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Nanney et al. (2007) state that policies aimed at promoting nutritional awareness in schools and about local healthy food choices would influence the food choices that people make within their own homes, possibly leading to better health outcomes.
Past studies on obesity in Missouri have identified obesity risk factors and nutritional deficiencies in populations of inner city youth, rural elderly, rural poverty-stricken, and rural youth (Kohrs, Wang, Eklund, Paulsen, & O'Neal, 1979; Kohrs, O'Neal, Preston, Eklund, & Abrahams, 1978; (Kohrs, Nordstrom, O'Nea, Eklund, Paulsen, & Hertzler, 1978). Previous measures to address obesity in Missouri have focused on school nutrition programs. However, the obesity rates continue to rise, and Missouri has adopted a program through the establishment of the Missouri Council on the Prevention and Management of Overweight and Obesity aimed at increasing activity levels, improving nutritional intake, creating an effective health care system, and creating effective obesity-related policies (Missouri Department of Health and Senior Services, 2005).
Intervention Model: Best Practices for Nutrition and Overweight
Missouri has adopted a general model based on best practices toward intervention in the obesity epidemic, aimed at the general areas of nutrition and obesity/overweight. Missouri's plan has the following three components:
1. A balance between diet and exercise efforts is necessary to prevent and mitigate obesity.
2. Science-based approaches are to be utilized to improve both diet and exercise issues.
3. Many levels of influence must be utilized for the proposed changes to be effective (Missouri Department of Health and Senior Services, 2005).
Best practice models that address nutrition and overweight can incorporate issues relating to nutrition and healthcare, nutrition and diet, nutrition and education, physical activity and healthcare, physical activity and education awareness, and policy issues dealing with developing and implementing nutrition and diet changes.
Using a concomitant model based on the ANGELO analysis matrix would be especially useful in eliciting environmental obesogenic factors that may be barriers to success of nutrition and overweight best practice models. The ANGELO model is a conceptual framework for understanding the obesogenic factors in an environment and a tool for developing intervention models as well (Swinburn, Egger, & Raza, 1999).
Elements of the Missouri initiative include breastfeeding babies, eating more fruits and vegetables daily, increasing calcium and dairy consumption, decreasing portion sizes, decreasing consumption of sweetened beverages, increasing physical activity, supporting physical sports in school, and decreasing television viewing. The plan is to be implemented by influencing environmental factors in the workplace (i.e. allowing breastfeeding at work, providing healthy snack options, etc.), in the family sphere (providing resources to families at risk for obesity), in the community (improving outdoor spaces for physical activity), as well as influencing access to and quality of healthcare for Missourians (Missouri Department of Health and Senior Services, 2005).
This was a policy initiative started in 2005. As of 2009, obesity was still on the rise in Missouri (Centers for Disease Control, 2010). Clearly, there are factors that may be hindering the prevention or mitigation of obesity in Missouri. Food deserts in Missouri are not an easy fix; while Missouri policy makers engage in identification of at-risk rural populations for obesity, they have yet to determine how best to get the resources that rural Missourians need to effectively turn the tide on obesity. The Federal Food Stamp Program is aimed at improving nutritional equality among low income Americans, yet the foods provided for in the program often contain artificial sweeteners, and high calorie and low energy matrixes; the flip side is that substitutions for healthier food choices are not allowed under the program (Ver Ploeg, Mancino, & Lin, 2006).
Importance of the Rural Context of Addressing Obesity
It is of note that in Missouri and the United States, the population trends are such that most of the population resides in urban and suburban areas. The demographics of rural residents (older, less educated, poverty level) are associated with increased rates of obesity over urban residents, though even obesity among rural youth is increasing (Patterson, Moore, Probst, & Shinogle, 2004).
Obesity is associated with income level, and people in rural areas are typically of a low-income status (Jackson, Doescher, Jerant, & Hart, 2006). Additionally, women are at greater risk of obesity than men, and obese women are more likely to have an increased risk of birth defects over their non-obese counterparts (Salihu, Dunlop, Hedayatzadeh, Alio, Kirby, & Alexander, 2007).
Clearly the obesity epidemic is a problem under scrutiny in Missouri, the United States, and the World. How to address the problem is the central question, and the answer varies by region, demographics, and availability of resources. Obesity is a primary medical condition that can lead to stroke, heart disease, osteoarthritis, juvenile and adult hypertension, cancer, and cognitive impairment, to name a few. The Missouri example of rural obesity illustrates the nature of the problems in addressing the obesity epidemic. Rural populations are at greater risk of obesity due to socio-economic factors, including access to affordable and quality healthcare. Food deserts are created by virtue of geographic isolation, and policy makers may be hampered by their ability to effectively implement the best of best practice programs due to access problems of the rural communities. It is clear that the awareness of the problem exists, yet the tools to change the course of the problem may not yet be available, or are of limited efficacy. Future policy tools and programs should aim at addressing the access problems of policy programs addressing obesity; how do we get the resources available to the populations that need them the most? What are the barriers to implementation, and what limitations exist that can be addressed with current tools? Those are the important questions facing rural policy makers, such as in Missouri, in addressing intervention programs for the obesity epidemic.
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