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Commentary on "trends in cigarette smoking obesity in Appalachian Kentucky".

In this issue of the Southern Medical Journal, Schoenberg and colleagues not only explore the role of smoking and obesity in mortality and morbidity rates in Appalachian Kentucky but they also present a case that further supports the need for analyzing health problems with socio-ecological lenses. This is particularly true in marginalized populations that experience prejudice, discrimination, and racism; barriers to education, public services, and decent housing; and the burden of underemployment, inequalities, and isolation. Marginalized populations experience considerable health disparities that undermine our communities and these disparities can be addressed only through more integrated approaches that include effective responses to their pressing individual, social, environmental, and economic needs. The Appalachian region extends 205,000 square miles from southern New York to northern Mississippi and includes 13 states with a population of more than 25 million people. Despite the geographic and demographic variability, the region as a whole negatively compares with the rest of the United States in many health and social indicators. A 2004 report commissioned by the Appalachian Regional Commission found persistent health disparities and ‘‘considerable excess in mortality from leading causes of death,’’ particularly in the central and southern portion of the region. A follow-up analysis of the socioeconomic conditions that may facilitate these disparities identified poverty and the percentage of individuals without health insurance to be associated with higher mortality from leading causes of death (eg, heart disease, cancer). The report pointed to other indicators such as unemployment and educational achievement aspotential contributors to theobserved adverse health outcomes and concluded that the region experiences differences in individual and collective health behaviors, as well as industrial and occupational structures that contribute to health disparities and represent an opportunity for communitylevel interventions. Schoenberg et al explored the role of smoking and obesity in premature death and established trends in rates of cigarette smoking and obesity in Appalachian Kentucky. The authors found higher rates of smoking and obesity compared with national and non-Appalachian Kentucky rates. These results are consistent with the literature. One study attributed smoking to 60% of the mortality disadvantage of southern states (Alabama, Arkansas, Georgia, Kentucky, Louisiana, Mississippi, Tennessee, and West Virginia) compared with other regions of the United States. Obesity also is a leading risk factor for premature death and often is compared with cigarette smoking. Data support the association among obesity, the early onset of chronic illnesses and disability, and increased mortality. Furthermore, the results of the Schoenberg et al study confirm the relevance of socioeconomic status and access to health care to the prevalence of smoking and obesity in Appalachian Kentucky. The authors emphasize the importance of individual-level interventions, as well as the promotion of communityand state-level policy in addressing disparities in smoking and obesityrelated behaviors. Similarly, the literature provides evidence of the social and geographic influences (eg, built environment) on health disparities. Health disparities have been linked to contextual variables such as racial segregation, income inequalities, immigrant status, and poverty, as well as population composition variables such as income, race, and educational level. These influences and variables represent an opportunity to promote and implement ecological approaches. Both smoking and obesity result from the interaction of biological, social, and cultural factors and from the environments that promote unhealthy behaviors. As such, they must be addressed through health and social interventions, particularly the implementation of policies that facilitate access to highquality education, equal employment opportunities, economic development, affordable housing, and clean environments. Invited Commentary