AUSTIN — Losing weight is tough, but when folks in Tyler, Texas, decided to do something about obesity, they dropped a combined 32,000 pounds over four years.

Incentives such as new cars and $1,000 grocery gift cards motivated participants, who must lose at least 5 percent of their body weight to be eligible for a drawing.

Those getting smaller through Lighten Up East Texas have shed 10,272 pounds so far this year. 

“Basically we lost the collective weight of an elephant,” said George Roberts, CEO of the Northeast Texas Public Health District, of the 11,000 people who’ve participated.

But it’s going to take more than a contest to overcome the obesity, cancer, infant mortality and litany of other public health problems that would make the 35-county northeast Texas region one of the nation’s least-healthy states if it stood alone, according to new research.

If it were a state, northeast Texas would be among the worst in death rates for three of the top four leading causes of death in the United States, including stroke and heart disease, according to the report by University of Texas System and UT Health Northeast.

As a state, its overall mortality would be near the worst in the country — at 45th. Texas ranks at 31st. 

Death rates in the region were 18 percent higher for men, 20 percent higher for women, 16 percent higher for whites, and 7 percent higher for blacks than in the state overall, according to the report on 2014 data.

“What’s the word between ‘challenge’ and ‘crisis’?” asked Roberts while searching for a single term to describe the rests. 

The big smoking gun, in many cases, is tobacco use. 

Nearly one-quarter of adults in northeast Texas were smokers two years ago, compared to 15 percent statewide, the researchers found.

In 2013, nearly 14 percent of live births in the region were to mothers who smoked during pregnancy – compared to 4 percent statewide.

Dr. Joseph Zasik, who practices pulmonary and critical care medicine in Tyler, noted a patient he recently saw who is recovering from open-heart surgery. 

“He’s still smoking a pack a day, hasn’t gone to rehab, and he’s complaining that he’s short of breath and tired,” he said. “It sort of makes you feel like you’re spinning your wheels.”

The population of the region is largely rural. More than  half the 1.5 million people in northeast Texas live in rural areas.

The population is slightly older compared to Texas overall, and incomes are below the state’s average, even though the unemployment rate is slightly lower.

All of those factors – along with lower levels of college attendance – contribute to public health ills.

“It’s a poor, older part of our state,” said Dr. David Lakey, a physician who is associate vice chancellor for population health for the University of Texas System. “You have to be careful and not just say, ‘You should have known better.’”

Lakey said no one program will resolve the issues.

“It’ll take a multi-pronged approach,” he said.

Part of the prescription is a new school of community and rural health at the University of Texas Health Science Center at Tyler. The first students begin classes there in January.

Lakey is senior vice president for population health at the center, called UT Health Northeast. 

Roberts agreed that the region needs a “collective solution” to a modern public health problem. 

“What killed people in 1900 was infectious diseases. What kills people now is chronic diseases — our lifestyle,” he said.

Eileen Nehme, a population health professor at UT Health Northeast, said the recent report illuminated something the Tyler weight-loss challenge had shown: Grassroots efforts will play a part in any solution to the region’s ailments.

“Effective change happens at the community level because it spreads through the social system,” she said. 

John Austin covers the Texas Statehouse for CNHI’s newspapers and websites. Reach him at jaustin@cnhi.com.