Chronic disease accounts for about 75% of the health care costs in the United Sates and several studies document the benefits of a healthy diet for weight control, and for illnesses such as diabetes, cardiovascular disease and certain types of cancer [3
]. Consuming at least five daily servings of fruits and vegetables are considered an essential part of an overall healthy balanced diet [2
]. Our study found that less than 1 in 4 rural US adults consumed five or more servings of fruits and vegetables, a result similar to previous research [48
], and a proportion that falls dramatically short of the targets set by HP 2010. Our results also revealed that compared to non-rural adults, a smaller proportion of rural adults reported consuming five servings of combined fruits and vegetables. The findings reported here underscore the continued need for developing targeted interventions that effectively result in healthier dietary choices while addressing possible issues of the availability and accessibility of healthy foods such as fresh fruits and vegetables.
While it may be ironic that rural adults, who live where fruits and vegetables grow, were less likely to consume at least five daily servings it is not necessarily unexpected [48
]. The importance of community environment as a contributor for individuals adopting a healthy lifestyle, including the availability of low cost health food choices, is increasingly being recognized [50
]. Although rural communities produce fruits and vegetables, they typically have fewer stores that offer a wide selection of healthy lower-cost food than non-rural communities [49
] and rural residents are more likely to live in a food deserts [56
]. Since approximately 20% of the US population lives in rural settings [51
] strategies aimed at improving access to healthy foods for rural residents could yield significant health benefits. Furthermore, an additional related issue is the ability and/or willingness of rural residents to travel greater distances to food stores where a greater availability of and choices for fruits and vegetables might be found [31
In addition to environmental access issues, rural residents are typically poorer than their non-rural counterparts and affordability is likely an important contributing factor to fewer rural residents consuming greater amounts of fruits and vegetables. Our results indicate that a higher proportion of rural residents earning less than $35,000 did not consume at least five servings of fruits and vegetables when compared to their non-rural counterparts. Food costs correlate to store type and food tends to be less expensive in larger supermarkets than smaller markets or convenience stores. These higher priced food outlets may be the only local and convenient food source for some rural communities. In addition to a convenience factor, transportation costs may be a barrier to purchasing less expensive healthier food that might be available in a nearby community.
Our findings also reveal several differences in the consumption of fruits and vegetables by characteristics such as gender, age, education, race/ethnicity, physical activity and reported health status. Similar to other studies [22
], this study found that in rural populations women and those with more education were more likely to consume five or more daily servings of fruits and vegetables. Likewise rural adults over age 65 were more likely to eat at least five servings of fruits and vegetables daily. Data regarding race and ethnicity from previous studies are mixed. In some studies, Caucasians consumed more fruits and vegetables than African Americans while other studies using national data demonstrated the converse [52
]. Our study found that Caucasians were less likely to consume five servings of fruits and vegetables and that the difference was greater for Caucasians living in rural settings, even though they tended to be better educated and have higher income levels than rural non-Caucasians (combined African Americans, Hispanics, other/Multiracial). The reasons for this difference are not clear and further study to confirm this finding and to understand the reasons why may be helpful in tailoring interventions to improve dietary choices among rural residents.
Those rural residents engaging in at least moderate physical activity and with a lower BMI were also more likely to consume five servings of fruits and vegetables. While physical activity and weight do not directly affect diet choices, our findings add to the body of knowledge that unhealthy lifestyles choices tend to coexist or cluster among individuals [52
] just as healthy lifestyle choices do.
Finally, of interest is the distribution of fruit and vegetable consumption by rural and non-rural adults by state. This distribution indicated that in only 11 states did rural adults have a higher prevalence of consuming five or more daily servings of fruits and vegetables than non-rural adults. The reason for this prevalence difference is unclear especially since of those 11 states only one, Hawaii, ranked as a top ten US State for fruit and vegetable production. This finding does suggest the need for further investigation---specifically to answer the question, are there differences between the rural populations in the states where there is a high prevalence of rural adults who are consuming at least five daily servings of fruits and vegetables and those states where such is not occurring? This might provide insight into the role that community environment plays in diets and for what strategies for improving diets might be best suited to a specific rural settings. Also issues such as climate might be more important for rural residents who may be more likely to grow their own food (e.g., vegetables) and could account for some differences among states.
Several potential limitations to this study should be noted. First, the survey is based on telephone derived data and may be skewed because those who could not be reached by phone could not participate in the survey. For example, persons of lower socioeconomic status may have been excluded because of poorer phone access. However, the fact that the vast majority of US residents live in households with telephones minimizes this bias. Furthermore, US cell phone numbers are now included in the pool of phones contacted for the survey. In addition, study strength is the use of a large multi-state database that includes a robust sample of rural residents weighted to reflect the demographics of rural and non-rural US populations.
A second limitation is that the survey used close-ended questions, which limit a responder’s options to fully explain response choices. However, while a different question format may have yielded different results, the survey questions were worded such that the answer choices covered a wide range of response possibilities. A third and related limitation is that the answers are self-reported, which introduces the possibility of recall bias on the part of the survey participants.
Fourthly, the question asking respondents about the number of servings of vegetables is somewhat ambiguous and may have led to an under-reporting of the number of servings of vegetables consumed. For instance no refined measure of consumption was included hence eating vegetables at both lunch and dinner may in actuality constitute more than two servings depending upon the amount of vegetables consumed. Furthermore, the questions did not specifically address vegetables in foods such as stews or soups. However, there is no reason to suspect that there would be reporting differences between rural and non-rural populations suggesting the data can yield meaningful comparisons.
A fifth potential bias resulted from the languages of the survey – English and Spanish. Individuals who did not speak English or Spanish were excluded from this survey. Not all US residents speak the two languages of this survey as a result those adults from other cultures who do not speak either English or Spanish and who have vegetable rich (e.g., Chinese) or fruit and vegetable rich (e.g., Mediterranean) diets may have been excluded and as a result the aggregated data may not be representative of actual consumption by all adults who are residing in the United States.
Finally, in the US, no standard definition exists for rural. In the BRFSS data used in this study, MSA was the only possible definition for rural. The main weakness of the MSA definition is that it does not differentiate well between nonmetropolitan or rural counties. The strengths, however, of the MSA definition are that it is stable over time and it is familiar to policy makers.