The obesity gap between town and country is widest in the South

**About 46 million people — 14% of the United States — live in
non-metropolitan counties.** They already have higher rates of the diseases
obesity drives: diabetes, coronary heart disease and arthritis.

The 2016 Behavioral Risk Factor Surveillance System put the obesity figures
themselves at:

The gap was significant **overall, in all four census regions, in all nine
divisions, and in roughly half the states that have both kinds of county.**

Where the gap is widest, and why that is odd

Those two regions are otherwise unalike — different economies, different
settlement patterns, different politics. What they share is a rural/urban
difference, which is the point: the divide is not a Southern phenomenon
wearing a national label.

By absolute prevalence the ranking is different again: highest in the
South (32.0%) and Midwest (31.4%), and by division in the **East South
Central (35.3%)** and West South Central (33.9%).

It is not one group carrying the difference

**With the exception of Hispanic adults and people with less than a high school
education, the higher non-metropolitan prevalence appeared in every
sociodemographic group** the survey measured — age, sex, race and ethnicity,
education, income and employment.

That rules out the easy explanation that rural counties simply contain more of
whichever group already had the highest prevalence.

What does explain it

Three findings from other years, all pointing the same way:

• 2013 BRFSS: adults in non-metropolitan counties were **less physically
  active** and less likely to meet physical activity recommendations
• 2011 data: across all regions, rural adults were **less likely to have
  access to healthier food retailers** — supermarkets, large grocery stores,
  fruit and vegetable specialists
• Persistent poverty and food insecurity are more common in rural than
  urban areas

And the South, which has both the highest prevalence and the widest gap, also
has the highest rate of persistent poverty and **the largest difference in
poverty rate between its metropolitan and non-metropolitan residents.**

Why the usual advice does not transfer

CDC has 24 obesity-prevention policy and environmental strategies. Two
systematic reviews looked at how they fare in rural settings, and the friction
is geographic rather than attitudinal.

"Increase the availability of healthier food and beverage choices" runs
into **long distances between food suppliers and retailers, and between
retailers and consumers**, which raises cost and cuts the availability of
fresh food. The adaptations follow from that: **strengthen networks between
producers, distributors and retail outlets**, and **shorten the distance the
customer travels** — for example, more nearby farmers' markets. Also: nutrition
policies in schools and workplaces, and partnerships with the **Cooperative
Extension Service** to promote federal food assistance benefits.

Physical activity strategies have to account for **geographic dispersion,
transport difficulties, and limits on community resources**. What has worked:
opening public buildings such as school facilities after hours, **bicycle
paths, paved pavements and outdoor recreation facilities**, **better signage
for places that already exist**, stronger school physical education, and
workplace policies.

Two limits worth holding onto

The weight and height are self-reported, and self-reporting **understates
BMI, particularly among people with a higher BMI** — so these numbers are
floors. Whether that bias is the same in rural and urban counties **is not
known**, which is a limit on the size of the gap, not on its existence.

And **"non-metropolitan" here is two of the six NCHS county types collapsed
into one** (micropolitan and noncore), done to keep the sample big enough for
state comparisons. The category is broad by necessity.

Source: Centers for Disease Control and Prevention, MMWR.