The Washington PostDemocracy Dies in Darkness

Opinion Let’s be honest about why the covid death rate is so high in the U.S.

Health-care workers treat a covid-19 patient in Connecticut earlier this month. (Allison Dinner/Bloomberg News)
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In many ways, we’re fortunate that the coronavirus pandemic didn’t strike, say, 30 years earlier. In the early 1990s, the science behind what would become the mRNA-based coronavirus vaccines was still in its infancy. Ditto smartphones, which have been instrumental in gathering and disseminating pandemic-related data. Zoom was pretty much science-fiction, too.

In one major respect, though, the United States would clearly have been better off in 1990. At that time, the maximum adult obesity rate reported for any state was 15 percent.

In 2020, by contrast, no state reported a rate lower than 20 percent, according to the Centers for Disease Control and Prevention. Sixteen states’ rates were above 35 percent.

And obesity turned out to be a major risk factor for covid hospitalization and death, especially among the non-elderly. It is linked to impaired immune function and decreased lung capacity; it can make ventilation more difficult, according to the CDC. Thus, the United States might well have gotten through the pandemic at far lower cost, economic and human, without the decades-long obesity epidemic that preceded it.

This reminder that obesity constitutes not only a public health problem in its own right but also a significant source of vulnerability to outbreaks of infectious disease emerges from a new report about covid’s varying impact on nations around the world.

Fraught as the subject is with potential for victim-blaming and body-shaming, lives depend on discussing it forthrightly.

The study, published Feb. 1 in the Lancet, produced headlines because of its intriguing finding that infection rates were lower, and vaccine coverage higher, in countries where polls show a high level of interpersonal trust and trust in the authorities — regardless of how pandemic-ready a given nation appeared according to conventional indicators of preparedness.

When it comes to deaths per infection, however, the study found two factors loomed largest: the aging of a given country and its average body-mass index, a measure of obesity.

The United States’ national average body-mass index ranks near the heaviest among all countries. If instead we were just average — roughly the level of Denmark — the death rate would have been 19.5 percent lower between Jan. 1, 2020, and Sept. 30, 2021, the study’s lead author, Thomas J. Bollyky of the Council on Foreign Relations, told me in an interview. That is, some 157,000 fewer people would have died during those 21 months. The toll now stands at just over 900,000.

By extension, the United States’ overall covid death rate might have ranked nearer the middle of its peer nations, rather than at the top, as it now does.

Caveat: The Lancet article does not report clinical research; strictly speaking, it describes not causes but correlations. Also, Bollyky told me aging was twice as strongly correlated with death rates as obesity was.

Nevertheless, it’s a striking correlation. Of the 16 states with adult obesity rates 35 percent or higher, 10 — Alabama, Arkansas, Indiana, Kentucky, Louisiana, Mississippi, Ohio, Oklahoma, Tennessee and Texas — rank in the top 20 for age-adjusted per capita covid death rates, according to Bioinformatics CRO, a consulting firm.

To be sure, these states rank among the lowest for accepting vaccines, which became widely available a year into the pandemic. Absent such high levels of obesity they still would have been better off, though. “If we don’t improve the broader health of the population, it increases its vulnerability to deadly viruses,” Bollyky says.

In this country’s so far futile battle against obesity, the decline in U.S. sugar consumption over the past two decades has been a rare bright spot, though it is still tops in the developed world — an astounding 73 pounds per capita per year, according to the Agriculture Department.

Meanwhile, consumption of cheese hit 38.35 pounds per person in 2020, up from 24.6 in 1990, encouraged in part by a USDA-backed dairy-promotion program.

This is just one example of the federal government’s mixed messages on diet and nutrition. The Department of Health and Human Services promotes smart dietary standards, while a few blocks down Independence Avenue, USDA’s congressionally mandated farm programs not only promote cheese but subsidize corn and other staple ingredients of the high-fat, heavily processed, American diet.

Though a crucial support to low-income families, the federal Supplemental Nutrition Assistance Program, which paid $104.5 billion worth of benefits in 2021, covers nutritionally counterproductive purchases of candy, cake and soda. Food-industry lobbyists have resisted proposals to change that.

The good news about obesity, Bollyky says, is that it was "the only policy-amenable factor” among those that made the U.S. more vulnerable to covid.

In other words, there are steps government can take, at least at the margins, to fight the obesity epidemic. It should start by not doing things that make it worse.