“Everyone knows everyone”: a qualitative examination of influences of eating disorder risk among rural US adolescents

Background: Rural adolescents face disproportionately higher rates of disordered eating, though it is unknown what about living in a rural community impacts disordered eating risk. The objective of the present study was to understand how rural adolescents describe their rural culture as impacting eating disorder risk using a qualitative study design. Methods: Semi-structured interviews using the American Psychiatric Association Cultural Formulation Interview were conducted among individuals (M_age = 20.0, Range 16–25) who developed disordered eating as an adolescent (10–19 years of age) while living in a rural community. Interviews were recorded and transcribed verbatim, and transcripts were analyzed using inductive thematic analysis. Results: Four themes were identified: “Everyone knows everyone,” Diet Culture & Weight Stigma, Body Ideals, and Initiating Events. Participants reported that everyone in their community knew everyone else and about their lives. Participants described this innate sense of community as being helpful at times, and harmful at other times. The sense of community was seen as a strength when participants felt they could get support from their community members. But felt that the close sense of community was harmful as there was a very narrow definition of acceptable social standards and a strong pressure to meet those expectations. Participants reported a strong cultural overvaluation of thinness, including the normalization of dieting and disordered eating, as well as frequent experiences of implicit and explicit weight stigma. Relatedly, body ideals differed by gender, but thinness was valued by girls and younger adults and muscularity by boys. Participants described many situations they believed contributed to their disordered eating, including chronic stressors like food insecurity, traumatic events like deaths, and a fear of rejection for not fitting social expectations in their rural communities. Conclusions: Findings suggest that specific aspects of living in rural communities may uniquely increase eating disorder risk, particularly the pressure to fit the narrowly defined social expectations in rural communities. However, the study also identified aspects of living in rural communities that participants viewed as protective and potentially useful in future preventative efforts, such as having a strong sense of community and support from that community.