One in three Minnesota adults now meets the definition of obese — putting the state at elevated risk for chronic disease and in the middle of the pack nationally after years of above average health.

Minnesota's obesity rate has been rising steadily for decades, but the latest federal survey data was a blow for a state that has spent millions to confront epidemic weight gain and its health effects. Minnesota ranked eighth lowest among states with a 17.4% adult obesity rate in 2000. It now ranks 25th with a rate of 33.6%.

Public health leaders were undeterred because the federal data showed stable eating and exercise levels, and people have developed better body images that motivate healthier habits. Both trends could pay off, eventually. New weight-loss medications have been controversial because of their cost and questions about their long-term effectiveness, but offer hope.

"We're in it for the long game," said Kris Igo, director of Minnesota's Office of Statewide Health Improvement Initiatives.

Why Minnesota has lost ground is a mystery when it comes to the federal Behavioral Risk Factor Surveillance Survey, which provides annual estimates of obesity as well as smoking, drinking and other health issues. Despite the advantages of lower poverty and uninsured rates, Minnesota had the tenth-highest percentage point increase among states since 2000 in adult obesity.

"It's pretty clear we're going in the wrong direction," said Nico Pronk, chief science officer for Bloomington-based HealthPartners and chairman of a federal roundtable on obesity solutions.

Minnesota's increasing diversity is reflected in its obesity rate, which is defined by a combination of weight and height known as the Body Mass Index (BMI). A typical 5-foot-9 male would pass the obesity threshold at 203 pounds, and a 5-foot-4 female would do so at 175 pounds. The rate is two to three percentage points higher among the state's Black and Hispanic adults than among white adults, but it has nearly doubled for white adults since 2000 as well.

John Moeller blamed weight gain on comfort eating during an unhappy relationship and on the COVID-19 pandemic that restricted mobility and at one point shut down his health club. The commercial pilot resolved this July to pair workouts at LifeTime Fitness in Eagan with smarter eating — and to resist temptations when flying to Paris and other food meccas on jets that are loaded with desserts.

"The chocolate lava fountain cake they are serving is really good," he said.

Moeller was flirting with severe obesity when he started taking tuna packets and protein shakes on flights, and cut out cheap frozen pizzas at home. His 15-year-old twin children helped, eliminating cookies from the pantry, and he has lost 47 pounds so far and said he doesn't stick out so much from his fellow pilots.

Moeller's strategy mirrors Minnesota's strategy — to make the healthy choice easier.

The state in 2010 launched a Statewide Health Improvement Program (SHIP) that invested in local solutions, such as building trails to increase exercise options in dense urban areas. Farmer's markets and food shelves gained funding to offer fresh produce in "food deserts," low-income areas that lack options beyond convenience marts and fast-food chains.

"We make it really hard in our society to make the healthy choice," said Marna Canterbury, a board member of the Valley Outreach food shelf in Stillwater and HealthPartners' vice president of community health. "You can get an Oreo cup that fits in your minivan holder, but it's much harder to get fresh fruit."

More food shelf visitors filled their carts with fresh and canned produce after Valley moved it to attractive displays in the front, replacing canned ravioli and boxed dinners.

It's not surprising that such approaches work even while obesity increases, said Dr. Iesha Galloway-Gilliam, a weight-management specialist with Hennepin Healthcare. Today's eating habits get passed along through genetic expression to the next generation and influence its habits, she said, which is why a recent forecast of a 46% adult obesity rate in Minnesota by 2030 is probable.

"We are significantly behind the eight ball," she said, "but we have to put things in place now with how we are changing our environment to have a chance at impacting this decades from now."

How to respond to rising obesity is in some dispute. The American Medical Association declared obesity a disease in 2013, noting its correlation with diabetes, stroke and heart disease. Obesity was a common complication in COVID-19 deaths as well.

On the other hand, the nation's fixation with weight created decades of blame and shame, which fueled depression and other health problems. A countermovement has emerged to reduce weight bias and focus on other measures of health than BMI, which doesn't account for different body types or differentiate people with obesity who don't have health problems.

"Saying, 'Oh, we just need everybody to lose weight' or 'we just don't need to have fat people around any more and then all of our issues are going to go away' is such a silly perspective," said Cat Polivoda, owner of the Cake Plus-Size Resale clothing boutique in Minneapolis. She also created Matter of Fat, a podcast that promoted body positivity for its five-year run through 2022.

Melissa Dvorak has concerns about the movement. As a physician assistant at an M Health Fairview Surgical Weight Loss Clinic in Edina, she differentiated the benefits of a healthy body image from the risks of ignoring obesity. She wants insurers to expand eligibility so that more people can opt for earlier treatments and surgeries.

"We want ... to take away the stigma of higher weight, but we also don't want to forget that this is a disease," she said.

Growth in obesity showed signs of tapering prior to the pandemic, but COVID-19 resulted in people staying home and exercising less. Job losses and fears about the disease also increased stress, which "can create more cravings and snacking behaviors," Galloway-Gilliam said.

The impact showed among Minnesotans who were defined as overweight — a range of 170 to 200 pounds for a 5-foot-9 male. Many had hovered at that level for years, but reached obesity during the pandemic.

Use of a new class of GLP-1 medications has surged, with Blue Cross and Blue Shield of Minnesota reporting a 63% increase in prescriptions in the 12 months ending in September. The drugs have shown a remarkable impact on appetite and digestion, but appear to require continuous use to maintain the weight-loss benefits.

Prime Therapeutics, a pharmacy benefits manager, reported earlier this year that total medical spending increased among people with obesity who took these drugs compared to those who didn't.

Pronk said the medications offer exciting promise to individuals who can access them but aren't a solution for the broader population. The out-of-pocket cost of as much as $1,000 per month puts them out of reach for low-income Minnesotans who are at greater risk. The obesity rate is already 39% for Minnesota adults with household incomes of $15,000 or less.

Minnesota gained national attention for its SHIP grants, which have totaled about $250 million since 2010, but Pronk said more state action is needed.

Minnesota has the lowest obesity rate in the Upper Midwest, but is behind states such as California, where the rate is 28%. Minnesota enacted two obesity prevention policies since 2009, compared to 96 in California, according to the State of Obesity 2023 report by Trust for America's Health.

"We can't just do this by treatment alone because it won't stop the influx of new people" becoming obese, Pronk said. "We need something to slow it down."