Most Americans would agree that the rising rates of obesity in this country and around the world are concerning. Mainstream and social media outlets are full of information about the obesity epidemic, its harm to our health, and its skyrocketing costs. The fight to get Americans to a “healthy” weight has created a $3.8 billion weight loss industry with solutions ranging from nutrition and exercise plans to cleanses and diet pills to extreme weight loss programs and surgeries. Some of these “solutions” have good intentions, and others do more harm than good, creating a backlash of anti-diet culture. Overall, there seems to be a dichotomy developing between the push to aggressively combat the rising rates of obesity and the pushback on a weight-obsessed culture that values one highly flawed BMI number over all other indicators of health.
Both arguments have valid points, but in either case, the conversation tends to center solely around the individual. We view health and weight as an individual problem or responsibility rather than a societal one. And while I agree that there is a substantial individual component to health, what is severely lacking from the mainstream conversation around obesity is the issue of health equity. The medical and public health communities are acutely aware of this issue, but I find it a moot point in the public square. The discussion around obesity should be like a three-legged stool – finding a balance between promoting individual healthy lifestyles without shaming or stigmatizing people or leading them to extreme behaviors, while also recognizing that not everyone in this country has an equal opportunity to be healthy.
Before going further on health equity, it is important to note that according to the CDC, over 40% of U.S. adults and around 20% of U.S. children are considered obese. Serious health problems are associated with obesity, including Type 2 diabetes, high blood pressure, high cholesterol, heart disease, stroke, and certain types of cancer. The data that rising rates of obesity are harming our population’s health cannot be denied. In 2019, the CDC estimated that the annual medical cost of obesity was almost $173 billion. The obesity epidemic has caused medical providers to reevaluate their standards for medical care, most recently at the pediatric level. The American Academy of Pediatrics (AAP) just revised its Clinical Practice Guideline for the Evaluation and Treatment of Children and Adolescents with Obesity for the first time in 15 years, taking a more proactive stance than in the past. The new guidance takes a paradigm shift and advises that treatment should begin as soon as obesity is identified and with the highest intensity deemed appropriate based on age and obesity status. Treatment can range from lifestyle factors like diet and exercise to medication or even surgery for children 13 years and older.
This dramatic change in the standard of medical care is making headlines and has many parents concerned. Questions have been raised about the mental health status of children and teens and the harm that can be done by “fat shaming” and other forms of anti-fat bias. Some people speak of their own life-long struggles with yo-yo dieting, poor self-esteem, and negative body image due to early childhood experiences around weight. There have also been studies looking at psychological factors such as weight stigma, stress, and depression as predictors of obesity, indicating this could be a bi-directional relationship. It may often feel like a vicious cycle between the two – weight shame causing mental health challenges and mental health challenges causing weight gain. Conversations surrounding obesity must consider the mental and physical health of every child, teen, and adult. One cannot be considered more important than the other and must be addressed holistically.
But remember that three-legged stool I mentioned? Amidst all these arguments repeated in mainstream media about obesity as a disease versus the harm done by anti-fat bias, a massive point is concerningly absent. And that is the significance of health equity as it pertains to health and obesity. The Robert Wood Johnson Foundation states, “health equity means that everyone has a fair and just opportunity to be as healthy as possible. This requires removing obstacles to health such as poverty, discrimination, and their consequences, including powerlessness and lack of access to good jobs with fair pay, quality education and housing, safe environments, and health care.”
To the credit of the AAP, their new guidance does lay out ample discussion about the importance of health equity as part of the obesity conversation. Likewise, the CDC has developed tools to advance health equity and help reduce or eliminate gaps in social determinants of health. But this conversation needs to be elevated with everyday Americans. It is far too easy to place the blame on kids being lazy, helicopter parenting preventing kids from riding bikes in the street, sedentary jobs, overuse of technology, too much time in our cars, and an abundance of calorically dense, processed foods. Every one of those things does contribute! There is no question that lifestyle changes can move the needle on the obesity epidemic. I work with people every day on changing habits to improve their health, and it works. But not everyone has the same resources to make those lifestyle changes or get the support they need.
There are communities in this country where riding your bike isn’t safe. Children cannot play in the streets for fear of gangs, drug dealers, and worse. There are neighborhoods where parks and other green spaces do not exist. For kids experiencing food scarcity, free or reduced lunch might be their most nutritious meal of the day. Food deserts and food swamps have profound effects on the rates of obesity and other chronic diseases, and these environments are experienced more often by marginalized communities. Advertisements for ultra-processed foods have been shown to target Black and Hispanic children disproportionately. Socioeconomic status, race and ethnicity, education level, sexual orientation, religious affiliation, and gender all affect one’s ability to receive culturally appropriate and quality health care in this country. The resources necessary to experience wellness, including maintaining a healthy weight, are not equally accessible. We will not see improvement in the obesity epidemic until we are willing to take a health equity view.
This cannot come from medical providers and public health officials alone, though they will clearly play major roles. For our health (and weight) to improve as a nation, health and healthcare must be a value of Americans. Policies, systems, and laws need to change to reduce the disparities experienced by marginalized groups. “Eat less, move more” means nothing if you don’t have secure housing, quality education, access to nutritious foods, and safe neighborhoods. Yes, healthy equity is a larger, lengthier goal to achieve. It feels easier to blame this on cheeseburgers, milkshakes, and televisions than to consider the daunting challenge of health inequities. But we will never solve the obesity epidemic by looking at individual behaviors alone. To impact meaningful change, we need to focus less on personal responsibility and more on health equity.
Holly Ohlsson is the Owner of Holly Ohlsson Coaching, a lifestyle medicine-centered Health and Wellness Coaching practice. She is a Board-Certified Health and Wellness Coach (NBHWC) and a Functional Medicine Certified Health Coach (FMCHC). She received a Bachelor of Science in Mechanical Engineering from Duke University and is currently pursuing a Master of Science in Health and Wellness Management from Tulane University.