Money appears to be a strong separator between the lean and the obese in Minnesota, which has one of the nation's widest economic gaps when it comes to excess weight gain.
Minnesota ranked 42nd among states for its disparity, because the obesity rate of 28 percent for all adults in the state in 2016 bloated to 38 percent among those in the lowest income bracket, according to a state report card released Thursday by the Commonwealth Fund, a Washington, D.C., health policy research foundation.
The gap was hardly news to Minnesota public health officials, who have issued millions of dollars in grants so low-income communities can gain better access to fresh food and fitness opportunities. The state's showing relative to other states was nonetheless frustrating.
"Minnesota always scores quite well in lots of surveys, but when we look at the data, we have some of the greatest disparities in the nation," said Chris Tholkes, an assistant division director for statewide health improvement projects at the Minnesota Department of Health.
The obesity statistic stuck out in a report that otherwise was good news for Minnesota, which ranked third among states for health and health care, and grim news for the nation, which saw increases in "deaths of despair" due to suicide and opioid abuse.
"Obesity rates continue to rise," said Dr. David Blumenthal, Commonwealth's president, who called it a "public health crisis of grave concern."
Minnesota's overall adult obesity rate is below the national average, but the state was one of 19 that saw a significant increase between 2013 and 2016. The Commonwealth report's obesity figures were based on behavioral surveys by the U.S. Centers for Disease Control and Prevention.
Income influenced the increase. The gap in the obesity rate between Minnesota's richest and poorest adults was only 6 percentage points in 2013 but grew to 12 percentage points by 2016, the Commonwealth report showed.
Minnesota also had economic gaps in the rates of adults who smoke and those who've lost six or more teeth, but those gaps between rich and poor were closer to national averages, the report showed.
Poor health outcomes for low-income Minnesotans are partly tied to the state's rural areas, where healthy food is inaccessible for some residents, Tholkes said.
Health officials have also pointed to the struggles of refugees to adjust to Western diets and more sedentary routines.
The problem is bigger than health care and is influenced by access to jobs, housing and transportation, but community leaders can chip away, said Janelle Waldock, vice president of community health and health equity at Blue Cross and Blue Shield of Minnesota.
The movement in Minneapolis to restrict menthol tobacco products is one public health example, she said.
"That effort was led by African-American community leaders and youth of color in Minneapolis who were calling on the City Council to make that policy change."
State health reports also show an economic disparity with regard to obesity — which is defined as a body mass index (BMI) of 30 or higher or a weight of 203 pounds or more for someone whose height is 5-foot-9.
However, when it comes to being overweight, or having a BMI between 25 and 30, the disparity between the poor and wealthy evaporates.
A state analysis of 2015 CDC survey data showed that people in Minnesota making $75,000 or more were actually more likely to be overweight than people making $25,000 or less.
The rise in overall obesity applies only to adults. Minnesota has seen declines in its childhood obesity rate amid a wave of efforts, including healthy snack carts at schools and walking "bus routes" in urban areas.
In addition to the state Health Department, Blue Cross' Center for Prevention has funded community programs to confront obesity. Allina Health's backyard initiative has sought health improvements in the low-income neighborhoods surrounding its flagship Abbott Northwestern Hospital in Minneapolis.
Health officials hope these efforts will eventually reverse the obesity trend. Tholkes drove Tuesday to Bemidji to discuss projects among American Indian tribes, which have tried to restore historically lean indigenous diets and reduce consumption of mass-produced foods.
She also expressed optimism over efforts to improve produce selection in food shelves for low-income Minnesotans.
"The older school model was really around, 'Any food is good food. People just need to eat,' " she said. "There is some truth in that, but people need to eat nutritious food also."
Minnesota ranked fifth best for its rates of insured children and adults, according to Commonwealth. Expansions of state low-income Medicaid health plans influenced that data.
Minnesota also had the seventh smallest gap among states in 2016 in the insured rates of its high- and low-income populations.
The number of Minnesotans who skipped health care because they couldn't afford it declined from 2013 to 2016. Improved health coverage should affect the obesity rate as well, Waldock said.
If helping other Minnesotans isn't motivation enough, she noted that the state loses $2.2 billion in productivity every year because of poorer health among minority residents and low-income workers.
"We care about this because our mission is to make a healthy difference in all people's lives," she said. "But if you're not on board from that perspective, we should all care about it because it's hitting all of our pocketbooks."