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Rural kids seen as more obese, study shows

By Larry Dreiling

Country living is often thought of as inherently healthful: bucolic countryside open for running and playing, fresh fruits and vegetables from a home garden or a nearby friendly farmer, and a slower pace of life with time to cook and eat as a family.

Given the history of 19th-century urban squalor and poverty, some might be forgiven for thinking that children in urban areas are more likely to suffer from poor health than children in rural areas; but in today’s United States, this is no longer the case.

In recent years, researchers have found that children living in rural areas are more likely to be overweight or obese than children living in urban areas, according to a study by the Ann Arbor, Mich., based Altarum Institute, prepared by researchers Sarah Lifsey and Karah Mantinan.

The study found children living in rural areas are about 25 percent more likely to be overweight or obese than their peers in metropolitan areas. Children in rural families are also at increased risk of poverty compared to children in urban or suburban families and face lower access to health care, lower levels of physical activity, poorer-quality food, and limited options for transportation.

Rural communities face unique challenges when it comes to obesity prevention. Geographical distances between the home and opportunities for physical activity and healthy eating can place a time and cost burden on families, and rural areas often have limited private and public health care opportunities that give access to childhood obesity interventions.

These challenges, along with the challenges associated with the high rate of poverty in rural areas, make it difficult to implement some of the healthy and active living changes that are often recommended by the childhood obesity prevention literature, the study said.

Few places to play

One common misconception the study indicated is that rural residents have more access to “wide open spaces” and other opportunities for physical activity. However, studies of rural areas have found that there is little open public space available.

Rural communities may be unincorporated and lack a central government body that can provide or care for public spaces, resulting in a lack of space or neglect of existing spaces.

Small population sizes and low tax bases also limit the efficacy of local governments, and sparsely populated communities mean fewer community partners who can unite and cooperate to bring physical activity opportunities to the community.

In communities where space is available, rural children face several barriers to utilizing that space. There are few destinations for physical activity in rural communities, and the distance between the home and these opportunities is a barrier for many families. This is a particularly true for rural youth who rely on adults for transportation to access physical activity opportunities.

Another barrier to physical activity is the state of the roads themselves. Residents of rural areas are more likely to be hurt or killed in traffic incidents, and rural communities are more likely to have high-speed roads, few marked pedestrian crossings, and a lack of wide shoulders or sidewalks for walking or biking.

Finally, some studies have found that a fear of crime in public spaces is a barrier for rural families, even though this problem is more associated with urban areas. A study of the physical activity environment in rural Maine found that fears of crime, “stranger danger,” and encountering groups of ill-behaved youth in public recreational areas such as parks and basketball courts were significant deterrents to physical activity.

The Altarum findings are corroborated by findings from a PhotoVOICE project exploring rural families’ own perceptions of physical activity barriers, where vacant homes, loitering characters, and drug activities were seen as barriers to both the use of existing common space and allowing children to play unsupervised in the neighborhood.

Promising practices from urban and suburban areas, such as sidewalk development, walking to school, and physical out-of-school time programs can be difficult to implement in rural areas where distances between the school and the home can limit the viability of active transportation and where travel burdens reduce the appeal of driving children to after school activities.

High fuel cost of healthy foods

Farms may be found in rural communities, but this is no guarantee that families have access to fresh and healthful foods. Families in rural counties have a higher risk of food insecurity compared to their urban peers.

Like urban families, rural families can live in “food deserts,” where there are few grocery stores or other sources of healthy food. Unlike in urban areas, solutions such as increased public or semipublic transportation to shopping centers are difficult to support in areas with few people and long distances between homes, and attracting new stores to open in rural areas with few people to support them is often financially untenable.

Rural food deserts are associated with both higher rates of poverty and higher rates of childhood obesity.

As with physical activity, the long distances between food sources and the home and the time and cost constraints of travel are major barriers to healthy eating for rural families.

A study of the rural food environment in Maine found that rural shoppers felt that the biggest barrier to obtaining food was high in cost, often choose shopping locations based on sales and coupons. Travel distance to shopping centers was another barrier, with some parents traveling more than 80 miles round trip to shop.

Although this is a barrier, the study found that even low-income rural families generally have access to a car and many have large freezers to preserve bargain windfalls or seasonal produce and game. This study suggested that gasoline subsidies and subsidies for freezers might be appropriate “food desert” mitigation strategies in rural communities.

Federal nutrition programs are important to families in rural areas, as about 29 percent of rural households with children participate in at least one federal nutrition program such as the School Breakfast Program; the Women, Infants, and Children Program; the Child and Adult Care Food Program; and the National School Lunch Program.

However, even children with access to food in the schools may not be getting the nutrition that they need for good health. A study of middle school children in a rural Mississippi community found that fruit and vegetable intake was low, with an average intake of less than one fruit serving and less than one vegetable serving per day. The students also consumed relatively large amounts of soft drinks and sodium. A significant number of the children’s daily calories came from meals at school, including soft drink and snack machines at the schools.

Other studies have confirmed that healthy choices can be lacking at schools, and rural schools with small budgets may rely heavily on cheaper but less healthy items over whole grains, fresh fruits, and vegetables.

Innovative ideas

Despite these barriers, in recent years, rural communities and stakeholders have developed promising practices tailored for these areas:

—Work with the schools. Children spend a significant amount of their time in school, and having school bus schedules and family transportation plans already built around the school day makes improvements to the school environment convenient. Gym class and recess are often the most common sources of physical activity for children in rural areas, and rural families see time for physical education, the availability of recreational equipment and space, and access to the school grounds afterhours as facilitators to physical activity.

Afterschool sports clubs are another source of activity, although, as noted above, youth in rural areas often face transportation barriers. In these cases, transportation interventions should focus on finding ways to transport youth to and from these physical activity opportunities, such as late school buses and organized car pools.

School meals have been the focus of many well-publicized projects to increase the healthfulness of children’s daily diets, and this source of food may be of particular importance to rural children.

School meals are an obvious area of improvement, and tactics such as requiring the inclusion of a fruit or vegetable with meals, offering healthy choices among regular and a la carte items, and improving choices in soda and vending machines.

—Engage programs and groups already working in rural areas. Rural communities have some unique stakeholders compared to urban communities, and leveraging these existing relationships can be a useful tactic. For example, 4-H Youth Development programs are a common enrichment activity for rural youth, and a recent study found that linking a parent-centered obesity prevention intervention to the program could be a promising practice.

Telemedicine, a growing practice in communities where specialty clinics are distant, was found to increase participation from rural families in a North Carolina childhood obesity intervention.

Rural communities can have an advantage in access to local farms and land suitable for gardening. Collaborations between communities and local farmers or philanthropic organizations capable of teaching gardening skills could be an opportunity.

—Engage ethnic and tribal groups. While children in rural areas, particularly small rural areas, are mostly white, there are significant minority populations in these areas. In particular, children from American Indian or Alaska Native families are most likely to reside in small rural areas. Within the rural population, minority children are even more likely to be overweight or obese, with African-American children living in rural areas at the highest level of prevalence. Increasing diversity in rural areas means that providers and community interventions need to be culturally competent to include these populations.

Reaching these groups, the study said, involves working with existing cultural and social institutions, such as the Mvskoke Food Sovereignty Initiative, which works to coordinate clinicians from the Indian Health Services; dietitians and nutritionists; administrators of the tribe’s WIC and Head Start programs; and other community representatives to improve access to fresh, traditional foods.

Other rural interventions focusing on minority populations include the Child Health Initiative for Lifelong Eating and Exercise, a Head Start-based intervention aimed at American Indian and Hispanic families in rural communities in New Mexico; and Ninos Sanos, Familia Sana, which engages school and community stakeholders in a predominantly Mexican-American rural community.

—Work with employers. Work in rural communities has become more sedentary over time, with heavy farm labor and manufacturing moving to machines. However, obesity is costly to employers, and some employers have started employer-sponsored health promotion efforts. Technical assistance in particular to small employers and rural county governments to help develop employee wellness programs that encourage parents to model healthy behaviors for their children would be an opportunity.

—Develop materials specific to rural communities. The Robert Wood Johnson Foundation developed the Rural Active Living Assessment Tools in 2009 specifically to assess physical activity environmental factors in rural areas. These tools are designed for local community stakeholders to use.

Empowering local community stakeholders to observe, measure, and decide the future direction of their communities is particularly important for rural communities where independence is valued and few government resources exist.

Other resources include the Rural Assistance Center, funded by the U.S. Department of Health and Human Services Rural Initiative, which features a Rural Obesity Prevention Toolkit developed by the Nutrition Obesity Research Center’s Walsh Center for Rural Analysis, as well as a resource guide for rural areas developed by the University of North Carolina at Chapel Hill’s Active Living by Design.

Altarum Institute integrates independent research and client-centered consulting to deliver comprehensive, systems-based solutions that improve health and health care. A nonprofit, Altarum serves clients in the public and private sector.

Learn more about the study at

Larry Dreiling can be reached by phone at 785-628-1117 or by email at

Date: 5/5/2014


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