Obesity Fight Needs Non-traditional Partners

It's already tough enough for rural healthcare providers to survive.

There are a number of reasons why. One the biggest is that rural providers generally care for a sicker, older population that includes a higher mix of Medicare, Medicaid, and indigent patients, so reimbursements tend to be smaller.

A study published in the Journal of Rural Health now shows that it's not going to get any easier. University of Florida researchers found that 40% of rural residents are obese, compared with 33% of urban residents. No pun intended, but this is huge.

Earlier studies had already shown that overweight and obesity is a bigger problem in rural areas, but those studies put the difference in the 2% to 3% range. That estimate is now doubled. With about 60 million people live in rural America , and assuming that the UF findings are valid, 24 million rural residents are obese as measured by the Body Mass Index of height and weight.

"The problem [is that] the earlier studies were based on surveys that asked people to self-report height and weight," UF study author Michael G. Perri told HealthLeaders Media. "The study we did was based on measured heights and weights. One thing we are well aware of is that people tend to underreport their weight and over report their height. Everybody is five to 10 pounds heavier than they report and an inch shorter than they claim."

Obesity is a preventable condition that is linked to any number of serious and expensive-to-treat chronic diseases and other medical conditions such as Type 2 diabetes, coronary heart disease, high-blood pressure, cancer, sleep apnea, osteoarthritis, liver and digestive tract complications, and even mental illness.

As the nation's obese population grows larger in size and number—and there is no indication that this trend is reversing—these are all conditions that rural provider will have to contend with more frequency and in numbers disproportionately higher than those of their colleagues in non-rural settings.

"We simply cannot ignore the link between obesity and poverty, and the disproportionate impact this is having on rural America," Alan Morgan, CEO of the National Rural Health Association, said on the advocacy group's Web site. "If we truly want to decrease healthcare costs and improve the nation's health status, we are going to have to start viewing obesity as a top-tier public health concern for rural Americans."

This greater demand to provide and manage care for the obese will come as healthcare reform turns towards reimbursement models that reward quality outcomes and prevention over fee for service. Rural healthcare providers must get on the front end of this epidemic and emphasize prevention. Unfortunately there doesn't seem to be much coordination for this in any broad fashion.

"I don't think there is any single entity that will be able to turn the tide on this epidemic of obesity both in the nation and specifically in rural areas. It is going to have to be a convergence of many factors coming together," says Perri, who is also a professor and dean of the UF College of Public Health and Health Professions.

He believes the most cost-effective route may be to use existing infrastructures to provide nutrition and health education to rural families.

"One thing that jumps out is cooperative extension services in almost every county throughout the country. Part of their mission is nutritional education," Perri says. "In rural areas the extension office is highly valued as a place to go and get assistance. Often the extension offices are the places to go for the WIC (Women, Infants and Children) Program. We can teach family and consumer science agents in the offices how to do weight management programs targeting children and adults and families."

Perri points to another UF study that he co-authored that tracked 298 obese adults in six counties using cooperative extension as the venue for treatment. "We taught the extension agents how do to standard lifestyle behavioral treatment programs. We also were interested in how do we get people to maintain the changes that they have made," he says.

"We were able to produce weight losses that were equivalent or even better than those seen in diabetes prevention programs."

In the second phase of the study, the researchers randomized people for different follow-up care programs, either by mail, by telephone, or face-to-face. "We were particularly interested in effectiveness and cost effectiveness," Perri says.

"We showed the follow-up programs that were face-to-face or by telephone were significantly better than the follow-up by mail. That suggests that once we get people to lose weight we may be able to help them sustain it without having them come in for additional sessions other than telephone follow-up sessions."

Perri says related studies have demonstrated effectiveness in educational nutrition with just the parent rather than the entire family. "Particularly for school-age children, the parents often are the gatekeepers of food preparation and intake. We found you can get equal effectiveness whether the parents are alone or have the kids come in as well," he says.

All of this was accomplished outside of the traditional rural healthcare system of hospitals, clinics, and physicians' offices.  "The nice thing is that it takes it out of the whole medical reimbursement arena and the other piece is you don't have to establish a new infrastructure. The kind of activities fit nicely with the mission of the extension services," Perri says.

This may makes perfect sense, but Perri says the idea is embraced neither by rural providers nor extension services.

"They are coming from totally different angles. We have people with different world views," he says. "The folks in cooperative extension are coming largely from the perspective of agriculture. They feel somewhat uncomfortable moving towards healthcare as part of their mission. The folks in hospitals and clinical care see cooperative extension as the folks who help farmers and run 4-H clubs. There hasn't been a concerted effort to bring the two groups together."

This has to change. I suspect that it will. A big motivator will be money.

Providers are entering a new world of disease management, coordinated care, quality outcomes, and smaller reimbursements. It behooves them to step beyond the confines of the healthcare establishment to find new and nontraditional partners who can effectively and cost-effectively educate rural families about nutrition.