improve the health of employees and lower their health
care costs. So far, 18 employers from the region
have signed on to participate. In May, leaders and representatives
of the employers will meet to design specific activities such
as a 10,000 steps program in which participants receive pedometers
and are encouraged to walk 10,000 steps each day.
to the activities themselves, research will be conducted on the
effectiveness of the effort. The Center for Rural Health Practice
will evaluate the hypothesis that employers hold such sway over
people in rural areas that they can really be powerful change
agents when it comes to health, as can churches and
Indeed, some of the most promising programs are community-wide
initiatives, the Center’s Michael
Meit said. And because rural communities
are smaller and tend to have closer social
networks, they may be in a better position
than urban areas to engage in such initiatives.
the challenges are greater, I think it’s
easier to implement programs in rural
areas,” says Meit. “I think
obesity is [becoming] the number one
health issue in this country. Unfortunately,
rural seems to be disproportionately
affected. We need to get out in front
of this thing. We need to be the leader.
There’s no reason we shouldn’t
be the leader.”
Why Is Rural Fatter?
According to Rural Healthy People 2010, “there is evidence
that rural life presents special challenges to maintaining a healthy
weight.” Researchers Tom Tai-Seale and Coleman Chandler list
several cultural and structural limitations in rural areas that
hamper both diet and exercise.
- Higher dietary fat and calorie consumption, and lower
frequency of exercise
- More television watching
- Lack of nutritional education
- Lack of access to nutritionists
- Lack of physical education
classes in schools and recreational facilities in general
there is demography. According to Tai-Seale and Coleman, “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.”
Source: “Nutrition and Overweight Concerns in Rural Areas:
A Literature Review,” Rural Healthy People 2010.
Starting with this issue, the Rural Monitor will feature a column by
Wayne Myers, M.D. on the current state of health care in this country,
with a particular focus on rural areas.
Myers, a pediatrician, founded
the University of Kentucky Center for Rural Health in 1990 and served
as its director for seven years. The center works with other agencies
to train rural people in health professions and, under Myers' direction,
became one of two recipients of a 1997 award for primary care education
from the Pew Health Professions Commission. Myers served as director
of the Office of Rural Health Policy in the Department of Health
and Human Services' Health Resources and Services Administration from
1998-2000 after more than two decades of leading or consulting for
rural health projects in the United States and abroad. He is the past
president of the National Rural Health Association and currently serves
on its Board of Trustees.
In this issue, his "Going (for) Broke" looks
at the future of the Medicare Trust Fund.
In addition, starting with the next (Summer)
issue of the Monitor, Tom Corbett will write a column on human
Corbett has emeritus status at the University of Wisconsin-Madison
and remains an active affiliate with the Institute for Research
on Poverty where, until recently, he served as Associate Director.
He has long studied trends in welfare reform and social programs
that affect the well-being of vulnerable families. Over the years,
he has worked on welfare reform issues at all levels of government,
including a year as senior policy advisor at the U.S. Department
of Health and Human Services. He continues to work with a number
of states through networks of senior state welfare officials
in the Midwest and West Coasts and on issues of program and systems
integration to deliver better services to challenged families.
Look What's Coming
by Wayne Myers, M.D.
Going (for) Broke
The Medicare Trustees recently announced that the Medicare Trust
fund will go broke in the year 2019 instead of 2026 as previously
projected. This announcement got a lot more attention than it deserved.
Suppose your mechanic told you that your old Ford will need a new
engine at a half million miles. HA! That old Ford will be history
long before 500,000 miles. And our current way of organizing and
paying for health care will be history before 2019.
Of all the money
that changes hands in this country, 15 percent goes for health
care. Health care has been taking larger and larger bites of our
economy for the last 75 years. In 1930 it took about three and a
half percent. By 1970 it had doubled to seven percent. We tried regulating
the building of expensive hospital beds and gadgets (1974) and putting
controls on payments to doctors and hospitals (1984) to rein in
costs. Despite these efforts the health bite doubled again in only
25 years, hitting 14 percent in the mid ‘nineties.
growth slowed for a few years as we tried various new business
approaches to paying medical bills. But by the year 2000 patients,
employers, hospitals and clinicians were fed up. The brakes began
to slip. Health care costs are again growing twice as fast as the
economy. If this expansion continues as it has ever since the Great
be spending a quarter of our total economy on health care by the
time the Medicare Trust Fund goes bust. This won’t happen.
Our current approach to organizing and paying for care will break
down long before 2019. It is already breaking down. The main payers
for health care are employers and government. Health benefits are
front and center in labor relations today as we saw in the West
Coast grocery workers’ strike. Large national
companies are reneging on retirement benefit agreements. Most
employers are shifting part of the costs of premiums to employees.
Some are quietly saying that they will no longer be able to provide
health insurance to their workers by the end of the decade. Similarly,
States are finding they can’t pay their Medicaid bills. And
there is the 15 percent of Americans with no health insurance at
all. Medicare looks to be the best funded of the lot.
crescendo is one symptom of the way our health care is organized,
or, more accurately, not organized. There is another even more
important effect. Our disorganized health care kills a lot of
people. For example, mistakes in the care of hospital inpatients
kill more people than car wrecks. We can identify several aspects
of our health care that simultaneously waste money and kill people.
The Institute of Medicine of the National Academy of Sciences has
estimated the health cost of medical mistakes and outlined ways to
prevent them. The good news is that several of the things we need
to do to save lives would also save lots of wasted money. We can
have safer care while getting costs under control.
Our health care
organization is extremely fragmented. Patients have to cross multiple
boundaries between independent organizations in any major episode
of care. When patients cross organizational boundaries, work is
duplicated, records are lost, errors creep in and patients get hurt.
The death of the girl killed by her heart-lung transplant at Duke
a few months ago is an example. The organ blood type got lost moving
among hospitals. The costs of duplicate management and record-keeping
run into the hundreds of billions of dollars. This fragmentation
makes it impossible to develop the kind of error detection systems
in use by other industries, such as the airlines.
In the next issue
of The Rural Monitor we’ll look at the Institute
of Medicine findings and recommendations. We’ll see
how small town health care can act on some of these recommendations
right now while large systems founder. Rural health care
can develop the models to lead the country out of this mess.
Wayne Myers, a pediatrician, founded the University of Kentucky
Center for Rural Health and served as its director. He also served
as director of the Office of Rural Health Policy in the Department
of Health and Human Services' Health Resources and Services Administration.
He is a past president of the National Rural Health Association and
currently serves on its Board of Trustees.
Around the Country
by Erica Hauck
Northwest Pennsylvania Rural AIDS
Although AIDS is most often associated with inner-city populations,
thousands of rural residents are newly diagnosed with HIV every
Due to their location, rural HIV patients face barriers that
HIV patients in urban areas do not: long commutes to receive
health care, difficulty finding a doctor who specializes in the
treatment of HIV and AIDS, and the greater sense of stigma and
denial of the problem among rural populations.
in rural Pennsylvania, however, are finding help in overcoming
these barriers through the Northwest Pennsylvania Rural AIDS
The Alliance, funded primarily through the federal
Ryan White Care Act, takes a comprehensive team approach to delivering
services to about 200 HIV-positive people in its 10,000 square-mile
area, most of them from poor populations. That approach simultaneously
addresses the multiple needs and barriers faced by its underserved
clientele, focusing not only on access to medical care, but also
on other social services needed by its clients. Some of the services
provided include referrals to area physicians who specialize
in HIV and AIDS care; a traveling clinic that offers early intervention
medical services; assessment of eligibility for public programs
like Medicaid; mental health counseling; temporary financial
assistance with utility bills; provision of food from local food
banks; dental and visual medical care; strategies for adhering
to drug regimens and counseling; and overall service management.
According to Alliance Coordinator Jeff Curtis, the major strength
of the Alliance lies in its team-based approach to providing
service” to its clients. The organization consists of 16
full-time employees and several contracted professionals who
provide clients with a multitude of services under one umbrella.
It also has formed partnerships with other organizations in the
area to provide social services to its clients and help raise
awareness of the issue.
“In rural areas, people often believe
it’s not here,
it’s not us,” said Curtis. “It’s true
that urban areas got it first. But it’s spreading.”
more information, contact Jeff Curtis, Project Coordinator, at
(814) 764-6066, or email@example.com.
Virginia to Create Rural Agency
The State of Virginia is in the process of creating a permanent
point for rural concerns.
The new Center for Rural Virginia will
serve three primary purposes: conducting analysis and research
on topics of relevance to rural areas; providing a forum for
rural advocacy; and offering technical assistance to rural communities
to help them form partnerships and conduct strategic planning.
Virginia will join other States—including
North Carolina, Pennsylvania, Texas, Georgia and Arkansas—which
have created State-level agencies for rural concerns.
was established by House bill 1213, which has been passed by
both chambers of the General Assembly and is expected to soon
be signed into law by the governor. Its creation follows the
recommendation of the Rural Virginia Prosperity Commission.
Commission was created by the State’s General Assembly
in January 2000 to study the strengths, needs and priorities
of rural areas. It was comprised of State House and Senate members
and private citizens and staffed by faculty at Virginia Tech
and the Cooper Center for Public Service at the University of
Virginia-Danville. After holding six regional public meetings
throughout the State and consulting with numerous groups and
agencies interested in rural issues, the Commission presented
its final report, with a comprehensive set of recommendations
meant to be enacted as a package. Many of the recommendations,
such as improving capital access and broadband capabilities in
rural areas, already have resulted in legislation.
most important result of the recommendations is the creation
of the Center for Rural Virginia. Like the Commission that established
it, the Center will be composed of private and public sector
However, the Center will be responsible for leveraging
outside funds for its operations. The Virginia Senate is expected
to approve an appropriation for the Center of about $150,000
a year, but most of its operating funds will come from private
funds or State and Federal grants.
Randy Arno, a faculty member
at the Cooper Center, and a primary agent in the establishment
and work of the Commission, said “The
Center (for Rural Virginia) will serve as a platform from which
to identify and launch programs for rural Virginia, and a means
through which to protect rural resources.”
For more information,
contact Randy Arno of the Cooper Center for Public Affairs
at (434) 489-1535 or Dr. Wayne Purcell of Virginia Tech at (540)
CALL FOR INPUT
Something newsworthy going on in your part of rural America?
Send a one-paragraph summary to the editor at: firstname.lastname@example.org.
Spotlight on Rural Research
by Thomas D. Rowley
A Hungry Irony
Ironically for a nation of overeaters, many in this country have
too little to eat—or at least too little of the right kind
According to The Food Assistance Landscape, March 2004 by
the U.S. Department of Agriculture, 11 percent of U.S. households
insecure,” meaning that the households were uncertain of
having, or unable to acquire, enough food for all household members
because they did not have enough money or other resources for food.
Worse, 3.5 percent (3.8 million) of households were food insecure
to the point of one or more members going hungry at least some
time during the year because they could not afford to eat. On average,
food insecure households with hunger experienced the condition
for a few days each month in eight or nine months of the year.
help combat food insecurity and hunger, USDA administers 15 domestic
food assistance programs. The goals of the programs are to: provide
needy persons with access to a more nutritious diet; improve
the eating habits of the Nation’s children; and help farmers
by providing an outlet for distribution of food purchased under
farmer assistance programs.
In all, approximately one in five
Americans participates annually in at least one of the 15 programs.
That figure, however, may soon increase due to the soft economy
and high unemployment rates. In fact, expenditures for the programs
already increased 9.4 percent in fiscal year 2003, to a record high
$41.6 billion. Five of the 15 programs accounted for 94 percent of
- The Food Stamp Program is the largest food
assistance program, accounting for 57 percent ($23.7 billion)
of spending. The program provides monthly benefits for eligible
participants to purchase approved food items at authorized food
stores. Participation in the program averaged about 21.3 million
people per month; the average participant received $83.91.
- The Special Supplemental
Nutrition Program for Women, Infants, and Children (WIC) helps safeguard the health of low-income pregnant, breastfeeding
and postpartum women, and infants and children up to age five who
are at nutritional risk. The program provides a package of supplemental
foods, nutrition education and health care referrals. During
fiscal 2003, spending for WIC totaled $4.5 billion. Monthly participation
averaged 7.6 million, with children (ages one to four) comprising
50 percent of the total. USDA reports that nearly half of
all children (47 percent) born in the United States today are born
into families receiving WIC.
- The National School Lunch Program provides nutritious low-cost or free lunches to schoolchildren
by providing schools with cash and commodities. Any child at
a participating school may enroll in the program. Children of families
with incomes at or below 130 percent of poverty receive free meals,
those of families between 131 and 185 percent of poverty receive
reduced-price meals, and those of families with incomes over 185
percent of poverty pay full price, though the meal is subsidized
by USDA to a certain degree. Spending for the program in fiscal
2003 was $7.2 billion, with an average of 28.3 million children
participating in the program each day.
- The School Breakfast Program provides low-cost breakfasts
to schoolchildren, with low-income children receiving
free or reduced-price meals under the same eligibility requirements
as the lunch program. In 2003, some 8.4 million children participated
in the program each school day. Spending for the program was
- The Child and Adult Care Food Program subsidizes healthy
meals and snacks in participating child care centers and homes
and adult day care facilities. Total spending for this program
was $1.9 billion, with a total of 1.8 billion meals served.
Even the Needy
In still more irony, even people in need of assistance
battle the bulge. Indeed, many low-income people lack the
resources to afford or access a healthier, more nutritious
on relatively “cheaper” foods higher
in fat, salt and sugar and lower in nutritional
content. As evidence of this ironic twist, conversations
with providers at rural health facilities serving
the poor reveal a high incidence of obesity, hypertension
and diabetes among their patients.
In deep east
Texas, Dr. Duane Tisdale sees poor, uninsured immigrants
from Mexico at a mobile clinic run by the St. Paul
Foundation and the Northeast Texas Public Health
District. In addition to their chronic poverty,
most of the patients are struggling with chronic
diseases—many of them related to diet and
“People come from another
culture and try to adapt to our culture and our
diet and they don’t adapt well,” Tisdale
see a lot of degenerative diseases related to lifestyle—things
like diabetes and hypertension.”
The Food Assistance Landscape, March 2004 is available at http://www.ers.usda.gov/publications/fanrr28-4/fanrr28-4.pdf.
For more information on food security and food assistance in general,
The Rural Monitor is published by the Rural
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Reprint Policy: Articles, photos, and charts appearing in the Rural Monitor may be reprinted with the permission of the Rural Assistance Center and proper citation. For permission, please contact email@example.com