This opinion column was submitted by Steve Shane, a Reno-based pediatrician who also practices obesity medicine.  
Obesity was officially recognized by the American Medical Association as a disease in 2013. Obesity is not a choice! The disease of obesity is a very complicated interplay of many genetic, hormonal, behavioral, social, economic and environmental factors. It is chronic and progressive in course.
The COVID pandemic has amplified the effects of these factors. Obesity triples the risk of hospitalization and is a leading risk factor for death in COVID infection. Obesity affects all systems putting individuals at increased risk for depression, heart disease, fatty liver disease, kidney disease, diabetes, hypertension, elevated cholesterol and 13 cancers, to name a few. The Milken Institute reported in 2020 that obesity cost the U.S. in 2018 $370 billion in medical costs, $1 trillion in lost workdays and 320,000 lives.
Nationally, obesity prevalence has quadrupled in the last five decades, largely due to change in societal behaviors and infrastructure. The WHO reports that obesity worldwide has tripled in the same time period and that in 2017 that more than 4 million people were dying annually due to overweight and obesity. CDC data from the National Health and Nutrition Examination Survey in which body mass index (BMI is the most common parameter used for determining weight status) is directly measured shows that 41.9% of all adults and 19.7% of all children have obesity in the U.S. as of 2020.
In Nevada, we only have self-reported data for adults, which often under-represents the true obesity prevalence when compared to direct measurements. In 2020, 28.7% of adults in Nevada reported being obese, according to the CDC Behavior Risk Factor Surveillance System; this is double the rate seen in 1995. The CDC National Health Interview Survey in 2020 revealed 16% of Nevada youth aged 10-17 years had obesity — about the national average. Actual measurements of BMI performed by the Washoe County School District for the 2018-2019 school year revealed that a third of 4th, 7th and 10th graders sampled had elevated BMI — 15.4% with overweight and 18.8% with obesity. Black and Hispanic youth had the highest rates — consistent with national trends. More worrisome, CDC national data showed that childhood BMI rate of increase doubled during the height of the COVID pandemic.
Healthy inequity has recently come to the forefront when looking at disparities in the prevalence of obesity and associated comorbidities amongst different subsets of our population (e.g., those of color, those with disabilities). Social Determinants of Health, systemic racism and weight stigma are significant factors that have been identified when looking at prevention and treatment of chronic diseases such as obesity and type 2 diabetes. Nationally, Hispanic Americans, Black Americans and Native Americans have the highest rates of obesity. Type 2 diabetes mellitus is 50% higher in Black Americans, 50% higher in Hispanic Americans, and twice as high in Native Americans when compared to White Americans. Location of housing, economic stability, education access, health care access and built neighborhood environment all are factors when it comes to obesity risk. Lastly, systemic racism and weight stigma create chronic toxic stress, causing elevated stress hormones that promote increased risk of obesity and inflammation that increases other chronic diseases. Both also promote mental health problems, provide barriers to quality health care and education, and barriers to fair and equitable employment opportunities.
Prevention and management of obesity continues to use the foundation of lifestyle modification with behavioral change regarding nutrition, sleep, physical activity and optimizing mental health. This is easier said than done when you are genetically predisposed, economically disadvantaged, working two jobs and live in a food desert! Due to complex protective metabolic systems in our bodies, sustainable weight loss with lifestyle change alone is difficult, and other adjuncts are often needed such as anti-obesity medications and metabolic bariatric surgery. Frequently, a weight loss of only 5% is necessary for meaningful risk reduction from complications like diabetes and cardiovascular disease.
Unfortunately, FDA-approved medications for treating obesity are not covered by Nevada Medicaid and some commercial plans — when more expensive therapies for much less prevalent diseases are. Ironically, the Nevada Public Employee’s Benefits Plan provides coverage for obesity treatment and has documented a significant cost savings when utilized for those with the disease. Therapies for the most common chronic disease globally should be available just like they are for cancer, hypertension or diabetes. Currently, it is estimated that only 2% of those who meet an FDA-approved indication for antiobesity medication receive it. In 2020, the Obesity Medicine Association published a position statement advocating for long-term use of medications for obesity when indicated; this can double to triple the odds of sustainable significant weight reduction and reduce medical and societal costs.
The State of Nevada currently does not include obesity in its chronic disease prevention programming when over a quarter of the population has obesity. Nevada only invests about $1 per capita directly from the state budget for chronic disease prevention — diseases that are caused by obesity. The America’s Health Rankings 2021 report shows Nevada in the bottom quartile for clinical care and health outcomes, and ties Wisconsin for lowest expenditure per capita for public health funding. Net medical costs for cardiovascular disease, diabetes and cancer totaled $313 million in 2021 for the 20% of the population covered by Medicaid. We cannot afford to leave obesity out of our disease prevention strategy.
It is time that we acknowledge the shortcoming in the prevention and management of the disease of obesity. I propose that our state government recognize obesity as a real disease, develop a statewide surveillance system to directly measure obesity prevalence, utilize evidenced-based policy and models for wellness promotion and obesity prevention, and provide unbiased access to proven therapies for obesity. The disease is complex and did not become such a pervasive problem overnight. Numerous reputable organizations and agencies like the Robert Wood Johnson Foundation, CDC, Milken Institute and the American Academy of Pediatrics all agree that it will require significant investment in multi-sector community programming over a period of years to slowly reverse the tide. All strategies employed need to be equitable to all, including our most vulnerable populations who carry the greatest burden of this disease.
We owe our citizens, particularly our children, a better chance for a healthier tomorrow.
Steve Shane is a Reno-based pediatrician who also practices obesity medicine.
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