Obesity is a nationwide epidemic, but it hits some communities in the U.S. harder than others. Rural areas have significantly higher rates of obesity compared to urban ones, which likely contributes to their higher rates of chronic disease.
You wouldn’t know this, though, from the share of public health research devoted to improving diet quality in rural areas. Most healthy eating interventions have taken place in urban settings. Now a new study of a healthy eating initiative in rural Waupaca, Wisconsin—population 6,000—highlights the need for greater attention to, and targeted solutions for, these farther-flung communities.
Much of Waupaca meets the USDA criteria for a rural food desert, meaning that its residents are predominantly low-income and live more than 10 miles from the nearest grocery store. The 10-month pilot study, conducted by researchers from Drexel University and the University of Wisconsin-Madison, enlisted two supermarkets (the only ones in town) and seven restaurants in a healthy eating initiative called “Waupaca Eating Smart” (WES). Participating operators agreed to offer healthy, WES-approved food options; to consider adding new dishes that featured fruits and vegetables prominently; and to advertise the program with signs, pins, and other materials. The pilot was not designed to measure health outcomes per se, but to demonstrate the campaign’s feasibility and inform a future effectiveness trial.
For the purposes of the study, the scarcity of food options in Waupaca turned out to be a kind of advantage, according to lead researcher Ana Martinez-Donate, a professor of community health and prevention at Drexel University. With few restaurants and grocery stores available, residents were a captive audience for WES’s healthy eating messages. “You may be able to ‘saturate’ the area more easily and with [fewer] resources than what would be true for a bigger city with a much higher number of restaurants and stores,” says Martinez-Donate. Even though the campaign only included nine establishments, those made up one-third of all restaurants and half of all food stores in Waupaca.
Moreover, the close ties between residents of the rural town amplified the social impact of individual consumers. “A few interested businesses in a small place can make a bigger difference, serving as models for other businesses and motivating them to adopt the same strategies,” Martinez-Donate tells CityLab. “Those social connections and personal relationships really carried a little more weight than what we might have expected to see in a bigger town.”
But that doesn’t mean the same approach couldn’t translate to an urban area. While the power of word-of-mouth seemed distinctive for this tight-knit rural community, Martinez-Donate believes a similar mechanism is at play at the neighborhood level in a larger city. That’s one thing any community can learn from Waupaca: the need to establish and maintain relationships between patrons, businesses, and public health officials to sustain the campaign as a whole.
That said, the study detected only minimal changes in consumer behavior and attitudes with respect to healthy eating. While the restaurant data suggested an increase in the percentage of customers ordering “healthy” menu items, this effect wasn’t statistically significant. In stores, customers perceived the food offerings to be healthier, but they weren’t more likely to order them.
Others have questioned the efficacy of federal policies aimed at “eliminating” food deserts—a cornerstone of First Lady Michelle Obama’s “Let’s Move” children’s health initiative. There’s little empirical evidence that this focus on access has a significant impact on consumers’ health outcomes. In a recent Policy Forum article, Harvard researchers Jason Block and S. V. Subramanian argue that public health officials will need to use a range of different strategies to reduce diet quality disparities across the U.S., from taxing unhealthy food and incentivizing healthy options to implementing large-scale educational initiatives and improving school lunches. “Rather than assuming that ‘if we build it, they will come’ and eat healthfully, why not focus solely on policies that have more face validity, especially those that directly target economic and racial/ethnic disparities in diet quality?” the authors ask.
Any healthy eating initiative has to start with access to healthy food, but it can’t end there. The next step is to build consumer demand—and that’s where education can come in. For Martinez-Donate, the Waupaca study demonstrated the importance of collaboration between sectors—healthcare facilities, schools, and workplaces—to educate consumers and reinforce nutritional changes to the retail environment.
Those lessons apply to any community with limited food options, but it’s time public health officials and researchers took a closer look at rural areas in particular. As Martinez-Donate put it: “A food desert can be anywhere.”