• Social Determinants Grab Spotlight in New Obesity Report

    Historical Trends, Policies and Recommendations Also Reviewed

    October 28, 2021, 3:52 p.m. Michael Devitt — At the start of the 21st century, no state in the United States had an adult obesity rate over 25%.

    obesity concept

    As recently as 2012, no state had an adult obesity rate over 35%.                         

    Today, 48 states have an adult obesity rate of 25% or higher, and in 16 states, the adult obesity rate is 35% or higher.

    Those are just some of the findings from The State of Obesity 2021, an annual report from Trust for America’s Health. Published in September with support from the Robert Wood Johnson Foundation, the 92-page report features a special section that examines the relationship between COVID-19, obesity and social determinants of health, which shows how the pandemic impacted longstanding racial and economic inequities that furthered the obesity crisis throughout the country, especially in low-income communities and communities of color. It also assesses the latest data on adult and childhood obesity rates, reviews current policies and programs, and outlines potential policy actions for federal, state and local agencies.


    The report examines the obesity crisis from several perspectives.

    Story Highlights

    A section titled “COVID-19, Obesity and Social Determinants of Health” summarizes the pandemic’s effects on various aspects of American society, and includes

    • reviews of scientific studies that examine the pandemic’s impact on personal changes in weight, with substantial segments of the population experiencing undesired weight gain and others experiencing undesired weight loss;
    • an overview of the social, economic and environmental factors that have been affected by the pandemic, and how those effects impacted the health and well-being of Americans with regard to physical activity levels, eating habits, behavioral changes, stress, and access to services and support networks;
    • a flowchart that illustrates how inequities have contributed to obesity from historical, socioeconomic, physical and policy contexts;
    • a discussion of ongoing and proposed policy changes implemented in response to the pandemic; and
    • an interview with Angela Odoms-Young, Ph.D., an associate professor in the Division of Nutritional Sciences at Cornell University College of Human Ecology, titled “Understanding Our Society Will Help Us Understand Obesity.”

    The “Obesity-Related Data and Trends” section analyzes data from the National Health and Nutrition Survey and the Behavioral Risk Factor Surveillance System to track recent changes in obesity rates in American adults. Among the key findings:

    • Obesity rates varied considerably at the state level, with a low of 24.2% in Colorado and a high of 39.7% in Mississippi.
    • Demographically, for people ages 20 and older, Black adults had the highest overall obesity rate (49.6%), followed by Latino adults (44.8%) white adults (42.2%) and Asian adults (17.4%).
    • Generally, adults with lower incomes and lower education levels were more likely to have obesity. In individuals with incomes just above the federal poverty level, the adult obesity rate was 42.6%, compared with 29.7% in people with income levels at or above 400% of the federal poverty level. Similarly, the adult obesity rate was 35.6% in adults who had less than a high school education, but only 22.7% in college graduates.
    • An analysis of NHANES data in children found that in 2017-2018, the last year for which information was available, 19.3% of youth ages 2 to 19 years had obesity, with obesity rates slightly higher in boys than in girls.
    • Similar results were seen in the 2018-2019 National Survey of Children’s Health, which indicated that the youth obesity rate was 15.5% in children ages 10 to 17, and the 2019 Youth Risk Behavior Survey, which found a 15.5% obesity rate in high school students (grades 9 through 12).

    It should be noted that, given the report’s findings, substantial evidence exists to indicate that elements of structural racism have historically contributed to higher obesity rates in underserved communities and communities of color. A 2019 International Journal of Environmental Research and Public Health study,  for example, found that racial inequality with regard to poverty, unemployment and home ownership were associated with higher obesity rates, and concluded that structural racism was associated not only with higher obesity rates, but also fewer grocery stores, more fast food restaurants and higher fast food-to-grocery store ratios.

    It should also be noted that a section in The State of Obesity on social determinants of health states that “real change in reducing obesity and improving health at the population level requires understanding and action on all the drivers of high obesity rates — from addressing historical to present-day inequities and underinvestment that result in limited resources in communities to ensuring availability and encouraging culturally appropriate, healthy choices for individuals.”

    The “Obesity-Related Policies and Programs” section functions as a reference point for people interested in learning more about existing federal, state and local policies and programs. It provides important background information for those seeking historical context, along with current developments, budgetary data and research, and is divided into four subsections:

    • “Economics of What We Eat and Drink” discusses policies that promote healthy eating such as beverage taxes and the Health Food Financing Initiative, along with the challenges posed by the marketing of certain types of foods and beverages.
    • “Nutrition Assistance and Education” reviews federal nutrition programs such as the Special Supplemental Nutrition Program for Women, Infants and Children, the Supplemental Nutrition Assistance Program, and a number of smaller programs at the state and local levels. Child care and educational programs such as Head Start and the CDC’s Healthy Schools Initiative are also discussed, as well as dietary guidelines, nutrition labels and menu labels.
    • “Community Policies and Programs” covers the importance of effective community design and land use, highlights CDC initiatives that fund community efforts to reduce obesity such as the Childhood Obesity Research Demonstration project and the Racial and Ethnic Approaches to Community Health program, and connects those efforts with the benefits of physical activity.
    • “Healthcare Coverage and Programs” examines how obesity rates affect the costs of programs such as Medicare and Medicaid. It states that while health care professionals do not receive enough training on nutrition or treating obesity, many physicians desire such training. The report also features several recommendations that hospitals and health care institutions should adopt to ensure that clinicians are following the latest best practices.

    Finally, the “Recommendations” section states that the obesity crisis cannot be overcome without addressing the social, economic and environmental factors that underpin it, such as poverty, a lack of resources that support health and wellness, and food insecurity. To effect change, the report’s authors state, a systems approach is required that will reduce longstanding inequities, target obesity prevention programs in communities with the highest needs, and implement evidence-based initiatives that promote healthy behaviors and outcomes.

    The section includes five general recommendations intended to increase health equity, decrease food insecurity, update marketing strategies that lead to health disparities, improve safety and access to opportunities for more physical activity, and strengthen obesity prevention measures throughout the health care system. Each general recommendation is supplemented by specific actions and directives for federal, state and local government agencies.

    Family Physician Perspective

    In an email to AAFP News Keisha Harvey Mansfield, M.D., founder and medical director of Dr. K’s Family Medicine in Bogalusa, La., and co-author of an Academy guide on lifestyle medicine, explained why the report’s findings should matter to family physicians.

    “The social determinants of health are great predictors of health and compliance,” Mansfield said. “Considering that we are still battling a pandemic, these findings are important because of the apparent risk of having complications from COVID-19 are linked to having obesity, whether you are an adult or child.”

    Mansfield also suggested that FPs pay attention to their patients’ social needs and the ways obesity can be managed.

    “People with unmet social needs have poorer health outcomes. They were the most impacted by the coronavirus socially, financially and medically,” said Mansfield. She called obesity “a multifaceted chronic disease that deserves a multifactorial approach to be adequately addressed and treated” that would involve meeting a patient’s social, environmental and health needs.

    Mansfield provided additional details on how FPs can manage obesity in underserved communities and communities of color.

    “The first step is screening your patient population and finding where the greatest needs are, then working with local groups to help meet those needs,” she said.

    “Family physicians will have to dedicate more time learning about nutrition, physical activity and obesity management. We will also have to advocate for more time and the appropriate reimbursement to discuss obesity as a disease and its short- and long-term consequences if untreated with our patients. Lastly, we will have to advocate for more insurance benefits for our patients for obesity management, including prescription coverage.”

    AAFP Resources

    The Academy has several resources for FPs interested in learning more, including educational materials for patients, policies and clinical service recommendations, and a collection of content from American Family Physician.