This Article  • Full text  • PDF  • Send to a friend  • Save in My Folder  • Save to citation manager  • Permissions  Citing Articles  • Citation map  • Citing articles on HighWire  • Citing articles on ISI (364)  • Contact me when this article is cited  Related Content  • Related letters  • Related articles  • Similar articles in JAMA  Topic Collections  • Obesity  • Alert me on articles by topic

Katherine M. Flegal, PhD; Barry I. Graubard, PhD; David F. Williamson, PhD; Mitchell H. Gail, MD, PhD

JAMA. 2005;293:1861-1867.

Context  As the prevalence of obesity increases in the United States, concern over the association of body weight with excess mortality has also increased.

Objective  To estimate deaths associated with underweight (body mass index [BMI] <18.5), overweight (BMI 25 to <30), and obesity (BMI 30) in the United States in 2000.

Design, Setting, and Participants  We estimated relative risks of mortality associated with different levels of BMI (calculated as weight in kilograms divided by the square of height in meters) from the nationally representative National Health and Nutrition Examination Survey (NHANES) I (1971-1975) and NHANES II (1976-1980), with follow-up through 1992, and from NHANES III (1988-1994), with follow-up through 2000. These relative risks were applied to the distribution of BMI and other covariates from NHANES 1999-2002 to estimate attributable fractions and number of excess deaths, adjusted for confounding factors and for effect modification by age.

Main Outcome Measures  Number of excess deaths in 2000 associated with given BMI levels.

Results  Relative to the normal weight category (BMI 18.5 to <25), obesity (BMI 30) was associated with 111 909 excess deaths (95% confidence interval [CI], 53 754-170 064) and underweight with 33 746 excess deaths (95% CI, 15 726-51 766). Overweight was not associated with excess mortality (–86 094 deaths; 95% CI, –161 223 to –10 966). The relative risks of mortality associated with obesity were lower in NHANES II and NHANES III than in NHANES I.

Conclusions  Underweight and obesity, particularly higher levels of obesity, were associated with increased mortality relative to the normal weight category. The impact of obesity on mortality may have decreased over time, perhaps because of improvements in public health and medical care. These findings are consistent with the increases in life expectancy in the United States and the declining mortality rates from ischemic heart disease.

Author Affiliations: National Center for Health Statistics, Centers for Disease Control and Prevention, Hyattsville, Md (Dr Flegal); Center for Weight and Health, University of California at Berkeley (Dr Flegal); Division of Cancer Epidemiology and Genetics, National Cancer Institute, Bethesda, Md (Drs Graubard and Gail); and Division of Diabetes Translation, Centers for Disease Control and Prevention, Atlanta, Ga (Dr Williamson).

RELATED LETTERS

Underweight, Overweight, Obesity, and Excess Deaths
Walter C. Willett, Frank B. Hu, Graham A. Colditz, and JoAnn E. Manson
JAMA. 2005;294(5):551.
EXTRACT | FULL TEXT  

Underweight, Overweight, Obesity, and Excess Deaths
Howard D. Strickler, Charles Hall, Judy Wylie-Rosett, and Thomas Rohan
JAMA. 2005;294(5):551-552.
EXTRACT | FULL TEXT  

Underweight, Overweight, Obesity, and Excess Deaths
James Greenberg
JAMA. 2005;294(5):552.
EXTRACT | FULL TEXT  

Underweight, Overweight, Obesity, and Excess Deaths
Eric L. Ding
JAMA. 2005;294(5):552.
EXTRACT | FULL TEXT  

Underweight, Overweight, Obesity, and Excess Deaths—Reply
Katherine M. Flegal, Barry I. Graubard, Mitchell H. Gail, and David F. Williamson
JAMA. 2005;294(5):552-553.
EXTRACT | FULL TEXT  

The Effect of Obesity on Disability vs Mortality in Older American: The Potential Implication of Testosterone—Reply
Soham Al Snih, Kenneth J. Ottenbacher, Kyriakos S. Markides, Yong-Fang Kuo, Karl Eschbach, and James S. Goodwin
Arch Intern Med. 2007;167(22):2528.
EXTRACT | FULL TEXT  

RELATED ARTICLES

Secular Trends in Cardiovascular Disease Risk Factors According to Body Mass Index in US Adults
Edward W. Gregg, Yiling J. Cheng, Betsy L. Cadwell, Giuseppina Imperatore, Desmond E. Williams, Katherine M. Flegal, K. M. Venkat Narayan, and David F. Williamson
JAMA. 2005;293(15):1868-1874.
ABSTRACT | FULL TEXT  

Deaths Attributable to Obesity
David H. Mark
JAMA. 2005;293(15):1918-1919.
EXTRACT | FULL TEXT  

THIS ARTICLE HAS BEEN CITED BY OTHER ARTICLES

Commentary: Is the concern regarding overweight/obesity in India overstated?
Adams and Subramanian
Int J Epidemiol 2008;0:dyn144v1-dyn144.
FULL TEXT  

Population-Based Prevention of Obesity: The Need for Comprehensive Promotion of Healthful Eating, Physical Activity, and Energy Balance: A Scientific Statement From American Heart Association Council on Epidemiology and Prevention, Interdisciplinary Committee for Prevention (Formerly the Expert Panel on Population and Prevention Science)
Kumanyika et al.
Circulation 2008;118:428-464.
ABSTRACT | FULL TEXT  

Classification of malnutrition in cystic fibrosis: implications for evaluating and benchmarking clinical practice performance
Lai and Shoff
Am. J. Clin. Nutr. 2008;88:161-166.
ABSTRACT | FULL TEXT  

Weighing in on Weight Screening in the Dental Office: Practical Approaches
Hague and Touger-Decker
Journal of the American Dental Association 2008;139:934-938.
ABSTRACT | FULL TEXT  

Body Mass Index in Adolescence in Relation to Cause-specific Mortality: A Follow-up of 230,000 Norwegian Adolescents
Bjorge et al.
Am J Epidemiol 2008;168:30-37.
ABSTRACT | FULL TEXT  

Waist Circumference and Mortality
Koster et al.
Am J Epidemiol 2008;167:1465-1475.
ABSTRACT | FULL TEXT  

Update on Obesity
Bessesen
J. Clin. Endocrinol. Metab. 2008;93:2027-2034.
ABSTRACT | FULL TEXT  

Association of body mass index with all-cause and cause-specific mortality: findings from a prospective cohort study in Mumbai (Bombay), India
Pednekar et al.
Int J Epidemiol 2008;37:524-535.
ABSTRACT | FULL TEXT  

Leukocyte Telomere Length and Carotid Artery Intimal Medial Thickness: The Framingham Heart Study
O'Donnell et al.
Arterioscler. Thromb. Vasc. Bio. 2008;28:1165-1171.
ABSTRACT | FULL TEXT  

Kinin B1 Receptor Deficiency Leads to Leptin Hypersensitivity and Resistance to Obesity
Mori et al.
Diabetes 2008;57:1491-1500.
ABSTRACT | FULL TEXT  

The Impact of Obesity on Cardiovascular Disease Risk Factors and Subclinical Vascular Disease: The Multi-Ethnic Study of Atherosclerosis
Burke et al.
Arch Intern Med 2008;168:928-935.
ABSTRACT | FULL TEXT  

Body Mass Index, Physical Activity, and Bladder Cancer in a Large Prospective Study
Koebnick et al.
Cancer Epidemiol. Biomarkers Prev. 2008;17:1214-1221.
ABSTRACT | FULL TEXT  

Obesity reduction and its possible consequences: What can we learn from Cuba's Special Period?
Franco et al.
CMAJ 2008;178:1032-1034.
FULL TEXT  

Overweight and Obesity Are Associated With Psychiatric Disorders: Results From the National Epidemiologic Survey on Alcohol and Related Conditions
Petry et al.
Psychosom. Med. 2008;70:288-297.
ABSTRACT | FULL TEXT  

Comparison of Strategies for Sustaining Weight Loss: The Weight Loss Maintenance Randomized Controlled Trial
Svetkey et al.
JAMA 2008;299:1139-1148.
ABSTRACT | FULL TEXT  

Underweight, overweight and obesity as risk factors for mortality and hospitalization
Ringback Weitoft et al.
Scand J Public Health 2008;36:169-176.
ABSTRACT  

The Gap Gets Bigger: Changes In Mortality And Life Expectancy, By Education, 1981-2000
Meara et al.
Health Aff (Millwood) 2008;27:350-360.
ABSTRACT | FULL TEXT  

Pharmaceutical Expenditures as a Correlate of Population Health in Industrialized Nations
Liu et al.
The Annals of Pharmacotherapy 2008;42:368-374.
ABSTRACT | FULL TEXT  

The Canary in the Coal Mine of Coronary Artery Disease
Olshansky and Persky
Arch Intern Med 2008;168:261-261.
FULL TEXT  

Is the obesity epidemic exaggerated? Yes
Basham and Luik
BMJ 2008;336:244-244.
FULL TEXT  

Physical Activity: The Epidemic of Obesity and Overweight Among Youth: Trends, Consequences, and Interventions
LaFontaine
AMERICAN JOURNAL OF LIFESTYLE MEDICINE 2008;2:30-36.
ABSTRACT  

Sleep duration, general and abdominal obesity, and weight change among the older adult population of Spain
Lopez-Garcia et al.
Am. J. Clin. Nutr. 2008;87:310-316.
ABSTRACT | FULL TEXT  

Joint Effects of Tobacco Use and Body Mass on All-Cause Mortality in Mumbai, India: Results from a Population-based Cohort Study
Pednekar et al.
Am J Epidemiol 2008;167:330-340.
ABSTRACT | FULL TEXT  

Heart Disease and Stroke Statistics--2008 Update: A Report From the American Heart Association Statistics Committee and Stroke Statistics Subcommittee
Rosamond et al.
Circulation 2008;117:e25-e146.
FULL TEXT  

Clinic-Based Support to Help Overweight Patients With Type 2 Diabetes Increase Physical Activity and Lose Weight
Christian et al.
Arch Intern Med 2008;168:141-146.
ABSTRACT | FULL TEXT  

Immigration and Generational Trends in Body Mass Index and Obesity in the United States: Results of the National Latino and Asian American Survey, 2002-2003
Bates et al.
Am. J. Public Health 2008;98:70-77.
ABSTRACT | FULL TEXT  

Impact of Energy Intake, Physical Activity, and Population-wide Weight Loss on Cardiovascular Disease and Diabetes Mortality in Cuba, 1980 2005
Franco et al.
Am J Epidemiol 2007;166:1374-1380.
ABSTRACT | FULL TEXT  

The Effect of Obesity on Disability vs Mortality in Older American: The Potential Implication of Testosterone Reply
Al Snih et al.
Arch Intern Med 2007;167:2528-2528.
FULL TEXT  

Adolescent Overweight and Future Adult Coronary Heart Disease
Bibbins-Domingo et al.
NEJM 2007;357:2371-2379.
ABSTRACT | FULL TEXT  

Shattuck Lecture: improving American health.
Freudenberg et al.
NEJM 2007;357:2405-2406.
FULL TEXT  

Cardiorespiratory Fitness and Adiposity as Mortality Predictors in Older Adults
Sui et al.
JAMA 2007;298:2507-2516.
ABSTRACT | FULL TEXT  

Body Mass Index, Weight Loss, and Mortality in Community-Dwelling Older Adults
Locher et al.
J. Gerontol. A Biol. Sci. Med. Sci. 2007;62:1389-1392.
ABSTRACT | FULL TEXT  

Cancer incidence and mortality in relation to body mass index in the Million Women Study: cohort study
Reeves et al.
BMJ 2007;335:1134-1134.
ABSTRACT | FULL TEXT  

Assessment of Child and Adolescent Overweight and Obesity
Krebs et al.
Pediatrics 2007;120:S193-S228.
ABSTRACT | FULL TEXT  

Obesity, mortality, and bariatric surgery death rates.
Livingston
JAMA 2007;298:2406-2408.
FULL TEXT  

Asymmetric Paternalism to Improve Health Behaviors
Loewenstein et al.
JAMA 2007;298:2415-2417.
FULL TEXT  

The Changing Relationship of Obesity and Disability, 1988-2004
Alley and Chang
JAMA 2007;298:2020-2027.
ABSTRACT | FULL TEXT  

Cause-Specific Excess Deaths Associated With Underweight, Overweight, and Obesity
Flegal et al.
JAMA 2007;298:2028-2037.
ABSTRACT | FULL TEXT  

Is Disability Obesity's Price of Longevity?
Gregg and Guralnik
JAMA 2007;298:2066-2067.
FULL TEXT  

Actuarially speaking: an overview of life expectancy. What can we anticipate?
Blacklow
Am. J. Clin. Nutr. 2007;86:1560S-1562S.
ABSTRACT | FULL TEXT  

Keeping the young-elderly healthy: is it too late to improve our health through nutrition?
Rivlin
Am. J. Clin. Nutr. 2007;86:1572S-1576S.
ABSTRACT | FULL TEXT  

Perceptions of Body Weight Among Older Adults: Analyses of the Intersection of Gender, Race, and Socioeconomic Status
Schieman et al.
J. Gerontol. B Psychol. Sci. Soc. Sci. 2007;62:S415-S423.
ABSTRACT | FULL TEXT  

Impact of Smoking and Preexisting Illness on Estimates of the Fractions of Deaths Associated with Underweight, Overweight, and Obesity in the US Population
Flegal et al.
Am J Epidemiol 2007;166:975-982.
ABSTRACT | FULL TEXT  

Review: Obesity and cardiometabolic syndrome in children
Velasquez-Mieyer et al.
Therapeutic Advances in Cardiovascular Disease 2007;1:61-81.
ABSTRACT  

Ecologic Correlates of Obesity in Rural Obese Adults
Lee et al.
J. Am. Coll. Nutr. 2007;26:424-433.
ABSTRACT | FULL TEXT  

Medical costs of obese Japanese: a 10-year follow-up study of National Health Insurance in Shiga, Japan
Nakamura et al.
Eur J Public Health 2007;17:424-429.
ABSTRACT | FULL TEXT  

Association of Overweight With Increased Risk of Coronary Heart Disease Partly Independent of Blood Pressure and Cholesterol Levels: A Meta-analysis of 21 Cohort Studies Including More Than 300 000 Persons
Bogers et al.
Arch Intern Med 2007;167:1720-1728.
ABSTRACT | FULL TEXT  

Diagnostic performance of body mass index to detect obesity in patients with coronary artery disease
Romero-Corral et al.
Eur Heart J 2007;28:2087-2093.
ABSTRACT | FULL TEXT  

Long-Term Mortality after Gastric Bypass Surgery
Adams et al.
NEJM 2007;357:753-761.
ABSTRACT | FULL TEXT  

Economics of Health and Mortality Special Feature: Nature and causes of trends in male diabetes prevalence, undiagnosed diabetes, and the socioeconomic status health gradient
Smith
Proc. Natl. Acad. Sci. USA 2007;104:13225-13231.
ABSTRACT | FULL TEXT  

Thematic review series: Adipocyte Biology. Sympathetic and sensory innervation of white adipose tissue
Bartness and Song
J. Lipid Res. 2007;48:1655-1672.
ABSTRACT | FULL TEXT  

Meta-analysis: The Effect of Dietary Counseling for Weight Loss
Dansinger et al.
ANN INTERN MED 2007;147:41-50.
ABSTRACT | FULL TEXT  

The impact of obesity on mortality in UA/non-ST-segment elevation myocardial infarction
Buettner et al.
Eur Heart J 2007;28:1694-1701.
ABSTRACT | FULL TEXT  

Relationship of Body Mass Index With Outcomes After Coronary Artery Bypass Graft Surgery
Wagner et al.
Ann. Thorac. Surg. 2007;84:10-16.
ABSTRACT | FULL TEXT  

Explaining the Decrease in U.S. Deaths from Coronary Disease, 1980-2000
Ford et al.
NEJM 2007;356:2388-2398.
ABSTRACT | FULL TEXT  

Prevalence, Challenges, and Solutions for 18F-FDG PET Studies of Obese Patients: A Technologist's Perspective
Botkin and Osman
J. Nucl. Med. Technol. 2007;35:80-83.
ABSTRACT | FULL TEXT  

Obesity Is the Major Determinant of the Abnormalities in Blood Pressure Found in Young Women with the Polycystic Ovary Syndrome
Luque-Ramirez et al.
J. Clin. Endocrinol. Metab. 2007;92:2141-2148.
ABSTRACT | FULL TEXT  

Overweight and Obesity in Sexual-Minority Women: Evidence From Population-Based Data
Boehmer et al.
Am. J. Public Health 2007;97:1134-1140.
ABSTRACT | FULL TEXT  

Effect of BMI on Lifetime Risk for Diabetes in the U.S.
Narayan et al.
Diabetes Care 2007;30:1562-1566.
ABSTRACT | FULL TEXT  

Abdominal Adiposity and Mortality in Chinese Women
Zhang et al.
Arch Intern Med 2007;167:886-892.
ABSTRACT | FULL TEXT  

Biomarkers of Obesity and Subsequent Cardiovascular Events
Musaad and Haynes
Epidemiol Rev 2007;0:mxm005v1.
ABSTRACT | FULL TEXT  

Obesity, Inflammation, and Periodontal Disease
Pischon et al.
J. Dent. Res. 2007;86:400-409.
ABSTRACT | FULL TEXT  

The Risk to the American Fast-Food Industry of Obesity Litigation
Werner et al.
Cornell Hotel and Restaurant Administration Quarterly 2007;48:201-214.
ABSTRACT  

Associations Between Body Composition, Anthropometry, and Mortality in Women Aged 65 Years and Older
Dolan et al.
Am. J. Public Health 2007;97:913-918.
ABSTRACT | FULL TEXT  

Intelligence in early adulthood and life span up to 65 years later in male elderly twins
Holsinger et al.
Age Ageing 2007;36:286-291.
ABSTRACT | FULL TEXT  

Association Studies of BMI and Type 2 Diabetes in the Neuropeptide Y Pathway: A Possible Role for NPY2R as a Candidate Gene for Type 2 Diabetes in Men
Campbell et al.
Diabetes 2007;56:1460-1467.
ABSTRACT | FULL TEXT  

The Effect of Obesity on Disability vs Mortality in Older Americans
Al Snih et al.
Arch Intern Med 2007;167:774-780.
ABSTRACT | FULL TEXT  

Neonatal hyperleptinaemia programmes adrenal medullary function in adult rats: effects on cardiovascular parameters
Trevenzoli et al.
J. Physiol. 2007;580:629-637.
ABSTRACT | FULL TEXT  

Heterogeneity in the Prevalence of Risk Factors for Cardiovascular Disease and Type 2 Diabetes Mellitus in Obese Individuals: Effect of Differences in Insulin Sensitivity
McLaughlin et al.
Arch Intern Med 2007;167:642-648.
ABSTRACT | FULL TEXT  

Prospective Effect of Job Strain on General and Central Obesity in the Whitehall II Study
Brunner et al.
Am J Epidemiol 2007;165:828-837.
ABSTRACT | FULL TEXT  

Aging, Adiposity, and Calorie Restriction
Fontana and Klein
JAMA 2007;297:986-994.
ABSTRACT | FULL TEXT  

Poor Nutritional Habits: A Modifiable Predecessor of Chronic Illness? A North Carolina Family Medicine Research Network (NC-FM-RN) Study
Gaskins et al.
J Am Board Fam Med 2007;20:124-134.
ABSTRACT | FULL TEXT  

Association between Body Mass Index and Mortality Is Similar in the Hemodialysis Population and the General Population at High Age and Equal Duration of Follow-Up
de Mutsert et al.
J. Am. Soc. Nephrol. 2007;18:967-974.
ABSTRACT | FULL TEXT  

Heart Disease and Stroke Statistics--2007 Update: A Report From the American Heart Association Statistics Committee and Stroke Statistics Subcommittee
Rosamond et al.
Circulation 2007;115:e69-e171.
FULL TEXT  

The Association Between Body Mass Index and Clinical Outcomes in Acute Lung Injury
Morris et al.
Chest 2007;131:342-348.
ABSTRACT | FULL TEXT  

Association between plasma adiponectin levels and unstable coronary syndromes
Wolk et al.
Eur Heart J 2007;28:292-298.
ABSTRACT | FULL TEXT  

Accuracy of Anthropometric Indicators of Obesity to Predict Cardiovascular Risk
Schneider et al.
J. Clin. Endocrinol. Metab. 2007;92:589-594.
ABSTRACT | FULL TEXT  

An Overview Of Cardiovascular Disease Burden In The United States
Mensah and Brown
Health Aff (Millwood) 2007;26:38-48.
ABSTRACT | FULL TEXT  

Overweight, obesity, and mortality.
Appels et al.
NEJM 2006;355:2699-2699.
FULL TEXT  

Risk Factors for Mortality in Middle-aged Women
Tice et al.
Arch Intern Med 2006;166:2469-2477.
ABSTRACT | FULL TEXT  

Lack of evidence on diets for obesity for children: a systematic review
Gibson et al.
Int J Epidemiol 2006;35:1544-1552.
ABSTRACT | FULL TEXT  

Midlife Risk Factors and Healthy Survival in Men.
Willcox et al.
JAMA 2006;296:2343-2350.
ABSTRACT | FULL TEXT