This study found that obesity was related to frequency of use of specific food outlets that may encourage overeating, such as buffets, cafeterias, and fast food restaurants. Obese rural adults reported living in communities that were not “activity-friendly” or supportive of physical activity. Characteristics of the perceived physical activity environment associated with obesity among this sample included the perception that the community was not pleasant for physical activity. Thus, both physical activity environments and patterns of use of food environments were related to obesity among rural adults. Food environment characteristics per se were not related to weight status in the present study.
Though there were relatively few disparities in perceived access to healthful food options in the community between low and high educated rural adults, those with a high school education or less reported lower access to a large selection of fruits and vegetables and were more likely to report often shopping at convenience stores. They also reported more often eating at buffets and cafeterias. Perhaps individuals with less education, also likely to have lower incomes, were attracted to buffets and cafeterias because of convenience or greater perceived value.
Previous studies found that participants reported not feeling safe from traffic while walking or biking in rural communities (Boehmer et al., 2006
; Parks et al., 2003
). The presence of fewer, or poorer quality, sidewalks and/or higher traffic speeds on roads are features more often associated with rural, rather than urban areas (Boehmer et al., 2006
; Catlin et al., 2003
; Giles-Corti et al., 2003
; Parks et al., 2003
; Wilcox et al., 2000
). There are now numerous studies documenting an association between built environment characteristics and obesity or weight status (Papas et al., 2007
). To our knowledge, this study is only the second in the United States to document an association between obesity and the perceived physical environment features specifically in rural communities (Boehmer et al., 2006
Few previous studies have examined whether obesity rates are associated with access to healthy and unhealthy foods and specific types of food establishments, and that limited evidence is mixed (Giskes et al., 2007
; Faith et al., 2007
). The present study did not find that perceptions of the food environment were related to weight status among rural adults, but previous research was extended by inclusion of measures of frequency of use of specific types of food outlets. The present findings build on earlier results that use of fast food restaurants may be a risk factor for obesity (Pereira et al. 2005
Strengths of this study include the large, multi-state sample of rural residents, the nationally tested measures of physical activity environment characteristics, and the use of reliable measures of the eating environment. Limitations include the cross-sectional design, which limits our ability to establish causality. Perceptions may be influenced by unique situational and personality characteristics, so clear interpretations cannot be made with confidence. In addition, BMI was calculated based on self-reported height and weight. Inclusion of objective measures of the physical activity and food environments in rural environments would allow for disentangling objective versus perceived influences. Adults in the overweight category were excluded; this allowed for greater contrast but also limited the applicability of findings to obese and normal-weight adults. Because this study sampled persons in a two-mile radius of walking trails selected because they were built near rural towns, residents of the most isolated areas were not included.
Because research on the built environment and obesity has been mainly limited to urban and suburban populations, future studies should focus on residents of rural areas to determine specific aspects of their neighborhood environment that may decrease obesity risk. In particular, additional studies should examine aspects of the food environment as they relate to obesity. New research should include longitudinal designs that better take into account temporal effects. Also, both perceived and objective measures of the neighborhood environment should be incorporated (Boehmer et al., 2006
). Studies in urban and suburban communities show evidence of an interaction between the neighborhood environment and individual-level risk factors (Joshu et al. 2008
); this needs to be examined for rural settings.
If present findings are replicated, they can provide guidance for interventions that are relevant for residents of rural areas. Consistent with ecological models of behavior, there was evidence of environmental and individual correlates of weight status. Perceptions of safe street shoulders are likely related to traffic speed and volume, and rural residents may have few other places to walk or bicycle than the shoulders of roads (Boehmer et al., 2006
). If confirmed, these findings suggest interventions need to be found to enhance the perception of safety of people who want to walk or bicycle along rural roads. Potential strategies are to widen the shoulders, use signage to identify pedestrian and cycle areas, construct paths separated from the road, and reduce vehicle speed limits. Some policy strategies (e.g., making it illegal to drive too close to cyclists) require minimal funding.
Although perceived access to food outlets with unhealthy food was not directly associated with weight status in the present study, it is clear that healthy foods must be available for people to choose them. One implication of these findings is that simply making healthy foods available is not sufficient to prevent or reduce obesity. It may be necessary to intervene at multiple levels. Options to explore in future studies include providing incentives to increase availability and affordability of healthy foods; working with food outlet owners and managers to reduce the range, convenience, and low cost of unhealthy food items; and changes in state or federal taxation and agricultural policies to reduce the relative price of healthy foods compared to unhealthy foods. Further research is needed to understand the factors that lead rural adults with lower levels of education to more frequently patronize food outlets that appear to facilitate less healthy eating patterns.
In summary, these findings add to a growing evidence base of neighborhood environment correlates of obesity and make a unique contribution regarding the environment-obesity relationship within rural communities. As these associations are clarified, interventions options will become more apparent.