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The weight of obesity: Lessons from the fattest state

America is getting fatter, and Mississippi is leading the way. Local physicians are working hard to stem the tide. Part 3 of a 3-part series.

By Victoria Stagg Elliott, amednews staff. Oct. 20, 2003.

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Dwalia South, MD, rarely sees people walking in her small town of Ripley, Miss. Recreational facilities are rare in this rural area. There are no local shops down the street because these businesses have been replaced by national chain stores on the outskirts of town. Thus, simple errands are a drive away. And even if there was someplace to walk, the heat and humidity would still make this choice unlikely.

"The only people you see walking anywhere are people who have already had their first heart attack and the doctor has said, 'you need to get out and walk,' " said Dr. South, a native of the area and medical director of the clinic system at North Benton County Health Care Inc.

It's true. Ripley might be a small town. But in terms of the community's weight problem, it offers a telling window on a statewide, even nationwide, battle. Each generation there seems to be larger than the last. Exercise opportunities are sparse, while fast-food and buffet-style restaurants are more convenient than ever. Portions are supersized. And even the school system has begun to rely on revenues from soft drink and candy machines to infuse cash into the education system.

"We're selling our children's health to the devil for money," said Dr. South.

Dr. South is very aware of how difficult healthy choices are in these surroundings. Much like many of her patients, she struggles with her own weight and walks most mornings to keep it under control. She tries to eat right, but she concedes that she doesn't do all that well. And in much the same vein, she strives to convince her patients to make the small changes that could affect their weight, but it seems even harder in Mississippi than in other places.

The state, according to the Centers for Disease Control and Prevention, has the highest rate of obesity in the country. More than 60% of its residents are overweight. It also has the dubious honor of being the first state to have more than a quarter of its population be obese.

To be fair, Mississippi may be leading the pack in terms of excess pounds, but every other state is following. Colorado is considered the leanest with an obesity rate of around 14%. But even Colorado, despite an environment that many describe as being more conducive to a healthier lifestyle, has experienced a doubling of girth -- twice as many obese people as a decade ago.

Many others are following the lead

"Mississippi is just the tip of the iceberg," said Mary Gayle Armstrong, MD, medical director for the office of health promotion at the Mississippi State Dept. of Health. "This is not just a Mississippi problem. It's a national problem." But delving into what puts Mississippi at the pole position may be a key to mediating the country's obesity epidemic.

"If we began to understand the differences between some of these states, I think we'd have a better handle on what we should be focusing on," said William H. Dietz, MD, PhD, director of the CDC's division of nutrition and physical activity.

Many of the factors that experts believe are driving up Mississippi's obesity rates are shared with other states. Mississippi just seems to have them in spades.

Sprawl has been linked to obesity, and the state is one of the most rural in the country -- with little in the way of public transportation, bike lanes or walker-friendly areas. The state is also the poorest.

According to 2001 Census data, nearly 20% of Mississippi's population lives in poverty, the highest rate in the nation. This means that residents are eating unhealthy food because it is often cheaper than healthier alternatives. Several studies have also shown that those who are insecure about their food supply are more likely to be overweight or obese and that those who live in poorer neighborhoods are less likely to have access to free recreation facilities.

Cultural factors and lifestyle influences are also contributors.

Experts say physical activity is not a favorite leisure time option in Mississippi -- the way it is in places like Colorado.

Outside recreation is often undermined by weather, which in Mississippi is frequently hot and sticky, and more conducive to staying in the air conditioning. And the surroundings are often not accommodating.

"In Mississippi, I wouldn't feel safe biking. The roads are narrow or they're highways," said, J. Eric Christman, MD, a gynecologic oncologist at the University of Colorado in Denver, but who lived in Mississippi for much of the 1970s.

"The opportunities for exercise in Colorado are just limitless. Most of the people I encounter bicycle, hike, walk, go to the mountains, spend a lot of time outdoors. We have hundreds miles of bike paths."

A Mississippi newspaper conducted an assessment of the state's future job market, predicting an increase in health care sector jobs while also profiling a personal trainer who was having a hard time making a living because of lack of demand.

Want some tea with that sugar?

Mississippi doctors also say that gatherings -- more so than elsewhere -- revolve around the consumption of large amounts of food. The local cuisine is high-fat and high-sugar, even if requested otherwise, and probably is not even healthy in small portions. For example, Scott Nelson, MD, a family physician based in Cleveland, Miss., and an area native, fights a constant battle to get unsweetened tea when he dines out.

"More than other areas of the country, social events revolve around food and heavy eating," he said, "And in the South, when you order tea, you're going to get sweetened tea with an astronomical amount of sugar. Everything is sweetened with sugar and fat and spiced with salt. But, as we know, those habits are bad."

The Mississippi population is also one-third African-American and, according to several studies, people of this ethnicity are more likely to have a larger body mass index than Caucasians and are also less likely to stigmatize excess weight. Physicians working in Mississippi also point out that local attitudes do not appear to relate negative social consequences to being heavy.

"No one feels any particular shame about their size," said Marshall Bouldin, MD, director of the metabolic clinics at the University of Mississippi in Jackson.

Many also point to a certain fatalism -- a sense among younger people that since their parents and grandparents were overweight, and developed diabetes and other ill-effects of the excess pounds, they are doomed to follow these footsteps.

"We've got to put the message out there that even though you may inherit a genetic predisposition towards obesity, there are things you can do," said Dr. Nelson.

Although there is little hard data nailing down why so many Mississippians -- along with people from throughout the country -- are maxing out the scales and even less about exactly which interventions would be most effective on a populationwide basis, there is a lot of focus on trying to make a dent in the problem. The state government established the Mississippi Council on Obesity Prevention and Management, and the public health department has numerous programs, including those that encourage increased awareness of the issue as well as concrete actions to prevent or reverse its incidence.

"We're still gathering information because we have to understand the situation a bit better," said Dr. Armstrong. "But there are a lot of things happening."

Most suspect that it will take numerous initiatives attacking the problem from all sides to properly address the issue, although there is some anecdotal evidence that early efforts are having an impact.

If you pave it they will walk

In Dr. Nelson's town, for example, the local government recently turned an abandoned rail line running through the center of town into a trail that people can use to walk, jog and bike. His patients seem to be exercising more because they're taking advantage of this new local resource. "It has been extremely popular," said Dr. Nelson. "I have several overweight patients who are also diabetic who are using it, and I've seen an improvement in control."

Such small steps are important, but experts warn that major changes have to be made, and they have to be made now. They worry about what the economic cost of overweight and obesity and its resulting complications will do to a state that is already at the bottom of the economic pile.

"Mississippi is already the poorest state in the union, and the inability to take care of the health problems that come with this [title are] causing us to drop further and further behind," said Dr Bouldin, a native of the state.

They also warn that what Mississippi is now experiencing may be the harbinger for the rest of the Union.

"We've got to reverse the sedentary lifestyle culture and diet that permeates America," said Dr. Nelson. "The problems that we face in 2003 here may very well foreshadow what the rest of the United States may be facing."

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