Perspectives on healthy eating among Appalachian residents.

Most Americans consume far below the recommended daily intake (RDI) for fruits and vegetables and far above the RDI for suboptimal foods.1–3 Such dietary patterns have been linked to overweight and obesity, metabolic syndrome, and other chronic conditions.4 Rural residents are more likely than their urban counterparts to experience these conditions, oftentimes leading to premature mortality.5 Social determinants, including lower socioeconomic status, lower likelihood of health insurance coverage, and more limited access to safety net and preventive medical services, place rural residents at elevated risk of and from these chronic conditions.6 Kentucky residents, particularly those living in the rural, Appalachian portion of the state, suffer even higher rates of overweight, obesity, and associated chronic conditions than other rural residents.7 In 2005, 62.5% of adults in Kentucky were overweight or obese, as compared to 58.5% for the United States.8 Residents of the eastern Appalachian portion of Kentucky have among the highest rates of obesity and overweight in the United States, estimated between 62.5% and 76.2% (See Figure 1, which also highlights study counties. Data obtained from the CDC’s Behavioral Risk Factor Surveillance System).8–10 Rates of diabetes and cardiovascular disease in Appalachian counties in Kentucky also are among the highest in the state and the United States.10–12 Figure 1 Overweight and Obesity Among Adults in Kentucky 2008–2010 Likely associated with these negative health outcomes, Kentucky ranks third nationally for those least likely to consume the RDI of fruits and vegetables; only 21.1% of Kentuckians and 19% of Appalachian residents meet this RDI, compared with 23.4% of Americans nationwide.13 In part, these consumption patterns stem from regional food ways, which tend to emphasize meats, biscuits, and fried foods over vegetables; these food preferences have become important components of rural Appalachian identities.15 Common uses of locally acquired ingredients and methods of preparation shared among rural Appalachians serve as an expression of belonging that not only reaffirms cultural ties to place, but also to family and community.14 The preference for these unhealthy foods among rural Appalachians, including the expectation that these culturally appropriate foods should be present at home and community events, has been identified as a potential barrier for individuals in the region to making healthy dietary choices.15 Dietary patterns in rural Appalachia also are shaped by a broad range of interacting social, cultural, geographical, and economic processes. For instance, some research has suggested that the economic transition in the region from farming and mining to employment in the service industry has contributed to a rising dependence on fast foods.16 Coupled with issues of food affordability,15 limited access to high-quality grocery stores,17 and increased demands on the use of time, the spiking number of fast food establishments in rural Appalachian communities has been met with a corresponding dependence on these foods in regional diets. This dependence sometimes supplants former food practices which are viewed as more time intensive to prepare.12 Given that Appalachian residents experience disproportionate risk of overweight, obesity, and associated negative health outcomes, new approaches to improve dietary intake are needed. These approaches will be most successful if they are grounded in local perspectives and address the interactions between regional food ways and shifting social, cultural, and economic contexts. Thus, the purpose of this article is to explore how rural, Appalachian residents think about healthy eating and their ideas for improving dietary intake.