Obesity risk factors for women living in the Appalachian region: an integrative review.
Obesity is a contributing factor in many chronic illnesses that lead not only to poorer health outcomes, but also to higher health care costs. In 2000, the estimated medical cost of obesity was $117 billion. Obesity has both direct medical costs (prevention, diagnosis, treatment services) and indirect costs (mortality and morbidity) (Center for Disease Control and Prevention, 2009). Obesity is a complex epidemic rooted in biological, social, and economic factors. The Social Determinants of Health framework (Wilkinson &Marmot, 2008) suggest that individuals who live in poverty experience shorter life expectancy and poorer health than the more affluent. The Appalachian region is largely rural and characterized as having high poverty rates, low educational attainment, aging population and high rate of chronic illness (Tessaro & Smith, 2005).
Life expectancy for women living in the Appalachian region has seen a decline in recent years, and obesity and obesity-related illnesses have been cited as major contributors. The prevalence of obesity among white women in the Appalachian region is estimated at 6.9% to 25%; among black women it is estimated at 11.3% to 47.1% (Halverson et al, 2004). Five
Appalachian states (AL, MS, SC, TN, and WV) have overall obesity prevalence rates equal to or greater than 30% (Centers for Disease Control and Prevention, 2009; Halverson et al., 2004; Ezzatil et al., 2008). Race seems to be a risk factor in obesity, with prevalence for white women in the Appalachian region estimated at 6.9% to 25%, while among black women prevalence is estimated at 11.3% to 47.1%. Many biological, socio-cultural and economic factors play a role in the development of obesity among women, including weight gain associated with pregnancy, menopause, estrogen metabolism, a sedentary lifestyle, and socio-economic status. The health consequences of obesity include coronary heart disease, type 2 diabetes, cancers (including breast and colon), respiratory problems, hypertension, and stroke, all contribute to the disparities in life expectancy for Appalachian women (Halverson et al., 2004; Centers for Disease Control and Prevention, 2009).
The Appalachian region is mostly white, with some representation of blacks and Native Americans (Denham, Meyer, Toborg, & Mande, 2004). The region includes 420 counties that follow the spine of the Appalachian Mountains, which spread across parts of 12 states and all of West Virginia. Eighty- two of these 420 Appalachian counties are considered distressed counties (Appalachian Regional Commission, 2010). Forty-two percent of the people living in the Appalachian Region are in rural areas, as compared with 20% of people in the US as a whole (Appalachian Regional Commission, 2010a). Poverty rates in the region range between 13 and 27%. The number of residents with at least 12 years or more of education ranges from 68 to 77%, (Appalachian Regional Commission, 2009) and most people are employed in blue-collar jobs. Unemployment is high, with many families dependent on public assistance and Supplemental Security Income (SSI) for disability. Residents have limited access to health care. This is the nation's most economically depressed and medically underserved area, with proportionately more counties considered distressed than in the rest of the nation (Bagi, Reeder, & Calhoun, 2002).
From this perspective, the lives of Appalachian women are shaped by the distribution of money, power and resources, and these forces are responsible for health inequities in this population, including obesity. This review presents what is currently known about factors that contribute to the high obesity levels among Appalachian women, identifies best practice interventions, and recommends areas for future research.
A comprehensive literature search was conducted for the years 1989 to 2009 using four electronic databases: CINAHL, ERIC, Medline, and Academic Search Premier. We used the keywords (mesh terms): "Appalachian region" AND "women" OR "female" AND "obesity", OR "female" AND "mortality", with and without and "obesity".
The following criteria were used for inclusion in the review: (a) adult population (19+ years old); (b) randomized controlled trial, observational study, epidemiological study, qualitative study, or secondary analysis of data from the Appalachian region; (c) original report, not a review or meta-analysis; and, (d) findings reported separately for women. The search returned a total of 926 hits; however, only 8 studies met the inclusion requirements. They are summarized in Table 1.
The eight studies were conducted in the Appalachian region between the years of 2002 and 2009. Five studies used a combination sample from both rural and urban settings in the region(Armstrong, et al., 2004; Denham, et al., 2004; Ezzatil, Friedman, Kulkarni, & Murray, 2008; Halverson, Barnett, & Casper, 2002; Ramsey & Glenn, 2002). Three studies were conducted only in rural settings (Schoenberg, Hatcher, & Dignan, 2008; Tessaro, et al., 2007; Tessaro & Smith, 2005). One study was conducted in West Virginia and did not state whether the sample was from a rural or urban setting; however, the majority of the counties in West Virginia are rural(Rye, Rye, Tessaro, & Coffindaffer, 2009). Five studies were quantitative, using secondary analysis descriptive designs (Armstrong, et al., 2004; Ezzatil, et al., 2008; Halverson, et al., 2002; Ramsey & Glenn, 2002; Rye, et al., 2009). Two studies were qualitative and used ethnographic designs (Denham, et al., 2004; Schoenberg, et al., 2008). Only one study was an intervention study (Tessaro, et al., 2007). Four studies reported on biological factors that were associated with obesity in Appalachian women, (Ezzatil, et al., 2008; Ramsey & Glenn, 2002; Rye, et al., 2009; Schoenberg, et al., 2008) and four studies reported on socio-cultural factors associated with obesity in these women (Armstrong, et al., 2004; Denham, et al., 2004; Halverson, et al., 2002; Tessaro, et al., 2007). Two studies obtained samples from the National Center for Health Statistics (Armstrong, et al., 2004; Ezzatil, et al., 2008).
Adult Appalachian women were included in all eight studies, and the range of participants' reported ages in the studies was 40-64 years. The highest level of education reported in three studies was high school (Ezzatil, et al., 2008; Rye, et al., 2009; Schoenberg, et al., 2008). Four studies did not report the level of education of participants (Armstrong, et al., 2004; Denham, et al., 2004; Halverson, et al., 2002; Tessaro, et al., 2007). Only two studies compared Black and White women, and in both of these studies the majority of participants were white women (Ramsey & Glenn, 2002; Schoenberg, et al., 2008). Two studies did not report the race of participants (Ezzatil, et al., 2008; Tessaro, et al., 2007). In three studies the majority of women earned an annual income less than $20,000 (Ramsey & Glenn, 2002; Schoenberg, et al., 2008; Tessaro et al, 2007).
Four studies found a decrease in life expectancy for Appalachian women and an increase in chronic illnesses related to obesity (Armstrong, et al., 2004; Ezzatil, et al., 2008; Halverson, et al., 2002; Schoenberg, et al., 2008). One study found that women living in rural regions had the highest rate of obesity (Ramsey & Glenn, 2002).
Socio-cultural Factors Related to Obesity in Appalachian Women
Physical Activity. Many Appalachian residents do report engaging in some type of physical activity. According to the Behavioral Risk Factor Surveillance System, when residents of Appalachian states were asked if they participated in any form of exercise in the past month, an average of 27.33% reported "no"(CDC, 2008). When examining women, the Appalachian Regional Commission (2004) reported 19.6% to 58% of white Appalachian women are physical inactivity, as compared to 12.9% to 54% of white women in the nation. Also, 35.8% to 67.2% of Appalachian black women reported physical inactivity, as compared to 25.4% to 58.1% black women in the nation. Some studies have found relationships between the lack of physical activity and long work hours, low motivation or will power, and lack of resources to participate in regular exercise, such as fitness centers, walking paths or bike paths (Rye, et al., 2009; Schoenberg, et al., 2008).
Using a cross sectional survey design, Rye and colleagues examined barriers to physical activity among low-income Appalachian women aged 40 to 60 years (n=733). Lack of support and lack of willpower were the greatest barriers to physical activity. Interestingly, among these women, lack of time was not perceived as a major barrier to physical activity.
Schoenberg and colleagues interviewed 52 middle-aged rural Appalachian women in focus groups. Women perceived that lack of character or intelligence contributed to low physical activity. Further, they said cable TV and the Internet had replaced walks to visit neighbors. Long work schedules and insufficient resources such as fitness centers also contributed to sedentary lifestyle.
Diet/Nutrition. Residents of the Appalachian region are often older, with higher poverty rates, and more limited access to healthcare than their non-Appalachian counterparts (Armstrong, et al., 2004; Ezzatil, et al., 2008; Halverson, et al., 2002; Ramsey & Glenn, 2002). The association between poverty and obesity may be related to the low cost of energy dense foods. Many Appalachian women report eating fewer fruits and vegetables, more red meat, and more foods high in saturated fats than their non-Appalachian counterparts (Schoenberg, et al., 2008; Wewers, Katz, Paskett, & Fickle, 2006). People with lower incomes are more likely to be able to afford these non-nutrient energy dense foods, including refined grains and foods containing high fat and sugar. They are less likely to be able to afford lean meats, fish, fresh vegetables, and fruits. In the studies, Appalachian residents said that overeating, defined as frequently consuming high calorie foods, was often a problem (Schoenberg, et al., 2008; Wewers, et al., 2006). Moreover, many women reported being taught to prepare traditional Appalachian foods, with recipes handed down through generations for cornbread, fried potatoes, biscuits and gravy, stack cakes, chicken "n' dumplings, and grilled cheese sandwiches, all dense with calories to sustain those performing heavy manual labor (Ramsey & Glenn, 2002; Schoenberg, et al., 2008; Tessaro, et al., 2007).
Education and Socioeconomic Status. The women living in the Appalachian region received less primary education as compared to other parts of the nation (Ramsey & Glenn, 2002; Rye, Rye, Tessaro, & Coffindaffer, 2009). Ramsey & Glenn, 2002, found that obese women often had less primary education. Often women living in urban and suburban areas with higher income level have more education and report better health than women living in rural areas. As noted earlier, the Appalachian region has high poverty and low education levels (Ramsey & Glenn, 2002).
Cultural Norms. The Appalachian community also holds values that are related to obesity; cultural heritage influences food choices. Two studies reviewed here concluded that the Appalachian family is the central unit for making decisions about food selection and preparation. The mother plays the dominant role in the family, and other members of family learn from the mother's choices (Denham, et al., 2004; Schoenberg, et al., 2008), which tend to be high calorie.
Effects on Mortality and Economic Burden. The health consequences of obesity include elevated mortality rates and economic burden. Living in the Appalachian region is linked to health disparities, more chronic illnesses and higher mortality rates for women. Over the past few decades, average life expectancy has increased for most Americans; however, for women in this region life expectancy has decreased (Armstrong, et al., 2004; Ezzatil, et al., 2008). Mortality rates are higher for white, older Appalachian women than for women in the rest of the nation, and mortality is most often due to heart disease and stroke (Armstrong, et al., 2004; Ezzatil, et al., 2008; Halverson, et al., 2002). Biological Factors Related to Obesity in Appalachian Women
Genetic risk factors influence energy metabolism and makes some individuals susceptible to weight gain and obesity. Even with genetic susceptibility, however, a nutritious diet and regular physical activity enable maintenance of a healthy weight. None of these studies described caloric intake or energy expenditure or genetic variations in the metabolism of women living in the Appalachian region. Future research should examine associations between caloric intake and energy expenditure of women living in this region.
Appalachian women are an understudied population in the US. Life expectancy in these women declined in recent years, with obesity and obesity-related illnesses cited as contributing factors (Halverson, et al, 2004). Biological factors in obesity include gender, age, and genetic variations in metabolism. Socio-cultural factors include socioeconomic levels, educational levels, and cultural norms. This review summarizes what is known about biological, socio-cultural and economic factors that contribute to the high levels of obesity among Appalachian women. These women clearly experience high rates of obesity, which is a multifaceted problem and is associated with both biological and environmental factors.
The per capita income of people living in the Appalachian region is approximately $4,000 less than the national average, and 15.3% of households are at the poverty level (Armstrong, et al., 2004). Only 68% to 77% of people living in the Appalachian region have at least 12 years of education (Wewers, et al., 2006). They also have low health literacy skills, which compounds the problem of obesity. Finally, the Appalachian region has many barriers to healthy lifestyles, including limited access to health care and limited facilities for recreational activity (Tessaro, et al., 2007).
These studies did not include body mass indices (BMI's) or caloric intake of participants. Further, the majority of the studies were cross sectional or qualitative; few obesity intervention studies have been conducted with Appalachian women, making it impossible to draw causal associations. Future investigations should test interventions for women in Appalachia and other regions with high obesity rates.
IMPLICATIONS FOR NURSING
Despite their limitations, the studies reviewed provide evidence that awareness of barriers to physical activity can assist nurses in developing approaches to increase activity in Appalachian women. In addition, exploring cultural influences on food selection and preparation can suggest strategies for decreasing high calorie diets and overeating. Decreasing obesity in rural Appalachian women can in turn assist in decreasing chronic illness related mortality.
Best practice strategies for addressing the increasing obesity rates in Appalachian women include emphasis on education about health promotion and better access to preventive health care in low-income, medically underserved communities. Given the documented increase in mortality among Appalachian women and its relationship to obesity, interventions should be tailored to women. Best practice interventions take into account Appalachian cultural and socioeconomic features, such as income and health literacy needs. Nurses can re-educate Appalachian women about healthy food choices using educational material that are culturally diverse and written at a low literacy level. Also, interventions directed at providing women with motivational and support training helps them make better healthcare decisions. Exploring obesity interventions using information technology systems or Telehealth will allow education to be delivered in remote rural regions.
Health care policies need to focus on ways to improve living environments and make healthier communities, especially communities with high obesity rates and few resources. Health care services to low-income households, including nutrition education, and health screenings to manage weight, need to be a priority. Community coalitions and neighborhood associations promoting active lifestyles for Appalachian women can provide health interventions which focus on reducing obesity, and improving health outcomes for people living in rural regions.
Appalachian Regional Commission.(2009). Economic overview. Retrieved August 5, 2009, from http://www.arc.gov/index.do?nodeId=26
Appalachian Regional Commission. (2010a). The Appalachian region. Retrieved January 29, 2010, from http://www.arc.gov/appalachian_region/TheAppalachianRegion.asp
Appalachian Regional Commission. (2010b). ARC-Designated distressed counties, fiscal year 2010. Retrieved February 1, 2010, from http://www.arc.gov/appalachian_region/ ARCDesignatedDistressedCountiesFiscalYear2010.asp
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Tara O'Brien MSN, RN (1) Laura A. Talbot EdD, PhD, RN, GCNS-BC (2)
(1) School of Nursing, University of North Carolina at Charlotte, email@example.com
(2) Director, HSR PhD Program, Dean Colvard Distinguished Professor in Nursing, University of North Carolina at Charlotte, firstname.lastname@example.org
Table 1. Appalachian Women & Obesity First Author Purpose Sample Design Armstrong To determine Residents of Quantitative the extent to all Secondary which death Appalachian data analysis rates from counties in colorectal 13 states cancer by age, race, & Sample group gender was provided subgroups of from the Appalachians Multiple differ from Cause of rates of the Death Public same sub File; Death groups Certificate, elsewhere in which was the US provided by the National Center for Health Statistics (NCHS).Sample size was not provided Age 50-80 Men & women were analyzed separately for the study Denham To determine Sample group Qualitative if behavioral was provided Study health from the interventions Multiple could be more Cause of successful if Death Public culturally File; Death sensitive Certificate, which was provided by the NCHS Age 50-80 Focus groups, (Mean age common themes 3645 for the were analyzed adult women's group) Gender analyzed separately for the study Sample size 52 focus groups included 469 persons Adolescents n =16, adult men n= 30 adult women = 273 Ezzati To compare Sample group Quantitative average life was provided Secondary expectancies by the US data analysis in various Census regions of population the US from 1961 to 1999 which was provided by the NCHS Men & women were analyzed separately for the study Sample size was not provided Halverson To examine Residents of Quantitative geographical, all Secondary racial/ Appalachian data analysis ethnic counties in differences 13 in heart Appalachian disease & states stroke mortality. Sample group was provided National Vital Statistics System by the NCHS White men 35-64 White men 65& older White women 35-64 White women 65& older Black men 35-64 Black men 65& older Black women 35-64 Black women 65 & older Sample size was not provided Ramsey To 4,391 women Quantitative investigate living in the Descriptive the southern study differences region of the between US rural, urban, & suburban Urban n= Data from southern 1,042 National women based Suburban Health Survey on n=1,977 Rural socioeconomi n= 1,372 ages c factors 40-64 Rye To 733 women Quantitative investigate living in Descriptive the West Virginia prevalence of Health Risk/ lack of time 244-aged 40-64 Behavioral & motivation 489-aged 50-60 Survey as barriers to physical activity among low income women Tessaro To evaluate a 262 Women Quantitative computer living in Intervention based rural West interactive Virginia 131 nutrition Intervention intervention 131 Control Mean age 50.25 Schoenberg To determine Snowball Qualitative what sample from Focus groups Appalachian four rural using open women Appalachian ended consider the Kentucky questions most pressing counties n = threat to 52 65% women their Mean age 52 communities First Author Setting Contributing Outcome Rural/Urban Factors Armstrong 13Appalachia Socio- Death rates counties in cultural among obese both rural factors white men & and urban related to women were settings of the lack of significantly the education & higher for Appalachian geographic colorectal region isolation cancer in the (access to Appalachian care) region than in the rest of the country Denham 24 Socio- Appalachian Appalachian cultural mothers play counties in factors a major role ten states in related to in the health both rural sensitivity of their and urban of the family settings of delivery of members and the education play a major Appalachian methods role for region promoting positive health behaviors for the family. Ezzati All US states Biological Life both rural factors expectancy and urban related to decline for settings of chronic women living the US diseases in the deep south of the U.S. extending into the Appalachian region. Patterns of female mortality rise are consistent with smoking, high blood pressure & obesity Halverson 403 Socio- Nearly 35% of Appalachian cultural the US counties in factors counties with 13 included low the highest Appalachian education rates of states both attainment, heart disease rural and low per mortality for urban capita white men & settings of income, women are in the limited Appalachia Appalachian access to 25% of region medical care counties with were the highest associated rates for with higher Black men & rates of women are the morbidity & Appalachian mortality region Ramsey Women living Biological Participants in urban, factors for with higher suburban, and white women incomes & Rural regions associated educational analyzed with levels had separately morbidity & better health for the study mortality outcomes rates Women living in rural regions had the highest rate of obesity & reported the poorest health. Obesity & poor health related Rye Rural and Biological A lack of urban areas factors time & of West associated support was Virginia with lack of the greatest motivation & barrier time reported by contributed participants to higher rates of obesity for women Tessaro Two rural Socio- The computer counties of cultural based West Virginia factors interactive included to nutrition low income intervention and rural showed region with a potential history of change in the chronic diets for the disease women in the intervention group Schoenberg Four rural Biological Participants Appalachian factors of identified counties in poor diet & the greatest Kentucky exercise threats to contribute to their obesity communities as substance abuse, cancer, heart disease & diabetes, poor diet, lack of exercise, & obesity Several Appalachian areas have the highest rates of obesity & physical inactivity in the country First Author Suggested Future Strategy Armstrong Appalachian region may benefit from targeted obesity prevention to eliminate health disparities. Denham In Appalachian families women most often have the power to influence the family health needs (including chronic conditions such as obesity), but often need support to make effective use of this role. Ezzati Programs need to be established that increase insurance coverage for interventions for chronic disease. Halverson Distressed counties need to use direct money & resources to make policy decisions at the local level to improve health outcomes for people living in the region. These policy changes would include various approaches to promote a healthy lifestyle for people living in the Appalachian Ramsey Community health care providers should use community based health strategies to manage weight through new or existing programs. Programs need to be sensitive to income & educational factors that characterize rural regions Rye Motivational counseling is a critical intervention to increase motivation & social support for physical activity, which will assist in decreasing the prevalence of obesity. Tessaro Personal delivery of information may not always be available in rural regions. Technology may be one way to bridge the gap between education and behavior change. Schoenberg Lifestyle- related choices comprise the core risk factors for developing chronic disease. The best approach for addressing these threats is to develop coalitions to target troublesome community health problems. Community health promotion can best be implemented by respecting existing community knowledge, priorities, & capacities through community research partnerships that point to proven interventions.