Original ResearchIncreases in morbid obesity in the USA: 2000–2005
Introduction
In the USA, different studies have documented that most Americans are overweight (a body mass index (BMI) over 25) or obese (BMI⩾30). About one in four adult Americans would be classified as obese, based on self-reported weight; more than one in three would be classified as obese, based on objectively measured weight. These rates have roughly tripled in the past 20 years.1, 2, 3, 4 In England, one in five adults are obese and that rate has also tripled over the last 20 years, although starting from lower levels of prevalence than the USA.5, 6
The typical definition of obesity, a BMI of over 30 (which is 35 pounds (16 kg) overweight at a height of 5′9″ (175 cm)), obscures the heterogeneity of this group. Severely obese individuals who are 100 or 200 pounds (45 or 90 kg) or more overweight have much more serious health problems and they encounter very different challenges in the healthcare system than the majority of obese individuals. For a person 5′9″ (175 cm) tall, being 100 pounds (45 kg) overweight translates into a BMI of 40. Among middle-aged adults, a BMI of 35–40 is associated with twice the increase in healthcare expenditure above normal weight (about a 50% increase) than a BMI of 30–35 (about a 25% increase); a BMI of over 40 doubles healthcare costs (about 100% higher costs above those of normal weight).7
Does severe obesity simply parallel the general trend in obesity? Or is there something fundamentally different about clinically severe or morbid obesity? While trends for lower weight categories have been published repeatedly, there are no similar updates for severe obesity, partly because such estimates require large population samples. An earlier study reported that before 2000, the prevalence of higher levels of obesity increased faster in the USA than the prevalence of moderate obesity.8 This paper updates estimates through 2005. Recent years are of particular interest, given the dramatic expansion of bariatric surgery, which so far is the only effective treatment for morbid obesity. In the USA, the number of bariatric surgical procedures increased from 13 000 in 1998, to over 100 000 in 2003.9 The president of the American Society for Bariatric Surgery, estimates that 175 000–200 000 weight-loss procedures will be performed in 2006,10 more than a 10-fold increase in eight years.
There are two conflicting opinions about trends in clinically severe or morbid obesity. Clinicians tend to consider morbid obesity a rare pathological condition that is not affected by behavioural changes in the general population. This view would suggest that the incidence of morbid obesity changes little over time and that a new efficacious treatment could make a large difference in the prevalence of this condition. Epidemiologists tend to lean towards the opposite view, namely that severe obesity is part of the general population distribution and small increases in the population BMI would have proportionally larger effects in the extreme tail.11 Which of those views better describes reality is an empirical question, but the answer has major ramifications for public health and healthcare systems. If the epidemiological view is correct, then a medical approach to treating morbid obesity in order to reduce its prevalence will be futile. In contrast, a public health approach that focuses on reducing weight gain across the whole population is more likely to contain morbid obesity as well, even without explicitly targeting it.
Section snippets
Methods
This study analysed data from the Behavioral Risk Factor Surveillance System (BRFSS), a cross-sectional telephone survey of non-institutionalized adults in the USA, for the period between 1986 and 2005. The BRFSS has been used for tracking health behaviours over time and study details are documented elsewhere.12
Individuals were classified into weight categories based on their BMI (weight in kilograms divided by the square of height in meters) calculated from self-reported weight and height. In
Results
Table 1 gives adjusted estimates of prevalence from 2001 to 2005 and percentage increases compared to 2000; the higher the BMI group, the faster the increase. The prevalence of a BMI>30 increased by 24% between 2000 and 2005, but the prevalence of a BMI over 40 increased twice as fast (52% higher in 2005 than in 2000) and the prevalence of a BMI over 50 increased three times as fast (75% higher in 2005 than in 2000). The numbers differ slightly from descriptive statistics because they are
Discussion
Reports that the majority of adults are now overweight or obese have raised the public profile of the obesity epidemic in Europe and the USA. Milestones included governmental reports such as Tackling obesity in England by the National Audit Office, or the Call to action by the Surgeon General in the USA.5, 21 Nevertheless, the most dramatic part of the ‘obesity epidemic’ has received very little attention in either those reports or the public press, namely that the prevalence of morbid obesity
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