There are a number of reasons society may be slow to change its common understanding of a topic. A large body of science disproving the prevailing theories, in addition to years of discourse, are usually prerequisites for shifting popular opinion. But what about cases where both the science and the discourse have been present for over a decade, and popular opinion still hasn’t changed? 

Such is the case with obesity. “People living with obesity continue to face that social stigma that we’re trying to eradicate,” said Lesli Foster, Emmy and AP award-winning journalist and news anchor for WUSA9, introducing a webinar by the Black Women’s Health Imperative on obesity and cardiovascular disease in Black women. “It’s this widespread perception in our community that obesity is a lifestyle issue, but since 2013  we know the American Medical Association has recognized obesity as a chronic disease, a disease caused by a range of issues that could be biological, genetic, environmental, just like any other serious chronic disease. So we’re working to change the language and the perception of living with obesity.”

Obesity is directly related to cardiovascular disease (CVD), or heart disease, which is a spectrum of conditions involving the heart and blood vessels. CVD is the primary cause of death in the U.S. and annually kills more people than all forms of cancer and accidents combined. Black Americans are 30% more likely to die from CVD than white people, and women are especially vulnerable: in the United States, CVD kills a woman every 80 seconds and more than 50,000 Black women each year.

Obesity affects over 100 million adults, adolescents, and children, including 30% of Medicare beneficiaries. The prevalence is highest among Black and Hispanic communities, affecting 45% of Hispanic adults and 50% of non-Hispanic Black adults. Nearly 60% of Black women over the age of 20, and fully 80% of Black and Hispanic women, are living with obesity or are overweight and continuing to face social stigma because of the chronic disease.

Tiffani Bell Washington, M.D. explained that body weight is a far more complicated affair than most people recognize. Though the assumption about a thin person may be that they eat healthily or exercise to stay fit, they may in fact have a very poor diet and little to no exercise. “Then you have people who may have a larger body, and you may make assumptions about them that they’re not eating healthy, they’re not living right, and they may in fact be following all of the rules that we put on people, but their bodies are just more prone to store body weight as fat,” Dr. Washington said. “It’s a very genetic-based disease.” 

Dr. Washington offered more insight into the way body weight works on an individual level and why poor diet and exercise do not explain obesity. “There are some people who have set points that are just higher. And by ‘set points’ I mean even if they eat very healthy, they eat fruits and vegetables, they exercise, their weight, because of their brain, is going to be on the higher end. And even if they were to diet or do these other things, they still may not lose weight easily,” she said. “And then you have other people who have a higher propensity to burn fat, burn calories, and they store less fat in general.”

The AMA’s decision to classify obesity as a disease happened a decade ago. “It was a big deal for us because it made it so that people were less focused on this being a personal failing and something that our patients are doing wrong, something that we are doing wrong, and more that this was an actual disease that could be treated. It should be recognized that that was a very important distinction. Now, that was 10 years ago. I have to be honest and say I don’t know that the unified opinion of obesity has changed that much even in the medical community, unfortunately, or in the lay public,” Dr. Washington said. “It tends to be something where people are blamed for their obesity.”

Although diet and exercise are unreliable ways of managing obesity, it is still a treatable disease. There are many FDA-approved medications to help with obesity that each work in different ways. However, these medications are expensive and lack Medicare coverage, which sets the precedent for private insurance to also not cover them. This policy failure is one of many political determinants of health, as Dr. Yolandra Hancock, M.D. clarified. 

Political determinants of health are those government policies that determine the more commonly-known social determinants of health, often involving housing, health care, transportation, and insurance. Whether or not medications, care, and doctor visits are covered by insurance is a direct result of political policy, just to name a few examples. “I always say there’s health in all policies,” Dr. Hancock said. “Obesity isn’t simply a disease of overconsumption or lack of physical activity, the disease of obesity develops coming out of the social determinants of health.”

And yet social determinants of health can hardly change in a meaningful way without first changing the political determinants of health at the root of the problems. Racism encoded in ages-old housing district policy results in ZIP codes stratified by class and race, which lead low-income, predominantly Black and Hispanic neighborhoods to become food deserts with less space for outdoor exercise. ‘Fixing’ obesity by overcoming the challenges posed by these and similar situations, each the result of political determinants of health, is not as simple as popular opinion would hold. As Dr. Hancock said, “If I live in an environment that makes it difficult for me to be able to do that, then how can we, as health care professionals, say, ‘Well, just eat healthier. Just go out and exercise?’” 

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