Dietary guidance could help rural residents prevent cancer

There is consistent evidence that a low-fat, high-fiber diet plays a role in the prevention of chronic diseases including cancer. National dietary guidelines reinforce the findings. But sorting through all of the information and adopting healthy choices can be overwhelming even for those with easy access to information and healthy foods.

Now, a Public Health Division study finds that even for groups that may face challenges to healthy lifestyles — rural residents, minorities — direct guidance can make a difference.

The study found that individually tailored feedback, brief telephone counseling and mailed nutrition information decreased fat intake and increased fiber consumption among residents in a rural population. Participants successfully changed their fat and fiber habits during the study. The analysis is the first to demonstrate the feasibility of affecting dietary behavior changes in a rural population using low-intensity and low-literacy strategies. The changes in dietary patterns compared favorably to other low-intensity trials.

Dr. Elizabeth Fries, a former postdoctoral fellow in the PHS Cancer Prevention Program and current co-director of Cancer Control at Massey Cancer Center, Virginia Commonwealth University, led the intervention effort. The findings, based on more than 750 rural, partly minority, lower-educated Virginia residents, were published in the February issue of the American Journal of Preventive Medicine.

Cancer-mortality rates are disproportionately high among rural, African-American and low-income populations, making cancer prevention in these communities a high priority. Both men and women in rural areas have higher rates of self-reported obesity than their urban-dwelling peers. Rural minorities face the double burden of experiencing health factors based on rurality, as well as health disparities related to race and ethnicity.

Rural populations may be further compromised in their health efforts due to lack of appropriate nutrition education and reduced access to heath care. "Access to health care is the largest problem," Fries said. "In rural Virginia, it can take one to two and a half hours to get to a good hospital. Local physicians are overburdened and have little time for nutrition counseling."

Despite the need, few dietary change trials have been conducted in rural residents. "By its very nature, people are spread out in a rural setting, and it's so much harder to connect with people and recruit them to a study," said Dr. Shirley Beresford, who co-authored the study along Dr. Deborah Bowen, both of PHS. "Being able to contact enough people so you have enough power to study behavior changes means that you really have to have a good network to allow you to reach the intended population. Elizabeth is to be commended in being able to recruit a large number of participants."

Fries and colleagues recruited three physician practices to participate in the study; the doctors provided lists of potential participants. The researchers successfully utilized the input of a community advisory board to make decisions about the content and pictures in the intervention materials. Methods included physician-based invitation letters, personalized dietary feedback and low-literacy nutrition booklets mailed to participants' homes. Participants completed questionnaires about their dietary habits at one, six and 12 months post-intervention.

The study provided a unique, inexpensive intervention model for low-literacy rural residents. Fries hopes to extend this model to other behaviors, including obesity.

"Without dietary intervention programs like these, you can't actually implement dietary guidelines in any meaningful way," Beresford said. "These behavioral change studies are extremely important in evaluating different ways to translate guidelines, messages or public-health recommendations into behavior — long-term behavior, we hope."

"If we can affect long-term behavior, then we should be able to turn that into a 'best practices' set of tools that would be accessible to all rural physician practices."

Patricia Edinboro, Laura Manion and Dr. Donna McClish, all of Massey Cancer Center, and Dr. Jennifer Ripley, Regent University, also contributed to the paper.