By: Dr. Eeks
Using the argument that most people who get really sick or die from COVID-19 have comorbidities to justify people not getting vaccinated or not worrying about the virus seems aloof from our reality as a country. For one, look around. America is a nation saturated with comorbidities. We are also a grey-haired nation, and while COVID is much more severe in older age groups, with older age naturally comes more comorbidities. By 2040, 1 in 5 Americans will be 65 or older, which is not just interesting from a comorbidity perspective, but also from a national security perspective (young people fight wars) and how the government will help fund the most expensive healthcare system on the planet (by and large, it’s young people who work and pay taxes).
Data from the 2018 National Health Interview Survey shows that just under 52% of US adults have at least 1 of 10 selected chronic conditions (arthritis, cancer, chronic obstructive pulmonary disease, coronary heart disease, asthma, diabetes, hepatitis, high blood pressure, stroke or weak/failing kidneys.) A little over 27% of US adults had multiple chronic conditions. The highest prevalence of chronic conditions was seen in women, non-Hispanic white adults, adults over 65 and those living in rural areas.
There are now numerous studies showing that obesity leads to more severe cases of COVID-19 and data showing that obesity worsened during the pandemic. This recent study showed that 48% of Americans gained weight during the pandemic and those who were overweight before COVID were most likely to gain weight. Depression and anxiety were strong predictors of weight gain, which probably increased independently during the pandemic, especially with all the shutdowns. Between 1999 and 2018, the obesity prevalence in the US increased from 30.5% to 42.4%. Updated data from the CDC shows that 16 states now have obesity rates higher than 35%. Last year it was 12 states, but Delaware, Iowa, Ohio and Texas made the list this year and joined Alabama, Arkansas, Kansas, Louisian, Michigan, Mississippi, Oklahoma, South Carolina, Tennessee and West Virginia. While everyone is affected by growing obesity rates, the fastest rate is in minority groups, who also happen to be hit the hardest by COVID. The other states aren’t in the clear. All states have more than 20% of adults with obesity and 20 states have obesity rates between 30-35%. The Midwest and the South have the highest prevalence of obesity (34%) and the Northeast has the lowest (28%). This data is based on self-reports, so we can safely assume that the rates of obesity are even higher due to underreporting.
Obesity sets the stage for subsequent diseases and health issues, which, as you can imagine, costs a lot. This study published in 2009 shows that in 1998, the medical cost of obesity was estimated to be 78.5 billion dollars with roughly half funded by Medicare and Medicaid. It also shows that an increased prevalence in obesity was responsible for approximately $40 billion in increased medical spending through 2006 and that the medical costs of obesity could have risen to $147 billion per year by 2008. Think of the rising costs in a country that struggles to provide affordable healthcare .
On top of rising rates of obesity in adults, we also see it happening in kids, which is disheartening when you consider that many of them will develop corresponding chronic health problems at younger and younger ages. A recent JAMA study on a cohort of 191,509 kids showed that kids gained more weight during the pandemic than before the pandemic, with the biggest change happening in the 5–11-year-old age group. Overweight or obesity increased in this age group from 36.2% to 45.7%. The absolute increase in 12-15-year olds was 5.2% and 3.1% among 16-17-year olds. A study published this Fall by the CDC looked at obesity trends in 432,302 kids ages 2-19. Results showed that the monthly rate of increase in BMI nearly doubled during the COVID-19 pandemic compared to pre-COVID. Alarmingly, the proportion of kids ages 2-19 with obesity increased from 19.3% in August 2019 to 22.4% in August 2020. Similar to the JAMA study, kids aged 6-11 experienced the largest increase in rate of BMI change: their pandemic rate of change was 2.5 times as high as their pre-pandemic rate. (I know the BMI isn’t the most accurate measurement for obesity, but it’s an easy and cost-effective one to deploy at the population level.)
Overall, 1 in 5 kids or adolescents are obese. In 2017-2018, the prevalence of obesity was 19.3% and affected 14.4 million children or adolescents. The obesity prevalence was 13.4% in 2-5-year olds; 20.3% in 6-11-year olds and 21% in 12-19-year olds. Rates of obesity were highest in Hispanic and Black children and lowest in non-Hispanic Asian children.
Why did obesity get worse during an infectious disease pandemic made worse by obesity?
Myriad things could have contributed, including staying home more, shutdowns, not going to gyms or having a place to exercise, not playing sports, eating more due to stress or anxiety, and losing jobs and lost work could have contributed to a change in the kinds of food people were eating. Processed foods tend to cost less. As for kids specifically, the move from in-person learning to remote, at-home learning could have contributed. Just sitting more in front of a screen could have done it. This recent cross-sectional study of adolescents showed the mean total daily screen time was 7.7 hours per day during the pandemic compared to 3.8 hours per day before the pandemic- essentially a doubling of screen time for our kids. The loss of school lunches, gym time, and youth sports could have also played a role.
I want to point out that while the pandemic may have made obesity worse, it wasn’t like our obesity rates were improving until COVID happened. And while people complain that “public health people aren’t talking about how unhealthy or fat we are,” I’ll point out that in the October 27,1999 issue of JAMA, the CDC published an alarming report about a growing obesity epidemic that threatened the health of millions of Americans. Jeffrey Koplan, who was director of the CDC at that time and one of the authors of the report made this statement, “Overweight and physical inactivity account for more than 300,000 premature deaths each year in the US, second only to tobacco-related deaths. Obesity is an epidemic and should be taken as seriously as an infectious disease epidemic.” Despite that alarming report in the late nineties, our obesity rates have continuously climbed higher. So, it’s not that public health officials aren’t talking about obesity. They are. They have been. There even has been well-intentioned initiatives, like the former first lady Michelle Obama’s Let’s Move Campaign to help curb child obesity. Unfortunately, what we are doing isn’t working and the question is why.
The biggest reasons most likely have to do with our incompetence or lack of real commitment to improving the social determinants of health for people most at risk for obesity. Social determinants of health include things like access to healthy, affordable food, access to a good education, access to a safe, green place to exercise or play, a job that will allow someone to make enough money to eat healthier, access to affordable healthcare, clean air and quality housing. Improving the social determinants of health would also help lower one’s level of stress, and chronic stress contributes to obesity. In the field of public health, you’ll constantly hear the words “social determinants of health.” It’s like a record always playing in the background and has become an almost automatic response to the “why” question year after year after year. Same answer, all those years, and I think it’s because we as a country are not invested in putting in the work, the money, the time or the ruffling the feathers needed to improve the social determinants of health. Even then, it might not be enough. Obesity is complicated. We might need to promote more medication for obesity, like Semaglutide that was recently approved. The medication also needs to be affordable, and we know that the US has a horrible track record of making drugs affordable. We also have to consider medication that causes weight gain and if there are better alternatives. This study shows that 1 out of 5 US adults take a prescription medication that causes weight gain.
Recently I had Dr. Fatima Cody Stanford, an obesity expert at Harvard University, on my Causes or Cures podcast. She mentioned that we have to start treating obesity like a disease, focus more on medications and focus on obesity being an inherited trait. She also talked about how fat-shaming doesn’t work and keeps people who need help for obesity from pursuing care. Folks who struggle with obesity have shared sad stories about going to a doctor or hospital only to be fat-shamed. Perhaps more education is needed, because if fat-shaming worked, no one would be fat. Just like you can’t shame someone into getting a vaccine, you can’t shame someone to drop weight. Shame: Human nature isn’t so sweet, so we’ve been doing it forever. If it worked, we wouldn’t have a problem. Interestingly, there is also a societal push for more body positivity to hit back at all the years of fat-shaming, and I specifically asked Dr. Standford how one balances that movement with tackling the obesity epidemic. If you are interested, you can listen to the podcast here.
We also should be targeting the unhealthy food industry, not just for years of lobbying government officials who make food policies, but I’m sad to report that the unhealthy food industry got only stronger during the pandemic. That’s irony for you. The unhealthy food industry got stronger during an infectious disease epidemic fueled by obesity which is made worse by the unhealthy food industry. This report outlines over 100 ways in which the unhealthy food industry got more powerful during COVID. This might be controversial to some, but remember all of the food incentives for COVID vaccines? I was against them, but some people strongly disagreed with me and said things like, “Who cares about the free donuts if they get people vaccinated?!?” I can understand where that sentiment is coming from, but. Plus, there’s very little evidence to suggest that vaccine incentives worked, as this failed Ohio vaccine lottery study shows. It’s not about the free donuts though. It’s about the food companies having a long history of using “social responsibility initiatives” as a way to market their food, get more people hooked and therefore make more money. This report from the NCD Alliance highlights some of the ways the unhealthy food industry did this during the pandemic, including distributing food packs, unhealthy snacks and sugary drinks to health workers and deprived neighborhoods, and fast-food restaurants offering free food and deals to health workers. Some companies capitalized on the shutdown and stay-at-home orders and used patriotism to do it. McCain, a frozen food manufacturer in Canada said, “Eat More French Fries, Canada” and linked it to helping farmers affected by the pandemic. In the US, Burger King waived delivery fees on orders over 10$ and encouraged folks to “Stay home of the Whopper!” Burger King also encouraged people to stay home and be “Couch po-ta-triots.” The move to at-home work and schooling inspired some companies to create Zoom backdrops advertising their foods or beverages and some paired up with popular video games to boost their brand. There are numerous other ways the food industry became more powerful. Read the report, it’s well done.
We are the United States of Comorbidities. We were before the pandemic, during the pandemic, and our comorbidities made fighting the pandemic more difficult. Of course, that is linked to having one of the highest death rates of all countries. We will also be the United States of Comorbidities after the pandemic. We cannot change that status overnight. It is going to take a major shift in thinking, priorities and financial investment. We have to consider that fact when considering what tools are needed during this pandemic. For example, no matter how you feel about the COVID vaccines, I get irritated when someone reads a study that shows the vaccine keeps a particular population out of the hospital and out of the graveyard and waves it away by saying, “Well, they didn’t take into account the social determinants of health and comorbidities.” Okay…, so what if they do? Then what? Can you change someone’s weight or make an individual’s job, living situation, environment, access to food and lifestyle better over night? We haven’t been able to do it in years. Do you really think you can make their situation better at a faster rate than an infectious, airborne disease finds them? Doubtful. We need to be realistic about the population we have, not the population we wish we had.
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