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Original Research

Examination of cardiovascular risk factors and rurality in Appalachian children

Submitted: 10 September 2016
Revised: 16 November 2016
Accepted: 4 December 2016
Published: 20 March 2017

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Author(s) : Lilly CL, Umer A, Cottrell L, Pyles L, Neal W.

Citation: Lilly CL, Umer A, Cottrell L, Pyles L, Neal W.  Examination of cardiovascular risk factors and rurality in Appalachian children. Rural and Remote Health (Internet) 2017; 17: 4200. Available: (Accessed 24 October 2017). DOI:


Introduction: The prevalence of childhood cardiovascular disease (CVD) risk factors often increases in more rural geographic regions in the USA. However, research on the topic often has conflicting results. Researchers note differences in definitions of rurality and other factors that would lead to differences in inference, including appropriate use of statistical clustering analysis, representative data, and inclusion of individual-level covariates. The present study’s objective was to examine CVD risk factors during childhood by geographic distribution in the US Appalachian region as a first step towards understanding the health disparities in this area.
Methods: Rurality and CVD risk factors (including blood pressure, body-mass index (BMI), and cholesterol) were examined in a large, representative sample of fifth-grade students (N=73 014) from an Appalachian state in the USA. A six-category Rural-Urban Continuum Codes classification system was used to define rurality regions. Mixed modeling analysis was used to appropriately cluster individuals within 725 unique zip codes in each of these six regions, and allowed for including several individual-level socioeconomic factors as covariates.
Results: Rural areas had better outcomes for certain CVD risk factors (lowest low-density lipoprotein cholesterol (LDL-C), and blood pressure (BP) and highest high-density lipoprotein cholesterol (HDL-C)) whereas mid-sized metro and town areas presented with the worst CVD risk factors (highest BMI% above ideal, mean diastolic BP, LDL-C, total cholesterol, triglyceride levels and lowest HDL-C) outcomes in children and adolescence in this Appalachian state.
Conclusions: Counter to the study hypothesis, mid-sized metro areas presented with the worst CVD risk factors outcomes in children and adolescence in the Appalachian state. This data contradicts previous literature suggesting a straightforward link between rurality and cardiovascular risk factors. Future research should include a longitudinal design and explore some of the mechanisms between cardiovascular risk factors and rurality.

Key words: cardiovascular disease, child health, geography, USA.

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