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Ali H. Mokdad, PhD; Mary K. Serdula, MD, MPH; William H. Dietz, MD, PhD; Barbara A. Bowman, PhD; James S. Marks, MD, MPH; Jeffrey P. Koplan, MD, MPH

JAMA. 1999;282:1519-1522.

ABSTRACT
Context  The increasing prevalence of obesity is a major public health concern, since obesity is associated with several chronic diseases.

Objective  To monitor trends in state-specific data and to examine changes in the prevalence of obesity among adults.

Design  Cross-sectional random-digit telephone survey (Behavioral Risk Factor Surveillance System) of noninstitutionalized adults aged 18 years or older conducted by the Centers for Disease Control and Prevention and state health departments from 1991 to 1998.

Setting  States that participated in the Behavioral Risk Factor Surveillance System.

Main Outcome Measures  Body mass index calculated from self-reported weight and height.

Results  The prevalence of obesity (defined as a body mass index 30 kg/m²) increased from 12.0% in 1991 to 17.9% in 1998. A steady increase was observed in all states; in both sexes; across age groups, races, educational levels; and occurred regardless of smoking status. The greatest magnitude of increase was found in the following groups: 18- to 29-year-olds (7.1% to 12.1%), those with some college education (10.6% to 17.8%), and those of Hispanic ethnicity (11.6% to 20.8%). The magnitude of the increased prevalence varied by region (ranging from 31.9% for mid Atlantic to 67.2% for South Atlantic, the area with the greatest increases) and by state (ranging from 11.3% for Delaware to 101.8% for Georgia, the state with the greatest increases).

Conclusions  Obesity continues to increase rapidly in the United States. To alter this trend, strategies and programs for weight maintenance as well as weight reduction must become a higher public health priority.

INTRODUCTION

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Although attempts to lose weight are common in the United States,^1-2 the prevalence of obesity has increased since the 1980s.^3-4 Such increases will tremendously affect public health since obesity is strongly associated with several chronic diseases, such as cardiovascular diseases and diabetes.^5-6 Recent estimates suggest that obesity-related morbidity may account for 6.8% of US health care costs.⁷

Recently published trend data from the National Health and Nutrition Examination Surveys (NHANES) show the percentage of obese persons has increased from 14.5% in the years 1976-1980 to 22.5% in 1988-1994.³ To monitor obesity trends since 1994 and to present state-specific results, we used data from a large population-based survey to examine changes in the prevalence of obesity among adults in the United States from 1991 to 1998.

METHODS

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We analyzed data from all states that participated in the Behavioral Risk Factor Surveillance System (BRFSS). The BRFSS, a cross-sectional telephone survey of noninstitutionalized adults aged 18 years or older, is conducted by the Centers for Disease Control and Prevention and state health departments. The BRFSS questionnaire concerns personal behaviors that increase risk for 1 or more of the 10 leading causes of death in the United States.⁸

The BRFSS uses a multistage cluster design based on random digit dialing methods to select a representative sample from each state's noninstitutionalized residents.^9-10 Data collected from each state are pooled to produce nationally representative estimates.⁹ Further details about the BRFSS have been published.^9-10

We calculated body mass index (BMI) (weight in kilograms divided by the square of height in meters) based on self-reported weight and height. Participants were classified as obese if their BMI was greater than or equal to 30 kg/m².¹¹ Questions on leisure-time physical activity were included in the BRFSS only in 1991, 1992, 1994, 1996, and 1998 and were used to create a leisure-time physical activity score: inactive, irregularly active, regular, not intense, and regular, intense.¹² We used SAS and SUDAAN statistical software in the analyses and to account for the complex sampling design.^13-14 Because of the large sample size (more than 100,000 participants each year), we have not emphasized statistical testing.

We excluded from our trend analyses 6 states because they did not collect weight and height for 1 or more years: Arkansas (1992), the District of Columbia (1995), Kansas (1991), Nevada (1991), Rhode Island (1994), and Wyoming (1991, 1992, and 1993). However, we included the data for all available years for these and all other states in our maps. We used the US Bureau of Census method of grouping states into regions.

RESULTS

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The prevalence of obesity increased from 12.0% in 1991 to 17.9% in 1998 (Table 1). Obesity increased in men and women and across all sociodemographic groups (Table 2), with the highest increase among the youngest ages and higher education levels. Among Hispanic men, the prevalence of obesity increased from 10.0% in 1991 to 18.3% in 1997 and for Hispanic women from 13.2% to 23.4%. The prevalence of obesity increased steadily from 1991 to 1998 in all states (Figure 1).

View this table: [in this window] [in a new window] Table 1. Obesity Prevalence in Adults and Mean Weight by Year, 1991 to 1998*

View this table: [in this window] [in a new window] Table 2. Changes in Obesity Prevalence in Adults by Characteristics*

View larger version (54K): [in this window] [in a new window] Figure. Prevalence of Obesity Among US Adults From Years 1991, 1993, 1995, and 1998 Data were calculated using the Behavioral Risk Factor Surveillance System. States are white in the years 1991 and 1993 because information on weight and height was not collected.

In 1991, 4 of the 45 participating states had obesity rates of 15% or higher (Table 3). By 1998, 37 states had rates higher than 15%. The magnitude of the increase varied by region (ranging from 31.9%-67.2% increase in the mid Atlantic and South Atlantic regions, respectively) and by state, ranging from 11.3% in Delaware to 101.8% in Georgia.

View this table: [in this window] [in a new window] Table 3. Changes in Obesity Prevalence in Adults by Region and State*

In 1991, the level of leisure-time physical activity was 29.7% inactive, 28.4% irregularly active, 33.2% regular not intense, and 8.7% regular intense. In 1998, they were 28.6% inactive, 28.2% irregularly active, 29.6% regular not intense, and 13.6% regular intense.

To exclude the possibility that demographic differences accounted for the variation in obesity prevalence between the states, we computed the age-, sex-, and race-adjusted prevalence of obesity. Although the adjusted rates were higher than the unadjusted rates, similar patterns were observed among states and over time. Therefore, we only report the unadjusted estimates.

COMMENT

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These data show that obesity increased in every state, in both sexes, and across all age groups, races, educational levels, and smoking statuses. Rarely do chronic conditions such as obesity spread with the speed and dispersion characteristic of a communicable disease epidemic. However, this rapid trajectory of obesity may present both clues to origin and measures for efficient attempts to control its spread.

Since overweight participants in self-reported studies tend to underestimate their weight and all participants tend to overestimate their height; true rates of obesity are likely underestimated.^15-16 Moreover, people without telephones are not surveyed through BRFSS, and such individuals are likely to be of lower socioeconomic status, a factor that is associated with obesity.^17-18 The net effect of these limitations is that the prevalence of obesity reported herein is likely a conservative estimate. In fact, the prevalence of obesity from NHANES III (1988-1994) in which weight and height were measured by health professionals was 22.5% in adults, more than a third higher than the rates reported in our survey.³

The BRFSS data provide states with unique population-based estimates of self-reported obesity against which prevention efforts may be evaluated. State-level population-based estimates of obesity should be used to provide each state with a basis for setting priorities for public health interventions.

This rapid increase in obesity in all segments of the population and regions of the country implies that there have been sweeping changes in US society that are contributing to weight gain by fostering energy intake imbalance. Such changes are unlikely to be due to diminished individual motivation to maintain weight or in genetic or other biological changes in the population.

We focused on describing the changes in patterns of obesity instead of its contributory factors, such as alterations in diet, activity patterns, or other behaviors that affect energy balance. However, our data demonstrate that a major contributor to obesity—physical inactivity—has not changed substantially at the population level between 1991 and 1998. By focusing on the challenge of stopping the obesity epidemic and the profound negative health consequences of obesity, it is important to increase the awareness and involvement of health professionals in dealing with the epidemic.

Our data suggest that the development of strategies and programs for weight maintenance as well as weight reduction must become a higher priority. Public health messages should focus increasingly on balancing energy intake with physical activity. To control the obesity epidemic, a wide range of population groups, including physicians and other health care professionals, public health professionals, legislators, communities, work sites, and organizations, must become engaged in working toward a solution.

AUTHOR INFORMATION

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Acknowledgment: We thank David E. Nelson, MD, MPH, and Nancy L. Silver, MS, for their valuable assistance.

Corresponding Author and Reprints: Ali H. Mokdad, PhD, Division of Nutrition and Physical Activity, 4770 Buford Hwy NE, Mailstop K26, Atlanta, GA 30341-3717 (e-mail: ahm1{at}cdc.gov).

Author Affiliations: Division of Nutrition and Physical Activity (Drs Mokdad, Serdula, Dietz, and Bowman), Office of the Director, National Center for Chronic Disease Prevention and Health Promotion (Dr Marks), and Office of the Director (Dr Koplan), Centers for Disease Control and Prevention, Atlanta, Ga.

REFERENCES

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1. Serdula MK, Williamson DF, Anda RF, Levy A, Heaton A, Byers T. Weight control practices in adults. Am J Public Health. 1994;84:1821-1824. FREE FULL TEXT 2. Williamson DF, Serdula MK, Anda RF, Levy A, Byers T. Current weight loss attempts in adults. Am J Public Health. 1992;82:1251-1257. FREE FULL TEXT 3. Flegal KM, Carrol MD, Kuczmarski RJ, Johnson CL. Overweight and obesity trends in the United States: prevalence and trends, 1960-1994. Int J Obes Relat Metab Disord. 1998;22:39-47. FULL TEXT | ISI | PUBMED 4. Galuska DA, Serdula M, Pamuk E, Siegel P, Byers T. Trends in overweight among US adults from 1987 to 1993: a multistate telephone survey. Am J Public Health. 1996;86:1729-1735. FREE FULL TEXT 5. National Institutes of Health Consensus Development Panel on Health Implications of Obesity. Health implications of obesity. Ann Intern Med. 1985;103:1073-1077. FULL TEXT | ISI | PUBMED 6. Pi-Sunyer FX. Health implications of obesity. Am J Clin Nutr. 1991;53(suppl 6):1595S-1603S. 7. Wolf AM, Colditz GA. Social and economic effects of body weight in the United States. Am J Clin Nutr. 1996;63(suppl 3):466S-469S. 8. Remington PL, Smith MY, Williamson DF, Anda RF, Gentry EM, Hogelin CG. Design, characteristics, and usefulness of state-based behavioral risk factor surveillance: 1981-1987. Public Health Rep. 1988;103:366-375. ISI | PUBMED 9. Waksberg JS. Methods for random digit dialing. J Am Stat Assoc. 1978;73:40-46. FULL TEXT | ISI 10. Nelson DE, Holtzman D, Waller M, Leutzinger CL, Condon K. Objectives and design of the Behavioral Risk Factor Surveillance System. In: Proceedings of the Section on Survey Methods of the American Statistical Association National Meeting; August 10, 1998; Dallas, Tex. 11. WHO Expert Committee on Physical Status. The Use and Interpretation of Anthropometry: Report of a WHO Expert Committee. Geneva, Switzerland: World Health Organization; 1995. World Health Organization Technical Report Series 854. 12. Caspersen CJ, Pollard RA, Pratt SO. Scoring physical activity data with special consideration for elderly populations. In: Proceedings of the 21st National Meeting of the Public Health Conference on Records and Statistics: Data for an Aging Population; July 13-15, 1987; Hyattsville, Md. National Center for Health Statistics/Dept of Health and Human Services publication PHS 88-1214. 13. SAS System [computer program], Version 6.12. Cary, NC: SAS Institute Inc; 1998. 14. Shah BV, Barnwell BG, Bieler GS. SUDAAN User's Manual, Release 7.5. Research Triangle Park, NC: Research Triangle Institute; 1997. 15. Rowland ML. Self-reported weight and height. Am J Clin Nutr. 1990;52:1125-1133. FREE FULL TEXT 16. Palta M, Prineas RJ, Berman R, Hannan P. Comparison of self-reported and measured height and weight. Am J Epidemiol. 1982;115:223-230. FREE FULL TEXT 17. Aday LA. Designing and Conducting Health Surveys: A Comprehensive Guide. San Francisco, Calif: Jossey-Bass Publishers; 1989:79-80. 18. Bray GA. An approach to the classification and evaluation of obesity. In: Bjorntrop P, Brodoff BN, eds. Obesity. Philadelphia, Pa: JB Lippincott Co; 1992:301.

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Health Care Expenditures Associated With Overweight and Obesity Among US Adults: Importance of Age and Race
Wee et al.
Am. J. Public Health 2005;95:159-165.
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Overweight and Components of the Metabolic Syndrome in College Students
Huang et al.
Diabetes Care 2004;27:3000-3001.
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Bariatric Surgery: A Systematic Review and Meta-analysis
Buchwald et al.
JAMA 2004;292:1724-1737.
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Reasons for Increasing Trends in Large for Gestational Age Births
Surkan et al.
Obstet Gynecol 2004;104:720-726.
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The More Food Young Adults Are Served, the More They Overeat
Levitsky and Youn
J. Nutr. 2004;134:2546-2549.
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A long-term high-protein diet markedly reduces adipose tissue without major side effects in Wistar male rats
Lacroix et al.
Am. J. Physiol. Regul. Integr. Comp. Physiol. 2004;287:R934-R942.
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Impact of Obesity on Medical Problems and Quality of Life in Taiwan
Tsai et al.
Am J Epidemiol 2004;160:557-565.
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Urban Sprawl and Risk for Being Overweight or Obese
Lopez
Am. J. Public Health 2004;94:1574-1579.
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Length of Hospital Stays Among Obese Individuals
Zizza et al.
Am. J. Public Health 2004;94:1587-1591.
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Postoperative sternal dehiscence in obese patients: Incidence and prevention
Molina et al.
Ann. Thorac. Surg. 2004;78:912-917.
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Household Food Insecurity Is Associated with Adult Health Status
Stuff et al.
J. Nutr. 2004;134:2330-2335.
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Body mass index and cardiovascular disease in the Asia-Pacific Region: an overview of 33 cohorts involving 310 000 participants
Asia Pacific Cohort Studies Collaboration
Int J Epidemiol 2004;33:751-758.
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Efficacy of Pharmacotherapy for Weight Loss in Adults With Type 2 Diabetes Mellitus: A Meta-analysis
Norris et al.
Arch Intern Med 2004;164:1395-1404.
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Narrowing of the Proximal Jejunal Limbs at Their Passage Through the Transverse Mesocolon: A Potential Pitfall of Laparoscopic Roux-en-Y Gastric Bypass
Smith and White
Am. J. Roentgenol. 2004;183:141-143.
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