Rural Obesity: The Missouri Example

Rural Obesity: The Missouri Example

The problem of obesity is an issue of developed countries. Lack of food shortages, sedentary lifestyles, poor health care in some areas, and lack of education on nutritional awareness all contribute to problems of obesity. In the United States, rural areas such as those in Missouri face additional socio-economic problems such as poverty and lower education levels that contribute to the obesity problem. Tackling the obesity epidemic in rural Missouri requires more than just best practices. The following report discusses aspects of rural obesity in Missouri, problems of intervention, and areas of possible research.

Rural Obesity: The Missouri Example

Obesity in the United States has become a pandemic, with states across the nation seeing a progressively upward trend in the percentage of their respective populations that qualify as obese, with BMI's of over 30%. Obesity is greater in areas with rural populations. Health problems related to obesity are greater among rural populations. This research paper will examine the issue of rural obesity among the population of the rural area of Missouri in the United States. First an examination of the population at risk is put forth, followed by a discourse on the nature of the problem of obesity within this population. Relevant comparisons are made between the at-risk population and other population variables. Past research to address the problem is discussed, with implications for future research. The research reviews the importance of the rural context on the issue of rural obesity, with emphasis on the impact of analyzing data related to the at-risk population and obesity. A best practices model is offered to illustrate an appropriate intervention strategy that is currently utilized to address the problem of obesity in Missouri, with relevant criticisms. A conclusion is offered to highlight the salient points of this research paper and synthesize the topics.

At-Risk Population

The population under scrutiny is the rural population of the southern to Midwestern United States with emphasis on Missouri, hereafter referred to as the 'at-risk population.' The problem of obesity in this geographic area has progressed more quickly than any other area of the United States, with obesity rates in the southern states exceeding 30%, and in Missouri exceeding 25% (Jackson, Doescher, Jerant, & Hart, 2006) (Centers for Disease Control, 2010). Proximally 98% of the United States is considered rural area, with the remaining 2% considered either urban or suburban area. However, approximately 75% of the nation's population resides in the urban and suburban areas (Howarth, 1996). The prevalence of obesity in urban/suburban areas is lower than in rural areas, suggesting other variables are at work in the continued rise in obesity among rural populations, including those in Missouri (Patterson, Moore, Probst, & Shinogle, 2004).

Contributing factors to obesity among rural population are poor access to health care, increasing population diversity, food insecurity resulting in 'food deserts' (more reliance on convenience markets with poor quality food), economic transitions from an industrial labor-intensive lifestyle to a commuting, sedentary light-labor lifestyle, low population density, and relatively few opportunities for physical activity such as one might find in parks districts (i.e. swimming, sports, physical fitness classes) (NACO - National Association of Counties, 2008).

Missouri is state located in the Midwestern portion of the United States, with a strongly rural and southern cultural flavor. As of 2009, the population was approximately 5.9 million, with over half of the state's population living in the two major urban centers, Kansas City and St. Louis. The demographic breakdown is approximately 87% white, 12% African-American, and the remaining population being of Asian, Hispanic, or Native Hawaiian/Pacific Islander ethnic origin (the U.S. Census Bureau, 2009). The amount of land area classified as rural is approximately 98%, with about 30% of the population living in the rural areas. Thus, most of the state's population resides in about 2% of the land area (urban) (Missouri Census Data Center, 2000). This corresponds roughly to the national average, though only 20% (estimated) of the U.S. population resides in rural areas.

The majority of the United States population resides primarily in urban and suburban centers, occupying approximately 2% of the land area. The rural population of the United States faces socio-economic stressors, due in part to the geographic context, that trickles down into distinct cultural components of specified rural areas, such as education, poverty, housing characteristics, and more, which seem to vary by rural area. Missouri population patterns tend to follow the nation's in terms of urban and rural divisions. Missouri's rural population is the case study for this research, described as the at-risk population.

Obesity

Obesity is a medical condition, characterized by an excess of body fat that has negative impacts upon health, such as heart disease, diabetes, stroke, osteoarthritis, sleep apnea, and more (Haslam & James, 2005). Obesity refers to a body mass index that is greater than 30km/m2. The Surgeon General has stated that obesity is an epidemic of which the United States is attempting to address through various strategies, including the establishment of a Research Obesity Taskforce by the National Institutes of Health (United States Mission Geneva, 2010). Obesity is typically addressed through diet and exercise, though once secondary conditions have set in such as diabetes, heart disease, and even cancer, the plan of care and treatment will likely look drastically different than one in which only nutrition and physical activity are included (Perri, et al., 2008). Obesity is a primary cause of preventable death, with rising rates occurring throughout the world, including the United States. Rural areas of the United States are exceeding 30% obesity rates. Health problems among the rural population have increased due to the obesity epidemic. As noted, problems such as lack of access to health care and a poor diet, with a lifestyle that increasingly sedentary all contribute to the progressive problem of rural obesity. The following comparison maps illustrate the changing face of obesity in the United States:

(Centers for Disease Control, 2010).

Obesogenic Society

The United States is a wealthy nation compared to the rest of the world. While the U.S. certainly has its share of poverty, hunger, and homelessness, the historical picture shows a nation where food sources are relatively plentiful. Famines are not a common feature in the U.S., and the welfare programs provide food items for those people that fall within the income guidelines. What the United States does have, is a plethora of junk food and fast food outlets. This phenomenon has give rise to a new term, obesogenics. The word refers to factors that make people overweight. These factors are found in environments that promote unhealthful eating, lack of exercise, and hence promote weight gain (Centers for Disease Control and Prevention, 2010).

Environmental factors can include fast food restaurants, convenience stores, 'food deserts', office environments that encourage sitting, environments with dishes of candy (often found on desks), and those with vending machines selling non-healthy food choices, schools with a lack of nutritional guidelines and an underdeveloped physical activity program, and things of a similar nature (Lake, Townshend, & Alvanides, 2010).

Lobstein and Dibb (2004) describe a potential link between childhood obesity and obesogenic environments. Wardle et al. (2008) find that epigenetic factors may be contributing forces to obesity, especially in childhood, and that obesogenic environments exacerbate the condition. Boehmer et al. (2006) found several links to obesogenic factors and obesity in rural environments, including a community not conducive to physical activity, feeling unsafe due to crime, distance to a recreational facility, dietary intake, sedentary lifestyles, and few outlets for physical recreation. Casey et al. (2008) demonstrated that survey respondent's attitudes on obesity were linked to the obesogenic factors in their environment; this study included participants from Missouri, and found that eating out at fast food restaurants and a community not conducive to physical activity were factors contributing to obesity. Additionally, the Casey study found that participants who perceived their environments as promoting healthier behavior were less likely to be obese.

Rural Obesity in Missouri

As the maps above show, Missouri has increased in its obesity rate from the 20-24% range to the 25-29% range over the time period of 2001 to 2008. The trend is set to continue.

Salihu et al. (2007) showed that extreme obesity among Missourians was linked to stillbirth, and was not limited to ethnicity. Indeed, obesity is associated with both cognitive impairment of the offspring due to elevated circulating triglycerides, as well as being associated with overall increased risk for birth defects (Watkins, Rasmussen, Honein, Botto, & Moore, 2003).

Nutritional choices among the rural may be limited due to the concept of the 'food desert.' A food desert refers to an area where healthy food choices are restricted, possibly due to geographic isolation such as is found with rural areas (Morton & Blanchard, 2007). Fresh produce may not be available, and policy initiatives may not extend to areas that are geographically difficult to get to, set up programs for healthy eating, and implement those programs (Morton, Bitto, Oakland, & Sand, 2009).

Haire-Joshu et al. (2010) found that a lack of policy outside of the school environment was a major contributing factor to obesity among rural Missourians, and that a model database of obesity-related policies across environments was needed to support healthy behaviors. 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).