The Obesity Problem in Rural America

Obesity is a touchy subject, it is personal. Being overweight is common, but what is becoming even more common is severe obesity. That is what is propelling these articles. This is part two of “Obesity; The “Second Hand Smoke” of Modern America“ addressing the issue of increased cost of healthcare due to severe obesity. This article will look at how rural patients tend to be more at risk for severe obesity than their urban counterparts. Nurses General Nursing Article

The Obesity Problem in Rural America

Vulnerable Population

Public health has focused on the vulnerable patients in our society for the past few decades, but now they are looking at how "place" plays a factor. According to the article, "Health in Rural America: Remembering the Importance of Place," In the 19th and 20th century, public health focused on the urban slums. Keeping these patients healthy meant they could continue to work for the industrial machines. Because of outbreaks such as cholera, smallpox, and yellow fever it was necessary to focus on these issues in order to keep the public as healthy and safe as possible. Expanding the horizon of public health awareness to rural areas has made it necessary to address how location plays a part.

Rural America

It is common to picture rural Americans as hardworking and traditional, having chosen to live in a farming small town community. Many rural areas look like small suburban towns with health risks much like those of urban patients such as obesity and smoking. Access to care is important but not always the total solution because as stated in the article mentioned earlier, the patients don't always respond to an increase in the number of health care practitioners. Prevention and education on healthy lifestyle is suggested to help this population in conjunction with access.

Obstacles to Health Care Access

There are many obstacles facing the delivery of healthcare to rural areas such as low population density, lack of access to grant funding, transportation issues, lower public funding, and the possibility of fragmented care. Also, the demographic changes of rural areas such as younger people moving out of the rural settings, leaving an increasingly aged population. Technology has changed the job market, decreasing the need for agricultural jobs. Addressing the needs of the rural population means building on the positive aspects of the community like the close social networks, high quality of life, neighborliness, and reciprocity. Helping these communities means recognizing their unique social qualities.

In a groundbreaking study, author Christie A. Befort PhD et. al. in the article, "Prevalence of Obesity Among Adults From Rural and Urban Areas of the United States: Findings From NHANES (2005 - 2008)," it is found that "rural residents have higher rates of chronic disease compared to their urban counterparts, and obesity may be a major contributor to this disparity." The things measured were body mass index (BMI), height and weight, demographic, diet, and physical activity.

Obesity Statistics

The numbers show obesity is more common among rural residents with 39.6%, and urban 33.4% of the population being obese. Married rural residents were found to have a larger degree of obesity, while urban residents are at an increased risk for obesity related to less education and inactivity. With these numbers, there is reason to give greater attention to obesity in America.

There are more than 70 million rural residents who have higher rates of chronic disease and mortality. The obesity issue is a major contributing factor to these health problems. In the latter mentioned research article, these stats were listed:

Age 20 -39 rural obesity rate - 31.8%, and urban 41.8%, as we can see urban young people have a higher BMI.

Age 60 - 75 rural residents 26.1% obese, while urban had a 15.6%. We can see from the numbers that older rural residents have a higher percentage of obesity.

Gender percentage of obese residents is very similar between the two genders as well as rural versus urban.

Minority women who live in rural areas suffer from a larger rate of cardiovascular disease, which is the number one killer of women in this country. Over the past 30 years, a greater number of rural residents have been affected by CVD according to the article by Herman A. Taylor, et. al., "Cardiovascular Disease Among Women Residing in Rural America: Epidemiology, Explanations, and Challenges."

Rural Life

As mentioned before, the thoughts of rural living evoke images of healthy food, active, less stress, and a strong community and family dynamic. However, there are many factors that inhibit a healthy lifestyle such as high levels of poverty, social isolation, and fractured healthcare. Rural people, according to the study by Taylor, have a higher percentage of diabetes, sedentary lifestyle, obesity especially in rural African-American women.

In the rural health facilities, women are less likely to receive an EKG, even though cardiovascular disease is the number one killer. Treatment to these women is often delayed, or not available. They are less likely to be given cardiac consultation or even a cardiac consult. Not only is good care hard to get, many of these rural residents are self-employed and insurance is too expensive. If they work for a company, these companies are often small and don't offer insurance or medical leave. Other factors that may affect rural residents from living healthier is a lack of trust towards healthcare workers, lack of preventative resources, and access to healthy food.

Need for Education

In the light of recent studies, we see the need for education and prevention among rural residents. There has been a weight management study performed by Michael G. Perri, et. al., and is presented in the article, "Extended-Care Programs for Weight Management in Rural Communities." The researchers performed a six month program in rural counties that had a higher rate of obesity, sedentary lifestyle, and chronic disease. The average weight was 96.4kg and there was an average weight loss of 10kg. They found the participants were more more compliant with the weight loss program when receiving counseling over the whole time period. Participants without counseling tended to regain their weight in the following year, but those who received the extended counseling, usually over the phone improved maintaining weight loss.

In conjunction with all the articles and research presented, we have first hand information from a nurse who works with rural patients named Judi. She listed the problems she sees that inhibit rural patients from getting the proper health care they need to live a healthy lifestyle. First, there are no fitness centers, making it difficult for people to find a place to get away from the house and focus on themselves. The only hospital accessible to her patients is a critical care hospital that runs of bare bones staff. Also, there are few primary care providers, and those are often from the "city." These providers come into the rural area only 1 -2 days a week, and not being a part of the community makes it difficult for them to connect with their rural patients. Specialist are not present in the rural community, forcing the patient to drive 65 miles to see them. On top of that the patients can have difficulty navigating the roads, buying gas, or even having access to a car.

To be more specific, Judi tells us about her dialysis patients:

"I will say that my patients (in nephrology, mostly end stage renal disease) are getting bigger and bigger. It is no longer unusual for me to have patients that weigh 200+kg (440#). Needless to say, their co-morbidities are huge also.

And...they require very long dialysis times and they still don't receive adequate dialysis even with five hours of dialysis. They are uncomfortable in the chairs - we have very few bariatric chairs in most dialysis units. They require extra long needles in order to go thru the additional adipose tissue. They are not eligible for transplant so they have no hope to ever get off dialysis which leads to depression."


As we have seen, rural residents have more obstacles to obtaining health care than to urban residents. Location often limits rural people access to healthy fresh food, and things like gyms that are readily available in cities. Recognizing that there is a problem of increased obesity in rural areas is a large step in getting these residents the help they need to live a healthier lifestyle. Please read my first article addressing how obesity increases the cost of healthcare, and look for the third article that addresses obesity among children.

Thank you to Judi for adding her experience, helping us to see the whole picture for her dialysis patients.


Befort, Christie A. PhD, Nazir, Niaman MD, Perri, Michael G. PhD. "Prevalence of Obesity Among Adults From Rural and Urban Areas of the United States: Findings From NHANES (2005 - 2008). 31 May, 2012. The Journal of Rural Health. 28: 392-397. 1 Jan. 2016. Web.

"Health in Rural America: Remembering the Importance of Place." October 2004, Vol 94: 10. American Journal of Public Health. 1 Jan. 2016. Web.

Perri, Michael G. et. al., "Extended Care Programs for Weight Management in Rural Communities." 24 November, 2008. American Medical Association. 22 Feb. 2016. Web.

Taylor, Herman A. et. al. "Cardiovascular Disease Among Women Residing in Rural America: Epidemiology, Explanations, and Challenges." 2 Jan. 2002. American Public Health Association. 22 Feb. 2016. Web.

Gastrointestinal Columnist

Brenda F. Johnson, BSN, RN Specialty: 25 years of experience in Gastrointestinal Nursing

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Specializes in Case mgmt., rehab, (CRRN), LTC & psych.

Thanks for turning the spotlight on rural patient populations and their health issues, which tend to be an afterthought to most people. I suspect the overdependence on cheap refined grains is fueling the obesity epidemic in rural areas, but what do I know? I'm only a nurse.

I can't say I totally agree with everything in this article. I grew up in Appalachia myself (rural America). I am an LPN. I am female, 5"4, 145 lbs. I have had genetic high BP since the age of 22 (triggered during last couple months of pregnancy). I have always had access to a family doctor my whole life. I also have a family cardiologist I see. I love to work out as well. I walk every day, and use my treadmill and elliptical often as well. I am a healthy weight for my height & try to eat right too. There are gyms in my area, and most local hospitals offer some type of exercise programs, or gyms patients can join. Healthy eating, obesity, & diabetes education brochures and posters are offered in almost all clinics and hospitals in the area.

Most locals are aware that poor eating habits & lack of exercise contributes to obesity. In my personal opinion, it's a "choice" to not eat right or exercise, no matter where you live. However, I do think some people have health issues and can't control their weight (thyroid problems, injury of a limb, etc.), & aren't able to exercise. I myself though, live in rural America, and choose to be healthy! :)

Specializes in SICU, trauma, neuro.

I too am from a very rural community in Wisconsin. Most of my extended family still live there. The obese from what I can tell are obese for the same reasons suburban and urban dwellers are: sedentary lifestyle, dietary choices, and non-modifiable factors like genetics. There is possibly a higher consumption rate of fresh corn on the cob during the summer (with butter and salt of course) because so many farmers and gardeners grow it...and because it's delectable. :D. But otherwise, the grocery stores carry the same things any other grocery store carries. Five miles south of my childhood home is a local frachise grocery store, and 20 miles north is a Wal Mart Supercenter. Fresh produce is very abundant in the summer! You can't drive more than a couple miles without seeing handmade signs for fresh berries, tomatoes, or corn. There are lots of commercial berry patches, Amish wives selling surplus, etc.

My parents receive medical care at a Mayo Clinic affiliated practice; my mom's MD even does dietary education with her, as she has high triglycerides and is trying to avoid meds. Local EMS is all volunteer, and the nearest hospital is 20 miles away, but anecdotally I see more people dying not because they didn't get EKGs but because they don't call 911. Men especially -- the Scandinavian farming type tend to be quite stoic. But my 93 yr old grandma survived bilateral PEs a few years ago, her family and team was so quick to act!

Excercise is an issue in the winter. It's often dangerously cold to go for a walk, and daylight is short. At winter solstice time, the sun sets before 1630. They've had some small fitness centers open in recent years though, and people can buy a treadmill as easily as suburbanites can -- nearest Wal Mart is 20 miles. My parents took up Nordic skiing and snow shoeing for variety, weather permitting. :)

Yeah, I have some reservations about this research as well.

My parents and in-law's generation grew up working on farms and ranches. Our local cardiologists rave about how healthy our elderly population is around here - people who worked physically hard all their lives are despite drinking whole milk straight from cows and lots of red meat.

I'm interested in what the people in the study did for a living. Are they working physically hard like the WWII generation?

Also, that generation grew up having large gardens, canning their own fresh food as well as eating it fresh from the garden.

My town boasts 600 people; there are about 1,000 in the whole valley. We have a gym and a yoga class and an exercise class at the local fairgrounds (just started a spinning class too). Lots of trails to hike around here as well. Fishing, hunting, etc.

Did this research study look at people in rural areas who still live a true rural lifestyle? Or did they look at people who move here from other areas due to a lower cost-of-living and live a sedentary lifestyle?

I don't think you can blame "rural" for obesity. I think it is the choices people make; the same choices they can make in city living.

Now, time for my hike to the local waterfall on part of the Pacific Crest Trail (yes, it goes through my neck of the woods).

Specializes in retired LTC.

I too found this paper interesting with reservations. To me, it seems somewhat 'outdated' or behind the times like by 40ish (?) years or so. 'Rural' isn't so rural anymore so like other PPs I question 'rural' being to blame. Genetics, sedentary lifestyle, poor food choices are the still out there. What has most prob changed is financial status of the rural population which allows/encourages all the same pitfalls that plague urban and suburban populations.

I did find the info re dialysis/ESRD pts new to me.

All the same, good food for thought (NO PUN intended).

Specializes in Urology.

As a person who lives in rural America I too have some problems with this information. Obesity has transcended rural and urban America to become a national epidemic. I myself live on a small farmette and am surrounded by various farms that include dairy, beef, chevon, and poultry. All of the farmers I know are lean and in shape. Some of them do have less than ideal lifestyle habbits (chew tobacco, etc) but overall they are pretty active. I agree with above posters about genetics and lifestyle being big modifiers. Nobody in my area has lack of healthcare access, we even have a low income clinic. While my area is not as rural as some, the county is still zoned agricultural and rightfully so, its full of farms.

The single biggest factor I could note to this conversation is the culture that America has created. There is just too much easy access to calorie dense foods and drink. Work has moved from the field to in front of a computer. We are consuming more and doing less so its no wonder people are getting larger around the waist.

I remember watching a documentary (food inc I believe) where it discussed the notion that we live in this paradoxical time period where the poor are getting fat and the rich are staying slim. Traditionally in the past it was the other way around, where the poor were often skinny and the rich were fat. The documentary showed a family that could feed all of them (4) for 12 dollars at burger king but when it came time to buy some fresh vegetables it became unfeasable for them to buy the 4.50 head of broccoli, which leaves you 7 bucks to spend on other items. Sure you could do a pasta meal for cheap but the idea is to eat healthy but healthy is $$$ now days.

Work has moved from the field to in front of a computer. We are consuming more and doing less so its no wonder people are getting larger around the waist...................The documentary showed a family that could feed all of them (4) for 12 dollars at burger king but when it came time to buy some fresh vegetables it became unfeasable for them to buy the 4.50 head of broccoli, which leaves you 7 bucks to spend on other items.

I agree that we are more sedentary as a nation and that has nothing to do with rural or city life.

But where in the heck is that $4.50 head of broccoli sold?? I got mine for $1.65. Bought enough to make cream of broccoli soup for 4.

Specializes in Pediatrics, developmental disabilities.

Thanks for shedding light on another aspect related to the obesity epidemic.

I wonder if nurses who work in rural areas are impacted as well?

But then I see the demographics in a suburban mall..

Thanks for shedding light on another aspect related to the obesity epidemic.

I wonder if nurses who work in rural areas are impacted as well?

Not really... I grew up in the most rural part of Appalachia you can imagine, & still live about 25 min. away from there. I always had, & still do have, access to doctors, a grade school, high school, college, grocery stores, gyms, etc. I think when people think of rural areas, they often think of what they see on TV. Run down shacks with nothing in sight, which really isn't the case in most rural areas these days...

I became an LPN at age 27. I myself, love to work out. I am 5'4, 145 lbs. There are some very obese people in this area, and there are some very lean/fit people in this area. My husband grew up in a city area near N.Y. I have seen very obese people there when visiting his home town, and have also seen very fit people there as well. When he first introduced me to many of his friends & family, I was the skinniest person there.

I think in this day and age w/ smart phones, TV, internet, etc. we are all aware of what we need to do to stay a normal weight - eat right & exercise. I personally think that obesity is a choice unless one has true health issues contributing to their weight gain. In my personal opinion where one lives has absolutely nothing to do with how much they weigh.

Obesity is a huge epidemic and in rural areas more so. That being said, there are a lot of great studies going on for people with a condition called Prader-Willi syndrome (PWS) that will most likely help the entire population. The problem is, PWS occurs in about 1:15,000 live births. Therefore it is not profitable for companies to jump on board... The drugs they are testing now for PWS are showing amazing results at stopping hunger! Unfortunately it will take longer than normal to get through drug trials due to lack of funding... If we keep people obese we make money off their healthcare needs! Ok rant over...