The COVID-19 pandemic represents the single most disruptive health crisis of the past 100 years. It has disrupted basic, taken-for-granted societal routines, which subsequently has prompted dynamic changes in our behavior. The ramifications of these disruptions have yet to be fully quantified. But, suffice to say, a lot of people died in 2020 because of the pandemic—and not all of them had COVID-19.

In 2020, and now moving deeper into 2021, our society is witnessing a far greater number of deaths due to diabetes, heart disease, stroke, Alzheimer’s, and other diseases than we would typically see in a non-pandemic world. These deaths are a testament to the significant impact of the social isolation and dietary changes driven by this pandemic. It’s also a strong reminder that health is both environmental and communal in nature. It is not, as we so often think, simply a condition of the individual.

Obesity—the thread that links so many of the conditions that are devastating our nation’s collective health during this pandemic—is a case in point. One of the missed headlines in 2020 was a study released by the National Center of Health Statistics (NCHS) showing that the obesity rate had eclipsed 40 percent in the United States for the first time, with more than 73 percent of U.S. adults being obese or overweight. That obesity rate is up from 30.5 percent just two decades ago in 2000. The rise of obesity at such an alarming rate is not just a health emergency. It is, in fact, one of the largest national security threats our country has faced, given the economic and troop readiness effects of obesity on our military preparedness.

Obesity in America has often been blamed on the typical fast-paced, over-scheduled lives of Americans. For a majority of Americans, the pandemic put this fast-paced, commute-heavy, lifestyle on ice. In addition, spending more time at home should have meant many people suddenly had greater control over what they ate. Some people were able to take the opportunity to reinvent their lifestyles for healthier living. But most did not—and it’s not their fault.

So why have millions of Americans struggled with weight gain in the pandemic? Obesity is a complex disease, made all the more complex within the context of a global pandemic. Let’s take a look at four often-overlooked factors that have contributed to obesity’s deeper creep into our population these past 12 months.

Factor 1: stress and mood

In light of the pandemic, it’s become evident that our society has been underappreciating the role of stress and mood in our appetite and eating behaviors. But in fact, over the past year, these links have been well established. Consider:

• Perceived stress and the development of mild depression have been identified as the top predictors of weight gain during the pandemic.
• People with underlying mental health conditions were 34 percent more likely to gain weight during COVID-19 lockdowns.

As much as we might try to change our diet and exercise habits, we must not discount the emotional barriers to weight loss success, particularly in times of collective stress within our society. Stress and depression have very real psychological and physiological effects when it comes to appetite and our ability to control eating. If we don’t address these emotional barriers first, then changes in diet and activity are almost certainly doomed to fall short.

Factor 2: inadequate tools for healthy eating

In addition to the challenges of stress and depression within the pandemic, lockdowns and more time at home revealed a simple truth about our society: Many Americans lack the tools required to eat healthy. Prior to COVID-19, many ate the majority of their meals outside the house due to the convenience of not having to cook at home. When the pandemic hit and meals began to be consumed inside the house, the desire and emphasis on convenience remained.

Even though our social media feeds might have suddenly been filled with people baking their own bread, healthy cooking was not a respite for many Americans. For many people, healthy cooking for themselves and their families isn’t even a skillset we value or teach. So, they turned elsewhere. Given that entertainment budgets were suddenly going unspent in terms of movies, concerts, and other outings, people leaned heavily on takeout food (often of high-calorie comfort foods). When ordering groceries, many people also looked for the convenience of prepared and processed foods, rather than raw ingredients for cooking.

Factor 3: the economics of processed food

This brings us to the reality of processed foods. The link between weight gain and eating highly processed foods is well-established at this point. The problem, of course, is that highly processed foods are (quite counterintuitively, it would seem) much more affordable for the average American than fresh, raw ingredients. In other words, the subsidies that underwrite cheap processed food production are very literally underwriting America’s obesity epidemic.

We saw a sharp rise in processed food consumption in the pandemic, particularly with foods high in carbohydrates. Part of this can be attributed to the fact that many Americans are hurting financially right now, and these foods tend to be the most affordable option for feeding a family. In addition, processed foods cause our brains to release dopamine, that much-coveted pleasure catalyst. At a time when the average American is having trouble finding joy organically, processed foods offer a quick fix—all tied up in a nice, affordable (and devastatingly unhealthy) little package.

Factor 4: insufficient support within the health care system

Finally, we can’t overlook the fundamental insufficiencies within the U.S. health care system when it comes to managing obesity. The U.S. health care system is set up to address acute, obvious diseases—not ones as nuanced and complex as obesity. In terms of having access to programs and specialists that help people address the underlying causes of obesity—diet, lack of activity, poor sleep, substance use, emotional health challenges—the U.S. health care system fails its clients.

Obesity, behavioral, and substance use counseling are often the lowest reimbursable visits in health care, making it hard for physicians to offer them. Medicare pays a measly $24 for an obesity counseling session and limits this benefit to 5.5 hours each year. We spend more time watching processed food commercials. Obesity is a larger and more detrimental pandemic than COVID-19, and I don’t see any urgency or stimulus measures to address it. The Treat and Reduce Obesity Act was introduced into Congress in 2012 and has not yet to be passed. We have to do better.

The impact of the pandemic on the lives of Americans will be felt for years, if not generations, to come. This includes its alarming effect on health behaviors that contribute to the already formidable challenge of obesity in this country. Now, more than ever, we must look for creative solutions within the broader health ecosystem that can help individuals adapt their behaviors, in spite of socio-environmental challenges, to prevent, manage, and maybe even reverse chronic disease. The very health of our nation depends on new solutions to our country’s age-old societal, cultural, and behavioral challenges.

Rami Bailony is an internal medicine physician.

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