In addition to reducing the risk of developing many chronic diseases, there is an increasing and compelling body of clinical evidence supporting the benefit of diet and physical activity in not only health maintenance and disease prevention but also for disease treatment, a process referred to as Medical Nutrition Therapy (MNT) [13]. MNT is an essential component in the management and treatment of conditions such as type 2 diabetes, heart disease, hyperlipidemia, stroke and obesity [14-16]. Several widely disseminated clinical practice guidelines advise eating diets high in whole foods such as fruit, vegetables, and whole grains along with limiting animal protein and avoiding high energy low nutrient foods as an important component of disease management.

Another key HP2020 objective is to identify and track segments of the US population experiencing health inequities with the goal of eliminating disparities. Individuals living in rural settings are one population increasingly being identified as at risk for health disparities [1,17-19]. Health inequities or disparities are differences in health between societal strata or groups that are not only avoidable but that are also unnecessary, unfair and unjust [20]. Rural populations in the US experience a disproportionate burden of a number of chronic conditions and many of the major public health problems in rural areas such as obesity, diabetes and tobacco use require or at the very least call for population-level prevention-based interventions.

Hartley [17] urges researchers who have undertaken the examination of the health of rural Americans to explore why rural residency including culture, community and environment, reinforce negative health behaviors. Other researchers [19] aver that examining how and if rural residency affects health behaviors are equally important and that focusing on such may identify rural residency as a fundamental social cause [21] of health inequities.

While researchers have identified differences in fruit and vegetable intake related to race and ethnicity [22-24], age [25,26], socioeconomic factors [22,27,28] and sex [25,29], there is little population-based, national level research examining the consumption of fruits and vegetables by rural populations in the United States. Those studies we found investigating the fruit and vegetable intake of rural populations were limited because they either focused on regional or narrowly defined US populations (e.g., only Hispanic and African American groups or older rural adults) or rural settings outside the US [30-32]

Ultimately focusing on US adults living in rural areas acknowledges the importance of place in social epidemiology and public health concerns [33]. Specifically, when assessing health status, health service utilization, health service deficits, adequacy of health care, and health related behaviors---place or geography matters. It has long been held that the places where people live, work and play either protect and/or promote their health and contribute to the health risks they experience [34]. Previous research has indicated that rural residency is an independent risk factor for obesity [35,36], diabetes [37,38], and cardiovascular disease [37] suggesting that dietary habits such as the consumption of fruits and vegetables by rural individuals may differ from their non-rural counterparts.

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 [48-55]. 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 [56,57]. 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 [22-29], 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 [52-55]. 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.