Skip to main content
NIHPA Author Manuscripts logoLink to NIHPA Author Manuscripts
. Author manuscript; available in PMC: 2021 Jan 1.
Published in final edited form as: J Rural Health. 2019 Mar 13;36(1):104–110. doi: 10.1111/jrh.12361

Effects of the Strong Hearts, Healthy Communities Intervention on Functional Fitness of Rural Women

Kristin Pullyblank 1, David Strogatz 1, Sara C Folta 2, Lynn Paul 3, Miriam E Nelson 4, Meredith Graham 5, Grace A Marshall 5, Galen Eldridge 6, Stephen A Parry 5, Sean Mebust 1, Rebecca A Seguin 5
PMCID: PMC6744363  NIHMSID: NIHMS1031356  PMID: 30865324

Abstract

Purpose

The purposes of these analyses were to determine whether Strong Hearts, Healthy Communities (SHHC), a multi-level, cardiovascular disease risk reduction program for overweight, sedentary rural women aged 40 or older, led to improved functional fitness; and if changes in fitness accounted for weight loss associated with program participation.

Methods

Sixteen rural communities were randomized to receive the SHHC intervention or a control program. Both programs involved groups of 12–16 participants. The SHHC program met one hour twice a week for 24 weeks where participants engaged in aerobic exercise and progressive strength training. Program content addressed diet and social and environmental influences on heart-healthy behavior. The control group met one hour each month for 6 months, covering current dietary and physical activity recommendations. Objective measures of functional fitness included the 30-second arm curl, 30-second chair stand and 2-minute step test. Self-reported functional fitness was measured by the Physical Functioning Subscale of the MOS Short Form-36 (SF-36 PF).

Findings

The SHHC program was associated with increased strength and endurance, as represented by greater improvement in the chair stand and step test; and with increased physical function, as represented by the SF-36 PF. Adjustment for change in aerobic endurance, as measured by the step test, accounted for two-thirds of the intervention effect on weight loss at the end of the intervention.

Conclusions

SHHC participants experienced improved performance on objective measures of functional fitness, self-reported measures of physical function, and changes in weight were partially accounted for by changes in aerobic fitness.

Keywords: cardiovascular disease, fitness, obesity, physical activity, rural

INTRODUCTION

Functional fitness has been defined as the ability to perform the activities of daily living without difficulty and includes the physiological dimensions of strength, flexibility, aerobic capacity, and balance.1,2 Higher functional fitness levels are associated with decreased mortality,35 lower frequency of cardiovascular disease,57 and are positively associated with self-reported health-related quality of life across various demographic groups.811

While physical activity has been found to be a protective factor for maintaining physical function as adults age,12,13 only 21% of American adults are currently meeting the 2008 recommendations for physical activity14 and 23.1% report not doing any physical activity other than their regular job in the past 30 days.15 That percentage increases to 26.4% for women and 31.4% for rural populations.16 Rural women are not only more sedentary than their urban counterparts but they face higher levels of obesity and related chronic diseases such as diabetes, and are at greater risk for cardiovascular disease.1721 Lack of access to environmental supports for physical activity and healthy food options, as well as to healthcare resources contributes to this disparity.17,22,23

Evaluations of multiple healthy lifestyle programs to improve diet and increase physical activity have shown positive effects on functional fitness.1,2429 Rarely are any of these programs targeted at rural populations and rural women specifically. The purpose of this analysis was to determine whether a 6-month multi-level cardiovascular disease risk reduction program specifically designed for overweight, sedentary middle-aged and older rural women led to improved functional fitness and perceived function-related quality of life. Programs that consist of a dietary component or are a combination of physical activity and dietary interventions typically demonstrate better weight outcomes than those programs that focus only on physical activity.30,31 An additional objective was to assess whether different dimensions of functional fitness were related to the weight loss associated with the intervention.32

METHODS

Design

Strong Hearts, Healthy Communities (SHHC) was a community randomized 6-month trial for rural women aged 40 or older who were at increased risk for cardiovascular disease on the basis of being sedentary (not meeting the Physical Activity Guidelines for Americans or having an estimated total energy expenditure below 34 kcal/kg per day, per the 7-day Physical Activity Recall) and had a body mass index (BMI) ≥ 25 kg/m2. As described in more detail elsewhere,33 16 communities (12 in Montana, 4 in New York) were randomized after participant enrollment to receive the SHHC multi-level intensive intervention or the reduced dose control program. All communities had a Rural Urban Commuting Area (RUCA) code of 7 or higher,34 were designated as a medically underserved area (MUA) or population (MUP) by the Health Resources Administration,35 and had a median household income at least 15% lower than the corresponding value for the state. Each program involved groups of 12–16 participants co-facilitated by local health educators. The SHHC program met for one hour twice a week for 24 weeks, utilizing experiential learning for a variety of heart health topics including nutrition, physical activity, and stress. Participants engaged in aerobic exercise (20–30 minutes) and progressive strength training (10–15 minutes) during most classes. Aerobic walking DVDs were utilized so participants could walk indoors if the outside rural environment was not safe (eg poor weather conditions, lack of good sidewalks, poor lighting). Strength training components required only handheld weights. Participants were encouraged to track their aerobic exercise and strength training conducted outside of class, working towards a goal of 150 minutes of moderate to vigorous aerobic activity per week and 3 episodes of strength training per week. Program content addressed healthy eating aligned with the Mediterranean dietary pattern and DASH diet guidelines, and recognizing social and environmental influences on related heart-healthy behavior. Participants in each SHHC community were also involved in a HEART Club project that utilized a structured process to identify a key issue around the local food or physical activity environment and to plan and implement a project to address it.

The reduced dose control group met for one hour each month over 6 months. Classes covered current dietary and physical activity recommendations, but participants did not engage in any physical activity or any active learning modalities during these monthly meetings. The control program also did not include the civic engagement component that was part of the SHHC program.

Measures

Functional fitness tests conducted at baseline and 6 months consisted of the 30-second arm curl, the 30-second chair stand, and the 2-minute step test. These tests are valid and reliable measures of different dimensions of strength and endurance.2 One trial of each test was conducted but participants first observed how the test was to be done properly and were able to practice it prior to beginning the trial.

Arm curls were done to measure upper body strength. The 30-second arm curl was conducted with a 5 pound weight using the dominant hand, while the participant was seated. On the signal “go” the participant curled the weight through the full range of motion from full extension to full flexion. If the arm was more than halfway up at the end of 30 seconds, the curl was counted.

Chair stands were conducted to measure lower body strength. Participants sat in a straight-back or folding chair with a seat height of about 17 inches with feet flat on the floor and arms crossed against the chest. On the signal “go” the participant rose to a full stand before returning to a fully seated position. If a participant was more than half way up at the end of 30 seconds, it was counted as a stand.

The 2-minute step test is an aerobic endurance alternative to the 6-minute walk test when space or time is limited. It measures the number of full steps completed in 2 minutes, raising each knee to a point midway between the patella and the iliac crest. This point on the thigh was marked with a piece of tape which was then transferred to the wall so that knee height could be monitored. If the participant had one hand on the wall during the test, the steps still counted. Although both knees had to be raised to the correct height, only the number of times the right knee reached the target was counted.

In addition to the functional fitness tests, participants were also asked to complete the Physical Functioning Subscale of the MOS Short Form-36 (SF-36 PF)36 at baseline and at 6 months. The survey asks about vigorous activities (eg running, lifting heavy objects, participating in strenuous sports); moderate activities (eg moving a table, pushing a vacuum cleaner, bowling, playing golf); lifting or carrying groceries; climbing several flights of stairs; climbing one flight of stairs; bending, kneeling, or stooping; walking more than a mile; walking several blocks; walking one block; bathing or dressing yourself. For each activity, participants indicated whether their health limited the activity “a lot”, “somewhat” or “not at all”. Coded scores for high, medium and no limitations were 0, 50 and 100, respectively, and the total score for this scale was based on the average of all ten responses. Height and weight were also measured at baseline and at 6 months and were used to compute body mass index.

Demographic characteristics recorded at baseline and adjusted for in these analyses were age, marital status, race and ethnicity, and years of education. In addition, self-reported rating of health (excellent, very good, good, fair, poor) was recorded at baseline and adjusted for in the analysis.

Analyses

Univariate descriptive statistics for baseline values of sociodemographic characteristics and functional fitness were calculated separately for the intervention and control groups using SAS software version 9.4.37 The contrasts between SHHC and control for changes in each measure of functional fitness were analyzed using multilevel linear regression models (PROC MIXED) with study site as a random effect and adjustment for the sociodemographic characteristics and the baseline level of the functional fitness outcome being evaluated. Follow-up outcome measures were missing for 43 to 61 cases. The initial multivariate models used a complete case approach (i.e. analyses based on non-missing values for all variables in the models) on 128 to144 cases; a sensitivity analysis was also conducted on all 194 cases using multilevel multiple imputation to address potential selective attrition in follow-up assessments. Missing values were estimated with a multilevel model that included site as a random effect using the Fully Conditional Specifications method of imputation38 and 20 imputations. The software program, Blimp, was used for the multilevel multiple imputation.39 Included in the imputation were all variables considered in the analysis: intervention group, age, education, marital status, and perceived overall health at baseline; arm curl, chair stand, step-test, and SF-36 from baseline and follow-up. After imputation, outcome change-from-baseline scores were calculated in each of the 20 imputed datasets, and in SAS version 9.4 PROC MIXED was used to re-run the analyses and PROC MIANALYZE was used to combine the results.

In the final set of analyses, shown in Table 1, each measure of change in functional fitness was added separately to the multilevel linear regression model for the analysis of intervention effects on weight change; these analyses were conducted to assess the degree to which changes in functional fitness accounted for the larger weight loss experienced by the participants in the SHHC program.

Table 1:

Between Group Differences in Weight Change, with Added Adjustment for Measures of Change in Functional Fitness

Difference in Weight Change
SHHC-Control (95% CI)
% Reduction from
Primary Model
Model
Primary Model* −1.85 (−3.55, −0.16) -----
Primary Model plus adjustment for
 Arm Curls −1.82 (−3.39, −0.26) 1.6%
 Chair Stand −1.63 (−3.55, +0.30) 11.9%
 Step Test −0.58 (−2.45, +1.30) 68.6%
 SF-36 PF −1.35 (−3.35, +0.53) 27.0%
*

Adjusted for study site, education, age, marital status, and baseline weight

RESULTS

Characteristics of the women from the communities assigned to the two programs are presented in Table 2. There were no significant differences between groups at baseline.

Table 2:

Baseline Characteristics of Participants by Intervention Status

SHHC – Intervention
N = 101
Control
N = 93
Characteristic
Age: mean (SD) 59.0 (9.4) 58.7 (9.7)
Race/Ethnicity: % White, Non-Hispanic 95% 94%
Marital Status: % Married or with Partner 74% 69%
Education: % College Graduate 45% 50%
Body Mass Index: mean (SD) 34.9 (6.1) 35.5 (6.8)
Weight (kg): mean (SD) 92.2 (16.8) 95.5 (19.5)
Arm Curls: mean (SD) 18.2 (6.4) 15.3 (4.3)
Chair Stand: mean (SD) 12.6 (4.7) 11.5 (3.3)
Step Test: mean (SD) 76.2 (23.1) 75.3 (22.5)
SF-36 PF Subscale: mean (SD) 73.6 (21.4) 80.5 (20.6)
Perceived Health
 Excellent or Very Good: % 22% 20%
 Good: % 62% 60%
 Fair or Poor: % 16% 20%

Table 3 summarizes the 6-month changes in functional fitness observed for the women of each group and the difference between the changes by each group using the complete case approach. Both groups showed a similar improvement in the number of arm curls, but for the other two objective measures of fitness the more intensive SHHC program was associated with a greater increase in strength and endurance. The SHHC program participants also reported better physical functioning at 6 months relative to the control program participants. These conclusions were identical when examining multilevel models in the multiple imputed datasets (Table 4). In both analytic approaches, a few covariates were significant and are noted on Tables 3 and 4. Briefly, baseline functional fitness level was significant across all three functional fitness tests, age was a significant covariate for the chair stand, and perceived health was a significant covariate for SF-36.

Table 3:

Change in Functional Fitness by Intervention Status and Difference between the Changes Observed in Each Groupa

SHHC - Intervention Control
N Mean Change
Baseline to Outcome (95%
CI)
N Mean Change
Baseline to Outcome
(95% CI)
N Difference between
Changes Baseline to
Outcome (95% CI)
Arm Curlb 77 +5.9 (+2.8, +9.0) 67 +4.4 (+1.3, +7.6) 144 +1.5 (−2.9, +5.8)
Chair Standbc 77 +5.6 (+3.2, +8.0) 65 +0.9 (−1.5, +3.3) 142 +4.7 (+1.4, +8.0)
Step Testb 75 +31.6 (+22.5, +40.7) 63 +9.7 (+0.5, +18.8) 138 +21.9 (+9.4, +34.5)
SF-36 PFbd 69 +4.0 (−0.7, +8.9) 59 −4.0 (−8.6, +0.7) 128 +8.0 (+2.0, +14.0)
a

Adjusted for study site, education, age, marital status, perceived health, and baseline value of the measure of functional fitness

b

Significant covariate: baseline value of the measure of the functional fitness test

c

Significant covariate: age

d

Significant covariate: perceived health

Table 4:

Change in Functional Fitness by Intervention Status and Difference between the Changes Observed in Each Group (Multilevel Multiple Imputation)a

SHHC - Intervention Control
Mean Change
Baseline to Outcome (95% CI)
Mean Change
Baseline to Outcome (95% CI)
Difference between Changes
Baseline to Outcome (95% CI)
n = 101 n = 93 n = 194
Arm Curlb +6.1 (+3.2, +9.1) +4.5 (+1.6, +7.4) +1.6 (−2.5, +5.7)
Chair Standbc +5.7 (+3.7, 7.7) +1.5 (−0.5, +3.5) +4.2 (+1.5, +7.0)
Step Testb +30.6 (+22.2, +38.9) +8.9 (+0.4, +17.3) +21.7 (+10.2, +33.1)
SF-36 PFbd +5.6 (+0.4, +10.9) −2.4 (−8.0, +3.2) +8.1 (+1.2, +14.9)
a

Adjusted for study site, education, age, marital status, perceived health, and baseline value of the measure of functional fitness

b

Significant covariate: baseline value of the measure of the functional fitness test

c

Significant covariate: age

d

Significant covariate: perceived health

The relationship between these changes in functional fitness and the intervention-related weight loss at 6 months is shown in Table 1. As reported previously,32 the multivariable-adjusted weight loss after 6 months in the SHHC and control programs were 2.24 kg and 0.38 kg, respectively, leading to a net intervention effect of −1.85 kg. The values in Table 1 show the change in this intervention effect with additional adjustment for each measure of functional fitness. The addition of the objective measures of improved upper and lower body strength to the model had very little influence on the intervention effect on weight loss. In contrast, adjustment for change in aerobic endurance, as measured by the step test, accounted for 68.6% of the intervention effect on weight loss. As a composite measure of different types of functional fitness, the influence of improvement in SF-36 PF was somewhat in between the impact of the measures of strength and endurance (27%).

DISCUSSION

The challenge of implementing programs to promote healthy diet and physical activity in rural communities has been recognized by others40,41 and was addressed in an initial formative phase leading to the design of the SHHC intervention. Insights from environmental audits, focus groups and key informant interviews included the importance of having a structured program with a convenient indoor location for physical activity; recognizing limited local resources for healthy foods and being active, and identifying feasible strategies for enhancing existing resources; and addressing how family and friends uniquely influence health-related behaviors in small, relatively isolated communities.42,43 Accordingly, SHHC was designed as a low technology small-group program to improve functional fitness and reduce cardiovascular disease risk in rural communities. The program can be implemented in any community space such as a church or senior center and required minimal equipment. The scripted curriculum allows for ease of teaching, including the potential for groups of women to maintain programs after the initial program period without need for a long-term professional leader, which is essential in rural areas with limited resources.

Our findings are consistent with previous research on physical activity, functional fitness and weight, which also found that interventions combining physical activity with dietary change led to improved functional fitness and weight loss.25,27,28,30,31,44,45 To our knowledge, this is the first report of functional fitness and quality of life changes for rural women enrolled in a randomized, community-based cardiovascular disease risk reduction program.

The analysis indicated that 68% of the difference between groups for weight loss, the primary outcome previously reported for the project,32 was accounted for by changes in the step test, a measure of aerobic endurance. There was no significant change between groups in respect to arm curls (measure of upper body strength). While the change in chair stands (measure of lower body strength) was significant between the control and intervention groups, its statistical relationship to the group difference in weight loss was minimal. These findings are not surprising considering that strength training is more likely to have a greater effect on body composition (ie % fat versus lean mass) than weight change.46,47 However, strength training has been shown to independently contribute to reduced risk of diabetes and cardiovascular disease in middle-aged and older women48 and to promote physical function through prevention of sarcopenia.29,49

It is of note that the SHHC study found that physical activity was the primary factor driving weight loss since kilocalories consumed showed no significant changes between groups post intervention (baseline: 1785.6 kcal control, 1762.7 kcal intervention; post-intervention: 1582.3 kcal control, 1592.6 kcal intervention).50 These findings differ from most lifestyle modification studies.30,31 It is possible that there was behavioral compensation occurring in the intervention group for the increased exercise which led to diet not being a factor to the change in fitness.51

The strengths of this study include the randomization of communities to the intervention or control condition and the use of both objective and self-reported measures of functional fitness with well-established evidence of validity. The generalizability of the results may be limited for rural populations with different distributions of race, ethnicity and education, though the formative phase of the study addressed many common challenges in rural communities. Another limitation is the lack of follow-up measurement beyond the end of the 6 month period for intervention and control activities. Studies of maintenance strategies for initially achieved weight loss by women in rural communities indicate the challenge for sustaining the benefits of interventions in these settings.52,53 Due to these limitations, SHHC was revised54 and evaluation of the impact on Simple 7 utilizing the revised multilevel curriculum is currently being undertaken. There are plans for an add-on maintenance program with dissemination and implementation components.

Acknowledgements

We are grateful for the contribution of the participating health educators and assessment team members in Montana and New York, Jan Feist and Judy Ward for their programmatic support, and our National Advisory Board members for their contributions to this study.

Funding Sources: This study was supported by grant R01 HL120702 from the National Heart, Lung and Blood Institute, National Institutes of Health.

Footnotes

Disclosures: The authors have no competing interests. The funders of this study had no role in the design and conduct of the study; the collection, management, analysis and interpretation of the data; the preparation, review or approval of the manuscript; and the decision to submit the manuscript for publication.

Trials registration is at ClinicalTrials.gov: NCT03059472

REFERENCES

  • 1.Furtado HL, Sousa N, Simão R, Dutra Pereira F, Vilaça-Alves J. Physical exercise and functional fitness in independently living vs institutionalized elderly women: a comparison of 60- to 79-year old city dwellers. Clinical Interventions in Aging 2015;10:795–801. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 2.Rikli RE, Jones J. Development and validation of a functional fitness test for community-residing older adults. Journal of Aging and Physical Activity 1999;7:129–161. [Google Scholar]
  • 3.Farrell SW, Cortese GM, LaMonte MJ, Blair SN. Cardiorespiratory fitness, different measures of adiposity and cancer mortality in men. Obesity 2007;15(12):3140–3149. [DOI] [PubMed] [Google Scholar]
  • 4.Kroenke CH, Kubzansky LD, Adler N, Kawachi I. Prospective change in health-related quality of life and subsequent mortality among middle-aged and older women. Am J Public Health 2008;98:2085–2091. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 5.Kodama S, Saito K, Tanaka S, et al. Cardiorespiratory fitness as a quantitative predictor of all-cause mortality and cardiovascular events in healthy men and women: A meta-analysis. JAMA 2009;301(19):2024–2035. [DOI] [PubMed] [Google Scholar]
  • 6.Stefanick ML, Brunner RL, Leng X, et al. The relationship of cardiovascular disease to physical functioning in women surviving to age 80 and above in the Women’s Health Initiative. J Gerontol A Biol Sci Med Sci 2016;71:S42–S53. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 7.Cardoso C, Maia M, de Oliveira FP, Leite NC, Salles GF. High fitness is associated with a better cardiovascular risk profile in patients with type 2 diabetes mellitus. Hypertension Research 2011;34:856–61. [DOI] [PubMed] [Google Scholar]
  • 8.Wanderley FA, Silva G, Marques E, Oliveira J, Mota J, Carvalho J. Associations between objectively assessed physical activity levels and fitness and self-reported health-related quality of life in community-dwelling older adults. Qual Life Res 2011;20:1371–1378. [DOI] [PubMed] [Google Scholar]
  • 9.Sloan RA, Sawada SS, Martin CK, Church T, Blair SN. Associations between cardiorespiratory fitness and health-related quality of life. Health and Quality of Life Outcomes 2009;7:47. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 10.Olivares PR, Gusi N, Preito J, Hernandez-Mocholi MA. Fitness and health-related quality of life dimensions in community-dwelling middle aged and older adults. Health and Quality of Life Outcomes 2011;9:117. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 11.Purath J, Buchholz SW, Kark DL. Physical fitness assessment of older adults in the primary care setting. J Am Acad Nurse Pract 2009;21:101–107. [DOI] [PubMed] [Google Scholar]
  • 12.Semanik PA, Lee J, Song J, et al. Accelerometer monitored sedentary behavior and observed physical function loss. Am J Public Health 2015;105:560–566. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 13.Seeman T, Chen X. Risk and protective factors for physical functioning in older adults with and without chronic conditions: MacArthur Studies of Successful Aging. Journal of Gerontology 2002;57B:S135–S144. [DOI] [PubMed] [Google Scholar]
  • 14.Centers for Disease Control and Prevention website. State Indicator Report on Physical Activity, 2014. Available at: https://www.cdc.gov/physicalactivity/downloads/PA_State_Indicator_Report_2014.pdf. Published July 2014 Accessed July 9, 2018.
  • 15.Center for Disease Control and Prevention. Available at: http://www.cdc.gov/nccdphp/DNPAO/index.htm. Updated January 2018 Accessed July 16, 2018.
  • 16.United Health Foundation website. America’s Health Ranking. https://www.americashealthrankings.org/explore/annual/measure/Sedentary/state/ALL . Published 2018. Accessed July 9, 2018.
  • 17.Lundeen EA, Park S, Blanck HM. Obesity prevalence among adults living in metropolitan and nonmetropolitan counties—United States, 2016. MMWR Morb Mortal Wkly Repm 2018. June 15;67:653–658. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 18.Ferusu SA, Zhang W, Puumala MS, Ullrich F, Anderson J. The frequency and distribution of cardiovascular disease risk factors among Nebraska women enrolled in the WISEWOMAN screening program. Journal of Women’s Health 2008;17:607–617. [DOI] [PubMed] [Google Scholar]
  • 19.Roddy SJ, Noble Walker S, Larsen J, Lindsey A, Shurmur S, Yates B. CVD risk factors in rural women. Nurs Pract. 2007;32:53–55. [DOI] [PubMed] [Google Scholar]
  • 20.Hales CM, Fryar CD, Carroll MD, Freedman DS, Aoki Y, Ogden CL. Differences in obesity prevalence by demographic characteristics and urbanization level among adults in the United States, 2013–2016. JAMA 2018;319:2419–2429 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 21.Hageman PA, Pullen CH, Noble Walker S, Boeckner LS. Blood pressure, fitness, and lipid profiles of rural women in the Wellness for Women project. Cardiopulmonary Physical Therapy Journal 2010;21:27–34. [PMC free article] [PubMed] [Google Scholar]
  • 22.Trivedi T, Liu J, Probst J, Merchant A, Jones S, Martin AB. Obesity and obesity-related behaviors among rural and urban adults in the USA. Rural and Remote Health 2015;15:3267. [PubMed] [Google Scholar]
  • 23.Olsen JM. An integrative review of literature on the determinants of physical activity among rural women. Public Health Nursing 2013;30:288–311. [DOI] [PubMed] [Google Scholar]
  • 24.Toraman NF, Erman A, Agyar E. Effects of multicomponent training in functional fitness in older adults. Journal of Aging and Physical Activity 2004;12:538–553. [DOI] [PubMed] [Google Scholar]
  • 25.Errickson SP, Kolotkin RL, Skidmore MS et al. Improvements in functional exercise capacity after a residential behavioural change, diet and fitness program for obese adults. Physiother Res Int 2016;21:84–90. [DOI] [PubMed] [Google Scholar]
  • 26.Nakamura Y, Tanaka K, Yabushita N, Sakai T, Shigematsu R. Effects of exercise frequency on functional fitness in older adult women. Archives of Gerontology and Geriatrics 2007;44:163–173. [DOI] [PubMed] [Google Scholar]
  • 27.Anton SD, Manini TM, Milsom VA et al. Effects of weight loss plus exercise program on physical function in overweight, older women: a randomized controlled trial. Clin Interv Aging 2011;6:141–149. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 28.Villareal DT, Chode S, Parimi N et al. Weight loss, exercise or both and physical function in older obese adults. N Engl J Med 2011;364:1218–1229. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 29.Villareal DT, Aguirre L, Gurney AB et al. Aerobic or resistance exercise, or both, in dieting obese older adults. N Engl J Med 2017;376:1943–1955. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 30.Johns DJ, Hartmann-Boyce J, Jebb SA, Aveyard P. Diet or exercise interventions vs combined behavioral weight management programs: a systematic review and meta-analysis of direct comparisons. Journal of the Academy of Nutrition and Dietetics 2014; 114(10):1557–1568. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 31.Foster-Schubert KE, Alfano CM, Duggan CR, et al. Effect of diet and exercise, alone or combined, on weight and body composition in overweight-to-obese postmenopausal women. Obesity (Silver Spring) 2011;20(8):1628–38 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 32.Seguin RA, Paul L, Folta S et al. Strong Hearts, Healthy Communities: a community-based randomized trial for rural women. Obesity 2018;26:845–853 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 33.Seguin RA, Eldridge G, Graham ML, Folta SC, Nelson ME, Strogatz D. Strong Hearts, Healthy Communities: a rural community-based cardiovascular disease prevention program. BMC Public Health 2016;16:86. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 34.United States Department of Agriculture, Economic Research Service. Rural-Urban Continuum Codes
  • 35.Health Resources & Services Administration. October 2016. https://bhw.hrsa.gov/shortage-designation/types. Accessed December 30, 2016.
  • 36.Bohannon RW, DePasquale L. Physical functioning scale of the short-form (SF) 36: internal consistency and validity with older adults. J Geriatr Phys Ther 2010;33:16–18. [PubMed] [Google Scholar]
  • 37.SAS Institute, Cary North Carolina. July 2013. [Google Scholar]
  • 38.Enders CK, Keller BT, & Levy R (2017). A fully conditional specification approach to multilevel imputation of categorical and continuous variables. Psychol Methods. 2018;23(2):298–317. [DOI] [PubMed] [Google Scholar]
  • 39.Imputation Software. http://www.appliedmissingdata.com/multilevel-imputation.html. Accessed December 20, 2018.
  • 40.Fah PS, Pribulick M, Williams IC, James GD, Rovynak V, Seibold-Simpson SM. Promoting heart health in rural women. J Rural Health 2013;29:248–257. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 41.Khare MM, Koch A, Zimmermann K, Moehring PA, Geller SE. Heart smart for women: a community-based lifestyle change intervention to reduce cardiovascular risk in rural women. J Rural Health 2014;30:359–368. [DOI] [PubMed] [Google Scholar]
  • 42.Lo BK, Morgan EH, Folta SC et al. Environmental influences on physical activity among rural adults in Montana, United States: views from built environment audits, resident focus groups and key informant interviews. Int J Environ Res Public Health 2017;14:1173. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 43.Sriram U, Morgan EH, Graham ML, Folta SC, Seguin RA. Support and sabotage: a qualitative study of social influence on health behaviors among rural adults. J Rural Health 2018;34:88–97. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 44.Imayama I, Alfano CM, Kong A et al. Dietary weight loss and exercise interventions effects on quality of life in overweight/obese postmenopausal women: a randomized controlled trial. Int J Behav Nutr Phys Act 2011;8:118. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 45.Ross KM, Milsom VA, Rickel KA et al. The contributions of weight loss and increased physical fitness to improvements in health-related quality of life. Eat Behav 2009;10:84–88. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 46.Schmitz KH, Hannan PJ, Stovitz SD, Bryan CJ, Warren M, Jensen MD. Strength training and adiposity in premenopausal women: strong, healthy and empowered study. Am J Clin Nutr 2007;86:566–572. [DOI] [PubMed] [Google Scholar]
  • 47.Church TS, Blair SN, Cocreham S et al. Effects of aerobic and resistance training on hemoglobin A1c levels in patients with type 2 diabetes: a randomized controlled trial. JAMA 2010;304:2253–2262. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 48.Shiroma EJ, Cook NR, Manson JE et al. Strength training and the risk of the Type 2 Diabetes and cardiovascular disease. Med Sci Sports Exerc 2017;49:40–46. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 49.Straight CR, Berg AC, Reed RA, Johnson MA, Evans EM. Reduced body weight or increased muscle quality: which is more important for improving physical function following exercise and weight loss in overweight and obese older women? Exp Gerontol 2018;108:159–165. [DOI] [PubMed] [Google Scholar]
  • 50.Folta SC, Paul L, Nelson ME et al. Changes in diet and physical activity resulting from the Strong Hearts, Healthy Communities randomized cardiovascular disease risk reduction multilevel intervention trail. In review. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 51.Dhurandhar EJ, Kaiser KA, Dawson JA, Alcorn AS, Keating KD, Allison DB. Predicting adult weight change in the real world: a systematic review and meta-analysis accounting for compensatory changes in energy intake or expenditure. Int J Obes (Lond) 2015;39(8):1181–1187. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 52.Befort CA, Klemp JR, Sullivan DK et al. Weight loss maintenance strategies among rural breast cancer survivors: the rural women connecting for better health trial. Obesity 2016;24:2070–2077. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 53.Perri MG, Limacher MC, Durning PE et al. Extended-care programs for weight management in rural communities: the treatment of obesity in underserved rural settings (TOURS) randomized trial. Arch Intern Med 2008;168:2347–2354. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 54.Sriram U, Sandreuter KJ, Graham ML, Folta S, Pullyblank K, Paul L, Seguin RA. Process evaluation of Strong Hearts, Healthy Communities: a rural community-based cardiovascular disease prevention. In review. [DOI] [PMC free article] [PubMed] [Google Scholar]

RESOURCES