Obesity Rates & Trends Overview

Introduction

Obesity is one of the biggest health concerns in communities across the country, with about 70 percent of county officials ranking it as a leading problem where they live. Factors related to obesity are also rated as communities' priority health issues, including nutrition and physical activity at 58 percent, heart disease and hypertension at 57 percent and diabetes at 44 percent.1

There has been progress to address the epidemic. After decades of increasing, the national obesity rate among 2- to 19-year-olds has begun to level off and the rise of obesity among adults has slowed over time. Yet obesity remains a bigger threat to our health and country now than it was a generation ago. If trends continue, children today could be the first generation to live shorter, less healthy lives than their parents.

Obesity rates vary state-to-state, but remain high nationwide. Across the United States, more than one in three adults and one in six children (ages 2-19) are obese — and one in 11 young children (ages 2-5) are obese.2 Adult obesity rates range from a high of 37.7 in Louisiana to a low of 22.3 in Colorado.3 Childhood rates are highest in Mississippi (21.7 percent) and lowest in Oregon (9.9 percent).4 Obesity rates also differ from county to county, and neighborhood to neighborhood. More than 20 states have counties with adult obesity rates above 40 percent, including 29 counties in Mississippi and 14 counties in Alabama. Only two states have counties with adult obesity rates below 20 percent: 17 counties in Colorado and one in Massachusetts.5 (Note: County Health Rankings and Roadmaps data are available for every state at countyhealthrankings.org)

Individuals who are obese are at increased risk for type 2 diabetes, heart disease, some forms of cancer, dementia and a number of other health concerns. Children who are overweight or obese are at greater risk for high blood pressure, type 2 diabetes and heart disease. And the longer children are overweight or obese, the more likely they are to remain so into adulthood. At a broader level, high obesity rates also have a significant impact on the larger community.

Obesity is a financial issue. The obesity crisis costs our nation more than $150 billion in healthcare costs annually6 and billions of dollars more in lost productivity.7 The public and officials are rightly concerned about making sure every taxpayer dollar is spent wisely. Investing in obesity prevention provides a significant return on investment for the American taxpayer. Each state and community is impacted by the cost of obesity — severe obesity alone costs state Medicaid programs between $5 million in Wyoming and $1.3 billion in California each year.8 Overall obesityrelated healthcare costs range from $279 per person per year in Wyoming to $768 in Oregon.9 Employers want to operate businesses in places with healthier populations — with a workforce that is more productive and has lower healthcare costs.

Obesity is a national security issue. The obesity crisis also impacts our nation's military readiness. Being overweight or obese is the leading cause of medical disqualifications, with nearly one-quarter of service applicants rejected for exceeding the weight or body fat standards.10 Obese service members and members of their family who are obese cost the military about $1 billion every year in healthcare costs and lost productivity.11 Mission: Readiness has found that more than 70 percent of today's youth are not fit to serve in the military due to obesity or being overweight, criminal records, drug misuse or educational deficits.12

Obesity is a community safety issue. With millions of obese and overweight Americans serving as first responders, firefighters, police officers and in other essential community service and protection roles, public safety is at risk. Seventy percent of firefighters are overweight or obese, putting them at risk for cardiovascular events — the leading cause of line-of-duty deaths.13 Police officers have a shorter life expectancy compared with the general population, likely due to their higherthan-average obesity rates.14

Obesity is a child development and academic achievement issue. Obesityprevention is an investment in our children's ability to learn and grow. Childhood obesity is correlated with poor educational performance15 and increased risk for bullying and depression.16 If all kids have the opportunity to grow up at a healthy weight — a lifestyle that includes nutritious food and plenty of time for active play — they are more likely to reach their full potential.

Obesity is an equity issue. Obesity disproportionately affects low-income17 and rural communities18 as well as certain racial and ethnic groups, including Blacks,19 Latinos20 and Native Americans.21 Societal inequities contribute to these disparities. For example, in many communities, children have few safe outdoor spaces to play or accessible routes to walk or bike to school. Their neighborhoods may often be food deserts, having small food outlets and fast-food restaurants that sell and advertise unhealthy food and beverages, but lacking those with fresh and healthy foods at affordable prices. Thus, addressing the obesity epidemic is also a fight for health equity.

Obesity is a top national priority. Americans (registered voters) rated obesity as the top health concern in the country in a recent public opinion survey conducted by the Greenberg, Quinlan, Rosner Research and Bellweather Research groups. And nearly three-quarters (73 percent) support increasing investments to improve the health of communities, including addressing the obesity crisis and other major health concerns. Support spans across party lines (57 percent of Republicans, 87 percent of Democrats and 70 percent of Independents) and regionally across the country (75 percent in the Northeast, 71 percent in the Midwest, 72 percent in the South and 75 percent in the West).22

Obesity rates have doubled among adults and more than tripled among children since the 1980s. In response, health officials have been developing strategies to counter the trends. There have been signs of progress. Concerted efforts have helped to slow the growth among adults (rates remained the same in 45 states and Washington, D.C. and declined in one state (Kansas) last year), and childhood rates have stabilized nationally and even declined in some places during the past decade. In fact, obesity rates among children ages 5 and under declined from nearly 14 percent in 2003-2004 to under 10 percent in 2013-2014.23 Obesity rates among low-income 2- to 4-year-olds have also declined.24

Federal, state and local agencies play a key role in creating and supporting policies that benefit millions of families and neighborhoods across America. Experts at the Centers for Disease Control and Prevention (CDC), National Institutes of Health (NIH), U.S. Department of Agriculture (USDA), U.S. Department of Education, the Administration for Children and Families (ACF), Food and Drug Administration (FDA), academic research centers and state and local public health agencies across the country have researched and developed top strategies for preventing and addressing obesity among children and adults. These include improving nutrition standards for the foods and beverages offered through the Child and Adult Care Food Program (CACFP) and in schools nationwide. These agencies also provide the evidence base and technical assistance for every school district in the country to develop effective, strategic, local wellness plans to identify "hot spots" where the problems are the most severe, the needs are the greatest and where promising efforts can be most effective. Communities, schools and families around the country rely on the expert technical assistance, guidance, toolkits and evaluations demonstrating effective efforts that can make a difference to improve health. These efforts allow communities to learn from the best evidence and programs, so they can build on them for the benefit of their own communities.

The individual decisions people make about eating and activity are not made in a vacuum. Where families live, learn, work and play all have a major impact on the choices they are able to make. Healthy foods are often more expensive and less available in some neighborhoods, and finding safe, accessible places and having time to be active can be challenging for many.

For instance, most children spend significant periods of time in child-care and schools where food options may be beyond the control of their parents.

After years of growth, rates have been stabilizing and can now move in the right direction — but only if efforts receive sufficient resources and support to move forward.

The most successful approaches are often comprehensive, localized, "place-based" efforts — where leaders and members of a community build partnerships that bring together public health and healthcare providers; hospitals, schools and universities; child-care providers and centers; social service groups; philanthropies; community-based, faith-based and community development organizations; and transportation and housing planners — to assess the priorities within the local area; leverage existing community resources; and determine the most effective, evidence-based strategies that can best meet their needs. Experts have identified a range of policies and programs that communities can implement to help make healthy eating and physical activity part of people's daily routines, including improving school nutrition, complete streets initiatives, access to open space, incentives for healthy food purchases, food labeling and limits on advertising to children.

The most impactful strategies also typically focus on helping children maintain a healthy weight — since it is much easier and more effective to prevent obesity than to try to reverse it later — and to provide adults with opportunities for improved nutrition and increased physical activity, to be as healthy as possible no matter their weight.

The annual State of Obesity: Better Policies for a Healthier America report highlights obesity trends and top strategies, policies, programs and practices aimed at reversing the epidemic — to help children grow up at a healthy weight and adults be as healthy as possible at any weight. While the report focuses on progress and promising policies — it also shows that these approaches have not yet received a sufficient level of investment or prioritization to reverse rates on a large scale.

This year's report shows there is still an urgent need to address the obesity crisis — and that the health and financial stakes are too high to allow complacency. It also underscores the fact that there is a wide range of efforts that can make a difference. After years of growth, rates have been stabilizing and can now move in the right direction — but only if efforts receive sufficient resources and support to move forward.

The State of Obesity report series has documented the significant progress achieved over the past 15 years to reduce obesity rates. Evidence-based policies and practices can make a difference — but they need to be maintained and receive a sufficient level of investment to achieve results. Actions to limit policies and reduce funding for obesity-prevention efforts will have adverse consequences for the health of Americans.

Some key strategies to counter the crisis include:

For example, in New Mexico, the nonprofit Healthy Kids, Healthy Communities (HKHC) partners with state and local public health departments, schools and other stakeholders to support efforts that help children eat well and move more, serving nearly one in four public elementary school students in communities with the highest poverty rates in the state.

There are many bright spots to report — programs and policies that are making a real difference. For example, in New Mexico, the nonprofit Healthy Kids, Healthy Communities (HKHC) partners with state and local public health departments, schools and other stakeholders to support efforts that help children eat well and move more, serving nearly one in four public elementary school students in communities with the highest poverty rates in the state.25 The program includes supporting Safe Routes to Schools, more high-quality produce in schools, building physical activity into the school day, making healthier foods more available and affordable, especially in rural and remote areas, and supporting healthier child-care settings. The result? An 11.1 percent decline in overweight and obesity among third-graders and a 15.5 percent decline among kindergarteners in the state. If this and other successful efforts were scaled up, it would dramatically improve the health of the nation.

Achieving this goal will require all of society's institutions — governments, businesses, communities and families — to help. Simply put, communities all need to work together to invest in policies, practices and programs that work. Over time, these investments pay off — in terms of saving lives and healthcare costs. By working together, communities can create a Culture of Health and reduce the obesity epidemic.

National Obesity Trends

Children and Youth

Nationally, childhood obesity rates have remained stable for the past decade

Nationally, childhood obesity rates (ages 2 to 19) have remained stable for the past decade — at around 17 percent [National Health and Nutrition Examination Survey (NHANES), 2011-2014 data].26

  • Since 1980, childhood obesity rates (ages 2 to 19) have tripled — with the rates of obese 6- to 11-year-olds more than doubling (from 7.0 percent to 17.5 percent) and rates of obese teens (ages 12 to 19) quadrupling from 5 percent to 20.5 percent.27,28 [NHANES, 2011-2014 data]
  • Obesity rates have also become much higher starting in earlier ages — 8.9 percent of 2- to 5-year-olds are now obese and approximately 2 percent are extremely obese.29 [NHANES, 2011-2014 data]
  • Nearly 2 percent of young children (ages 2 to 5) are extremely obese, 4.3 percent of 6- to 11-year olds are extremely obese and 9.1 percent of 12- to 19-year olds are extremely obese (body mass index (BMI) at or above 120 percent of the sexspecific 95th percentile on the CDC BMI-for-age growth charts).30 [NHANES, 2011-2014 data]
  • There are also significant racial and ethnic inequities. Rates are higher among Latino (21.9 percent) and Black (19.5 percent) children than among White (14.7 percent) and Asian (8.6 percent) children (ages 2 to 19) — and the rates are higher starting at earlier ages and increase faster.31 [NHANES, 2011-2014 data]
    • 21.4 percent of Latina females and 22.4 percent of Latino males are obese.
    • 20.7 percent of Black females and 18.4 percent of Black males are obese.
    • 15.1 percent of White females and 14.3 percent of White males are obese.
    • 5.3 percent of Asian females and 11.8 percent of Asian males are obese.
    • Among preschoolers (ages 2 to 5), Latinos are three times as likely (15.6 percent) and Blacks are twice as likely (10.4 percent) to be obese than Whites (5.2 percent) and Asians (5.0 percent).
    • Among American Indian/Alaska Native children, 25 percent of 2- to 5-year-olds, 31 percent of 6- to 11-year-olds and 31 percent of 12- to 19-year-olds are obese.32 [Indian Health Service, 2008]
  • In addition, there are also significant inequities in rates of extreme obesity (BMI at or above 120 percent of the sex-specific 95th percentile on the CDC BMI-for-age growth charts):33 [NHANES, 2011-2014 data]
    • Almost 9 percent of Black, 7.6 percent of Latino, 4.4 percent of White and 1.3 percent of Asian children are extremely obese (ages 2 to 19).
    • Among preschoolers (ages 2 to 5), Latinos (7.6 percent) and Blacks (8.6 percent) are almost twice as likely to be extremely obese than Whites (4.4 percent).

Adults

  • Obesity rates exceeded 35 percent in five states, 30 percent in 25 states and 25 percent in 46 states. The lowest rate was 22.3 percent in Colorado. [Behavioral Risk Factor Surveillance System (BRFSS), 2015]
    • In 1985, no state had an adult obesity rate higher than 15 percent; in 1991, no state was over 20 percent; in 2000, no state was over 25 percent; and, in 2006, only Mississippi was above 30 percent.
  • Nationally, nearly 38 percent of adults are obese.34 [NHANES, 2013- 2014 data]
    • Nearly 8 percent of adults are extremely obese (BMI greater than or equal to 40.0).35
    • Obesity rates are higher among women (40.4 percent) compared to men (35.0 percent).36 Within the last decade (2005 to 2014), the obesity rate among women increased by 5.1 percent, while the rate among men only increased by 1.7 percent.
    • Women are also almost twice as likely (9.9 percent) to be extremely obese compared to men (5.5 percent).37
    • In addition, rates are the highest among middle-age adults (41 percent for 40- to 59-year-olds), compared to 34.3 percent of 20- to 39-year-olds and 38.5 percent of adults ages 60 and older.38
  • There are significant racial and ethnic inequities. [NHANES, 2013-2014 data]
    • Obesity rates are higher among Blacks (48.4 percent) and Latinos (42.6 percent) than among Whites (36.4 percent) and Asian Americans (12.6 percent).39
    • The inequities are highest among women: Blacks have a rate of 57.2 percent, Latinas of 46.9 percent, Whites of 38.2 percent and Asians of 12.4 percent. For men, Latinos have a rate of 37.9 percent, Blacks of 38.0 percent and Whites of 34.7 percent.40
    • Black women (16.8 percent) are more likely to be extremely obese than White women (9.7 percent).41
  • And there are income and/or education inequities.
    • Nearly 33 percent of adults who did not graduate high school were obese compared with 21.5 percent of those who graduated from college or technical college. [2008-2010 data]
    • More than 33 percent of adults who earn less than $15,000 per year are obese compared with 24.6 percent of those who earned at least $50,000 per year.42 [2008- 2010 data]

The State of Adult Obesity: Overview

After years of rapid increases, the growth in America's adult obesity rate has started to slow, and even decline, in some places. On a state level, adult obesity rates increased in four states (Colorado, Minnesota, Washington, and West Virginia), decreased in one state (Kansas), and remained stable in the rest. This supports trends that have shown steadying levels in recent years. Last year was the first time this annual report recorded any declines in adult obesity rates, with four states experiencing declines, and, overtime, growth has started to slow. In 2006, rates increased in 31 states; in 2010, rates increased in 16 states.

Yet, obesity remains one of America's most pervasive, expensive and deadly health problems. More than one-third of U.S. adults are obese (37.9 percent as of 2013-2014).43 Obesity increases the risk of developing high blood pressure, heart disease, type 2 diabetes, stroke, arthritis, liver disease, kidney disease, Alzheimer's disease, gallbladder disease and mental health issues, as well as many types of cancer.44 Each year, obesity is associated with more than 100,000 premature deaths.45 Obesity during pregnancy increases the chances of complications, including gestational diabetes, preeclampsia, cesarean delivery and stillbirth.46,47,48

The causes of obesity are complex and include individual, social and environmental factors, but it is clear that most Americans do not eat enough healthy food or get enough physical activity. For example:

Physical and social environments also play a role in the obesity epidemic. Communities designed for transportation by cars, jobs that require hours sitting behind a desk, and entertainment options that revolve around watching a screen all encourage a sedentary lifestyle. Meanwhile, processed food and sugar-sweetened beverages are heavily advertised, and often less expensive and more readily available than healthier alternatives.53 In many communities, there are no grocery stores where residents can buy affordable, nutritious foods. Research has shown that there is likely also a genetic susceptibility to obesity, though studies have shown that a healthy diet and physical activity can counteract these risks.54

Obesity costs our nation more than $149 billion in healthcare costs each year.55 Indirect costs attributable to obesity also run in the billions due to absenteeism in school and jobs and reduced productivity. One study estimated indirect absenteeism costs to be as much as $6.3 billion annually.56

Obesity threatens our military readiness, as well as the number of individuals capable of serving as first responders, firefighters and police officers. In fact, being overweight or obese is the leading cause of medical disqualifications, with 23 percent of armed services applicants rejected because of excessive weight or body fat.57 Research has estimated that obese service members cost the Defense Department $1.1 billion in medical costs and $105.6 million per year in lost productivity.58 Mission: Readiness — a group consisting of retired admirals and generals — has warned that the obesity crisis threatens the future strength of our military.59

In the United States, there are two primary instruments at CDC used to track adult obesity rates:

1. The Behavioral Risk Factor Surveillance System is the source for the state-by-state adult obesity data in this report. This survey's advantages include: (a) it is the largest ongoing telephone health survey in the world; (b) each state survey is representative of the population of that state; and (c) the survey is conducted annually, so new obesity data are available each year. Downsides of this survey include: (a) small samples that in some states prohibit meaningful information collection about particular racial and ethnic groups; and (b) survey respondents self-report their weight and height, which may result in reported obesity rates lower than actual rates, due to people's tendency to underreport their weight and exaggerate their height.60

2. The National Health and Nutrition Examination Survey is the source for the national adult obesity data in this report, and also measures childhood obesity rates. As a survey instrument, NHANES has several advantages: (a) it examines a nationally representative sample of Americans ages 2 and older; and (b) it combines interviews with physical examinations, increasing the accuracy of the data. A downside of the survey is the delay between collection and reporting. For example, the most recent published obesity rates from the NHANES are from 2013-2014.

State-by-State Adult Obesity Rates

The two maps below illustrate the major growth in state obesity rates between 1993, when the BRFSS became a nationwide surveillance system, and 2017. Note that CDC made some methodological changes to the survey in 2011, which do not allow for direct comparisons. However, these maps reflect trends confirmed by other surveys, which all show large increases in obesity rates over the past 25 years.

Trends in Obesity Among U.S. Adults

National Adult Obesity Rates

Nationally, 37.9 percent of American adults were obese in 2013-14 (NHANES).61 Rates of extreme or severe obesity are 7.7 percent, and more than 70 percent are overweight or obese.

After decades of increases, rates stabilized during the time period between 2003-2004 and 2011-12, and grew slightly among women from 2011-12 to 2013-14 (using measures of statistical significance).62 Obesity rates had nearly tripled since CDC first began tracking them in 1960, and have doubled since the 1980s.63

Obesity rates vary by sex, age and other characteristics. The obesity rate is higher among women (40.4 percent) than men (35.0 percent); women also have higher rates of class 3 obesity (9.9 percent vs. 5.5 percent for men).64 In 2011-2014, middleaged Americans (ages 40-59) had the highest obesity rate of any age group at 41.0 percent, followed by seniors (ages 60 and older) at 38.5 percent, and then young adults (ages 20-39) at 34.3 percent.

Notes

1 Alberti P, Sutton K, Baer I. Community Health Needs Assessments: Engaging Community Partners to Improve Health. Association of American Medical Colleges. Analysis in Brief. 2014;14(11). https://www.aamc.org/download/419276/data/dec2014communityhealth. pdf. Accessed July 18, 2017.

2 National Center for Health Statistics. NCHS Fact Sheet: National Health and Nutrition Examination Survey. https://www.cdc.gov/nchs/data/factsheets/factsheet_nhanes.pdf. January 2016. Accessed July 18, 2017.

3 Behavioral Risk Factor Surveillance System, 2016 Survey Data and Documentation. In U.S. Centers for Disease Control and Prevention. https://www.cdc.gov/brfss/data_documentation/index.htm (accessed August 2017).

4 Data query from the Child and Adolescent Health Measurement Initiative's Data Resource Center for Child and Adolescent Health website. Indicator 1.4: Childhood weight status in 4 categories, age 10-17 years; all states. http://www.nschdata.org/browse/survey/allstates?q=2462. Accessed May 26, 2017.

5 County Health Rankings & Roadmaps. http://www.countyhealthrankings.org/. Accessed July 18, 2017.

6 Kim DD, Basu A. Estimating the medical care costs of obesity in the United States: systematic review, meta-analysis, and empirical analysis. Value Health. 2016;19(5):602-13. doi:10.1016/j.jval.2016.02.008.

7 Trogdon JG, Finkelstein EA, Hylands T, Dellea PS, Kamal-Bahl. Indirect costs of obesity: a review of the current literature. Obes Rev. 2008;9(5):489?500.

8 Wang YC, Pamplin J, Long MW, et al. 2015. Severe obesity in adults cost state Medicaid programs nearly $8 billion in 2013. Health Affairs. 2015;34(11):1923-1931.

9 Wang YC, Pamplin J, Long MW, et al. 2015. Severe obesity in adults cost state Medicaid programs nearly $8 billion in 2013. Health Affairs. 2015;34(11):1923-1931.

10 Cawley J, Maclean JC. Unfit for service: the implications of rising obesity for U.S. military recruitment. Health Econ. 2012;21(11):1348- 1366.

11 Cawley J, Maclean JC. Unfit for service: the implications of rising obesity for U.S. military recruitment. Health Econ. 2012;21(11):1348- 1366.

12 Mission: Readiness. Unfit to fight. https://www.strongnation.org/articles/53-unfit-to-fight. Published April 30, 2015. Accessed June 28, 2017.

13 Wilkinson ML, Brown AL, Poston WS, Haddock CK, Jahnke SA, Day RS. Physician weight recommendations for overweight and obese firefighters, United States, 2011?2012. Prev Chronic Dis. 2014;11:140091. doi:http://dx.doi.org/10.5888/pcd11.140091

14 Violanti JM, Fekedulegn D, Hartley TA, Andrew ME, Gu JK, Burchfiel CM. Life expectancy in police officers: a comparison with the U.S. general population. Int J Emerg Ment Health. 2013;15:217?228.

15 Carey FR, Singh GK, Brown HS, Wilkinson AV. Educational outcomes associated with childhood obesity in the United States: cross-sectional results from the 2011?2012 National Survey of Children's Health. Int J of Behav Nutr and Phys Activ. 2015;12(Suppl 1):S3. doi:10.1186/1479-5868-12-S1-S3.

16 Centers for Disease Control and Prevention. Childhood Obesity Facts. https://www.cdc. gov/healthyschools/obesity/facts.htm. Accessed July 18, 2017.

17 Levine JA. Poverty and Obesity in the U.S. Diabetes. 2011;60:2667?2668. doi:10.2337/db11-1118.

18 Jackson JE, Doescher MP, Jerant AF, Hart LG. A national study of obesity prevalence and trends by type of rural county. J Rural Health. 2005:21(2):140-148. doi:10.1111/j.1748-0361.2005.tb00074.

19 Flegal KM, Kruszon-Moran D, Carroll MD, et al. Trends in obesity among adults in the United States, 2005 to 2014. JAMA. 2016;315(21):2284-2291. doi:10.1001/jama.2016.6458.

20 Flegal KM, Kruszon-Moran D, Carroll MD, et al. Trends in obesity among adults in the United States, 2005 to 2014. JAMA. 2016;315(21):2284-2291. doi:10.1001/jama.2016.6458.

21 U.S. Department of Health and Human Services, Office of Minority Health. Obesity and American Indians/Alaska Natives. https://minorityhealth.hhs.gov/omh/browse.aspx?lvl=4&lvlid=40. Updated December 27, 2016. Accessed June 26, 2017.

22 Trust for America's Health. Special Issue Brief: National Survey of Registered Voters on Public Health. http://www.tfah.org/report/133/. Accessed June 14, 2017. (Survey conducted on September 8-9, 2016 of a nationwide sample of 1302 registered voters across the country.)

23 Ogden CL, Carroll MD, Lawman, HG, Fryar CD, Kruszon-Moran D, Kit BK, Flegal KM. Trends in obesity prevalence among children and adolescents in the United States, 1988-1994 through 2013-2014. JAMA. 2016;315(21):2292-2299.

24 Pan L, Freedman DS, Sharma AJ, et al. Trends in obesity among participants aged 2?4 years in the Special Supplemental Nutrition Program for Women, Infants, and Children? United States, 2000?2014. MMWR Morb Mortal Wkly Rep 2016;65:1256?1260. doi: http://dx.doi.org/10.15585/mmwr.mm6545a2.

25 Robert Wood Johnson Foundation. Signs of Progress: New Mexico. http://www.rwjf.org/en/library/articles-and-news/2013/07/newmexico--signs-of-progress.html. Published June 2016. Accessed June 14, 2017.

26 Ogden CL, Carroll MD, Lawman, HG, Fryar CD, Kruszon-Moran D, Kit BK, Flegal KM. Trends in obesity prevalence among children and adolescents in the United States, 1988-1994 through 2013-2014. JAMA. 2016;315(21):2292-2299.

27 Centers for Disease Control and Prevention. Childhood Obesity Facts. https://www.cdc. gov/healthyschools/obesity/facts.htm. Accessed July 18, 2017.

28 Ogden CL, Carroll MD, Fryar CD, Flegal KM. Prevalence of obesity among adults and youth: United States, 2011?2014. NCHS data brief, no 219. Hyattsville, MD: National Center for Health Statistics. 2015.

29 Ogden CL, Carroll MD, Lawman, HG, Fryar CD, Kruszon-Moran D, Kit BK, Flegal KM. Trends in obesity prevalence among children and adolescents in the United States, 1988-1994 through 2013-2014. JAMA. 2016;315(21):2292-2299.

30 Ogden CL, Carroll MD, Lawman, HG, Fryar CD, Kruszon-Moran D, Kit BK, Flegal KM. Trends in obesity prevalence among children and adolescents in the United States, 1988-1994 through 2013-2014. JAMA. 2016;315(21):2292-2299.

31 Ogden CL, Carroll MD, Lawman, HG, Fryar CD, Kruszon-Moran D, Kit BK, Flegal KM. Trends in obesity prevalence among children and adolescents in the United States, 1988-1994 through 2013-2014. JAMA. 2016;315(21):2292-2299.

32 Indian Health Service. Healthy Weight for Life: A Vision for Healthy Weight Across the Lifespan of American Indians and Alaska Na- tives, Actions for Communities, Individuals, and Families. https://www.ihs.gov/healthy-weight/includes/themes/newihstheme/display_objects/documents/HW4L_Com- munities.pdf. Published 2011. Accessed July 18, 2017.

33 Ogden CL, Carroll MD, Lawman, HG, Fryar CD, Kruszon-Moran D, Kit BK, Flegal KM. Trends in obesity prevalence among children and adolescents in the United States, 1988-1994 through 2013-2014. JAMA. 2016;315(21):2292-2299.

34 Flegal KM, Kruszon-Moran D, Carroll MD, et al. Trends in obesity among adults in the United States, 2005 to 2014. JAMA. 2016;315(21):2284-2291. doi:10.1001/jama.2016.6458.

35 Flegal KM, Kruszon-Moran D, Carroll MD, et al. Trends in obesity among adults in the United States, 2005 to 2014. JAMA. 2016;315(21):2284-2291. doi:10.1001/jama.2016.6458.

36 Flegal KM, Kruszon-Moran D, Carroll MD, et al. Trends in obesity among adults in the United States, 2005 to 2014. JAMA. 2016;315(21):2284-2291. doi:10.1001/jama.2016.6458.

37 Flegal KM, Kruszon-Moran D, Carroll MD, et al. Trends in obesity among adults in the United States, 2005 to 2014. JAMA. 2016;315(21):2284-2291. doi:10.1001/jama.2016.6458.

38 Flegal KM, Kruszon-Moran D, Carroll MD, et al. Trends in obesity among adults in the United States, 2005 to 2014. JAMA. 2016;315(21):2284-2291. doi:10.1001/jama.2016.6458.

39 Flegal KM, Kruszon-Moran D, Carroll MD, et al. Trends in obesity among adults in the United States, 2005 to 2014. JAMA. 2016;315(21):2284-2291. doi:10.1001/jama.2016.6458.

40 Flegal KM, Kruszon-Moran D, Carroll MD, et al. Trends in obesity among adults in the United States, 2005 to 2014. JAMA. 2016;315(21):2284-2291. doi:10.1001/jama.2016.6458.

41 Flegal KM, Kruszon-Moran D, Carroll MD, et al. Trends in obesity among adults in the United States, 2005 to 2014. JAMA. 2016;315(21):2284-2291. doi:10.1001/jama.2016.6458.

42 Trust for America's Health and Robert Wood Johnson Foundation. F as in Fat: How Obesity Threatens America's Future ? 2011. Washington, D.C.: Trust for America's Health. http://www.tfah.org/report/88/. Published 2011. Accessed July 18, 2017. (Based on data using the previous BRFSS methodology in use from 2008-2010.)

43 Ogden CL, Carroll MD, Fryar CD, Flegal KM. Prevalence of obesity among adults and youth: United States, 2011?2014. NCHS data brief, no 219. Hyattsville, MD: National Center for Health Statistics. 2015.

44 NHLBI Obesity Education Initiative Expert Panel on the Identification, Evaluation, and Treatment of Obesity in Adults (US). Clinical guidelines on the identification, evaluation, and treatment of overweight and obesity in adults: the evidence report. https://www. ncbi.nlm.nih.gov/books/NBK1994/. Published 1998. Accessed July 18, 2017.

45 Flegal KM, Graubard BI, Williamson DF, et al. Excess deaths associated with underweight, overweight, and obesity. JAMA. 2005;293(15):1861-7.

46 Leddy MA, Power, ML, Schulkin J. The impact of maternal obesity on maternal and fetal health. Rev Obstet Gynecol. 2008;1(4):170?178.

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