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To the Editor: Obesity is a major cause of morbidity and mortality in the United States.¹ Each year, an estimated 300,000 US adults die of causes attributable to obesity.² Obesity also substantially increases morbidity and impairs quality of life.³ Overall, the direct costs of obesity and physical inactivity account for approximately 9.4% of the national health care expenditures in the United States.⁴ Last year, we reported that the prevalence of obesity (defined as body mass index 30 kg/m²) based on self-reported weight and height in US adults increased from 12.0% in 1991 to 17.9% in 1998.⁵ To determine whether this increase is continuing, we examined 1999 data from the Behavioral Risk Factor Surveillance System (BRFSS).

Methods
The BRFSS is a cross-sectional telephone survey of noninstitutionalized civilian adults aged 18 years and older conducted by the Centers for Disease Control and Prevention and state health departments.

The BRFSS questionnaire primarily includes questions about personal behaviors that increase risk for 1 or more of the 10 leading causes of death in the United States. The BRFSS uses a multistage cluster design based on random digit dialing methods of sampling to select a representative sample from each state's noninstitutionalized civilian residents aged 18 years and older. Data collected from each state are pooled to produce nationally representative estimates. We used data on self-reported weight and height to calculate BMI as weight (kg) divided by height (m²). The SAS (version 6.09; SAS Institute, Cary, NC) and SUDAAN (version 7.5; Research Triangle Institute, Research Triangle Park, NC) software programs were used in the analyses and to account for the complex sampling design.

Results
In 1999, obesity continued to increase in men and women across all sociodemographic groups and all regions of the United States (Table 1). The prevalence of obesity increased significantly from 17.9% in 1998 to 18.9% in 1999, an increase of 5.6% in 1 year and of 57% from 1991. Average weight increased from 76.2 kg in 1998 to 76.7 kg in 1999 (84.4 kg to 85.0 kg among men and 68.4 kg to 68.7 kg among women). In 1991, 4 of the 45 participating states had obesity rates of 15% or greater, whereas by 1999, 39 states had rates of 15% or greater. In 1991, none of the 45 participating states had obesity rates of 20% or greater; however, by 1998, such rates were seen in 7 states and in 1999, in 16 states.

View this table: [in this window] [in a new window] Table. Increase in Obesity Prevalence Among Adults, by Selected Characteristics, 1998 to 1999

Comment
This continuing trend in obesity is a critical public health threat in the United States. Clearly, genes related to obesity are not responsible for the epidemic of obesity because the US gene pool did not change significantly between 1991 and 1999. We have recently reported a 33% increase in diagnosed diabetes from 1990 to 1998.⁶ This increase was highly correlated with obesity, and this emphasizes that obesity is not just a cosmetic disorder but a major risk factor for chronic diseases.

Unfortunately, the prevalence of obesity is likely to continue increasing in the years ahead. The time has come to develop a national, comprehensive plan to prevent and treat the obesity epidemic. The general goals are to prevent further weight gain in individuals with normal weight or overweight, reduce body weight among obese and overweight individuals, and encourage individuals to maintain a lower body weight over the long term. The approach should develop appropriate interventions to promote improved nutrition and increased physical activity and to identify effective educational, behavioral, and environmental approaches to control and prevent obesity. Such intervention programs should be implemented by health departments and communities throughout the United States.

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
Centers for Disease Control and Prevention
Atlanta, Ga

1. Allison DB, Fontaine KR, Manson JE, Stevens J, VanItallie TB. Annual deaths attributable to obesity in the United States. JAMA. 1999;282:1530-1538. FREE FULL TEXT 2. Must A, Spadano J, Coakley EH, Field AE, Colditz G, Dietz WH. The disease burden associated with overweight and obesity. JAMA. 1999;282:1523-1529. FREE FULL TEXT 3. Fontaine K, Bartlett S. Estimating health-related quality of life in obese individuals. Dis Manage Health Outcomes. 1998;3:61-70. 4. Colditz G. Economic costs of obesity and inactivity. Med Sci Sports Exerc. 1999;31(suppl 11):S663-S667. 5. Mokdad AH, Serdula MK, Dietz WH, Bowman BA, Marks JS, Koplan JP. The spread of the obesity epidemic in the United States, 1991-1998. JAMA. 1999;282:1519-1522. FREE FULL TEXT 6. Mokdad AH, Ford E, Bowman BA, et al. Diabetes trends in the United States, 1990 to 1998. Diabetes Care. 2000;23:1278-1283. FREE FULL TEXT

Letters Section Editors: Stephen J. Lurie, MD, PhD, Senior Editor; Phil B. Fontanarosa, MD, Executive Deputy Editor.

JAMA. 2000;284:1650-1651.

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