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Healthiest places to live in the US

Robin Wulffson MD's picture
healthy living, suburban living, city living, urban living

The United States offers a full gamut of locations to reside ranging from dense urban to sparse rural. For many Americans, the choice is influenced to varying degrees by the location’s distance from employment, schools, relatives, and close friends. Many of those asked where they would live, based solely on health factors would place a large, densely-populated city at the bottom of their list; they might also place a pastoral rural community at the top.

However, two large studies suggest that a compromise between the two—the suburban lifestyle––is the most healthful. One was published on February 8, 2012 by researchers at Baylor University and Louisiana State University. The other was published last June by researchers at the UCLA Center for Health Policy Research

The Baylor/LSU study was published online in the Cambridge Journal of Regions, Economy and Society and will appear in its March print issue. It reported that counties and parishes with a greater concentration of small, locally-owned businesses have healthier populations (i.e., lower rates of mortality, obesity, and diabetes) than those that are home to large companies with "absentee" owners. Study co-author and Baylor sociologist Charles M. Tolbert, PhD explained, "Some communities appear to have thriving small business sectors that feature entrepreneurial cultures that promote public health. A place like this has a can-do climate, a practical problem-solving approach in which a community takes control of its own destiny," He added,"The alternative is the attitude that 'Things are out of our control.'"

The researchers evaluated 3,060 counties and parishes in the contiguous United States from the public health viewpoint. The study included a historical review. Beginning in the 1970s, communities wooed large employers from the outside, with the goal of providing high-paying jobs with benefits. At that time, small local employers offered lower pay, minimal benefits, little chance for advancement, and vulnerability to competition. In addition, some smaller businesses were impacted by nepotism.

Baylor sociologist and co-author Carson Mencken, PhD explained, “The old way of thinking was that you wanted to work for a big company because of pension plans, health insurance, dental insurance… But many of them have moved overseas to cheaper labor markets. So what we see are larger retailers, usually next to interstates, that pay low wages and may not even offer full-time jobs with benefits, but instead hire people to work 30 hours a week. There's a high turnover."

From 1998 through 2003, larger companies experienced a significant decrease in wages: 33% in real dollars. Furthermore, access to health insurance dropped to a comparable degree. Amid the current milieu of restructuring and globalization, some large companies are laying off employees from their full-time jobs; then rehiring them as short-time contract workers with no benefits. Locally-owned, smaller businesses are not increasing salaries or benefits; however, the pay differential is decreasing. Dr. Mencken explained, "It's in their financial interest to take a stake in the community, to make it a place where people want to live and work." Dr. Tolbert added, "When someone creates a 'mom and pop' business, it's a huge step to bring that first employee on board. If it's a relative or neighbor, they'll bend over backward to hire and retain them. They're going to bring on board somebody they trust, and they'll pull every hair and every tooth in their head before they lay off someone who's their neighbor."

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The Baylor/LSU study found that small businesses are more likely to support bond issues for health infrastructures, recruit physicians, push for local anti-smoking legislation, promote community health programs, and support local farmers' markets. The researchers found that counties with a greater proportion of small businesses have a healthier population. They looked at the number of small businesses per 100,000 individuals. They categorized small business as those with four or fewer employees; large manufacturing establishments were those with 500 or more employees; and large retailers were those with 100 or more employees.

The investigators reviewed data from the 2000 Census of Population and Housing, the 2007 Centers for Disease Control Obesity and Diabetes Estimates, National Center for Health Statistics Compressed Mortality records from 1994-2006, the 2002 County Business Patterns and the 2002 Nonemployer Statistics.

The UCLA Center for Health Policy Research study was focused on the state of California rather than the entire nation. However, the state contains densely-populated cities such as Los Angeles, numerous suburban areas, and rural communities. The researchers found that rural seniors have the highest rates of obesity, diabetes, and heart disease. More than half a million rural seniors are far more likely to be overweight or obese, physically inactive, and food insecure. All three conditions are risk factors for heart disease, diabetes and repeated falls: conditions more prevalent among rural seniors. Approximately 710,000 Californians aged 65 and over live in the countryside: almost one-fifth of all older adults in the state; however, rural elders experience unique challenges to healthy living, including a lack of sidewalks, street lights, transportation services, access to healthy food outlets, parks, exercise facilities and healthcare sites. California's rural areas are also challenged by a shortage of physicians and other primary care providers, compelling many seniors to travel long distances to seek care.

"The countryside can have an isolating effect," said Steven P. Wallace, the center's associate director and a co-author of the policy brief, "The Health Status and Unique Health Challenges of Rural Older Adults in California." "When even a trip to the grocery store is a significant drive, seniors can become trapped in their houses."

Using data from the 2007 California Health Interview Survey, center researchers found:

  • Rural seniors are more likely to be overweight and obese. Older adults in rural areas are more often overweight or obese (61.3%) than their urban (57.3%) and suburban (54.0%) counterparts.
  • Rural older adults do not get enough exercise. One in five rural seniors do not participate in either moderate or vigorous physical activity in their leisure time.
  • Rural and urban older adults are more likely to be food insecure. One in five low-income older adults in rural settings report that they cannot consistently afford enough food to last the month. This rate is about twice that of low-income suburban adults.

The new UCLA Center for Health Policy Research released on June 14, 2011 found that seniors have higher rates of heart disease and repeated falls and are more likely to be low-income than suburban older adults, a factor that exacerbates (worsens) many health conditions. Because so many of the health problems encountered by older adults living in the countryside are structural, the authors of the study recommend that policymakers consider a range of strategies to make rural environments more senior-friendly. Those recommendations include "senior walkability plans": identification of the routes seniors often use and subsequent improvements to those routes, including the creation or improvement of sidewalks, lighting and seating/benches.

The researchers noted that distance barriers faced by rural elders can be reduced with the help of the Internet in a variety of ways, including in-home monitoring, patient self-management and online ordering of prescriptions. However, they note that infrastructure and adoption hurdles in rural communities — including a lack of broadband infrastructure and an insufficient information technology workforce — must be addressed and that there must be assurances that insurance companies will fully reimburse rural providers that use telemedicine.

Other recommendations include the use of "universal design" principles in all public contracting, the promotion of federal subsidies and assistance programs to rural grocery stores and other health food outlets, expanded transportation services, and better incentives for primary care providers who work in rural areas.