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The Continuing Epidemics of Obesity and Diabetes in the United States
Ali H. Mokdad, PhD;
Barbara A. Bowman, PhD;
Earl S. Ford, MD,MPH;
Frank Vinicor, MD,MPH;
James S. Marks, MD,MPH;
Jeffrey P. Koplan, MD,MPH
JAMA. 2001;286:1195-1200.
ABSTRACT
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Context Recent reports show that obesity and diabetes have increased in the United States in the past decade.
Objective To estimate the prevalence of obesity, diabetes, and use of weight control strategies among US adults in 2000.
Design, Setting, and Participants The Behavioral Risk Factor Surveillance System, a random-digit telephone survey conducted in all states in 2000, with 184 450 adults aged 18 years or older.
Main Outcome Measures Body mass index (BMI), calculated from self-reported weight and height; self-reported diabetes; prevalence of weight loss or maintenance attempts; and weight control strategies used.
Results In 2000, the prevalence of obesity (BMI  30 kg/m2) was 19.8%, the prevalence of diabetes was 7.3%, and the prevalence of both combined was 2.9%. Mississippi had the highest rates of obesity (24.3%) and of diabetes (8.8%); Colorado had the lowest rate of obesity (13.8%); and Alaska had the lowest rate of diabetes (4.4%). Twenty-seven percent of US adults did not engage in any physical activity, and another 28.2% were not regularly active. Only 24.4% of US adults consumed fruits and vegetables 5 or more times daily. Among obese participants who had had a routine checkup during the past year, 42.8% had been advised by a health care professional to lose weight. Among participants trying to lose or maintain weight, 17.5% were following recommendations to eat fewer calories and increase physical activity to more than 150 min/wk.
Conclusions The prevalence of obesity and diabetes continues to increase among US adults. Interventions are needed to improve physical activity and diet in communities nationwide.
INTRODUCTION
Obesity and diabetes are major causes of morbidity and mortality in the United States.1-2 Evidence from several studies indicates that obesity and weight gain are associated with an increased risk of diabetes.3-4 Each year, an estimated 300 000 US adults die of causes related to obesity.5 Obesity also substantially increases morbidity and impairs quality of life.6-8 Overall, the direct costs of obesity and physical inactivity account for approximately 9.4% of US health care expenditures.9 The direct and indirect costs of health care associated with diabetes in 1997 were an estimated $98 billion.10
We recently reported that the prevalence of obesity among US adults (body mass index [BMI; calculated as weight in kilograms divided by the square of height in meters] 30 kg/m2), based on self-reported weight and height, increased from 1991 to 1999, and that the prevalence of diagnosed diabetes based on self-reported data increased from 1990 to 1999.11-14 We used data from the Behavioral Risk Factor Surveillance System (BRFSS) in 2000 to examine whether these increases in obesity and diabetes are continuing, the prevalence of attempting to lose or maintain weight, and the strategies used by the US adults to lose or maintain weight.
METHODS
The BRFSS is a cross-sectional telephone survey conducted by the Centers for Disease Control and Prevention and state health departments. The BRFSS questionnaire consists primarily of 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 or older. Data collected from each state are pooled to produce nationally representative estimates. A detailed description of the survey methods has been previously published.15-16
We used data on self-reported weight and height to calculate BMI. Participants were classified as obese if their BMI was 30 kg/m2 or more.17 Extreme obesity (obesity class III) was classified as a BMI of 40 kg/m2 or more.18 Self-reported weight and height were assessed by asking respondents, "About how much do you weigh without shoes?" and "About how tall are you without shoes?" Diagnosed diabetes was assessed by asking respondents, "Have you ever been told by a doctor that you have diabetes?" The answer was coded "yes" or "no;" to parallel the methods in our previous reports, respondents who answered yes include those with gestational diabetes. Classification of diabetes (type 1 or type 2) was not assessed. The questions on self-reported weight and height and self-reported diabetes did not change from 1991 to 2000.
Participants were asked to report the type, duration, and frequency of the 2 leisure-time physical activities they had participated in most frequently in the past month. These questions were used to create a leisure-time physical activity score: (1) inactive; (2) irregularly active; (3) regular, not intense; and (4) regular, intense.19
Respondents were asked, "Are you trying to lose weight?" Those who responded "no" were asked, "Are you trying to maintain weight?" Respondents who answered "yes" to either question were asked the following: (1) "Are you trying to eat fewer calories or less fat to lose weight?", (2) "Are you using physical activity or exercise to lose weight or keep from gaining weight?", and (3) "In the past 12 months, has a doctor, nurse, or health professional given you advice about your weight?"
The 2000 BRFSS questionnaire included the fruit and vegetable module. We used these questions to classify participants into 4 groups based on fruit and vegetable daily consumption: (1) less than once or not at all, (2) 1 to less than 3 times, (3) 3 to less than 5 times, and (4) 5 or more times.
To account for the complex sampling design, SAS and SUDAAN software programs were used in the analyses.20-21
RESULTS
The 2000 BRFSS is based on responses from 184 450 participants in 50 states. In 2000, the prevalence of obesity was 19.8% among US adults (Table 1), which reflects a 61% increase since 1991.11 A total of 38.8 million US adults were obese (19.6 million men and 19.2 million women), and approximately 2.1% (1.5% of men and 2.8% of women) of all participants had a BMI of 40 kg/m2or more, compared with 0.9% in 1991 (data available from the author). In 2000, most US adults—approximately 56.4% (65.5% of men and 47.6% of women) of all participants—were overweight (BMI 25 kg/m2), compared with 45% in 1991 (data available from the author).
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Table 1. Obesity and Diabetes Prevalence Among US Adults, by Selected Characteristics, Behavioral Risk Factor Surveillance System, 2000
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In 1991, 4 of the participating states had obesity rates of 15% or greater, whereas by 2000, all participating states except Colorado had rates of obesity of 15% or greater (Figure 1 and Table 2). In 1991, none of the participating states had obesity rates of 20% or greater; however, by 2000, 22 of the participating states had rates of obesity of 20% or greater. In 2000, Mississippi had the highest (24.3%) and Colorado had the lowest (13.8%) rate of obesity. Among races, blacks had the highest rate of obesity (29.3%) (Table 1).
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Figure 1. Prevalence of Obesity Among US Adults
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Table 2. Obesity and Diabetes Prevalence Among US Adults, by State, Behavioral Risk Factor Surveillance System, 2000
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The prevalence of a self-report of diagnosed diabetes increased from 4.9% in 199013 to 7.3% in 2000 (Table 1), a 49% increase. In 2000, approximately 15 million US adults aged 18 years or older had diagnosed diabetes (6.3 million men and 8.7 million women). In 1990, 4 states had diabetes rates of 6% or greater, whereas by 2000, 43 of the 50 participating states had diabetes rates of 6% or greater (Figure 2). In 2000, Mississippi had the highest rate (8.8%) and Alaska had the lowest rate (4.4%) of diagnosed diabetes. Blacks had the highest rate of diagnosed diabetes (11.1%) among all race groups, and participants with less than a high school education had the highest rate (12.9%) among the educational levels (Table 1). In 2000, 2.9% of US adults both were obese and had diabetes, compared with 1.4% in 1991 (data available from the author).
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Figure 2. Prevalence of Diagnosed Diabetes Among US Adults
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Weight control practices varied by BMI. While most participants were trying to lose or maintain weight, 20.1% of overweight participants and 13.5% of obese participants were not trying to lose or maintain weight (Table 3). About 27% of US adults did not engage in any physical activity, and another 28.2% were not regularly active. Only 24.4% of US adults ate fruits and vegetables at least 5 times a day. Among obese participants who were trying to lose weight, only 42.8% had been advised to lose weight by a health professional, and 15.6% of overweight participants had received such advice.
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Table 3. Percentage of US Adults Who Use Specific Weight Control Practices by Body Mass Index, Behavioral Risk Factor Surveillance System, 2000*
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Among participants who were trying to lose or maintain weight, 72.9% reported dieting, and 59.5% were increasing physical activity (Table 4). However, among participants attempting to lose or maintain weight, only 17.5% were following the 2 key recommendations: to eat fewer calories and to increase physical activity. Similarly, only 24.9% of these participants were consuming the recommended 5 servings of fruits and vegetables, while 40.6% were achieving the recommended physical activity levels (30 minutes of moderate activity 5 times/wk).
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Table 4. Prevalence of Specific Weight Control Practices by Selected Characteristics Among Persons Trying to Lose or Maintain Weight, Behavioral Risk Factor Surveillance System, 2000*
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COMMENT
During the 1990s, epidemics of obesity and diabetes developed among US adults. Our current findings indicate that most US adults (>56%) are overweight, about 1 in 5 is obese, and 7.3% have diabetes. However, if undiagnosed diabetes is considered, it is likely that almost 10% of US adults have diabetes based on a previous report that estimated the prevalence of diagnosed diabetes in 1988-1994 to be 5.1% for US adults aged 20 years or older; in this study, the prevalence of undiagnosed diabetes was 2.7%.22
Our estimates of the extent of the 2 epidemics of obesity and diabetes in US adults are conservative. In validation studies of self-reported weight and height, overweight subjects tend to underestimate their weight, and all participants tend to overestimate their height.23-25 Moreover, persons without telephones are likely to be of lower socioeconomic status, a factor associated with increased risk for both obesity and diabetes.22, 26
Both BMI and weight gain are major risk factors for diabetes.27-28 Body mass index is one of the strongest predictors of diabetes, and previous studies have shown that changes in BMI at the population level foreshadow changes in diabetes.3-4,29-32 For every 1-kg increase in measured weight, the risk of diabetes increased by 4.5% in a national sample of adults.3 In our previous BRFSS analysis for 1991-1998, every 1-kg increase in average self-reported weight was associated with a 9% increase in the prevalence of diabetes.13 From 1999 to 2000, the average weight of US adults increased by 0.5 kg (data available from the author), and the prevalence of diagnosed diabetes increased by about 6%.14
Both obesity and diabetes are largely preventable. Previous studies have demonstrated that changes in lifestyle are effective in preventing diabetes and obesity in selected groups of adults who are at high risk.33-35 In a recent clinical trial from Finland, lifestyle changes significantly reduced the risk of diabetes in middle-aged, overweight subjects.35 After a modest (4.7%) weight loss, those in the intervention group had a 58% reduction in incidence of diabetes over 4 years.35 Moreover, blood pressure, triglycerides, and high-density lipoprotein cholesterol levels also improved significantly.35 Therefore, increasing physical activity, improving diet, and sustaining these lifestyle changes can reduce the risk of both diabetes and increased weight.
The weight-related behaviors of US adults are clearly linked to these continuing epidemics. We found that 27.0% of US adults in 2000 did not engage in any leisure-time physical activity, and another 28.2% were not regularly active. These rates are similar to those reported for 1998 (28.6% inactive and 28.2% irregularly active).11 In 2000, 38.5% of US adults were trying to lose weight, 35.9% were trying to maintain weight, and 25.6% were doing neither. In 1996, these rates were 36.6%, 34.4%, and 29.0%.36 Furthermore, only 24.4% of US adults met recommendations for fruit and vegetable consumption in 2000 vs 22.7% in our previous report on BRFSS participants from 16 states in 1996.37
Strategies that US adults use to lose or maintain weight contribute to their failure to achieve their weight control objectives. In 2000, 72.9% of US adults reported that they had changed their diet to achieve their weight goal, and 59.5% reported that they had increased their physical activity.36 These rates have not changed substantially since 1996. Furthermore, in the year 2000, only 17.5% of US adults were following guidelines for increasing physical activity and lowering energy intake. Although this percentage has increased from 15.0% in 1996, it is still far below what will be needed to attain goals for healthy weight.
Our finding that only 42.8% of obese persons who had had a routine checkup in the past year had been advised by health care professionals to lose weight is disturbing. In 1996, this percentage was 42.4%, which prompted a call for physicians to be more involved in weight counseling.38-39 Persons who receive advice from a health care professional to lose weight are more likely to attempt to lose weight than those who do not receive this advice.38 Health care professionals should assess overweight and obesity and recommend weight loss (using the combination of a low-calorie diet and increased physical activity) to overweight and obese patients and weight maintenance to patients with normal weight.18
While overweight and obese individuals need to reduce their energy intake and increase their physical activity, many others must play a role to help these individuals and to prevent further increases in obesity and diabetes. That is, health care professionals must counsel their overweight and obese patients; workplaces must offer healthy food choices in their cafeterias and provide opportunities for employees to be physically active on site; schools must offer more physical education that encourages lifelong physical activity; urban policymakers must provide more sidewalks, bike paths, and other alternatives to cars; and parents need to reduce their children's television and computer time and encourage active play. In general, restoring physical activity to our daily routines is crucial to the future reduction of diabetes and obesity in the US population.
Unfortunately, the prevalence of obesity and diabetes has increased despite previous calls for action40; it is likely to continue to increase in the years ahead unless effective interventions are implemented. In the past 25 years, several promising approaches have been identified as targets for clinical and public health action. To control these dual epidemics, now is the time for implementing multicomponent interventions for weight control, healthy eating, and physical activity.
AUTHOR INFORMATION
Author Contributions: Study concept and design: Mokdad, Bowman, Ford, Vincor, Marks, Koplan.
Acquisition of data: Mokdad, Bowman, Ford, Vincor, Koplan.
Analysis and interpretation of data: Mokdad, Bowman, Ford, Vincor, Marks, Koplan.
Drafting of the manuscript: Mokdad, Bowman, Ford, Vincor, Marks, Koplan.
Critical revision of the manuscript for important intellectual content: Mokdad, Bowman, Ford, Vincor, Marks, Koplan.
Statistical expertise: Mokdad, Bowman, Ford, Vincor, Koplan.
Obtained funding: Mokdad, Bowman, Ford, Vincor, Marks, Koplan.
Administrative, technical, or material support: Mokdad, Bowman, Ford, Vincor, Marks, Koplan.
Study supervision: Mokdad, Bowman, Ford, Vincor, Marks, Koplan.
Acknowledgment: We thank Emmanuel Maurice, MS, MA, for his assistance.
Corresponding Author and Reprints: Ali H. Mokdad, PhD, Data Management Division, National Immunization Program, Centers for Disease Control and Prevention, MS E62, 1600 Clifton Rd, NE, Atlanta, GA 30333 (e-mail: ahm1{at}cdc.gov).
Author Affiliations: Data Management Division, National Immunization Program (Dr Mokdad); Division of Diabetes Translation (Drs Bowman and Vinicor), Division of Nutrition and Physical Activity (Dr Ford), and Office of the Director (Dr Marks), National Center for Chronic Disease Prevention and Health Promotion; and Office of the Director (Dr Koplan), Centers for Disease Control and Prevention, Atlanta, Ga.
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Am. J. Physiol. Endocrinol. Metab. 2008;295:E586-E594.
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Secular decline in mortality from coronary heart disease in adults with diabetes mellitus: cohort study
Dale et al.
BMJ 2008;337:a236-a236.
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Fetuin-A and Incident Diabetes Mellitus in Older Persons
Ix et al.
JAMA 2008;300:182-188.
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Do People With Diabetes Need Statins?
White
The Diabetes Educator 2008;34:664-673.
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Why Young Adults Hold the Key to Assessing the Obesity Epidemic in Children
Lee
Arch Pediatr Adolesc Med 2008;162:682-687.
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A 40-Year-Old Woman With Diabetes Contemplating Pregnancy After Gastric Bypass Surgery
Coustan
JAMA 2008;299:2550-2557.
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Metabolic syndrome and incidence of type 2 diabetes in patients with manifest vascular disease
Wassink et al.
Diabetes and Vascular Disease Research 2008;5:114-122.
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A high-carbohydrate diet in the immediate postnatal life of rats induces adaptations predisposing to adult-onset obesity
Srinivasan et al.
J Endocrinol 2008;197:565-574.
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Differential modulation of L-type calcium channel subunits by oleate
Tian et al.
Am. J. Physiol. Endocrinol. Metab. 2008;294:E1178-E1186.
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Prevention of Heart Failure: A Scientific Statement From the American Heart Association Councils on Epidemiology and Prevention, Clinical Cardiology, Cardiovascular Nursing, and High Blood Pressure Research; Quality of Care and Outcomes Research Interdisciplinary Working Group; and Functional Genomics and Translational Biology Interdisciplinary Working Group
Schocken et al.
Circulation 2008;117:2544-2565.
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The Joint Effects of Physical Activity and Body Mass Index on Coronary Heart Disease Risk in Women
Weinstein et al.
Arch Intern Med 2008;168:884-890.
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Intramuscular lipid oxidation and obesity
Houmard
Am. J. Physiol. Regul. Integr. Comp. Physiol. 2008;294:R1111-R1116.
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Comparison of Strategies for Sustaining Weight Loss: The Weight Loss Maintenance Randomized Controlled Trial
Svetkey et al.
JAMA 2008;299:1139-1148.
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Hypothalamic Phosphatidylinositol 3-Kinase Pathway of Leptin Signaling Is Impaired during the Development of Diet-Induced Obesity in FVB/N Mice
Metlakunta et al.
Endocrinology 2008;149:1121-1128.
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State of the Art Reviews: Patient and Physician Communication About Weight Management: Can We Close the Gap?
Beran et al.
AMERICAN JOURNAL OF LIFESTYLE MEDICINE 2008;2:75-83.
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Surgical treatment of obesity
Bult et al.
Eur J Endocrinol 2008;158:135-145.
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Dietary Cholesterol from Eggs Increases Plasma HDL Cholesterol in Overweight Men Consuming a Carbohydrate-Restricted Diet
Mutungi et al.
J. Nutr. 2008;138:272-276.
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Beliefs About Hospital Diabetes and Perceived Barriers to Glucose Management Among Inpatient Midlevel Practitioners
Cook et al.
The Diabetes Educator 2008;34:75-83.
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LDL Cholesterol Lowering in Type 2 Diabetes: What Is the Optimum Approach?
Nesto
Clin. Diabetes 2008;26:8-13.
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Physical activity for the prevention and management of youth-onset type 2 diabetes mellitus: focus on cardiovascular complications
Mcgavock et al.
Diabetes and Vascular Disease Research 2007;4:305-310.
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Ethical and policy issues relating to progenitor-cell-based strategies for prevention of atherosclerosis
Liao et al.
J. Med. Ethics 2007;33:643-646.
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Providing Long-Term Support for Lifestyle Changes: A Key to Success in Diabetes Prevention
Marrero and Ackermann
Diabetes Spectr. 2007;20:205-209.
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Association of Oxidative Stress, Insulin Resistance, and Diabetes Risk Phenotypes: The Framingham Offspring Study
Meigs et al.
Diabetes Care 2007;30:2529-2535.
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A Geographical Comparison of Prevalence of Overweight School-aged Children: The National Survey of Children's Health 2003
Tudor-Locke et al.
Pediatrics 2007;120:e1043-e1050.
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Visceral and Subcutaneous Adipose Tissue Volumes Are Cross-Sectionally Related to Markers of Inflammation and Oxidative Stress: The Framingham Heart Study
Pou et al.
Circulation 2007;116:1234-1241.
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Self-perceived weight status and exercise adequacy
Jackson-Elmoore
Health Educ Res 2007;22:588-598.
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Effects of Physical Activity and Weight Loss on Skeletal Muscle Mitochondria and Relationship With Glucose Control in Type 2 Diabetes
Toledo et al.
Diabetes 2007;56:2142-2147.
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Prognostic Impact of Metabolic Syndrome by Different Definitions in a Population With High Prevalence of Obesity and Diabetes: The Strong Heart Study
de Simone et al.
Diabetes Care 2007;30:1851-1856.
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Flow-Induced Remodeling in Resistance Arteries From Obese Zucker Rats Is Associated With Endothelial Dysfunction
Bouvet et al.
Hypertension 2007;50:248-254.
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Noninherited Risk Factors and Congenital Cardiovascular Defects: Current Knowledge: A Scientific Statement From the American Heart Association Council on Cardiovascular Disease in the Young: Endorsed by the American Academy of Pediatrics
Jenkins et al.
Circulation 2007;115:2995-3014.
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Avoidance of Complications in Older Patients and Medicare Recipients Undergoing Gastric Bypass
Hallowell et al.
Arch Surg 2007;142:506-512.
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Combined effects of rosiglitazone and conjugated linoleic acid on adiposity, insulin sensitivity, and hepatic steatosis in high-fat-fed mice
Liu et al.
Am. J. Physiol. Gastrointest. Liver Physiol. 2007;292:G1671-G1682.
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Depression Among Type 2 Diabetes Rural Appalachian Clinic Attendees
de Groot et al.
Diabetes Care 2007;30:1602-1604.
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CCAAT/Enhancer-binding Protein beta Deletion Reduces Adiposity, Hepatic Steatosis, and Diabetes in Leprdb/db Mice
Schroeder-Gloeckler et al.
J. Biol. Chem. 2007;282:15717-15729.
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Obstructive Sleep Apnea, Daytime Sleepiness, and Type 2 Diabetes
Chasens
The Diabetes Educator 2007;33:475-482.
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Glycemic Control and Absenteeism Among Individuals With Diabetes
Tunceli et al.
Diabetes Care 2007;30:1283-1285.
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Increasing Cardiovascular Disease Burden Due to Diabetes Mellitus: The Framingham Heart Study
Fox et al.
Circulation 2007;115:1544-1550.
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The International Pandemic of Chronic Cardiovascular Disease
McDermott
JAMA 2007;297:1253-1255.
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Liquid calories, sugar, and body weight
Drewnowski and Bellisle
Am. J. Clin. Nutr. 2007;85:651-661.
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Association of the Built Environment With Physical Activity and Obesity in Older Persons
Berke et al.
AJPH 2007;97:486-492.
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Insulin-Resistant Heart Exhibits a Mitochondrial Biogenic Response Driven by the Peroxisome Proliferator-Activated Receptor-{alpha}/PGC-1{alpha} Gene Regulatory Pathway
Duncan et al.
Circulation 2007;115:909-917.
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Adapting the Diabetes Prevention Program Lifestyle Intervention for Delivery in the Community: The YMCA Model
Ackermann and Marrero
The Diabetes Educator 2007;33:69-78.
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Cost-effectiveness of Systematic Depression Treatment Among People With Diabetes Mellitus
Simon et al.
Arch Gen Psychiatry 2007;64:65-72.
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Childhood Nutrition: Perceptions of Caretakers in a Low-Income Urban Setting
Kelly and Patterson
The Journal of School Nursing 2006;22:345-351.
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Life Expectancy Benefits of Gastric Bypass Surgery
Pope et al.
SURG INNOV 2006;13:265-273.
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A Proinflammatory State Is Detectable in Obese Children and Is Accompanied by Functional and Morphological Vascular Changes
Kapiotis et al.
Arterioscler. Thromb. Vasc. Bio. 2006;26:2541-2546.
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Predictors of nutrition counseling behaviors and attitudes in US medical students.
Spencer et al.
Am. J. Clin. Nutr. 2006;84:655-662.
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Associations of Adiposity from Childhood into Adulthood with Insulin Resistance and the Insulin-Like Growth Factor System: 65-Year Follow-Up of the Boyd Orr Cohort
Martin et al.
J. Clin. Endocrinol. Metab. 2006;91:3287-3295.
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Cannabinoid-1 Receptor Antagonist, Rimonabant, for Management of Obesity and Related Risks
Gadde and Allison
Circulation 2006;114:974-984.
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Health Behaviors Among Women of Reproductive Age With and Without a History of Gestational Diabetes Mellitus
Kieffer et al.
Diabetes Care 2006;29:1788-1793.
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Preventing Cardiovascular Disease and Diabetes: A call to action from the American Diabetes Association and the American Heart Association
Eckel et al.
Diabetes Care 2006;29:1697-1699.
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Preventing Cardiovascular Disease and Diabetes: A Call to Action From the American Diabetes Association and the American Heart Association
Eckel et al.
Circulation 2006;113:2943-2946.
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Trends in the Incidence of Type 2 Diabetes Mellitus From the 1970s to the 1990s: The Framingham Heart Study
Fox et al.
Circulation 2006;113:2914-2918.
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Primary Prevention of Ischemic Stroke: A Guideline From the American Heart Association/American Stroke Association Stroke Council: Cosponsored by the Atherosclerotic Peripheral Vascular Disease Interdisciplinary Working Group; Cardiovascular Nursing Council; Clinical Cardiology Council; Nutrition, Physical Activity, and Metabolism Council; and the Quality of Care and Outcomes Research Interdisciplinary Working Group: The American Academy of Neurology affirms the value of this guideline.
Goldstein et al.
Circulation 2006;113:e873-e923.
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LA DOLCE VITA VERSUS LA VITA SOBRIA
Hayflick
Gerontologist 2006;46:413-416.
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Nocturia and Obesity: A Population-based Study in Finland
Tikkinen et al.
Am J Epidemiol 2006;163:1003-1011.
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