essay on public health issues obesity

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• Published: 27 February 2019

Obesity: global epidemiology and pathogenesis

• Matthias Blüher 1  

Nature Reviews Endocrinology volume  15 ,  pages 288–298 ( 2019 ) Cite this article

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• Epidemiology
• Health policy
• Pathogenesis

The prevalence of obesity has increased worldwide in the past ~50 years, reaching pandemic levels. Obesity represents a major health challenge because it substantially increases the risk of diseases such as type 2 diabetes mellitus, fatty liver disease, hypertension, myocardial infarction, stroke, dementia, osteoarthritis, obstructive sleep apnoea and several cancers, thereby contributing to a decline in both quality of life and life expectancy. Obesity is also associated with unemployment, social disadvantages and reduced socio-economic productivity, thus increasingly creating an economic burden. Thus far, obesity prevention and treatment strategies — both at the individual and population level — have not been successful in the long term. Lifestyle and behavioural interventions aimed at reducing calorie intake and increasing energy expenditure have limited effectiveness because complex and persistent hormonal, metabolic and neurochemical adaptations defend against weight loss and promote weight regain. Reducing the obesity burden requires approaches that combine individual interventions with changes in the environment and society. Therefore, a better understanding of the remarkable regional differences in obesity prevalence and trends might help to identify societal causes of obesity and provide guidance on which are the most promising intervention strategies.

Obesity prevalence has increased in pandemic dimensions over the past 50 years.

Obesity is a disease that can cause premature disability and death by increasing the risk of cardiometabolic diseases, osteoarthritis, dementia, depression and some types of cancers.

Obesity prevention and treatments frequently fail in the long term (for example, behavioural interventions aiming at reducing energy intake and increasing energy expenditure) or are not available or suitable (bariatric surgery) for the majority of people affected.

Although obesity prevalence increased in every single country in the world, regional differences exist in both obesity prevalence and trends; understanding the drivers of these regional differences might help to provide guidance for the most promising intervention strategies.

Changes in the global food system together with increased sedentary behaviour seem to be the main drivers of the obesity pandemic.

The major challenge is to translate our knowledge of the main causes of increased obesity prevalence into effective actions; such actions might include policy changes that facilitate individual choices for foods that have reduced fat, sugar and salt content.

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Definition and Overview

The World Health Organization (WHO) defines overweight and obesity as having “excessive fat accumulation that presents a risk to health.” There are various methods to calculate body fat , as each range in accuracy and can have limitations. Body mass index (BMI) is one tool used to screen for excessive body fat. A BMI value of more than 25 is categorized as overweight, and a BMI value of more than 30 is categorized as obese.

Why use BMI?

Health impacts.

There are negative health impacts associated with excess body fat. The WHO estimates that in 2019, 5 million deaths from noncommunicable diseases such as cardiovascular disease and diabetes were caused by a high BMI, and rates of obesity continue to grow globally in children and adults. [1] According to the Centers for Disease Control and Prevention in the U.S., 1 in 5 children and 1 in 3 adults has obesity. [2] Children with obesity are more likely to have obesity as adults and the associated risks of heart disease, high blood pressure, type 2 diabetes, and certain types of cancer.

A healthy amount of body fat in children and teens varies based on age as well as sex. The Centers for Disease Control and Prevention (CDC) developed growth charts for boys and girls ages 2-19 that show the distribution of BMI values at each age. [3] By the CDC’s definition, a child whose BMI falls between the 85th and 94th percentile for age and sex is considered overweight; a BMI at the 95th percentile or higher for age is considered obese. As the rates of obesity rise in children, there is also a category for severe obesity in which the BMI is 120% of the 95th percentile. The American Academy of Pediatrics provides more specific classifications of severe obesity:

• Class 2 Obesity: BMI ≥120% to <140% of the 95th percentile or BMI ≥35 to <40 kg/m 2
• Class 3 Obesity: BMI ≥140% of the 95th percentile or BMI ≥40 kg/m 2

Obesity can negatively affect nearly every system in a child’s body – the heart, lungs, muscles, bones, kidneys, digestive tract, and hormones that control blood sugar and puberty – and can also take a heavy social and emotional toll. Children with obesity may be burdened by stigma and discrimination from bullying, teasing and victimization. Youth with obesity have substantially higher odds of remaining overweight or obese into adulthood increasing their risk of disease and disability later in life. [4]

The risk of developing diabetes, heart disease, and other weight-related health risks increases with an increasing body mass index (BMI). But evidence shows that in some ethnic and racial groups, weight gain and higher fat mass even if BMI remains in the normal range can still increase health risks.

The Nurses’ Health Study tracked patterns of weight gain and type 2 diabetes (T2D) development in 78,000 U.S. women to see differences by ethnic group. [5] All women were healthy at the start of the study. After 20 years, researchers found that at the same BMI, Asians had more than twice the risk of developing T2D than Whites; Hispanics and Blacks also had higher risks of diabetes than Whites, but to a lesser degree. Increases in weight over time were more harmful in Asians than in other ethnic groups – for every 11 pounds Asians gained during adulthood, they had an 84% increased risk of T2D; Hispanics, Blacks, and Whites who gained weight also had higher risk, but to a much lesser degree than Asians. Other studies have found that even with a lower BMI than Whites, increasing weight in Asians with a BMI of 25 or higher increased risk of high blood pressure, T2D, and early death from all causes. [6-8]

One reason for this difference could be amount and location of body fat. Even with a lower BMI than other populations, Chinese and South Asians tend to carry higher abdominal fat than Whites, which increases the risk for T2D, cardiovascular disease, and other metabolic disorders. [9-11] In contrast, some studies have found that blacks have lower body fat and higher lean muscle mass than whites at the same BMI, and therefore at the same BMI, may be at lower risk of obesity-related diseases. [12,13]

For this reason, the World Health Organization and other organizations have recommended a lower BMI cutoff to classify obesity in Asian people (BMI of 25-27 or greater) as well as a smaller waist circumference to measure visceral fat. [9,14]

Weight gain of greater than 10 pounds in adulthood also increases disease risk (i.e., heart disease, high blood pressure, type 2 diabetes, gallstones) even in those whose BMI remains in the normal range, according to research from the Nurses’ Health Study and Health Professionals Follow-up Study. [15-19]

With the five leading causes of death – heart disease, cancer , chronic lower respiratory disease, cerebrovascular diseases such as stroke, and unintentional injuries – obesity is a major risk factor for the first four. [20] Obesity is also associated with other health conditions such as sleep apnea, fatty liver disease, gallstones, infertility, respiratory diseases, gastroesophageal reflux disease, and musculoskeletal disorders such as arthritis. No less real are the social and emotional effects of obesity which may include discrimination, lower quality of life, and susceptibility to depression.

Economic Impacts

Obesity costs the U.S. health care system almost $173 billion annually. [2] This includes money spent directly on medical care and prescription drugs related to obesity. In the workplace, research has shown that the number of sick days, short-term disability, and workers’ compensation days increase with increasing BMI. [21] Compared with an employee with a BMI of 25, an employee with a BMI of 35 has nearly double the risk of a disability or workers’ compensation claim. Perhaps one of the most surprising consequences of the current obesity epidemic in the U.S. is its impact on recruitment for the armed services, with data showing that 3 in 5 young adults carry too much weight to qualify for military service. [2]

According to the WHO, worldwide obesity rates are rising with 1 in 8 people, or more than 1 billion people, around the world living with obesity. [14] A Lancet review showed that global adult obesity doubled from 1990 to 2022, and adolescent obesity quadrupled. [22] As low to middle-income countries adopt unhealthy eating patterns and behaviors of industrialized nations such as less physical activity, so do their obesity rates. Specific regions including Polynesia, Micronesia, the Caribbean, the Middle East, and north Africa showed the greatest increases in obesity, as well as higher-income countries such as Chile. [22] Increased eating out of home, access to ultra-processed low-nutrient-dense foods, and sedentariness (e.g., sitting at work, driving instead of walking or bicycling) have contributed. Higher cost and limited access to healthy foods and decreased opportunities for play and sports may cause inequalities in obesity and could limit the impact of policies that target unhealthy foods. [22]

The NCD Risk Factor Collaboration visualizes the prevalence of obesity globally as well as changing obesity rates in various countries since 1990. Below are data summaries of obesity rates for both adults and children around the world:

In 2018, the United States had the highest prevalence of adult obesity among high-income Western countries worldwide. [23]   From 1999 through 2018, the age-adjusted prevalence of adults with obesity increased significantly from 31% to 42%. [24]. If trends continue, projections estimate that by 2030 nearly 50% of adults will have obesity, and nearly 1 in 4 adults will have severe obesity (BMI ≥35). [25]

Obesity disproportionately affects U.S. racial/ethnic minority populations. Compared to 42% of non-Hispanic whites, 50% of non-Hispanic Black and 45% of Hispanic adults have obesity. [24] There are considerable differences in obesity among non-Hispanic Black adults by sex, with 57% of non-Hispanic Black women having obesity compared to 41% of men. [24] Trends estimate that severe obesity may become the most common BMI category among non-Hispanic Black and low-income adults by 2030. [25]

Obesity rates in Canada are not as high as they are in the U.S., but Canada has seen dramatic increases over the past three decades. Obesity prevalence among Canadian adults increased from 9% in 1975 to 31% by 2016. [23] Indigenous populations in Canada are also disproportionately affected by the burden of obesity. [26]

The U.S. has among the highest childhood obesity rates in the world, with nearly 1 in 3 children with overweight or obesity. In 2015-2016, nearly 19% of children 2-19 years old had obesity, affecting an estimated 14 million children nationwide. Obesity prevalence was highest among adolescents 12-19 years old (21%) and lowest among preschool-aged children 2-5 years old (14%). [27] Recently, the prevalence of obesity declined among children ages 2-5 years old, held steady for children 6-11 years, and continued to rise among adolescents 12-19 years. [28,29] Current trends suggest that an alarming 57% of children currently between 2 and 19 years old will have obesity at age 35. [30]

Overweight and obesity disproportionally affects racial/ethnic minority populations, and such disparities exist as early as age 2 and persist into adulthood. [27,30] The highest obesity prevalence are among Hispanic (26%) and non-Hispanic Black children (22%), compared with the lowest prevalence among non-Hispanic White (14%) and non-Hispanic Asian (11%) children. [27]

Canada has also seen a rise in childhood obesity since the late 1970s. Obesity rates have more than doubled, and in some age groups, tripled. [31] But childhood obesity rates are lower there than they are in the U.S; in 2013, 10% of children ages 6-11 years old and 17% of children ages 12-17 had obesity. [32] Childhood obesity is significant among Canada’s Aboriginal groups. In a 2006 survey of Aboriginal Peoples in Canada, nearly 33% of children ages 6-8 had obesity, and 13% among children ages 9-14. [33]

Over the past several decades, obesity has become a significant health challenge in Latin America. While undernourishment persists among vulnerable groups, so do overweight and obesity. Each year, obesity among the population grows by 3.6 million individuals, and now exceeds undernourishment as the greatest nutritional threat. [34] Between 1975 and 2014, among the largest increases in BMI in regions worldwide occurred for men in central Latin America, and for women in Andean Latin America and the Caribbean. [35] In 2016, approximately 104 million adults in Latin America had obesity; 15% of men and 16% of women. [23] Countries with the highest prevalence of obesity included Bermuda (women 43%, men 30%) and Puerto Rico (women 42%, men 29%). [23]

While Latin America has shown significant progress in reducing child stunting due to undernourishment, prevalence of overweight and obesity due to malnutrition has grown to be among the highest in the world. [34] As a result, Latin American children have the dual burden of undernutrition coexisting with overweight and obesity. [36] In 2016, 15% of children ages 5-9 years and 10% of adolescents ages 10-19 years had obesity in Latin America and the Caribbean. [34] Among girls ages 5-19 years old, central Latin America demonstrated the highest increase of BMI per decade worldwide over the past 40 years. [37] Inequality further exacerbates overweight and obesity in populations with lower income, and among women, indigenous peoples, Afro-descendants, and rural families. [34]

Since 1975, obesity rates have been rising across Europe, though not as rapidly or as high as they are in the U.S. [35] Countries with the highest prevalence include Malta and the United Kingdom, hovering around 30% for both men and women. Countries with the lowest obesity prevalence include Austria, Sweden, Denmark, and Switzerland for women and Moldova and Russia for men (<20% for all). [23] The rise in women’s BMI in central and southwestern Europe has been among the lowest over the past 40 years, one of the few places worldwide that can report such a trend. [23,35]

Over the past several decades, many European countries had among the largest increases in the number of children and adolescents with obesity. [37] More recently, obesity has plateaued in many regions, particularly in eastern, northwestern, and southwestern Europe, but prevalence rates remain high in Mediterranean countries. [37,38] In Greece, Malta, and Cyprus, 16% of boys ages 5-19 have obesity, and 11% of girls in Greece and Malta. [37]  

Regional surveys and analyses demonstrate similar childhood obesity trends in Europe. A 2019 systematic review of 130 studies across 28 European countries assessed prevalence trends in overweight and obesity among 2-13-year-old children between 1999-2016. [39] The prevalence of overweight and obesity tended to decrease in the Iberian region and increase in the Mediterranean regions, with no significant changes in Atlantic or Central Europe. Although the overall prevalence of childhood overweight and obesity remains high, trends have stabilized in most European countries, but continues to rise in some Mediterranean countries. [39]

Undernutrition has historically received more public health attention in Africa than overnutrition. Yet today, obesity and associated chronic diseases have become a growing problem across the continent. Some have called it a “silent epidemic,” striking countries that are still struggling with the health and economic burdens of malnutrition, stunting, infectious disease, and high childhood mortality rates. [40]

Obesity prevalence is higher among African women compared with men, and can vary widely from country to country. For example in 2016, 41% of women in South Africa had obesity (higher than in U.S. women) compared with 16% of men. In stark contrast, the lowest prevalence of obesity was in Ethiopia for women (7.3%) and in Uganda for men (2%); prevalence of undernutrition exceeds that of overnutrition in these African countries among many others. [35]  Between 1975 and 2016, Botswana experienced the largest increases in obesity prevalence in these African regions, jumping from 5% to 31%. [35]

Hunger, underweight, and stunting have long been the more pressing child nutrition concerns across Africa. Even today, more children and adolescents are moderately or severely underweight than obese, particularly in central, east, and west Africa. [35] Yet here too, child obesity rates are on the rise, particularly in southern Africa. In 1975, less than 0.5% of girls and boys in South Africa had obesity, but by 2016 the prevalence jumped to 13% for girls and 10% for boys. [37]

Researchers have taken a closer look at obesity trends in the six Persian Gulf states (Oman, Bahrain, United Arab Emirates, Saudi Arabia, Qatar, and Kuwait), since these countries have seen tremendous increases in wealth since the discovery of oil reserves in the 1960s. [41] Even in 1975, obesity prevalence in Kuwait, Qatar, and the United Arab Emirates exceeded 20% among women, raking among the top 20 countries worldwide with the highest prevalence. Among men, Kuwait and Qatar also ranked among the top 20 countries with the highest prevalence in 1975, but only at 12%. [23] In 2016, the prevalence of obesity increased to 47% in Kuwait and 45% in Qatar for women, and to approximately 30% for men in both countries. The most significant increases have been observed in Saudi Arabia and Jordan, from 6% in 1975 to around 30% in 2016. [23]

The Middle East and north Africa have seen sharp increases in obesity since 1975, and this region now has among the highest prevalence of child and adolescent obesity worldwide. [38] Girls in Kuwait and Egypt and boys in Kuwait, Qatar, and Saudi Arabia have the highest obesity prevalence in the region, all hovering around 20% of the child and adolescent population. [37] In 1975, girls in the Middle East and north Africa had higher age-standardized BMI than boys, but by 2016 this gap shrank or reversed as boys gained more weight than girls. [37]

Some countries in Asia have the lowest obesity prevalence worldwide, yet here too it has become a serious problem across the region over the past four decades, even while underweight concerns persist. Japan and South Korea have among the lowest obesity prevalence in the world (<9%) for both men and women. However, recent trends in China are of special concern. Although obesity rates are still low overall, there has been a substantial increase from <1% in 1978, to 6% for women and 7% for men in 2016. [23] China is one of the most populous nations on the planet with more than 1.4 billion people, so even small percentage increases in obesity prevalence translate into millions more cases of chronic disease. Furthermore, Asians have a higher risk of weight-related diseases like type 2 diabetes at lower BMI levels , further exacerbating the health issues related to overweight and obesity.

South Asian countries like Bangladesh, India, and Pakistan have among the highest prevalence of moderate and severe underweight worldwide; 20% in girls and 29% in boys. Nevertheless, trends in mean BMI have significantly accelerated in east, south, and southeast Asia between 1975 and 2016. Although obesity prevalence remains relatively low in south Asia, their large populations add up to large numbers of children who have obesity.

Compared to south Asia, the prevalence of child and adolescent obesity is greater in high income Asia Pacific and east/southeast Asia, particularly among boys. [37,38] Obesity prevalence in Malaysia, Taiwan, and China for boys was less than 0.5% in 1975 and jumped to 15% in 2016. Girls in Asia have lower obesity prevalence compared to boys, but has still been increasing over time, most notably in Malaysia where obesity increased from 0.2% to 10% during this time period. [37]  

It’s important to note that in Asian adults, the health complications associated with overweight and obesity start at a lower BMI than seen in the U.S. and Europe; therefore these estimates of child obesity prevalence in Asia likely underestimate the true public health burden of obesity in Asia.

The top 13 countries with the highest obesity prevalence worldwide are located within Oceania. Eight of the countries exceed 45% obesity prevalence among men, and 13 countries exceed 50% among women. American Samoa and Nauru have the highest obesity prevalence among women (68%) worldwide; for men it is Nauru at 60%. Australia and New Zealand have lower prevalence in the region but still hover around 30% for both men and women. [23]

Of the top 13 countries with the highest child and adolescent obesity prevalence in 2016, 11 were located in Oceania. There was more than 30% obesity prevalence for both girls and boys in the Cook Islands, Nauru, Palau, and additionally for boys in Niue and American Samoa. [37]

High-income countries in Oceania, Australia and New Zealand have childhood obesity rates in the double digits, but there’s some evidence that rates have hit a plateau. In Australia, 13% of boys and 11% of girls have obesity; in New Zealand the prevalence is higher at 18% and 15% respectively. [37] Overweight and obesity prevalence is even higher in some of New Zealand’s ethnic groups (Maori, 37%; Pacific Islanders, 57%) but have largely unchanged since early 2000. [42]

Risk Factors

Various factors can influence body weight or greater weight gain in specific areas of the body. Some of these cannot be changed, but others may be modified:

• Non-modifiable risk factors (risk factors you can’t change): age, gender, genes, ethnic origin, and sometimes medications that change how energy is processed in the body leading to weight gain. There’s also strong evidence that having obesity in infancy or childhood increases the chances of remaining obese in adulthood.
• Risk factors that can be modified: food and beverages consumed, level of physical activity, daily screen time (increased screen time is associated with reduced physical activity time and also increases exposure to marketing of unhealthy foods/beverages), poor sleep hygiene, uncontrolled negative stress. While easier said than done, evidence has shown that addressing these factors as early as possible, even in childhood, may reduce the risk of developing obesity.

Obesity is complex and not just about being born with a certain body size, taking in more calories than the body needs, or burning extra calories through exercise to lose weight. It is often the result of a combination of several non-modifiable and modifiable risk factors. When looking at diet and food, which is often the focus with obesity, there are various factors to consider than just calories in/calories out:

• Living in a food environment that lacks access to healthy food choices or income-related barriers to regularly consuming a variety of healthy foods.
• Amount of low-nutrient ultra-processed foods and sugary beverages consumed, especially when displacing high-fiber whole foods, which can increase cravings .
• Eating behaviors such as skipping meals and eating heavy meals or snacks at night before bed.
• Overeating portions not from hunger but from stress or boredom.

The environments that surround us also play an important role, as they can make a modifiable risk factor a non-modifiable one. Examples are when someone does not have the ability to secure healthy food choices due to living in a food desert or a safe place to perform regular physical activity .

There are various risk factors for obesity, but not everyone with these risk factors develops obesity. And not everyone who has obesity develops health problems. In these cases, genes may play a role. Studies of siblings or twins show genetic factors that can determine weight and body size throughout life. [43] Some research suggests differences in genes in people who are of normal weight versus those carrying extra weight that may influence appetite control, metabolic rate, or even ability to change behavior. Gene-nutrient interactions can also promote obesity. For example, genes that increase risk of developing obesity have been reported to be stimulated by saturated fatty acids but not by unsaturated fatty acids . [43] The gut microbiome may also play a role in a person’s risk of developing obesity and chronic health conditions. [44]

However, obesity caused by mutations in a single gene, or monogenic obesity, is rare and is more likely influenced by changes in many different genes, called “common” obesity. Still, the modern obesity epidemic is largely fueled by environmental factors, with excess energy intake and low physical activity pinned as the main culprits. [45] First-degree family members (parents, siblings) who live together typically share similar environments that increase the risk of obesity, and health-related habits of parents are often passed onto their children. Examples include food choices, meal preparation methods (cooking at home vs. reliance on fast food), exercise, screen time, and sleep habits, as well as lack of access to outdoor green space.

These findings suggest that genetic factors make a small contribution to obesity risk, and that our genes are not our destiny. Many people who carry potential “obesity genes” do not become overweight, and healthy lifestyles can counteract these genetic effects.

Is Prevention Possible?

Many factors contribute to rising rates of obesity in children and adults. Among them, the abundance of low-priced, high-calorie ultra processed foods and sugary drinks; incessant marketing driving people to eat more; and an environment that reduces the need for regular physical activity.

Although preventing weight gain over the years of life may not be possible for everyone due to a variety of circumstances, there are strategies to reduce the amount of weight change by increasing awareness of modifiable risk factors and working toward healthy lifestyle behaviors.

However, focusing only on the individual (e.g., nutrition and lifestyle education, weight loss medications) has little impact on global obesity prevalence. Prevention requires a broader scope that addresses food systems and an obesogenic environment , including policy changes such as regulating the marketing of ultra-processed low-nutrient-dense foods and taxing items such as sugar-sweetened beverages.

Indeed, what sometimes gets lost in the discussion is that obesity is preventable . We can turn around the obesity epidemic by collaboratively creating an environment where the default option is the healthy choice.

Obesity prevention at the individual level and beyond

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• 1 Stanley Medical College, India
• 2 University of Illinois College Medicine of Rockford, & Javon Bea Hospital, Mercy Health System, IL
• PMID: 34283488
• Bookshelf ID: NBK572122

Obesity is an alarmingly increasing global public health issue. Obesity is labeled as a national epidemic, and obesity affects one in three adults and one in six children in the United States of America. Several countries worldwide have witnessed a double or triple escalation in the prevalence of obesity in the last three decades (Figure 1, Figure2), probably due to urbanization, sedentary lifestyle, and increase consumption of high-calorie processed food.

The alarming increase in childhood obesity foreshows a tremendous burden of chronic disease prevention in the future public healthcare systems worldwide. Obesity prevention is a critical factor in controlling Obesity-related Non-communicable diseases (OR-NCDs), including insulin resistance/metabolic syndrome, featuring hyperinsulinemia, type 2 diabetes, hyperlipidemia, hypertension, and coronary artery disease.

The failure of the traditional obesity control measures has stressed the importance of a new non-stigmatizing public policy approach, shifting away from the traditional focus on individual behavior change towards strategies dealing with environmental change. The other big challenge related to overweight and obesity is weight bias and discrimination. In public settings such as work environments, healthcare facilities, and educational setup, obese individuals face discrimination.

Copyright © 2024, StatPearls Publishing LLC.

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Conflict of interest statement

Disclosure: Aditi Tiwari declares no relevant financial relationships with ineligible companies.

Disclosure: Palanikumar Balasundaram declares no relevant financial relationships with ineligible companies.

• Continuing Education Activity
• Introduction
• Issues of Concern
• Clinical Significance
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Prevention, prevention, prevention.

Losing weight is hard to do.

In the U.S., only one in six adults who have dropped excess pounds actually keep off at least 10 percent of their original body weight. The reason: a mismatch between biology and environment. Our bodies are evolutionarily programmed to put on fat to ride out famine and preserve the excess by slowing metabolism and, more important, provoking hunger. People who have slimmed down and then regain their weight don’t lack willpower—their bodies are fighting them every inch of the way.

This inborn predisposition to hold on to added weight reverberates down the life course. Few children are born obese, but once they become heavy, they are usually destined to be heavy adolescents and heavy adults. According to a 2016 study in the New England Journal of Medicine , approximately 90 percent of children with severe obesity will become obese adults with a BMI of 35 or higher. Heavy young adults are generally heavy in middle and old age. Obesity also jumps across generations; having a mother who is obese is one of the strongest predictors of obesity in children.

All of which means that preventing child obesity is key to stopping the epidemic. By the time weight piles up in adulthood, it is usually too late. Luckily, preventing obesity in children is easier than in adults, partly because the excess calories they absorb are minimal and can be adjusted by small changes in diet—substituting water, for example, for sugary fruit juices or soda.

Still, the bulk of the obesity problem—literally—is in adults. According to Frank Hu, chair of the Harvard Chan Department of Nutrition, “Most people gain weight during young and middle adulthood. The weight-gain trajectory is less than 1 pound per year, but it creeps up steadily from age 18 to age 55. During this time, people gain fat mass, not muscle mass. When they reach age 55 or so, they begin to lose their existing muscle mass and gain even more fat mass. That’s when all the metabolic problems appear: insulin resistance, high cholesterol, high blood pressure.”

Adds Walter Willett, Frederick John Stare Professor of Epidemiology and Nutrition at Harvard Chan, “The first 5 pounds of weight gain at age 25—that’s the time to be taking action. Because someone is on a trajectory to end up being 30 pounds overweight by the time they’re age 50.”

The most realistic near-term public health goal, therefore, is not to reverse but rather to slow down the trend—and even this will require strong commitment from government at many levels. In May 2017, the Trump administration rolled back recently-enacted standards for school meals, delaying a rule to lower sodium and allowing waivers for regulations requiring cafeterias to serve foods rich in whole grains. If recent expansions in food entitlements and school meals are undermined, “It would be a ‘disaster,’ to use the president’s word,” says Marlene Schwartz, director of the Rudd Center for Obesity & Food Policy at the University of Connecticut. “The federal food programs are incredibly important, not just because of the food and money they provide families, but because supporting better nutrition in child care, schools, and the WIC [Women, Infants, and Children] program has created new social norms. We absolutely cannot undo the progress that we’ve made in helping this generation transition to a healthier diet.”

Get the science right.

It is impossible to prescribe solutions to obesity without reminding ourselves that nutrition scientists botched things decades ago and probably sent the epidemic into overdrive. Beginning in the 1970s, the U.S. government and major professional groups recommended for the first time that people eat a low-fat/high-carbohydrate diet. The advice was codified in 1977 with the first edition of The Dietary Goals for the United States , which aimed to cut diet-related conditions such as heart disease and diabetes. What ensued amounted to arguably the biggest public health experiment in U.S. history, and it backfired.

At the time, saturated fat and dietary cholesterol were believed to be the main factors responsible for cardiovascular disease—an oversimplified theory that ignored the fact that not all fats are created equal. Soon, the public health blitz against saturated fat became a war on all fat. In the American diet, fat calories plummeted and carb calories shot up.

“We can’t blame industry for this. It was a bandwagon effect in the scientific community, despite the lack of evidence—even with evidence to the contrary,” says Willett. “Farmers have known for thousands of years that if you put animals in a pen, don’t let them run around, and load them up with grains, they get fat. That’s basically what has been happening to people: We created the great American feedlot. And we added in sugar, coloring, and seductive promotion for low-fat junk food.”

Scientists now know that whole fruits and vegetables (other than potatoes), whole grains, high-quality proteins (such as from fish, chicken, beans, and nuts), and healthy plant oils (such as olive, peanut, or canola oil) are the foundations of a healthy diet.

But there is also a lot scientists don’t yet know. One unanswered question is why some people with obesity are spared the medical complications of excess weight. Another concerns the major mechanisms by which obesity ushers in disease. Although surplus body weight can itself directly cause problems—such as arthritis due to added load on joints, or breast cancer caused by hormones secreted by fat cells—in general, obesity triggers myriad biological processes. Many of the resulting conditions—such as atherosclerosis, diabetes, and even Alzheimer’s disease—are mediated by inflammation, in which the body’s immune response becomes damagingly self-perpetuating. In this sense, today’s food system is as inflammagenic as it is obesigenic.

Scientists also need to ferret out the nuanced effects of particular foods. For example, do fermented products—such as yogurt, tempeh, or sauerkraut—have beneficial properties? Some studies have found that yogurt protects against weight gain and diabetes, and suggest that healthy live bacteria (known as probiotics) may play a role. Other reports point to fruits being more protective than vegetables in weight control and diabetes prevention, although the types of fruits and vegetables make a difference.

A 2017 article in the American Journal of Clinical Nutrition showed that substituting whole grains for refined grains led to a loss of nearly 100 calories a day—by speeding up metabolism, cutting the number of calories that the body hangs on to, and, more surprisingly, by changing the digestibility of other foods on the plate. That extra energy lost daily—by substituting, say, brown rice for white rice or barley for pita bread—was equivalent to a brisk 30-minute walk. One hundred calories a day, sustained over years, and multiplied by the population is one mathematical equivalent of the obesity epidemic.

A companion study found that adults who ate a whole-grain-rich diet developed healthier gut bacteria and improved immune responses. That particular foods alter the gut microbiome—the dense and vital community of bacteria and other microorganisms that work symbiotically with the body’s own digestive system—is another critical insight. The microbiome helps determine weight by controlling how our bodies extract calories and store fat in the liver, and the microbiomes of obese individuals are startlingly efficient at harvesting calories from food. [To learn more about Harvard Chan research on the gut microbiome, read “ Bugs in the System .”] The hormonal effects of sleep deprivation and stress—two epidemics concurrent and intertwined with the obesity trend—are other promising avenues of research.

And then there are the mystery factors. One recent hypothesis is that an agent known as adenovirus 36 partly accounts for our collective heft. A 2010 article in The Royal Society described a study in which researchers examined samples of more than 20,000 animals from eight species living with or around humans in industrialized nations, a menagerie that included macaques, chimpanzees, vervets, marmosets, lab mice and rats, feral rats, and domestic dogs and cats. Like their Homo sapiens counterparts, all of the study populations had gained weight over the past several decades—wild, domestic, and lab animals alike. The chance that this is a coincidence is, according to the scientists’ estimate, 1 in 10 million. The stumped authors surmise that viruses, gene expression changes, or “as-of-yet unidentified and/or poorly understood factors” are to blame.

Master the art of persuasion.

A 2015 paper in the American Journal of Public Health revealed the philosophical chasm that hampers America’s progress on obesity prevention. It found that 72 to 98 percent of obesity-related media reports emphasize personal responsibility for weight, compared with 40 percent of scientific papers.

A recent study by Drexel University researchers also quantified the political polarization around public health measures. From 1998 through 2013, Democrats voted in line with recommendations from the American Public Health Association 88.3 percent of the time, on average, while Republicans voted for the proposals just 21.3 percent of the time.

Clearly, we can’t count on bipartisan goodwill to stem the obesity crisis. But we can ask what kinds of messages appeal to politically divergent audiences. A stealth strategy may be to avoid even uttering the word “obesity.” On January 1 of this year, Philadelphia’s 1.5-cents-per-ounce excise tax on sugar-sweetened and diet beverages took effect. When Philadelphia Mayor Jim Kenney lobbied voters to approve the tax, his bid centered not on improving health—the unsuccessful pitch of his predecessor—but on raising $91 million annually for prekindergarten programs.

“That’s something lots of people care about and can get behind—it’s a feel-good policy, and it makes sense,” says psychologist Christina Roberto, assistant professor of medical ethics and health policy at the University of Pennsylvania, and a former assistant professor of social and behavioral sciences and nutrition at Harvard Chan. The provision for taxing diet beverages was also shrewd, she adds, because it spread the tax’s pain; since wealthier people are more likely than less-affluent individuals to buy diet drinks, the tax could not be slapped with the label “regressive.”

But Roberto sees a larger lesson in the Philadelphia story. Public health messaging that appeals to values that transcend the individual is less fraught, less stigmatizing, and perhaps more effective. As she puts it, “It’s very different to hear the message, ‘Eat less red meat, help the planet’ versus ‘Eat less red meat, help yourself avoid saturated fat and cardiovascular disease.’”

Supermarket makeovers

Supermarket aisles are other places where public health can shuffle a deck stacked against healthy consumer choices.

With slim profit margins and 50,000-plus products on their shelves, grocery stores depend heavily on food manufacturers’ promotional incentives to make their bottom lines. “Manufacturers pay slotting fees to get their products on the shelf, and they pay promotion allowances: We’ll give you this much off a carton of Coke if you put it on sale for a certain price or if you put it on an end-of-aisle display,” says José Alvarez, former president and chief executive officer of Stop & Shop/Giant-Landover, now senior lecturer of business administration at Harvard Business School. Such promotional payments, Alvarez adds, often exceed retailers’ net profits.

Healthy new products—like flash-frozen dinners prepared with heaps of vegetables and whole grains, and relatively little salt—can’t compete for prized shelf space against boxed mac and cheese or cloying breakfast cereals. One solution, says Alvarez, is for established consumer packaged goods companies to buy out what he calls the “hippie in the basement” firms that have whipped up more nutritious items. The behemoths could apply their production, marketing, and distribution prowess to the new offerings—and indeed, this has started to happen over the last five years.

Another approach is to make nutritious foods more convenient to eat. “We have all of these cooking shows and upscale food magazines, but most people don’t have the time or inclination—or the skills, quite frankly—to cook,” says Alvarez. “Instead, we should focus on creating high-quality, healthy, affordable prepared foods.”

An additional model is suggested by Jeff Dunn, a 20-year veteran of the soft drink industry and former president of Coca-Cola North America, who went on to become an advocate for fresh, healthy food. Dunn served as president and chief executive officer of Bolthouse Farms from 2008 to 2015, where he dramatically increased sales of baby carrots by using marketing techniques common in the junk food business. “We operated on the principles of the three 3 A’s: accessibility, availability, and affordability,” says Dunn. “That, by the way, is Coke’s more-than-70-year-old formula for success.”

Show them the money.

Obesity kills budgets. According to the Campaign to End Obesity, a collaboration of leaders from industry, academia, public health, and policymakers, annual U.S. health costs related to obesity approach $200 billion. In 2010, the nonpartisan Congressional Budget Office reported that nearly 20 percent of the rise in health care spending from 1987 to 2007 was linked to obesity. And the U.S. Centers for Disease Control and Prevention (CDC) found that full-time workers in the U.S. who are overweight or obese and have other chronic health conditions miss an estimated 450 million more days of work each year than do healthy employees—upward of $153 billion in lost productivity annually.

But making the money case for obesity prevention isn’t straightforward. For interventions targeting children and youth, only a small fraction of savings is captured in the first decade, since most serious health complications don’t emerge for many years. Long-term obesity prevention, in other words, doesn’t fit into political timetables for elected officials.

Yet lawmakers are keen to know how “best for the money” obesity-prevention programs can help them in the short run. Over the past two years, Harvard Chan’s Steve Gortmaker and his colleagues have been working with state health departments in Alaska, Mississippi, New Hampshire, Oklahoma, Washington, and West Virginia and with the city of Philadelphia and other locales, building cost-effectiveness models using local data for a wide variety of interventions—from improved early child care to healthy school environments to communitywide campaigns. “We collaborate with health departments and community stakeholders, provide them with the evidence base, help assess how much different options cost, model the results over a decade, and they pick what they want to work on. One constant that we’ve seen—and these are very different political environments—is a strong interest in cost-effectiveness,” he says.

In a 2015 study in Health Affairs , Gortmaker and colleagues outlined three interventions that would more than pay for themselves: an excise tax on sugar-sweetened beverages implemented at the state level; elimination of the tax subsidy for advertising unhealthy food to children; and strong nutrition standards for food and drinks sold in schools outside of school meals. Implemented nationally, these interventions would prevent 576,000, 129,100, and 345,000 cases of childhood obesity, respectively, by 2025. The projected net savings to society in obesity-related health care costs for each dollar invested: $31, $33, and $4.60, respectively.

Gortmaker is one of the leaders of a collaborative modeling effort known as CHOICES—for Childhood Obesity Intervention Cost-Effectiveness Study—an acronym that seems a pointed rebuttal to the reflexive conservative argument that government regulation tramples individual choice. Having grown up not far from Des Plaines, Illinois, site of the first McDonald’s franchise in the country, he emphasizes to policymakers that at this late date, America cannot treat its way out of obesity, given current medical know-how. Only a thoroughgoing investment in prevention will turn the tide. “Clinical interventions produce too small an effect, with too small a population, and at high cost,” Gortmaker says. “The good news is that there are many cost-effective options to choose from.”

While Gortmaker underscores the importance of improving both food choices and options for physical activity, he has shown that upgrading the food environment offers much more benefit for the buck. This is in line with the gathering scientific consensus that what we eat plays a greater role in obesity than does sedentary lifestyle (although exercise protects against many of the metabolic consequences of excess weight). “The easiest way to explain it,” Gortmaker says, “is to talk about a sugary beverage—140 calories. You could quickly change a kid’s risk of excess energy balance by 140 calories a day just by switching from a sugary drink a day to water or sparkling water. But for a 10-year-old boy to burn an extra 140 calories, he’d have to replace an hour-and-a-half of sitting with an hour-and-a-half of walking.”

Small tweaks in adults’ diets can likewise make a big difference in short order. “With adults, health care costs rise rapidly with excess weight gain,” Gortmaker says. “If you can slow the onset of obesity, you slow the onset of diabetes, and potentially not only save health care costs but also boost people’s productivity in the workforce.”

One of Gortmaker’s most intriguing calculations spins off of the food industry’s estimated $633 million spent on television marketing aimed at kids. Currently, federal tax treatment of advertising as an ordinary business expense means that the government, in effect, subsidizes hawking of junk food to children. Gortmaker modeled a national intervention that would eliminate this subsidy of TV ads for nutritionally empty foods and beverages aimed at 2- to 19-year-olds. Drawing on well-delineated relationships between exposure to these advertisements and subsequent weight gain, he found that the intervention would save $260 million in downstream health care costs. Although the effect would probably be small at the individual level, it would be significant at the population level.

Level the playing field through taxes and regulation.

When public health took on cigarette smoking, starting in the 1960s, it did so with robust policies banning television ads and other marketing, raising taxes to increase prices, making public places smoke-free, and offering people treatment such as the nicotine patch. In 1965, the smoking rate for U.S. adults was 42.2 percent; today, it is 16.8 percent.

Similarly, America reduced the rate of deaths caused by motor vehicle accidents—a 90 percent decrease over the 20th century, according to the CDC—with mandatory seat belt laws, safer car designs, stop signs, speed limits, rumble strips, and the stigmatization of drunk driving.

Change the product. Change the environment. Change the culture. That is also the policy recipe for stopping obesity.

Laws that make healthy behaviors easier are often followed by positive changes in those behaviors. And people who are trying to adopt healthy behaviors tend to support policies that make their personal aspirations achievable, which in turn nudges lawmakers to back the proposals.

One debate today revolves around whether recipients of federal Supplemental Nutrition Assistance Program (SNAP) benefits (formerly known as food stamps) should be restricted from buying sodas or junk food. The largest component of the USDA budget, SNAP feeds one in seven Americans. A USDA report, issued last November, found that the number-one purchase by SNAP households was sweetened beverages, a category that included soft drinks, fruit juices, energy drinks, and sweetened teas, accounting for nearly 10 percent of SNAP money spent on food. Is the USDA therefore underwriting the soda industry and planting the seeds for chronic disease that the government will pay to treat years down the line?

Eric Rimm, a professor in the Departments of Epidemiology and Nutrition at the Harvard Chan School, frames the issue differently. In a 2017 study in the American Journal of Preventive Medicine , he and his colleagues asked SNAP participants whether they would prefer the standard benefits package or a “SNAP-plus” that prohibited the purchase of sugary beverages but offered 50 percent more money for buying fruits and vegetables. Sixty-eight percent of the participants chose the healthy SNAP-plus option.

“A lot of work around SNAP policy is done by academics and politicians, without reaching out to the beneficiaries,” says Rimm. “We haven’t asked participants, ‘What’s your say in this? How can we make this program better for you?’” To be sure, SNAP is riddled with nutritional contradictions. Under current rules, for example, participants can use benefits to buy a 12-pack of Pepsi or a Snickers bar or a giant bag of Lay’s potato chips but not real food that happens to be heated, such as a package of rotisserie chicken. “This is the most vulnerable population in the country,” says Rimm. “We’re not listening well enough to our constituency.”

Other innovative fiscal levers to alter behavior could also drive down obesity. In 2014, a trio of strong voices on food industry practices—Dariush Mozaffarian, DrPH ’06, dean of Tufts University’s Friedman School of Nutrition Science and Policy and former associate professor of epidemiology at the Harvard Chan School; Kenneth Rogoff, professor of economics at Harvard; and David Ludwig, professor in the Department of Nutrition at Harvard Chan and a physician at Boston Children’s Hospital—broached the idea of a “meaningful” tax on nearly all packaged retail foods and many chain restaurants, with the proceeds used to pay for minimally processed foods and healthier meals for school kids. In essence, the tax externalizes the social costs of harmful individual behavior.

“We made a straightforward proposal to tax all processed foods and then use the income to subsidize whole foods in a short-term, revenue-neutral way,” explains Ludwig. “The power of this idea is that, since there is so much processed food consumption, even a modest tax—in the 10 to 15 percent range—is not going to greatly inflate the cost of these foods. Their price would increase moderately, but the proceeds would not disappear into government coffers. Instead, the revenue would make healthy foods affordable for virtually the entire population, and the benefits would be immediately evident. Yes, people will pay moderately more for their Coke or for their cinnamon bear claw but a lot less for nourishing, whole foods.”

Another suggestion comes from Sandro Galea, dean of the Boston University School of Public Health, and Abdulrahman M. El-Sayed, a public health physician and epidemiologist. In a 2015 issue of the American Journal of Public Health , they called for “calorie offsets,” similar to the carbon offsets used to mitigate environmental harm caused by the gas and oil industries. A “calorie offset” scheme could hand the food and beverage industries a chance at redemption by inviting them to invest in such undertakings as city farms, cooking classes for parents, healthy school cafeterias, and urban green spaces.

These ambitious proposals face almost impossibly high hurdles. Political battle lines typically pit public health against corporations, with Big Food casting doubt on solid nutrition science, deeming government regulation a threat to free choice, and making self-policing pledges that it has never kept. On the website for the Americans for Food and Beverage Choice, a group spearheaded by the American Beverage Association, is the admonition: “[W]hether it’s at a restaurant or in a grocery store, it’s never the government’s job to decide what you choose to eat and drink.”

Yet surprisingly, many public health professionals are convinced that the only way to stop obesity is to make common cause with the food industry. “This isn’t like tobacco, where it’s a fight to the death. We need the food industry to make healthier food and to make a profit,” says Mozaffarian. “The food industry is much more diverse and heterogeneous than tobacco or even cars. As long as we can help them—through carrots and sticks, tax incentives and disincentives—to move towards healthier products, then they are part of the solution. But we have to be vigilant, because they use a lot of the same tactics that tobacco did.”

Sow what we want to reap.

Americans overeat what our farmers overproduce.

“The U.S. food system is egregiously terrible for human and planetary health,” says Walter Willett. It’s so terrible, Willett made a pie chart of American grain production consumed domestically. It shows that most of the country’s agricultural land goes to the two giant commodity crops: corn and soy. Most of those crops, in turn, go to animal fodder and ethanol, and are also heavily used in processed snack foods. Today, only about 10 percent of grain grown in the U.S. for domestic use is eaten directly by human beings. According to a 2013 report from the Union of Concerned Scientists, only 2 percent of U.S. farmland is used to grow fruits and vegetables, while 59 percent is devoted to commodity crops.

Historically, those skewed proportions made sense. Federal food policies, drafted with the goal of alleviating hunger, preferentially subsidize corn and soy production. And whereas corn or soybeans could be shipped for days on a train, fruits and vegetables had to be grown closer to cities by truck farmers so the produce wouldn’t spoil. But those long-ago constraints don’t explain today’s upside-down agricultural priorities.

In a now-classic 2016 Politico article titled “The farm bill drove me insane,” Marion Nestle illustrated the irrational gap between what the government recommends we eat and what it subsidizes: “If you were to create a MyPlate meal that matched where the government historically aimed its subsidies, you’d get a lecture from your doctor. More than three-quarters of your plate would be taken up by a massive corn fritter (80 percent of benefits go to corn, grains and soy oil). You’d have a Dixie cup of milk (dairy gets 3 percent), a hamburger the size of a half dollar (livestock: 2 percent), two peas (fruits and vegetables: 0.45 percent) and an after-dinner cigarette (tobacco: 2 percent). Oh, and a really big linen napkin (cotton: 13 percent) to dab your lips.”

In this sense, the USDA marginalizes human health. Many of the foods that nutritionists agree are best for us—notably, fruits, vegetables, and tree nuts—fall under the bureaucratic rubric “specialty crops,” a category that also includes “dried fruits, horticulture, and nursery crops (including floriculture).” Farm bills, which get passed every five years or so, fortify the status quo. The 2014 Farm Bill, for example, provided $73 million for the Specialty Crop Block Grant Program in 2017, out of a total of about $25 billion for the USDA’s discretionary budget. (The next Farm Bill, now under debate, will be coming out in 2018.)

By contrast, a truly anti-obesigenic agricultural system would stimulate USDA support for crop diversity—through technical assistance, research, agricultural training programs, and financial aid for farmers who are newly planting or transitioning their land into produce. It would also enable farmers, most of whom survive on razor-thin profit margins, to make a decent living.

In the early 1970s, Finland’s death rate from coronary heart disease was the highest in the world, and in the eastern region of North Karelia—a pristine, sparsely populated frontier landscape of forest and lakes—the rate was 40 percent worse than the national average. Every family saw physically active men, loggers and farmers who were strong and lean, dying in their prime.

Thus was born the North Karelia Project, which became a model worldwide for saving lives by transforming lifestyles. The project was launched in 1972 and officially ended 25 years later. While its initial goal was to reduce smoking and saturated fat in the diet, it later resolved to increase fruit and vegetable consumption.

The North Karelia Project fulfilled all of these ambitions. When it started, for example, 86 percent of men and 82 percent of women smeared butter on their bread; by the early 2000s, only 10 percent of men and 4 percent of women so indulged. Use of vegetable oil for cooking jumped from virtually zero in 1970 to 50 percent in 2009. Fruit and vegetables, once rare visitors to the dinner plate, became regulars. Over the project’s official quarter-century existence, coronary heart disease deaths in working-age North Karelian men fell 82 percent, and life expectancy rose seven years.

The secret of North Karelia’s success was an all-out philosophy. Team members spent innumerable hours meeting with residents and assuring them that they had the power to improve their own health. The volunteers enlisted the assistance of an influential women’s group, farmers’ unions, homemakers’ organizations, hunting clubs, and church congregations. They redesigned food labels and upgraded health services. Towns competed in cholesterol-cutting contests. The national government passed sweeping legislation (including a total ban on tobacco advertising). Dairy subsidies were thrown out. Farmers were given strong incentives to produce low-fat milk, or to get paid for meat and dairy products based not on high-fat but on high-protein content. And the newly established East Finland Berry and Vegetable Project helped locals switch from dairy farming—which had made up more than two-thirds of agriculture in the region—to cultivation of cold-hardy currants, gooseberries, and strawberries, as well as rapeseed for heart-healthy canola oil.

“A mass epidemic calls for mass action,” says the project’s director, Pekka Puska, “and the changing of lifestyles can only succeed through community action. In this case, the people pulled the government—the government didn’t pull the people.”

Could the United States in 2017 learn from North Karelia’s 1970s grand experiment?

“Americans didn’t become an obese nation overnight. It took a long time—several decades, the same timeline as in individuals,” notes Frank Hu. “What were we doing over the past 20 years or 30 years, before we crossed this threshold? We haven’t asked these questions. We haven’t done this kind of soul-searching, as individuals or society as a whole.”

Today, Americans may finally be willing to take a hard look at how food figures in their lives. In a July 2015 Gallup phone poll of Americans 18 and older, 61 percent said they actively try to avoid regular soda (the figure was 41 percent in 2002); 50 percent try to avoid sugar; and 93 percent try to eat vegetables (but only 57.7 percent in 2013 reported they ate five or more servings of fruits and vegetables at least four days of the previous week).

Individual resolve, of course, counts for little in problems as big as the obesity epidemic. Most successes in public health bank on collective action to support personal responsibility while fighting discrimination against an epidemic’s victims. [To learn more about the perils of stigma against people with obesity, read “ The Scarlet F .”]

Yet many of public health’s legendary successes also took what seems like an agonizingly long time to work. Do we have that luxury?

“Right now, healthy eating in America is like swimming upstream. If you are a strong swimmer and in good shape, you can swim for a little while, but eventually you’re going to get tired and start floating back down,” says Margo Wootan, SD ’93, director of nutrition policy for the Center for Science in the Public Interest. “If you’re distracted for a second—your kid tugs on your pant leg, you had a bad day, you’re tired, you’re worried about paying your bills—the default options push you toward eating too much of the wrong kinds of food.”

But Wootan has not lowered her sights. “What we need is mobilization,” she says. “Mobilize the public to address nutrition and obesity as societal problems—recognizing that each of us makes individual choices throughout the day, but that right now the environment is stacked against us. If we don’t change that, stopping obesity will be impossible.”

The passing of power to younger generations may aid the cause. Millennials are more inclined to view food not merely as nutrition but also as narrative—a trend that leaves Duke University’s Kelly Brownell optimistic. “Younger people have been raised to care about the story of their food. Their interest is in where it came from, who grew it, whether it contributes to sustainable agriculture, its carbon footprint, and other factors. The previous generation paid attention to narrower issues, such as hunger or obesity. The Millennials are attuned to the concept of food systems.”

We are at a public health inflection point. Forty years from now, when we gaze at the high-resolution digital color photos from our own era, what will we think? Will we realize that we failed to address the obesity epidemic, or will we know that we acted wisely?

The question brings us back to the 1970s, and to Pekka Puska, the physician who directed the North Karelia Project during its quarter-century existence. Puska, now 71, was all of 27 and burning with big ideas when he signed up to lead the audacious effort. He knows the promise and the perils of idealism. “Changing the world may have been utopic,” he says, “but changing public health was possible.”

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Obesity: Health consequences of being overweight

What is not widely known is that the risk of health problems starts when someone is only very slightly overweight, and that the likelihood of problems increases as someone becomes more and more overweight. Many of these conditions cause long-term suffering for individuals and families. In addition, the costs for the health care system can be extremely high.

The good news is that overweight and obesity are largely preventable. The key to success is to achieve an energy balance between calories consumed on one hand, and calories used on the other hand.

To reach this goal, people can limit energy intake from total fats and shift fat consumption away from saturated fats to unsaturated fats; increase consumption of fruit and vegetables, as well as legumes, whole grains and nuts; and limit their intake of sugars. And to increase calories used, people can boost their levels of physical activity - to at least 30 minutes of regular, moderate-intensity activity on most days.

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Diet and physical activity: a public health priority

Obesity as a Public Health Issue Essay

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The website of Obesity in America (n.d.) defines obesity as “an excessive amount of body fat in relation to lean body mass”. To put it in the words of a layman a person has declared obese if his or her body weight is approximately 30% above the ideal weight for his or her average height. There are a number of factors that are responsible for obesity. The most prominent ones include eating a diet rich in fat and calories, leading a sedentary life, or both. Others include genetic, hormonal, behavioral, and environmental factors that can also cause obesity.

There has been a strong debate over the issue of obesity being a public or private matter. Americans appear to be ambivalent over the issue. According to Balko (2004), obesity is a private matter and not a public one. Balko is of the view that everyone should be responsible for his own actions and criticizes the involvement of the government in this issue. Balko points out a number of ways adopted by the government to overcome the problem of obesity. These include setting up a budget of $125 million for adopting a healthy lifestyle, banning snacks and sodas from schools and vending machines, and even introducing a “fat tax” on high-calorie foods. Taxing and depriving those with the food of their choice is actually a demotivating factor. Balko states that instead of adopting all these measures the government should encourage a habit of a moral, financial and personal sense of responsibility. In that way, all the costs, concerns, and worries will be left for only those who are actually obese.

While respecting Balko’s viewpoints let us examine Brownell and Nestle’s (2004) viewpoints who believe that obesity is a public issue.

Brownell and Nestle put the blame on the food industry for promoting unhealthy habits among children. The food industry attracts children towards unhealthy food through ads on TV and hoardings. At the same time, its budget is a lot higher than the budget spent on healthy nutrition education by the government. If the government spends $2 million, Mcdonald’s spends $500 million on the promotion of “We love to see you smile”. Today the teenagers consume sodas twice as much as milk. Furthermore, a survey had shown that French fries comprise 25% of all vegetables consumed by teenagers.

To support their methodology the food industry declares obesity to be a personal responsibility. They support their argument on three points. Firstly they state that people are overweight because of their own negligence, secondly the food industry responds to the demands of the consumers and does not create their demands, and thirdly not to market food to children and displaying calories on food is an attack on freedom.

Brownell and Nestle do not support the above arguments. Firstly since obesity is increasing every year so does that mean that people are becoming less responsible? Or is lack of responsibility becoming an epidemic? Secondly, humans are naturally attracted to high-calorie food. Thirdly the experiment of encouraging people to eat less and exercise more has not been successful. Fourthly eating being a personal responsibility is like the argument put forward by the tobacco industry which has done havoc all over the world. Brownell and Nestle are of the view that obesity is a public problem and that the government should do all efforts to eradicate it by all possible means.

While the arguments of Balko and Brownell both appear valid Americans seem to be split over the issue of obesity is a public or private matter.

In a survey carried out by Lake, Snell, Perry, and Associates (2003) 48% of Americans were of the view that obesity is a private matter and that people must deal with their own problems. 47% stated that it is a public health issue and that society needs to work together to eliminate this problem. About 81% of Americans are of the view that government should play its role in eliminating obesity. 35% stated that the government should play a major role. On the contrary, 18% of Americans were of the view that the government should play its part in this issue. Other than that 74% of the people believed that the healthcare providers and 65% believed that the schools should play a major role in this regard.

At the same time, a lot of people do not support some of the steps taken by the government to curb obesity. 62% of Americans expressed their disapproval for the government’s order of displaying calories on food items. 59% were against the food tax. Majority of the Americans are enthusiastic about educating their children about healthy food. At the same time, 84% supported the idea of banning junk food in school cafeterias.

To conclude it seems that Americans are ambivalent over the issue of obesity. We respect the ideas of Balko and Brownell and they both are true in their own ways. Both agree on the fact that obesity must be taken care of. Obesity is a problem that needs to be taken care of. It is up to the people to decide how to deal with it either privately or at the mass level through government intervention.

Balko, R. “Are You Responsible For Your Own Weight?”, TIME Magazine, (2004). Web.

Brownell, K. Nestle, M. “Are You Responsible For Your Own Weight?” TIME Magazine, (2004). Web.

Lake et al. “Obesity as a Public Health Issue, A look at Solutions”, Harvard Forums on Health, (2003). Web.

“Obesity Basics”, (n.d.). Web.

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Obesity Stigma: Causes, Consequences, and Potential Solutions

Susannah westbury.

1 School of Public Health and Preventative Medicine, Monash University, Melbourne, VIC Australia

Oyinlola Oyebode

2 Wolfson Institute of Population Health, Queen Mary University of London, London, UK

Thijs van Rens

3 Department of Economics, University of Warwick, Coventry, UK

Thomas M. Barber

4 Warwick Medical School, University of Warwick, Coventry, UK

Purpose of Review

This review aims to examine (i) the aetiology of obesity; (ii) how and why a perception of personal responsibility for obesity so dominantly frames this condition and how this mindset leads to stigma; (iii) the consequences of obesity stigma for people living with obesity, and for the public support for interventions to prevent and manage this condition; and (iv) potential strategies to diminish our focus on personal responsibility for the development of obesity, to enable a reduction of obesity stigma, and to move towards effective interventions to prevent and manage obesity within the population.

Recent Findings

We summarise literature which shows that obesity stems from a complex interplay of genetic and environment factors most of which are outside an individual’s control. Despite this, evidence of obesity stigmatisation remains abundant throughout areas of media, entertainment, social media and the internet, advertising, news outlets, and the political and public health landscape. This has damaging consequences including psychological, physical, and socioeconomic harm.

Obesity stigma does not prevent obesity. A combined, concerted, and sustained effort from multiple stakeholders and key decision-makers within society is required to dispel myths around personal responsibility for body weight, and to foster more empathy for people living in larger bodies. This also sets the scene for more effective policies and interventions, targeting the social and environmental drivers of health, to ultimately improve population health.

Introduction

Obesity is defined by The World Health Organisation as “ abnormal or excessive fat accumulation that may impair health ” [ 1 ]. The prevalence of obesity has risen exponentially over the last 50 years and is now so widespread that many have announced a state of obesity pandemic [ 2 , 3 ]. In 2016, WHO estimated that globally, over 1.9 billion adults were overweight, including more than 650 million adults with obesity [ 1 ].

Obesity is a chronic relapsing disease characterised by an inflammatory state and associated with significant mortality and morbidity [ 4 ]. There are > 50 obesity-related conditions that include metabolic dysfunction (type 2 diabetes, hypertension, non-alcoholic fatty liver disease, polycystic ovary syndrome, and cardiovascular disease), mood disorders (depression and anxiety), dementia, joint problems (osteoarthritis), chronic kidney disease, obstructive sleep apnoea, and at least thirteen types of cancer [ 5 – 8 ]. Furthermore, obesity confers a substantial burden on psychological and psychosocial functioning, and has profound consequences on global health economic expenditure [ 9 ].

Obesity stigma is characterised by prejudiced, stereotyped, and discriminatory views and actions towards people with obesity, often fuelled by inaccurate ideas about the causes of obesity [ 9 ]. Despite decades of research supporting the dominant influence of genetic and environmental factors in the development of obesity, in the public consciousness, obesity continues to be viewed as a result of individual-level decision-making. This misperception leads to harmful assumptions about the lifestyles and characters of people with obesity. Such ensuing obesity stigma permeates our current sociocultural and political landscape and has severe consequences for people living with obesity, including worsened mental health [ 10 •], increased mortality and morbidity [ 11 , 12 ], and poor healthcare provision [ 13 ]. Furthermore, a narrative of personal responsibility for obesity development orientates individual-level interventions that are naïve to the reality of underlying genetic and environmental causes of obesity, that in turn receive inadequate attention and support.

Herein, we describe our current understanding of the aetiology of obesity and provide an overview of the evidence base for the impact of genetic and environmental factors. We examine the pervading focus on personal responsibility for obesity development and how this mindset leads to stigma; we explore the widespread and far-reaching consequences of obesity stigma. Finally, we conclude by reviewing promising potential strategies that would reframe obesity within the public consciousness and facilitate more effective and evidence-based interventions to improve both the prevention and management of obesity.

Aetiology of Obesity

Our best current explanation for the global rise in the prevalence of obesity over recent decades promotes complex interactions between underlying genetic predisposition and our environment [ 14 ]. In essence, obesity results from a sustained positive energy balance in which excess calories are consumed, exceeding those that are expended [ 8 ]. It should be noted that this traditional view of the pathophysiology of obesity development is almost certainly an over-simplification, with important roles for hypothalamic regulation of appetite and energy expenditure, the effects of sugar consumption on such regulation (including both insulin and leptin resistance), and the complex interplay between such appetite and metabolism regulating pathways and the gut (including gut peptides, the autonomic nervous system, and the gut microbiota) [ 8 ]. These complex mechanisms, and the myriad ways in which our genes interact with environmental factors to influence body weight, remain incompletely understood [ 8 ].

Our brains and bodies are programmed to tightly regulate energy balance through both metabolic and hormonal systems that control appetite and satiety [ 8 , 15 ]. For our ancestors, fat storage was necessary for survival, likely favouring gene variants that led to weight gain rather than weight loss [ 8 , 16 ]. Key insights into such appetite-regulating genes stem from studies on single gene defects that strongly associate with obesity, including those in key genes such as proopiomelanocortin (POMC) and melanocortin 4 receptor (MC4R) [ 17 ] phenotypically characterised by intractable hunger and the development of severe obesity from an early age. However, such monogenic defects only affect a tiny proportion of the population with obesity, and cannot explain the recent global rise of obesity [ 16 , 17 ].

Given that obesity is a heritable condition and monogenic gene defects only affect a small minority of people, it is important to consider the origin of the heritability of obesity [ 18 ]. Genome-wide association studies (GWAS) reveal common polygenic gene variants, for example in the fat mass and obesity-associated (FTO) gene region, that are associated with changes in fat mass and contribute towards the development of obesity [ 19 ]. However, even considering polygenic effects, these account for only ~ 3% of the heritability of obesity [ 20 ], whilst twin studies show that the real heritability potential of obesity is somewhere between 40 and 70% [ 21 ]. One explanation for the missing heritability stems from epigenetic and epigenomic factors, in which the expression of genes through transcription and translation is influenced through DNA methylation and histone modification. Such modifications to the DNA molecule are influenced heavily by gene–environment interactions, wherein our dietary, physical, in utero, and other environmental exposures activate or silence specific genes, influencing the central control of appetite and metabolism, and ultimately body weight [ 17 , 22 ]. In essence, genetic predisposition to obesity manifests through gene–environmental interactions that underlie the pathophysiology of obesity.

In our evolutionary environment, caloric-restriction combined with a need for large amounts of physical activity (for example in the pursuit of prey, and to gather plant-based foods) a genetic predisposition for preserved body fat through appetitive and metabolic mechanisms would have been an advantage, benefitting those individuals and improving their survival (and reproductive) prospects during times of famine and other environmental threats [ 23 ]. In our modern-day obesogenic environments, such genetic predisposition for the preservation and deposition of fat within adipose tissue that so helped our evolutionary ancestors poses a great threat for modern-day hominids. In short, we are genetically maladapted to our modern-day environment [ 23 ].

Human biology helps to explain why we are seemingly so susceptible to environmental changes. Physiological processes regulating energy balance limit the extent to which individuals can “override” internal homeostatic systems and drivers to control their own body weight [ 24 ]. GWAS show that gene variants associated with BMI and food intake are mostly expressed in the central nervous system, particularly within the hypothalamus, and are therefore beyond conscious control [ 14 ] . In our obesogenic environment that promotes the desirability and availability of energy-dense food, combined with our modern-day society and culture that places so much emphasis on food and eating, it is exceedingly difficult for many individuals to defy the many automatic (including social, hedonic, and habitual) reflexes to eat, particularly when these are subconscious [ 24 ]. As put by Cohen et al., “ people have limited ability to shape the food environment individually and no ability to control automatic responses to food-related cues that are unconsciously perceived… ” [ 24 ]. This may help to explain the evidence for the difficulty experienced by many of losing and sustaining weight loss over a prolonged period [ 25 , 26 ]. Although there are behaviour changes that individuals can implement to mitigate against weight gain and the development of obesity, at a population level, human weight seems largely at the mercy of our genetic makeup and environment.

Having considered genetic factors in the pathogenesis of obesity, it is important to consider the environmental contributors. The radical changes to our human environment over recent decades have rendered our neighbourhoods and daily lives almost unrecognisable even compared to 50 years ago. The environmental changes that most impact our propensity for weight gain and the development of obesity include those that influence our intake and expenditure of energy.

Physical Activity

The technological revolution over the past 100 years has seen great changes to our physical world, characterised by mechanisation, computerisation, and automation [ 27 ]. Accordingly, there has been an unprecedented reduction in the need for humans to expend energy during the execution of everyday tasks that traditionally required physical exertion, for example, transportation and household chores [ 8 , 28 ]. Trends in the built environment increasingly limit opportunities for physical activity through changes in urban landscape and design, poor neighbourhood walkability, and limited options for public transport [ 29 – 31 ]. Although data from the USA shows the percentage of people engaging in formal exercise (such as running, cycling, and strength training) has remained relatively stable over recent decades [ 28 , 32 ], this accounts for only a small proportion of total daily energy expenditure, which is largely determined by occupation [ 33 ]. Workplace-related activity has steadily declined [ 32 ] alongside the rise of computer-based work-related tasks that involve sitting at a desk, increasing the proportion of the day spent sedentary [ 34 ]. This sedentary time is associated with overweight and obesity as well as insulin resistance, cardiovascular disease, and early mortality. Adverse relationships remain even for those who meet public health recommendations for moderate-to-vigorous physical activity [ 35 , 36 ]. Other sedentary behaviours such as watching television, video games, and screen-time have increased in popularity, and also appear to promote the overconsumption of food [ 37 ]. In culmination, these trends lead to an overall reduction in energy expenditure.

Global Food System

The global food system has shifted towards food that is increasingly processed, energy-dense, and nutrient-poor [ 27 ]. The “Western diet” is characterised by high levels of sugar and fat, high energy density, and low levels of fibre [ 8 ]. The marketing industry capitalises on human psychology in ways that maximise the efficacy of food promotion [ 27 ]. Further, increased commercial efficiency through mass production of energy-dense and highly processed foods has enabled affordability, whilst fresh and whole food produce such as fruits and vegetables have increased in price [ 38 ] which discourages a healthy diet [ 39 ]. In culmination, these trends have driven a large increase in energy consumption globally [ 40 ]. Between 1976 and 2000, The United States (US) Centers for Disease Control and Prevention (CDC) measured an increase in daily mean average energy intake of 179 kilocalories (7.3%) for men and 355 kilocalories (23.3%) for women [ 41 ]. This rise in energy intake mostly resulted from increased consumption of carbohydrates and sugary beverages [ 41 , 42 ]. Other contributors to increasing caloric intake included changes to eating patterns, including increased snacking [ 43 ] (resulting primarily from the increased carbohydrate content of highly processed foods and the “rollercoaster” effects on blood sugar levels) and larger meal sizes [ 44 ]. These changes to eating behaviour increase the demand for food and therefore maximise the profits of the food industry [ 45 ]. These important changes in diet and eating behaviours coincided with a dramatic increase in the prevalence of obesity within the US population, which more than doubled from 14.5 to 30.9% in the same timespan [ 41 ].

Similar trends have been observed at different timepoints worldwide. In high-income countries, the transition to a positive energy balance began during the 1970s and 1980s [ 46 ]. A majority of middle-income countries and many low-income countries followed suit, particularly in the context of upward economically mobile populations [ 27 ]. Rapid urbanisation accelerated the rate of obesity prevalence in transitioning low- and middle-income countries, as evidenced by population-based data from Jamaica, Nigeria, and nations of the Pacific Islands. These geographical factors and time-trends affirm the strong impact of local physical and food environments on key behavioural drivers of obesity [ 8 ].

An important epidemiological consideration is that obesity does not affect populations equally, but rather disproportionately impacts underprivileged groups, most exposed to the environmental determinants of obesity, including rural populations, the poor, and minority ethnic groups. Recent findings from the Non-Communicable Disease (NCD) Risk Factor Collaboration [ 47 ] showed that overweight and obesity are greater in rural than urban areas in all high-income countries (HICs). Furthermore, in low- and middle-income countries (LMICs), the rate of increase of overweight and obesity is greater in rural than in urban settings. Indeed, the expected prevalence of overweight and obesity in rural settings may soon overtake that in urban areas [ 47 , 48 ]. If this disproportionate burden of overweight and obesity in rural populations materialises globally, it will be compounded by additional challenges facing rural areas, including poverty, unemployment, worse healthcare access, lack of access to healthy, nutritious fresh produce, and insufficient public transport and infrastructure to facilitate physical activity [ 49 ].

Poverty has a complex relationship with overweight and obesity that varies according to country, income level, and type of income [ 50 ]. In HICs, obesity rates are highest amongst the poor [ 51 ]. In a large-scale study across the European older adult population, Salmasi and Celidoni showed low household income increased the probability of obesity by 0.146 for both men and women when controlled for key variables [ 52 ]. In contrast, overweight and obesity predominantly affects wealthier demographics in LMIC settings [ 53 ]. However, historical evidence suggests that as countries develop economically, the burden of obesity shifts towards the poorest people [ 51 ]. Unabated, these trends predict that in LMICs over the coming decades, the poorest population groups will experience the greatest rise in the prevalence of overweight and obesity [ 51 ].

In addition to socioeconomic status and wealth vs poverty, ethnic and racial groupings represent another important population-based contributor towards the development of obesity. In the USA between 2001 and 2002, African Americans, Native Americans, and Pacific Islanders had an obesity prevalence greater than 30%, whereas Asian Americans had an obesity prevalence of only 4.8% [ 54 ]. These disparities have multivariable and complex causes which are thought to include genetic variation [ 55 , 56 ] as well as ethnic-specific rural location and poverty in addition to differences in healthcare access, social marginalisation, and behaviour [ 57 ]. The weight trajectories of new migrants provide insight into the impact of socioeconomic, sociocultural, and gene–environment interactions. Many migrants to HICs from LMICs arrive with a health advantage which includes healthier body weight than the native population; however, after 10–15 years post-migration, weight gain results in rates of overweight and obesity that often overtake the native population rate [ 58 ]. The influence of ethnic predisposition was highlighted in the Oslo Immigrant Health Study, wherein the prevalence of obesity amongst immigrants varied from 51% (Turkish) to 2.7% (Vietnamese) amongst the population [ 59 ].

Personal Responsibility as a Dominant Explanation for Obesity in Public Discourse

Disease stigma is a social phenomenon that occurs when distinct groups, often those with pre-existing vulnerabilities, are discriminated against on the basis of a medical condition, resulting in stereotyping, labelling, isolation, and reduced status. Ultimately, this results in discrimination [ 60 ]. There is a long and well-documented history of disease stigmatisation in public health history, towards conditions such as cholera, leprosy, tuberculosis, syphilis, drug addiction, mental illness, and perhaps most profoundly in recent memory, HIV/AIDs [ 9 , 61 ].

Obesity stigma is characterised by negative and derogatory ideas about people with obesity. These stereotypes are closely linked to the concept that individuals with obesity are personally responsible for their own weight, despite a wealth of evidence as outlined above, that obesity largely reflects underlying genetic and environmental factors. Accordingly, assumptions are made about the character and behaviours of people with obesity, of being lazy, unhealthy, weak willed, greedy, glutinous and incompetent, and more broadly unclean, immoral, or otherwise defective [ 9 , 62 ]. The result is societal endorsement of stigmatisation and discrimination of obesity that sees people with obesity amongst the last acceptable targets of prejudice, contempt, and ridicule. Current evidence suggests that obesity discrimination has increased exponentially over past decades [ 63 ], to a level that compared with racial discrimination in the USA by the first decade of this century [ 64 ].

Evidence of obesity stigmatisation remains abundant throughout areas of media, entertainment, social media and the internet, advertising, news outlets, and the political and public health landscape. These drivers of obesity stigma are represented in Fig.  1 . Within these domains, we review evidence of messages that affirm both obesity stigma and intertwined narrative of personal responsibility for obesity.

Contributors and consequences of obesity stigma

Entertainment

The entertainment industry reinforces negative stereotypes of people with obesity through negative portrayals and underrepresentation. Characters with overweight and obesity are often portrayed as lonely, clownish, or misfits. Greenberg et al. found that of 1018 popular television show characters, overweight women were less likely to have romantic partners, display physical affection, or be considered attractive. Overweight men were less likely to have romantic partners or even friends and were more often shown eating. Furthermore, the representation of characters with overweight and obesity was less than half of that in the actual population, with only 25% of men and 14% of women having overweight or obesity [ 65 ]. Although Greenberg et al.’s work is now decades old, some of their findings have been repeated more recently [ 66 ]. This underrepresentation is consistent with a large quantity of research [ 62 , 67 – 70 ]. In books and films, obesity is further stigmatised through the association of obesity with the portrayal of “evil” characters, a notable example being the Dursley family in JK Rowling’s Harry Potter series, who were abusive towards Harry throughout his childhood, and frequently filmed from angles that emphasised their weight and during snacking, tea, and biscuit or meal times. Concerningly, weight stigmatisation in television content seems to be particularly prominent in shows targeting adolescents, particularly girls [ 71 ]. Children’s media features frequent negative messages associated with people who have overweight and obesity, who are more often depicted as unattractive, friendless, unkind, and the “bad guy” compared with their normal-weight counterparts [ 67 – 69 ].

Social Media

Social media is a leading source of news media and entertainment in the twenty-first century [ 72 , 73 ]. Chou et al.’s mixed methods analysis of popular social media platforms including Twitter, Facebook, internet blogs, and forums revealed extensive evidence of negative stigmatisation of people with obesity characterised by derogation, exclusion, personal attacks, sexism, and misogyny. Alarmingly, cyberbullying, hostility, and verbal aggression particularly towards women with overweight and obesity were pervasive [ 74 ]. On YouTube, Yoo and Kim found that videos expressing derogatory views towards people with overweight and obesity tend to attract a high number of views, ratings, and viewer interaction. Personal accountability for obesity was a dominant rhetoric on YouTube, correlating with a preponderance of recommendations for changes in personal behaviour [ 75 ].

Advertising

Obesity stigma is also perpetuated within the advertising and marketing industry, including the weight loss industry itself. Obesity has been exploited for economic gain in an industry valued at US $78 billion in the USA alone [ 76 ]. Paid advertisements both on commercial television and online traditionally portray people with overweight and obesity as both unattractive and unhappy, and focus exclusively on personal responsibility for obesity through promoting diet and exercise products [ 63 ]. Advertisers generally cultivate a belief that body weight is controllable through individual efforts and that leanness associates with success in all areas of life [ 77 ].

News and Journalism

The depiction of obesity in the news and journalistic media outlets reinforces the stigmatisation of people with obesity [ 78 ]. McClure et al. showed that images negatively portraying people with obesity, for example depicting unflattering poses or stereotyped actions like eating fast food, promote obesity stigma [ 78 ]. In a study of the British press, Baker et al. showed that there was a doubling in the amount of reporting within newspapers on obesity between 2008 and 2017 [ 79 •]. During this period, there was an increasing emphasis on individual responsibility and reduced focus on the social and political contributors towards obesity [ 79 •]. Chiang et al. demonstrated similar trends across the USA between 2006 and 2015, wherein each year had a greater proportion of articles that discussed individual attribution for obesity compared with either environmental attributions or a mixed model of both individual and environmental attributions [ 80 •]. This misrepresentation of the underlying contributors to the development of obesity reduces the societal perceived responsibility of governments and large corporations to address obesity [ 78 ].

Government, Policy, and Legislation

Political action over the last two decades has galvanised policy and legislation against collective responsibility for the obesity epidemic, consistently enforcing personal responsibility for body weight. The food industry has pushed this framing of personal responsibility in policy debates [ 81 – 84 ]. In 2005, the US Congress proposed a “ Personal Responsibility in Food Consumption Act ” that served to protect the fast food industry from civil lawsuits resulting from weight gain [ 85 ]. Similar bills and legislations have subsequently been introduced in over 20 US states [ 86 ].

The rhetoric of personal responsibility for obesity is often touted by government officials. Former UK Prime Minister Tony Blair reported that the problem of obesity was “ not, strictly speaking, public health questions at all. They are questions of individual lifestyle…They are the result of millions of individual decisions ” [ 87 ]. Australian member of Parliament Ewen Jones claimed “ It’s not the government’s fault that I’m fat, it’s my fault and I live with the consequences ” [ 88 ].

It is no surprise then that public health campaigns, which are largely funded and guided by political support, often misrepresent obesity as a personal choice. Even when environmental and societal contributors are represented in discussion, solutions to obesity focus on changing individual behaviour in lieu of strategies consistent with the evidence base [ 78 ]. Demonstrative campaign titles include “ Pouring on the Pounds: Don’t Drink Yourself Fat ” [ 89 ] and the UK’s “ Choosing a Better Diet ” and “ Choosing Activity ” campaigns [ 90 ]. These public health efforts to reduce obesity also have stigmatising effects. Despite “positive” intentions, well-publicised campaigns have been called out for reinforcing prevailing negative attitudes towards and stereotypes of people with obesity [ 91 – 94 ]. Specific concerns include an intense focus on body shape and size in the context of an “ideal” body type [ 94 ].

Body Positivity

It is worth mentioning the recent emergence of safe spaces for obesity-related issues and experiences that are free from judgement [ 95 ]. The body positivity and neutrality movements are two phenomena that reject narrow body ideals and focus on self-acceptance and respect for all body sizes [ 96 , 97 ]. These movements seem to be making progress in the representation of people with obesity in the media. Advertising campaigns that promote body acceptance appear to increase self-esteem and mood [ 98 ], and the use of average and plus-sized models tend to reduce body-focussed anxiety and improve body satisfaction of viewers [ 99 ]. Groups within social media and the internet are creating digital spaces where obesity stigma is challenged and people with obesity are included and empowered, having a voice that is rarely represented in the physical world [ 95 , 100 ].

These positive changes may suggest that we are amid a transitional period for the representation of people with obesity within our society. However, progress does not appear to be occurring across all domains, particularly in news, political, and public health media. Furthermore, the examples outlined here reflect a likely minority of trends in the representation of obesity, and obesity stigmatisation continues to appear rife within the public consciousness and lived experience of people with obesity.

Consequences of Obesity Stigma

The damaging effects of obesity stigmatisation are widespread and include psychological, physical, and socioeconomic harm [Fig.  1 ]. Strong evidence supports obesity stigma as an important contributor to poor mental health outcomes for people living with obesity, who are 32% more likely to develop depression compared with their normal-weight counterparts [ 101 ]. A recent large meta-analysis synthesising 105 studies including data on > 59,000 participants found perceived obesity stigma amongst individuals was associated significantly with poorer mental health ( r  =  − 0.35, p  ≤ 0.001), which remained significant following adjustment for relevant variables including body weight [ 10 •]. These data suggest that depression associates with obesity stigmatisation rather than obesity per se. Perceived obesity stigma also had a strong effect on body image dissatisfaction, quality of life, dysfunctional eating, and severity of depression or anxiety symptoms [ 10 •]. There is also evidence that internalised stigma, often referred to as obesity “self-stigma” or “weight bias internalization” (WBI), associates with similar negative mental health outcomes compared with externally based obesity stigma [ 102 ]. A recent meta-analysis by Alimoradi et al. revealed a similar moderate-large effect size for weight-related self-stigma and psychological distress (corrected Fisher’s Z : depression = 0.40; anxiety = 0.36) [ 103 ].

Beyond its severe mental health consequences, obesity stigma is also detrimental to short- and long-term physical health. Counter to traditional public health beliefs that social pressure encourages people with obesity to lose weight [ 25 ], ironically, evidence suggests that obesity stigma actually increases the risk of obesity. Obesity stigma may be associated with increased difficulty of losing weight and medication non-adherence and people with obesity may exclude themselves from some exercise settings [ 102 , 104 ]. Pearl and Puhl’s systematic review found that obesity self-stigma is associated with worse dietary adherence and reduced motivation and self-efficacy to complete health-promoting behaviours [ 105 •]. Unlike other public health issues addressing social norms, such as tobacco smoking [ 106 ], making obesity socially unacceptable does not appear to reduce obesity rates, and on the contrary results in increased harms.

In addition to worsening mental and physical health, obesity stigma may also augment all-cause mortality and shorten lifespan. Amongst participants from two large longitudinal studies in the USA, those who experienced weight stigma and discrimination had an increased mortality of almost 60% (The Health and Retirement Study, hazard ratio = 1.57, 95% CI: 1.34–1.84; Midlife in the United States Study, hazard ratio = 1.59, 95% CI = 1.09–2.31). This increased mortality risk persisted when controlled for common risk factors, including BMI [ 11 ]. Chronic psychological stress resulting from obesity stigma can trigger activation of the hypothalamo-pituitary adrenal axis with increased release of adrenally derived cortisol that in turn can drive increased fat deposition and appetite [ 107 , 108 ]. Enhanced cortisol release may contribute to increased mortality through weight gain and associations with inflammation, immune dysregulation, hypertension, insulin resistance, and oxidative stress [ 109 – 111 ]. Furthermore, enhanced cortisol release may also mediate some of the worsening effects of obesity stigma on abdominal obesity, glycaemic control, and the development of metabolic syndrome [ 12 ]. These associations parallel the pathophysiology contributing to worse health outcomes for those experiencing other forms of discrimination such as racism [ 112 , 113 ].

Obesity stigma contributes to poorer healthcare for people with obesity. There is growing evidence that healthcare providers have strong explicit and implicit biases against people with obesity [ 109 , 114 ]. Healthcare obesity stigma is characterised by stereotypes of laziness, lack of discipline, and willpower [ 115 ]. Inevitably, this mindset influences the judgement, behaviour, and decision-making of healthcare providers [ 115 ], who tend to have less respect for people with obesity [ 116 ] and believe that people with obesity are less likely to follow self-care recommendations or adhere to recommended treatments [ 117 , 118 ]. Healthcare providers have also been more likely to perceive the care of people with obesity as a “waste of time” [ 115 ], and are known to spend less time in consultations with people with obesity than their normal-weight counterparts [ 119 , 120 ]. Other healthcare issues that have previously reported stem from obesity stigma include the over-attribution of symptoms to obesity, failure to explore alternate diagnoses, reduced exploration of treatment options (“therapeutic inertia”), and hesitancy to conduct clinical examinations [ 121 , 122 ].

Understandably, people with obesity have reported avoiding healthcare encounters due to discriminatory and stigmatising experiences [ 123 , 124 ]. People with obesity report being mistreated and even ignored when receiving healthcare, and are up to three times more likely to report being denied healthcare [ 13 ]. Obesity stigma within healthcare and stigmatised judgements from healthcare professionals also perpetuates obesity by reducing the likelihood of people achieving their weight loss targets [ 125 ].

Finally, the socioeconomic impact of obesity is extensive. In employment, researchers from high-income countries believe that having obesity negatively impacts wages, promotion, and the potential for disciplinary action [ 126 , 127 ]. In the USA, people with obesity have previously been found to be less likely to be hired than their lean counterparts, even when qualifications are identical [ 128 ]. In Korea, women who are overweight receive less pay than lean women for the same work [ 129 ]. There is plentiful anecdotal evidence of people getting fired for having overweight or obesity [ 130 , 131 ]. In education also, obesity stigma appears to be present at all levels of schooling and college — at least in some countries — and leads to prejudice, rejection, and harassment, making educational spaces less safe for people with obesity [ 126 ]. In public settings too such as theatres, cinemas, shops, restaurants, and transport, obesity stigma may shape attitudes that people with obesity should not be accommodated for. Accordingly, people with obesity may be prevented from the same level of participation as their lean counterparts through a public infrastructure that fails to accommodate them adequately. Overall, obesity stigma has a substantial impact on socioeconomic factors through diverse means that include unequal standards in education, employment, career progression, salary, and public infrastructure.

Addressing obesity stigma is a healthcare imperative. As outlined, obesity stigma has severe consequences for people living with obesity, including but not limited to psychological distress, mental illness, increased mortality and morbidity, and worse healthcare [ 10 •, 11 – 13 ]. Furthermore, obesity stigma perpetuates obesity through physiological, psychological, and social effects, acting like a vicious circle [ 25 ].

Addressing obesity stigma is also an ethical imperative. Stigma burdens groups with undue discrimination, prejudice, and exclusion, and dehumanises them in the face of their community [ 60 ]. Burris argued that stigma evoked “ the total destruction of the individual’s status in organized society. It is a form of punishment more primitive than torture ” [ 132 ]. Stigma is especially unethical in the context of obesity insofar that it burdens already underprivileged and vulnerable groups, such as the global poor, rural, and certain minority ethnic groups [ 60 ].

Addressing obesity stigma is necessary to improve the public health efforts to prevent and manage obesity, which despite global efforts has had limited success to date [ 133 ]. Interventions that target the individual have had little success, partly due to obesity stigma-induced barriers to the widespread adoption of healthy behaviours [ 133 , 134 ]. When obesity is seen as a personal choice, as reinforced by obesity stigma, solutions focus on changing individual behaviours in lieu of synergistic strategies that focus on changing systems and environments to support healthy behaviours, the latter being consistent with the current evidence base [ 25 , 78 , 133 , 135 , 136 ]. However, such an approach is hampered through widespread obesity stigma within society. Re-calibrating this perception amongst society, including politicians, healthcare providers, and town planners, will help to support the development of effective public health strategies for the future that should properly address the many and diverse environmental and systemic contributors to the development of obesity, balanced with consideration of personal factors.

Firstly, it is important to acknowledge the striking paucity of research on the topic of reducing obesity stigma within society. Authors of systematic reviews have repeatedly highlighted this deficiency and the low quality of existing research papers within the field [ 137 – 139 ]. This scenario may reflect the early stages of this field and/or a lack of interest, perhaps stemming from an acceptance of obesity stigma (including amongst researchers). A prerequisite for tackling the problem of obesity stigma within society is the generation of high-quality research on effective interventions that have consistent theoretical frameworks, strong study designs, and sound methodologies [ 137 , 138 ]. Such data will facilitate the development of a consensus on the development of optimal strategies to reduce obesity stigma within society, and enable implementation of consistent and co-ordinated public health action [ 138 ].

Secondly, shifting public health messaging away from obesity and towards healthy behaviours, or alternatively away from behaviour completely, to allow the appropriate focus on the environments where the behaviour takes place, may facilitate the deconstruction of obesity stigma. We do not deny that there is strong evidence that having overweight and obesity increases all-cause mortality [ 140 ], and that weight loss can improve obesity-related morbidity [ 141 ]. However, benefits of healthy behaviours are often overlooked in the context of BMI [ 142 ]. The 15-year prospective Rotterdam study showed that physical activity moderated the risk of cardiovascular disease in people with overweight and obesity to the extent that there was no difference in CVD risk between people with high or normal-range BMI [ 143 ]. Other studies show that healthy diets may reduce all-cause mortality risk, particularly CVD risk, even when accounting for BMI [ 144 ].

Based on such evidence, placing too much emphasis on obesity per se, and focussing too much on weight loss purely to reduce obesity severity, is perhaps unhelpful. Although this may appear counterintuitive, such a traditional approach to obesity unfortunately also places emphasis on appearance and may actually demotivate and ostracise people with obesity [ 9 , 145 ], thereby hampering rather than helping with obesity management. An alternate approach, and one that we support, promotes the use of public health policies that encourage the adoption of healthy behaviours, including for example nutrient-rich diets cooked from their raw ingredients (rather than ultra-processed foods), regular engagement in physical activity, and sleep sufficiency by intervening to create environmental drivers for these behaviours. All people, including those with overweight and obesity, should be empowered and supported through structural interventions and policies and positive public health messaging to adopt such healthy lifestyle activities and behaviours [ 146 , 147 ]. This approach does not deny the harmful effects of excess body weight, but by detracting attention from body shape and size should help to diminish societal obesity stigma, whilst facilitating healthy living, that in turn should help in the prevention and management of obesity, stigma-free.

As interventions that rely solely on education and individual behaviour change are largely ineffective [ 148 , 149 ], enabling healthy behaviours will require both physical and food environmental changes and fiscal policies to support them [ 25 ]. Examples include improvements to the availability, accessibility, and affordability of fresh nutrient-rich foods, improved public transportation and urban planning to facilitate active and safe outdoor lifestyles [ 150 , 151 ]. Importantly, improving the “healthfulness” of our food and physical environments should also help to establish improved equity in the distribution of key resources within the population.

Thirdly, deconstructing obesity stigma through educational interventions is promising. Educational interventions that provide information on the genetic and environmental causes of obesity have shown some success in changing attitudes about how much control individuals have over their own body weight [ 139 , 152 ]. Other studies on healthcare students and workers have had modest success by evoking empathy and acceptance of persons with obesity through positive contact [ 139 ]. Current evidence suggests that the greatest efficacy on tackling obesity stigma is achieved when multiple and diverse educational strategies are combined [ 139 ].

Extrapolating these early findings, obesity could be reframed in public education efforts as a chronic condition that manifests primarily from a combination of genetic predisposition that interacts maladaptively with our obesogenic environment: factors that are predominantly beyond our individual control [ 9 ]. Furthermore, people living with obesity should receive positive representation in the media, including acceptance, inclusion, and empowerment. Importantly, the voices of people with obesity should be amongst the forefront of these public health campaigns [ 153 ]. This conceptual overhaul will require significant and sustained public education efforts that incorporate “top-down” and “bottom-up” approaches, such as education within schools and universities, and efforts to re-define obesity and its causes within government and industry [ 134 ]. Educational efforts could be targeted at institutions where the impact of obesity stigma is particularly pronounced, such as healthcare, educational settings, and places of employment [ 110 ].

The re-classification of obesity has been discussed by others as key to education efforts. Obesity was labelled a disease by the WHO International Classification of Diseases, the American Medical Association, and the World Obesity Federation in the early 2000–2010’s [ 154 ]. There is significant debate in academic and public realms on the appropriateness of this stance [ 154 ]. Some argue a disease label “legitimises” obesity by acknowledging biological and genetic underpinnings, and could increase attention and resource allocation to obesity research, prevention, and treatment [ 156 ]. In contrast, there is legitimate concern that a disease label will worsen the stigmatisation of people with obesity and increase discrimination [ 155 , 157 ]. There is also evidence that disease-labelling may disempower and reduce self-efficacy; Hoyt et al. found that labelling obesity as a disease reduced concerns about weight and predicted higher-calorie food choices amongst people with higher BMIs [ 158 ]. We caution against the labelling of obesity as a disease prior to more extensive investigation of its impact on obesity stigmatisation and psychosocial wellbeing, in addition to potential policy, fiscal, and healthcare impacts.

Fourthly, efforts to reduce obesity stigmatisation in the public domain could be spearheaded by legislation to prohibit prejudice and discrimination on the basis of weight [ 86 ]. Although educational efforts are important, without the support of our formal institutions, these messages are likely to be insufficient [ 159 ]. Few national or state legislations globally protect citizens from weight discrimination, providing legal freedom for industries to discriminate based on obesity status [ 62 ]. Weight-based discrimination should be formally recognised as a legitimate social concern and be included in antidiscrimination acts that prohibit discrimination based on other personal characteristics such as sex, marital status, or disability. Notably, it will be important to balance the need for protection and equal treatment of people with obesity against the risk of even greater obesity stigmatisation that may stem from such new legislation [ 160 ]. Position statements from government and public health organisations should demonstrate non-stigmatising language and discourse around obesity. There is support for this approach from people enrolled in an international weight-management programme across six countries [ 161 •].

Implementing these changes will take no less than a social overhaul and is likely to require decades of consistent action. However, the promise of change is already being seen through the body positivity movements and the creation of “safe spaces” for obesity in certain domains. Perhaps we can use the example of racial discrimination, which decades ago was rife globally, and in many countries acceptable and legally permitted and even encouraged through, for example, apartheid. Although, sadly, racial discrimination continues in our modern world, it is often illegal, and generally much better recognised and managed than in previous decades. We need to move towards such a scenario with obesity stigma and discrimination.

We predict that in the decades to come, we will look back at our current era in shame. We will recognise obesity stigma for what it is: discrimination just like any other form of discrimination that has become normalised within our society to an extent that its existence often even goes unnoticed. An important step on this long road will be to dispel myths around obesity, and to educate society on its true causes. Improved understanding should help to dispel associated myths around personal responsibility and should help to foster more empathy for people living with obesity. Gradually, such renewed understanding and insights should help us to have the courage and conviction to question obesity stigma when we encounter it, and hold the perpetrators to account, so that they too can question their misjudged beliefs and behaviours. As outlined, this approach will only work through a combined, concerted, and sustained effort from multiple stakeholders and key decision-makers within society. Only then can we hope for a transformed society which is finally freed from the shackles of obesity stigma, in which body weight no longer defines the people living in it.

National Institute for Health Research, ARC, Oyinlola Oyebode

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Public Health Issue: Obesity

Public health problems are medical issues that affect significant population size. One growing problem in the American community that affects a significant population is obesity. Obesity is a condition characterized by excessive or abnormal fat accumulation in the body. Obesity is a medical problem that directly increases the chances of one developing other diseases or health problems such as diabetes, high blood pressure, cancer, or even heart disease (CDC, 2021). Numerous risk factors can cause obesity. These include poor lifestyle choices, certain medical conditions, and genetics, among others. In the American community, obesity poses a serious concern, as seen by how its prevalence stands at 39.8 percent (CDC, 2021). Obesity has been widely connected to preventable and premature deaths due to conditions such as cancer, among others. As seen from the prevalence rate of 42.4% in 2017-2018 and 30.5% in 1999-2000, there is a steady increase in its prevalence. According to the CDC, the average medical cost spent on managing obesity in 2008 was $147 billion in the US (CDC, 2021). This is a clear indication of how costly it is to manage the condition. Numerous initiatives and efforts have been launched to prevent and manage childhood and adult obesity. This involves support from both the local, state, and national governments. Obesity prevalence varies from one state to another. Some states record high numbers of obesity cases. Michigan is one notable region that has sprung up in multiple debates and research programs.

Obesity in Michigan

With over 10 million people, Michigan stands out as an influential state in America. The state has consistently been ranked among the top 10 most obese regions in the country. With an obesity prevalence rate of 35.2 percent, such numbers pose a public problem in the state and country. According to the Michigan Department of Health and Human Services (MDHHS), 3 out of every ten adults are obese in the region. As of 2008, Michigan recorded the 8 th  highest obesity prevalence rate in the United States. This translated to 65.3% of Michigan adults being obese or overweight. 30.1% of this population were obese, while 35.2% were overweight (Plum Health, 2021). 39.8% were Blacks from the collected data, while 28.8% were Whites. A clear indication of a racial difference regarding obesity prevalence: based on the collected data, obese adults, had a higher prevalence of diabetes, heart attack, stroke, coronary heart disease, asthma, arthritis, inadequate sleep, high cholesterol, and high blood pressure compared to non-obese adults. Obese adults also reported the highest prevalence of poor mental health, poor life satisfaction, poor physical health, poor general health, and activity limitations compared to non-obese adults.

Population Needs and Assets

It is imperative to rely on evidence-based approaches to encourage weight loss through healthy exercising or healthy eating strategies. The lack of proper intervention programs affects most of the population in the region as they cannot understand which diet options, lifestyle decisions, or activities can put them at risk of developing obesity. Manifestation of chronic conditions in obese patients is higher compared to normal people. Such individuals are at risk of developing other chronic conditions such as diabetes due to obesity. Weight-related comorbidities cause big problems for the population in the region as it negatively affects the people’s emotional, psychological and physical well-being. There are different resources provided by state government agencies, nonprofit organizations, and community health centers that focus on addressing obesity prevalence in the community. As seen from the Michigan Health & Wellness website, there are credible and useful resources that help patients create a personalized plan that can guarantee better health. Such resources help patients keep track of daily food intake, physical activity, and nutritional pointers for a healthy diet. Such resources are also provided by public health organizations and practitioners who play an active role in combating obesity prevalence in the region. For instance, The Michigan Nutrition Obesity Research Center (MNORC) offers enrichment programs that promote communication on obesity and nutrition interventions research findings. MNORC ensures public policy decisions and knowledge are disseminated in an informed environment for the benefit of the respective population (Michigan Nutrition Obesity Research Center, n.d.). Such interventions are crucial and effective as they provide seminars and training focusing on nutrition interventions and how to manage metabolic disorders actively.

Health Disparities

There are health disparities that directly impact obesity prevalence in Michigan. These range from race, age, socioeconomic status, and other factors that can impact a person’s ability to lead a healthy life. This can be evident from the racial disparity witnessed in the region regarding obesity prevalence. For instance, as of 2008, 28.8% of obese individuals were Whites, while 39.8% were Blacks (Plum Health, 2021). This can be tied down to the fact that ethnic minorities have higher rates or risk factors for obesity. As seen from how most ethnic minorities have limited access to health insurance services and nutritious food, such factors can emerge as the reason behind the high number of obesity cases being reported amongst such groups. Also, the socioeconomic factor plays a direct role because individuals from lower backgrounds are more likely to find it difficult to afford health insurance, health services, and high-quality education, which can equip them to actively combat obesity in the community. Such disparities can be caused by the system, especially on the racial ground. The majority of Black community members find it difficult to access proper healthcare intervention programs and services that can enlighten them or help them protect themselves from obesity. The biased system makes it hard for people from low socioeconomic backgrounds to access proper services and resources, which can help prevent obesity prevalence within their community.

Cultural Needs

Cultural beliefs and practices have a direct impact on one’s health. As seen from how different cultures might have different family meals, it is crucial to ensure communities adopt nutritious meals that would not pose a health risk to the respective population. Some cultures believe being overweight is a sign of affluence. However, such notions should be discouraged by ensuring respective populations receive the right educational material, which can be used to educate them on which lifestyle habits or nutritional options are dangerous and act as risk factors for obesity. Families need to be educated on critical topics such as gender roles, child feeding, food cost, physical activity, and obesogenic environments to ensure a clear message is passed on across on which decisions and habits should be encouraged and which ones should be discouraged (Chatham & Mixer, 2019, p. 88).

Challenges and Barriers to Addressing Obesity

One barrier to addressing the obesity epidemic is the lack of recognition that obesity is a relapsing and chronic disease (Kim, 2020, p. 245). This poses a problem in the community as no long-term strategies are tailored to maintain weight loss or prevent weight regain. With different attitudes surrounding its management, misinformation from sources such as the internet, television programs, family, and friends pose significant health risks as they can encourage an individual to carry on with their habits and not seek the necessary medical attention needed to address the condition (Kim, 2020, p. 245). Insufficient counseling and training skills for obesity management also emerge as a challenge. Lack of basic knowledge in nutrition and exercise makes it difficult for obese patients to be assisted in the most convenient way possible. This makes it difficult for patients to be taken through a proper diagnosis and management plan. Hence, posing more risks to their condition. Moreover, as seen from how the cost of treatment is high, such factors make it difficult for low-income earners to afford proper treatment programs and interventions provided by medical practitioners and facilities. This is a clear indication of how obesity management faces multiple challenges in the community.

CDC. (2021). Overweight & Obesity. CDC. https://www.cdc.gov/obesity/data/adult.html

Chatham, R. E., & Mixer, S. J. (2020). Cultural influences on childhood obesity in ethnic minorities: a qualitative systematic review.  Journal of Transcultural Nursing ,  31 (1), 87-99.

Kim, T. N. (2020). Barriers to Obesity Management: Patient and Physician Factors.  Journal of Obesity & Metabolic Syndrome ,  29 (4), 244.

Michigan Nutrition Obesity Research Center. (n.d.).  Enrichment Programs.  MNORC. https://medicine.umich.edu/dept/mnorc/enrichment-programs

Plum Health. (2021).  Obesity Medicine.  Plum Health, PLLC. https://www.plumhealthdpc.com/blog/tag/Obesity+Medicine

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Consequences of Obesity

Health conditions, economic impact, military readiness.

People who have obesity, compared to those with a healthy weight, are at increased risk for many serious diseases and health conditions. In addition, obesity and its associated health problems have a significant economic impact on the US health care system. Obesity also affects military readiness.

Obesity in children and adults increases the risk for the following health conditions. 1,2,3

• High blood pressure and high cholesterol which are risk factors for heart disease.
• Type 2 diabetes.
• Breathing problems, such as asthma and sleep apnea.
• Joint problems such as osteoarthritis and musculoskeletal discomfort.
• Gallstones and gallbladder disease.

Childhood obesity is also associated with: 4,5,6

• Psychological problems such as anxiety and depression.
• Low self-esteem and lower self-reported quality of life.
• Social problems such as bullying and stigma.
• Obesity as adults.

Adults with obesity have higher risks for stroke, many types of cancer , premature death, and mental illness such as clinical depression and anxiety. 7,8

Annual obesity-related medical care costs in the United States, in 2019 dollars, were estimated to be nearly $173 billion. 9 Annual nationwide productivity costs of obesity-related absenteeism range between $3.38 billion ($79 per individual with obesity) and $6.38 billion ($132 per individual with obesity). 10

Direct medical costs may include preventive, diagnostic, and treatment services. Indirect costs relate to sickness and death and include lost productivity. Productivity measures include employees being absent from work for obesity-related health reasons, decreased productivity while at work, and premature death and disability 11

Just over 1 in 3 young adults aged 17-24 is too heavy to serve in the US military [PDF-774KB] . Among the young adults who meet weight requirements, only 3 in 4 report physical activity levels that prepare them for challenges in basic training. Consequently, only 2 in 5 young adults are both weight-eligible and adequately active for military service.

Also, 19% of active-duty service members had obesity in 2020, up from 16% in 2015. These individuals are less likely to be medically ready to deploy. Between 2008 and 2017, active-duty soldiers had more than 3.6 million musculoskeletal injuries. One study found that active-duty soldiers with obesity were 33% more likely to get this type of injury.

• NHLBI. 2013. Managing Overweight and Obesity in Adults: Systematic Evidence Review from the Obesity Expert Panel.
• Clinical Guidelines on the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults. 
• Bhaskaran K, Douglas I, Forbes H, dos-Santos-Silva I, Leon DA, Smeeth L. Body-mass index and risk of 22 specific cancers: a population-based cohort study of 5.24 million UK adults. Lancet. 2014 Aug 30;384(9945):755-65.
• Morrison KM, Shin S, Tarnopolsky M, et al. Association of depression and health related quality of life with body composition in children and youth with obesity. Journal of Affective Disorders  2015;172:18–23.
• Halfon N, Kandyce L, Slusser W. Associations between obesity and comorbid mental health, developmental, and physical health conditions in a nationally representative sample of US children aged 10 to 17.  Academic Pediatrics.  2013;13.1:6–13.
• Beck AR. Psychosocial aspects of obesity. NASN Sch Nurse.  2016;31(1):23–27.
• Kasen, Stephanie, et al. “Obesity and psychopathology in women: a three decade prospective study.” International Journal of Obesity  32.3 (2008): 558-566.
• Luppino, Floriana S., et al. “Overweight, obesity, and depression: a systematic review and meta-analysis of longitudinal studies.” Archives of general psychiatry  67.3 (2010): 220-229.
• Ward ZJ, Bleich SN, Long MW, Gortmaker SL (2021) Association of body mass index with health care expenditures in the United States by age and sex. PLoS ONE 16(3): e0247307. https://doi.org/10.1371/journal.pone.0247307
• Trogdon JG, Finkelstein EA, Hylands T, Dellea PS, Kamal-Bahl. Indirect costs of obesity: a review of the current literature. Obes Rev .2008;9(5):489–500.
• Hammond RA, Levine R. The economic impact of obesity in the United States. Diabetes, metabolic syndrome and obesity : targets and therapy . 2010;3:285-295.