The state of Indiana set a goal in 2010 to reduce the number of obese adults from 30 percent to 25 percent by 2020. But, those numbers are going in the opposite direction, particularly in rural areas.

According to the 2018 United Health Foundation Annual report, which compiled information gathered from the Centers for Disease Control and Prevention, 34.6 percent of adults in Indiana's rural population are obese, compared with 33.6 percent of all adults in Indiana.

Why are the numbers higher in rural areas?

There are several reasons, according to Lindsey Bouza, director for the Division of Nutrition and Physical Activity at the Indiana State Department of Health. They include less access to grocery stores and healthy foods; fewer opportunities to be physically active due to the lack of sidewalks, parks and other walkable areas; and even the Midwest weather.

“Many rural communities do not have the resources to address this critical health concern,” Bouza said. “Rural health care facilities are less likely to have nutritionists, dietitians or weight management experts available, and rural areas may lack facilities and infrastructure to encourage physical activity.

“Access to healthy and affordable food is also limited in many rural communities. Further, the distance that many rural residents must travel to access health care facilities, physical activity facilities and healthy food is an ongoing barrier.”

Obesity is a long-term concern, carrying risk factors for a range of chronic diseases, including heart disease, stroke, some cancers, and type 2 diabetes.

Starting young

While Western School Corp. is located in the town of Russiaville, many of its students are from rural areas.

School wellness is an ongoing focus across the board within the school system.

Emily Klingler, director of Food Service at the school system, said the growing number of obese youth over the past 30 years is certainly one reason that precipitated some changes in child nutrition.

It has also helped prompt the inclusion of local school wellness policies. Klingler noted that the combined nutrition and wellness policies are very much an ongoing effort to improve overall school health.

“Whether it’s food or activities, we’re all just trying to do the best we can for the students,” said Klingler, who is in her 12th year with the school and is also a registered dietitian.

“I think historically from the time I was in school to now, I think school food has changed for the better. We haven’t had fryers here even in our high school for probably well over eight years now. I think school meals are definitely healthier than they were.”

Klingler said the school system is five to six years into the new regulations, and while there were initial challenges, students have adapted over time.

Within the last year, Klingler noted, the Trump Administration has relaxed some of those rules, allowing 1-percent flavored milk for instance, versus fat-free milk, allowing schools to roll back to half of the grains required and relaxing some sodium requirements.

“With all these changes, we still want to present food and make food that kids are actually going to eat,” Klingler said. “If they’re not eating it, it’s not going to help the situation. We have to make food that they are going to want to eat, and that's good for them to eat.”

Angie Bowman, a nurse practitioner at Community Howard Regional Health in Kokomo, sees the limited access to good food, along with less activity beginning in youth, contributing to obesity in rural populations.

“Eating healthy takes more effort, more money, more time, a lot of planning, Bowman said. “It isn’t something that’s not doable, but I feel like it takes effort, and people are busier and busier. We’ve kind of gradually gotten less active and become overweight.

Barriers and goals

Bowman said the health care system shares some of the blame for rural obesity.

“We’re so pressed for time in health care, we have to see more and more patients so I think it’s maybe getting skipped over some," she said. "But it’s the root cause of so many things. People that are obese get cancer more often, they get fatty liver disease, they get arthritis.”

Indiana launched a very detailed plan to combat the state’s obesity problem with the Indiana Healthy Weight Initiative in 2010.

A comprehensive nutrition and physical activity plan for 2010-20 developed by the Indiana State Department of Health and the Indiana Healthy Weight Initiative Task Force, some of the goals included decreasing the percentage of adults who are obese from 30 percent to 25 percent by 2020; and decreasing the percentage of high school students who are obese from 13 percent to 10 percent by 2020.

"I feel like they set reasonable goals,” Bowman said. “It’s just multi-factorial as far as what we need to be able to do. If you’re the state of Indiana Health Department and you’re trying to figure out what to do here, it’s a little overwhelming. We didn’t get here overnight, so it’s not going to reverse overnight.

“So you try to fix it at the level of schools to try to talk kids into being more active and eating better at school. They try to change the foods and get the soda out, but then you’ve got to worry about what’s going on at home. Those kids don’t go to the grocery.”

It’s a concern Klingler shares.

“They’re used to certain things at home, so when we are trying to implement whole grain-everything here, it’s not always accepted,” Klingler said. “It’s a very big challenge. But what was a big challenge in the beginning, a lot of stringent things early on with calorie limits and ounces of meat and grain you could serve in a week, those were lifted in the first year, and that made menu planning more flexible.

“We’re only one piece of that puzzle though. I don’t know what they’re eating at home. It extends to kids bringing stuff from home for lunch, too. We can’t control that and we don’t want to attempt to. As long as we’re doing our part here to offer fresh food, good food products, that’s important that we’re modeling that behavior.”

But the challenges remain, and Bouza noted that the environment is built to encourage rather than discourage obesity.

“We live in an environment in which there is a proliferation of cheap, processed unhealthy foods; endless sugary drink options; large portion sizes at restaurants; 24/7 access to fast food; and a lack of access to affordable, healthy food,” Bouza said. “In addition, many roads lack sidewalks and bike lanes, many buildings lack stair access and many businesses offer drive-through services. Additionally, fewer families eat dinner together and technology use is at an all-time high.

“The rising rates of obesity have slowed down in recent years, but it will take a considerable amount of time to level off and reduce our rates — just as it took a long time to get to where we are now."

Solutions

Bouza said there are numerous obesity-prevention strategies that can be used in rural areas, including:

- Increasing the availability of healthy foods by working with schools, work sites and cooperative extension services;

- Opening public buildings such as school facilities after hours for physical activity purposes;

- And including bicycle paths, paved sidewalks and outdoor public recreation facilities in community planning.

The Rural Health Information Hub, formerly the Rural Assistance Center, is funded by the Federal Office of Rural Health Policy to be a national clearinghouse on rural health issues. It offers help to rural communities in creating a healthy community.

Suggestions from that program include a focus on tele-health, with health care professionals available by phone or online; help in creating community engagement to reach rural families; and much more.

Visit www.ruralhealthinfo.org for more information.