Obesity and its related health risks have made a lasting mark on our society for this generation and several to come. Not only are prevalence rates of obesity and overweight continuing to increase nationally and globally, but this burden strikes communities with already heightened health disparities and risks with increased fervor. Rural residents consistently battle additional challenges, including higher rates of obesity and related chronic diseases, compared to their urban counterparts.1,2 Although health disparities unique to rural populations could in part be explained by higher rates of poverty, greater representation of minority populations, and limited access to resources such as preventative services and health care within rural communities, many of these trials have also been, at least in part, attributed to geographic dispersion and other transportation challenges that characterize rural communities (eg, greater travel distances, lack of public transit, rising cost of gas). Despite the increased need apparent in rural communities, public health efforts are typically focused on more populated areas, even though 16% of Americans live in rural areas encompassing 72% of the United States land area.3

Policy is supported as a promising area of focus when attempting to make population or community-wide changes.4 Research over the past decade encourages behavior-change approaches that incorporate multiple levels of influence, including policy. Socioecological models and systems thinking are 2 approaches that have demonstrated the necessity of understanding and incorporating multiple domains of influence when attempting to change complex behaviors. Identifying and understanding effective policies for combatting obesity is a current challenge and call to action among some of our highest risk communities, including rural communities where health disparities and limited resources are more apparent and policy change poses different challenges. In fact, the Center for Disease Control and Prevention has recommended 24 community strategies to prevent obesity in the United States, focusing predominantly on how to implement and evaluate policy and environmental changes aimed at improving diet, physical activity, and sedentary behaviors.4

Although work focused on understanding the unique nuances of underserved rural communities has somewhat expanded in recent years, lack of resources and infrastructure often remain in these areas. Recent research highlights the unique traits of rural areas, suggesting that we need to better grasp how rural communities are different than urban areas, rather than assuming that rural communities act and respond as urban and suburban communities do.5-7 In addition, more often than not, research among rural communities highlights differences between rural communities, suggesting that there are both commonalities across the nation's rural landscape as well as great variation that needs to be acknowledged and considered.5 Both Jilcott-Pitts et al6 and West et al7 noted these tendencies when considering the Center for Disease Control and Prevention's "Common Community Measures for Obesity Prevention" (COCOMO) strategies, as several strategies were not applicable in rural communities and many were met with numerous barriers, some similar across the communities and several distinguishing. In response to these findings, the CDC-funded Nutrition and Obesity Policy Research and Evaluation Network (NOPREN) and the Physical Activity Policy Research Network (PAPRN) are conducting literature reviews to adapt COCOMO for greater applicability to rural areas.

When considering the challenges that rural communities face in the obesity epidemic, it is important to use evidence-based approaches and methodologies in practice, with the understanding that modifications might need to be made along the way to address the unique needs of each community. While application of the COCOMO strategies provides insight into specific obesity-prevention strategies to address, it could be fruitful for rural communities to take a broader position and begin by considering relevant "Health in All Policies" (HiAP) strategies. The HiAP framework presented by Gase et al8 provides 7 strategies that could help rural communities address common challenges. Specifically, strategies aimed at fostering cross-sector collaborations could greatly benefit rural communities already limited in resources and funding (eg, develop and structure cross-sector relationships, synchronize communications and messaging, coordinate funding and investments, and incorporate health into decision-making processes). Cross-sector collaborations could include the development of coalitions and community partnerships, both of which are supported as effective strategies for community building, empowerment, and sustainable change. In addition, if rural communities are able to establish cross-sector collaborations as a foundation presented within HiAP's strategies, they would also be better equipped to examine how health could be incorporated into many, if not all, decision-making processes within the community. Once these foundations are in place, evidence-based strategies like those presented within COCOMO could potentially be better received and accepted within the community.

Given the distinct characteristics of rural communities, practitioners and researchers need to continue to identify, examine, and better understand effective approaches for obesity prevention that are best suited for these areas. In addition to applying and adapting lessons learned from communities located in urban areas, broader strategies like those presented within the HiAP framework also need to be applied to help lay a solid foundation for more sustainable change within rural communities. Although some of these strategies could require long-term investment, they should produce a more solid infrastructure to aid in the prevention of obesity and, thus, positively impact the health of future generations.

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