Sato’s enlightening article “Decline in Physical Activity after Age 35 Increases the Risk of Obesity, Insulin Resistance, and Diabetes: A Cross-sectional Analysis of the MIDUS Study” brings the Obesity Crisis in the United States (US) back to the forefront of our attention [1]. The incidence of obesity and diabetes continue to rise nationally and globally, and the physical ramifications of obesity and associated health problems, including diabetes, have been studied for decades [2–5]. However, health leaders have the opportunity to curb this course.

Sato suggests strategies for mitigating the obesity and diabetes epidemics, emphasizing health promotion programs and relieving personal barriers to regular physical activity [1]. However, the primary goal of health promotion programs is population behavior change. The question of how to promote physical activity and the role of leadership in this process remains. This article adds to Sato’s recommendations, while providing a broader public health perspective.

Sato refers to maintaining motivation and identifying personal values to sustain prolonged physical activity habits [1], which are crucial, but typically not adequate. The Influencer model emphasizes strategies leaders should take to promote population behavior change. The model provides a framework to motivate and empower people by highlighting strategies leaders can take when addressing societal, structural and personal barriers [6]. While determining individual values and goals promotes personal motivation, integrating social and environmental support is imperative. 

Governmental policies can provide environmental influence on obesity and diabetes. In the US, most obesity related policies target the school environments [7]. Free school meals have been shown to decrease child obesity rates [8]. The increasing number of physical activity programs in schools have also curbed childhood obesity [9]. Healthy nutrition and physical activity are key factors to instill in youth to encourage healthy weight through adulthood. However, our society needs more systems to help individuals maintain these behaviors.

Recent policies targeting unhealthy food taxes harness environmental motivation to improve obesity and diabetes. Sugar taxes implemented in multiple cities throughout the United States have been successful [10–13]. However, research indicates that the health benefits from such taxes did not persist long-term [14]. Therefore, more robust efforts utilizing multiple sources of support from health leaders are indicated.

Health providers have both the clinical expertise and social influence to change patient behaviors. Using non-judgmental language and working to limit biases can improve care and enhance participation in healthy behaviors [15]. Social determinants of health are upstream factors that influence weight. Negative or unfavorable social determinants of health, i.e. no insurance, low income, low literacy, food insecurity, etc., have been correlated with obesity [16]. Addressing socioeconomic factors and potential barriers to behavior change is of utmost importance for successful health promotion, too [17,18]. Unfortunately, there is a pervasive negative stigma linked with obesity that health providers and the lay community perpetuate, which can diminish self-efficacy and treatment compliance [19,20]. The loneliness and isolation crisis has now elucidated the detrimental emotional and mental effects that can be connected with this negativity.

The U.S. Surgeon General formally identified loneliness and social isolation as an epidemic in 2023, citing strong associations with increased mortality, chronic disease burden, and diminished quality of life [21]. Research indicates social isolation and loneliness have profound implications for cardiometabolic health [21]. Furthermore, studies have demonstrated that loneliness and social isolation are associated with increased incidence of type 2 diabetes, even after adjusting for body mass index and traditional risk factors [22,23]. Individuals experiencing social isolation are more likely to engage in sedentary behaviors, experience barriers to physical activity, social withdrawal and exhibit reduced adherence to preventive care and treatment regimens [24]. Therefore, a paradigm shifts for addressing obesity and related behaviors could benefit from multiple perspectives [25].

Addressing the loneliness epidemic represents an opportunity to improve obesity and diabetes. Health system leaders are uniquely positioned to implement structural interventions that foster social connection, including group-based diabetes and weight management programs, social prescribing initiatives, and community health worker–led support models. Routine screening for social isolation and loneliness in primary care settings may further enable early identification of patients at elevated risk for poor outcomes [22]. Investments in community infrastructure, reimbursement for group visits and social care interventions, and integration of social determinants of health into chronic disease management frameworks are critical [20]. Leadership strategies that prioritize inclusivity, reduce stigma, and promote social belonging align with broader public health goals and may enhance the effectiveness of obesity and diabetes management.

Health at Every Size model supports weight inclusivity, deemphasizing biometric weight measures while favoring behaviors associated with beneficial health outcomes [26,27]. While research results regarding cardiovascular improvements, perception of body image and total caloric intake are inconsistent, the physical activity and psychological benefits are well established [28–30]. Health promotion programs founded upon HAES principles might garner greater success.

The obesity and diabetes epidemics are complex and multifactorial. Therefore, this requires an approach that addresses individual, social, and structural determinates of health. Sato’s article highlights the importance of physical activity to mitigate the obesity and diabetes crises in the United States. While engaging resources to improve personal motivation can be effective, social and environmental support to improve behaviors are necessary, as well. The negative stigma associated with obesity and diabetes can contribute to the isolation crises in the United States. Health leaders have the opportunity to have a positive influence, and addressing loneliness is a foundational component of sustainable, population-level health improvement. Incorporating weight inclusive elements in physical activity programs can also be beneficial.