In 2009, the rural population in northern Sweden was older and more often male, with less education, more abdominal obesity and higher cholesterol levels compared with the urban population. A sedentary lifestyle was more common in the rural areas. Thus, there is still a clustering of important cardiovascular risk factors in Swedish rural areas. Lack of jobs and opportunities to get an education influence young adults to move out of rural areas. A more diverse cultural life and a greater range of activities and entertainment attract younger people to urban living. Thus, it is probable that those who stay in the rural areas differ in many aspects from those who move to the urban environments.
The level of education differed between communities and the proportion of people with higher formal education was lower in rural areas than in towns and cities. Statistics Sweden reported a general increase in educational level among all Swedes including rural dwellers . However, rural communities still have a higher proportion of elderly who grew up with only primary education since that was more common back in the 40s. As this generation subsequently will pass away, the proportion of individuals with only primary education will decrease in rural areas.
A low educational level has been linked to a shorter life expectancy  and to higher levels of cardiovascular risk factors . A higher educational level might thereby improve the CVD risk factor profile of rural communities in the future, although a causal link has not been proven in prospective studies. Note that adjustment for education did not change any of our findings, thus adding further doubt to the hypothesis that low educational level is responsible for the more detrimental risk factor burden in rural areas.
Blood pressure and the proportion treated for hypertension did not differ. In the previous MONICA report from 1986–1999, the systolic blood pressure was higher in rural communities than in towns and urban areas , which was no longer evident in 2009. Possibly better awareness and treatment in rural areas has led to a decreased difference between rural and urban populations. From Västerbotten County, the VIP study reported an increased prevalence of hypertension in rural inland and coastland between 2005 and 2010 in contrast to the residential city of Umeå, which had a stable prevalence . We analysed both Norrbotten and Västerbotten together, and there might be a discrepancy between VIP and MONICA since the trends may not be similar in the two adjacent counties, and the age ranges were not identical.
The prevalence of obesity and overweight were 50% higher in rural populations. A recent US report noted more obesity in rural settings, possibly causing higher risk of diabetes and coronary heart disease . In northern Sweden no, or only slight, increases in diabetes have been found despite the increasing BMI [15, 20] and also CVD has decreased in both counties. However, it is possible that the rural population of northern Sweden might be at risk if BMI continues to increase. It should also be noted that obesity poses numerous other threats to health because obese people have a greater risk of sleep apnoea, stroke, cancer, osteoarthritis, gout, and back pain .
Waist and hip circumferences were higher in rural communities, which corroborates a previous Swedish study, although not population based . Probable explanations are less favourable dietary habits and less amount of physical activity as compared with urban populations. The combination of waist and hip circumferences better predicts CVD mortality than waist circumference alone, which underestimates the risk [21, 22]. This is so, presumably by a better prediction of the amount of visceral fat. To that, an increased hip circumference might be beneficial both by potentially reflecting an increased muscle mass and by a protective physiology of the gluteofemoral adipose tissue . The increased hip circumference seen in the rural population might therefore represent a metabolically beneficial sign, to some extent balancing the increased risk of co-morbidities linked to a disadvantageous increase in BMI and waist circumference. Still, a higher BMI and waist circumference in rural communities puts those persons at a higher risk of comorbidities associated with overweight and obesity.
We show that rural and middle-size communities have markedly higher cholesterol values (0.3-0.4 mm/L), but also that rural inhabitants use lipid lowering agents to a higher extent. Therefore we found no evidence for a treatment bias according to rurality, and those dwellers are not disadvantaged in regards to such medical care. On the other hand, it can be argued that with levels of total cholesterol that are still higher than in the urban areas, there is a need for more dietary changes and possibly also for more lipid lowering agents, at least among those at high cardiovascular risk.
High cholesterol levels have been noted in northern Sweden since the beginning of the WHO MONICA Project in 1986. This is regarded as the most important cause of a much higher CVD mortality in northern Sweden . Data from MONICA show that cholesterol levels have decreased continuously between 1986 and 2009 , but in the VIP study there has been a shift in the positive trend after 2008–2010 . This improvement in cholesterol has been seen in both rural and urban areas, but rural communities have had higher levels than urban areas throughout this period.
Much of the positive trend has been ascribed to public health interventions such as the Norsjö project, which evolved into the VIP Study , but it is possible that such interventions have been more successful in urban areas and perhaps better adopted by urban dwellers. Rural inhabitants have higher cholesterol levels mainly due to higher intake of saturated fat but also possibly due to more obesity, sedentary lifestyle and lower education [9, 12]. If cholesterol levels would reverse and increase in rural and middle-sized communities, it is possible that we would see an increased incidence and mortality from MI. The 2014 MONICA population survey will answer that question.
No significant differences based on community size in the prevalence of diabetes, fasting glucose or glucose tolerance were noted in our study. In a report from the northern Sweden MONICA between 1990–2009, an upward shift was seen in fasting and 2-h post-load plasma glucose levels, and increased prevalence of impaired glucose tolerance and impaired fasting glucose . If this trend continues, the rural inhabitants might be afflicted to a greater extent since they have a higher proportion of obese individuals.
The use of tobacco in the form of moist oral snuff and smoking did not differ between communities in accordance with a previous study . Regular leisure time physical activity was most common in urban areas and least common in rural areas. In a report from the Swedish Public Health Institute , a lack of studies from a rural perspective regarding physical activity in relation to the environment was observed. We know that a structural approach has been effective in urban areas with i.e. bicycle paths, walking trails in parks and good access to training facilities. Therefore, it is important to investigate further options to facilitate physically activity for rural inhabitants.
The development of society has made physically demanding employments, which were common in rural settings, very scarce today. Even forest and mining labour, which were previously very physically demanding, are now mostly sedentary and machine-operated by joy sticks. This needs to be compensated for by leisure time physical activity. In rural areas, long travelling distances, few walking and cycling trails and perhaps poor street lighting make motoring the traditional way to commute shop or visit friends. A structural approach is likely needed along with changes in culture or attitude to increase physical activity in rural settings.
In a report from the Swedish Public Health Institute 2007, health and it’s determinants in different types of municipalities were analysed . The focus was on the structure of the municipality and the associated health of its inhabitants. Sparsely populated municipalities had more ill health markers than larger municipalities. Overweight, obesity, sedentary lifestyle and mortality from MI and diabetes were more common, and vegetable consumption was lower in rural areas than in large towns and similar municipalities. Age and educational attainment were the strongest predictors of ill health, but living in a sparsely populated municipality was still an explanatory factor for ill health after regression analyses had been performed. These findings corroborate our results and extend them to the whole of Sweden.
That report  also investigated what characterized the lifestyle of the inhabitants in sparsely populated areas. They found a higher proportion living under the social security or poverty level, higher incapacity rates and lower life expectancy in both women and men. On the positive side, inhabitants of sparsely populated regions reported better mental health and less stress.
Cultural aspects of rural living along with the socioeconomic situation might also affect how the rural population adapts to primary preventive advice from authorities. In a recent article the health of men and masculinity in rural areas of Sweden was discussed . Structural factors, which characterized men in rural Sweden (versus urban Sweden) were lower educational attainment, lower-income jobs, and higher rates of unemployment. In rural communities a certain type of masculinity is encountered, such as hunting teams and snow scooter teams, which result in a lifestyle with less favorable eating, drinking and exercising habits. This male rural culture may also contribute to young women moving to cities more often than young men.
Strengths and weaknesses
Similar to most modern population studies, participation rates declined over time in the MONICA study reaching only 69.2% in 2009. Non-participants differed from participants in some important aspects being, on average, younger and more likely to smoke or report diabetes. They were also less likely to have had a vocational or university education . This may limit the external validity of the study and introduce some bias, especially among the youngest where participant rates were lowest. and caution is warranted in extrapolating the findings to the whole population. We do not know if participation rates differ by living area and therefore are not able to judge if comparisons between urban and rural living are affected.
The definition of urban and rural in our study was subjective. Small communities lying very close to a town or city might reflect a different way of living compared with small communities in very remote areas, which are common in northern Sweden. Participants may thus choose to report living in a rural setting even if they live very close to a city. Still, we show the expected differences in the distribution of cardiovascular risk factors in 2009.
Adjustment for educational level did not affect the results further after adjusting for age and gender. Since those with only primary education were probably represented mainly by the older population, the significance of education might be obscured by the higher mean age in rural communities. It is therefore possible that educational level might influence our results in a similar manner as age on the adjusted values of risk factors in our study. A high degree of collinearity between these two is evident.
BMI based on self-reported weight and length has been shown in many studies to be prone to underestimation, and the objectively measured BMI in MONICA adds further to the strength of this study.