Obesity and Health Status in Rural, Urban, and Suburban Southern Women

Priscilla W. Ramsey, PhD, RN, and L. Lee Glenn, PhD


South Med J. 2002;95(7) 

In This Article

Abstract and Introduction

Background: Obesity has reached epidemic proportions over the past 20 years.
Methods: This study investigated the differences in rates of obesity and perceptions of health status between rural, urban, and suburban Southern women based on selected socioeconomic factors. Using data from a national health survey, the reports from 4,391 women aged 40 to 64 years were included in the study.
Results: Significantly more rural women lived in poverty, reported a poorer health status, and had a greater prevalence of obesity. Urban women had the next highest obesity rate and a moderate health status. The healthiest group with the lowest obesity and poverty rates were suburban women.
Conclusion: Obesity and poor overall health are closely related in rural women. The greatest challenge to health care providers is to provide appropriate community-based weight-management programs.

Obesity among adults and children has increased dramatically in the past 20 years to reach epidemic proportions, and health care costs of excessive weight are estimated at more than $98 billion a year.[1] In a previous study investigating risk factors for cardiovascular disease in a poor, rural county in Tennessee, the authors found that morbid obesity was 6 times more common in women than men, particularly middle-aged women, and self-reported health status among obese women was significantly lower than that of women who were not obese.[2] It is unknown, however, whether these findings are limited to this specific geographic area, or whether it is as common a risk factor in other areas of the southeastern United States.

According to data obtained from the National Health and Nutrition Examination Survey (NHANES) II (1976-1980) and NHANES III (1988-1991), the age-adjusted prevalence rate for obesity increased from 20.6% to 25.4% in women, an annual increase of 0.9%.[3] The 1991 National Health Interview Survey found that, overall, women who live in the southern United States have higher weight-height ratios and a lower self-reported health status than women who live in the other 4 major geographic regions. Several socioeconomic factors have been investigated to explain these phenomena, including the effects of living in rural areas, income and educational levels, and family (marital) status.

Schneider and Greenberg[4] reported on the changing trends in mortality rates, comparing white women in states (all regions) that were classified as rural in 1940 and rural, moderately urban, or strongly urban in 1980. Their findings indicated that, in 1980, rural white women had higher mortality rates from heart and cerebrovascular disease than urban white women. In a separate study, Greenberg[5] reported finding more obesity and hypertension among rural residents, findings suggesting causal links between obesity and higher mortality rates.

The results of a 1993 national survey, the Multistate Telephone Survey (N = 387,704), however, identified conflicting differences in prevalence of obesity according to geographic regions. In 1993, the percentage of women in the Midwest who were obese (26.5%) was slightly greater than the percentage of obese women in the South (26.1 %).[3] Based on our experience with rural Appalachian populations, in which a relatively high prevalence of heart disease and risk factors for heart disease were present, these conflicting findings caused suspicion that rural residence, rather than geographic region, may be a major factor.

In the Schneider and Greenberg[4] study, women living in poverty in rural areas had greater mortality rates than those with higher incomes living in rural areas. These results led to the conclusion that poverty, rather than rural living, was the driving force for higher mortality rates. These findings were supported by the results from the 1979-1989 National Longitudinal Mortality Study (N = 530,000); mortality rates were increased in unemployed women and in those with low incomes and less education.[6]

Obesity risk factors associated with low income and low educational levels are supported by other studies as well. For example, women who were obese during adolescence have fewer years of education, higher rates of poverty, lower incomes,[7] and a lower perception of health status.[8] Risk factors for coronary heart disease are far more common among women in lower socioeconomic classes with less education.[9,10,11,12,13] Whether there are regional differences among obese women related to income and educational levels has not been investigated, however.

Investigations have determined that women who live alone (divorced, widowed, never married) have higher mortality rates than women who are married.[6,14] The findings in one study investigating rural/urban effects on mortality suggest that, although there is an increase in mortality rates in women living alone in general, rural women who live alone have a 60% higher relative risk of mortality than rural women who are married.[15] Because obesity is related to lower rates of marriage,[7] it also appears that marital status may be a factor in the prevalence rates of obesity in southern women. This study was limited to women because the tendency for obesity in rural women is more evident than obesity in rural men.[2] The purpose of our study, therefore, was to investigate (1) whether there are differences in prevalence rates of obesity among southern women associated with urban, suburban, or rural residency, income and educational levels, and marital status; and (2) whether there are differences in the health status of southern women based upon obesity, area of residency, income and educational levels, and marital status.


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