In the US, health reform will be debated throughout the summer. But an expensive contributor to health care costs gets little attention: overweight and obese people. Two easy numbers to remember:

• Two-thirds of Americans are overweight;
• One-third is obese.

Beyond the US, there is a global obesity epidemic. And in the least developed nations, the number of obese children now exceeds the number underfed.

Definitions

What do we mean by overweight and obese people? A generally accepted measure for these categories is the body mass index (BMI). The BMI defines being overweight and obese by two body dimensions: weight and height. There is general agreement on the following:

• a BMI between 25 and 30 is considered overweight;
• a BMI between 30 and 40 is considered obese, and
• a BMI over 40 is considered grossly obese.
• For example, consider Tables 1 and 2 below. They indicate what an average person of different heights would have to weigh to be overweight, obese, or grossly obese by these BMI categories.

 Table 1. – BMI Overweight/Obesity Measures (US: feet/lbs.)

Height	Overweight BMI=25-30	Obese BMI=30-40	Gross Obesity: BMI > 40
(feet)	(lbs.)	(lbs.)	(lbs.)
4′	82	98	131
4′ 6″	104	124	166
5′	128	154	205
5′ 6″	155	186	248
6′	184	221	295
6′ 6″	216	260	346
7′	251	301	401

 Table 2. – BMI Overweight/Obesity Measures (Metric: meters/kgs.)

Height	Overweight BMI=25-30	Obese BMI=30-40	Gross Obesity: BMI > 40
(meters)	(kgs.)	(kgs.)	(kgs.)
1.2	37.2	44.7	59.6
1.4	47.3	56.6	75.4
1.5	58.2	69.8	93.1
1.7	70.5	84.5	112.7
1.8	83.6	100.6	134.1
2.0	98.2	118.0	157.4
2.1	113.9	136.5	181.9

 What gives these BMI categories meaning? Medical researchers have found that being overweight and obese as measured by these BMI categories run significantly greater health risks than people with lower BMIs.

Most US citizens, when shown these tables, say the weights are far too low to qualify for being overweight or obese. That is because they are used to seeing overweight and obese people and accept them as the norm (remember: two-thirds of Americans are overweight).

At the same time, it is important to emphasize that the BMI is for an average human body in terms of muscle and bone mass. Looking at the players of the National Football League (NFL) Superbowl champion Pittsburg Steelers, we get the following BMI distributions.

Table 3. – Pittsburg Steelers

2009 Roster

BMI Classification
Not Overweight	4
Overweight	34
Obese	38
Grossly Obese	4
Total	80

Of colurse, professional football players large with greater bone mass than average. And they have spent years building up their muscles. As an even more extreme selection of people with abnormal body mass , consider the centers, guards and tackles of the American Football Conference (AFC) of the National Football League. Centers, guards, and tackles are selected for their “heft”.

Table 4. – AFC Centers, Guards, and Tackles

2009 Rosters

BMI Classification
Not Overweight	0
Overweight	1
Obese	258
Grossly Obese	36
Total	295

Again, these players are selected for their strength and size, and the average BMI classifications do not apply directly to them. However, it is also visually apparent that most of these players are grossly overweight for their heights and body types. And many spectators come to see these players as being of acceptable body weight – after all, they are athletes.

Obesity Costs and Risks

There are a growing number of excellent studies on the risks and costs of obesity. Most of the points summarized below were taken from The Trust for America’s Health 2009 report: F as in Fat: How Obesity Policies Are Failing in America. In essence, they document that being overweight makes worse almost any health problem you might have.

• Heart disease is the leading cause of death in the US and strokes are the third leading cause. Being overweight increases the risk of both;
• Cancer is the second leading cause of death in the US. 20% of cancer in women and 15% of cancer in men is attributable to obesity;
• Diabetes kills almost 4 million people annually and accounts for 11% of US health care costs. There is a direct link between diabetes and being overweight: 80% of people with the primary type of diabetes are overweight;
• Obese people are 83% more likely to develop kidney disease than those not overweight.

The US spends over $2 trillion on health care annually; one study estimates obesity costs at $214 billion annually, or approximately 10%. It is projected the health costs for being overweight and obesity will double every decade. This means it will beco,me an ever-increasing share of total health care costs.

The number of grossly obese people (BMI>40) went up 4 times between 1986 and 2000; the number of severely obese people (BMI>50) increased five times over the same period. The number of obese children is growing rapidly.

Data

US and global data provide a useful picture of obesity patterns.

United States

Table 5 provides data on US states with the highest and lowest obesity rates. The states with the highest rates are all in the southern part of the country. The states with the lowest rates are coastal or mountainous.

Table 5. – US States with Highest

and Lowest Obesity Rates

States	Obesity (%)
Highest
Mississippi	32.5
Alabama	31.2
West Virginia	31.1
Tennessee	30.2
South Carolina	29.7
Oklahoma	29.5
Kentucky	29.0
Louisiana	28.9
Lowest
Colorado	18.9
Massachusetts	21.2
Connecticut	21.3
Rhode Island	21.7
Hawaii	21.8
Vermont	22.1
District of Columbia	22.3
Utah	22.5

Source: http://healthyamericans.org/reports/obesity2009/Obesity2009Report.pdf

US obesity rates can also be examined by region, and here, the predominance of the southern states is also clear.

Table 6. – US Obesity Rates by Region*

Region	Obesity %	Population
Solid South	30.3	11,002,299
Bible Belt	29.9	15,457,275
Mid-West	27.5	39,486,115
South West	27.3	26,137,351
South Atlantic	26.5	31,411,968
Farm	26.3	12,948,473
Mid-Atlantic	25.1	42,431,668
West	24.0	36,484,848
Mountain	22.0	9,630,242
New England	21.9	11,068,992

Source: http://healthyamericans.org/reports/obesity2009/Obesity2009Report.pdf

* The states in each region can be found in the Annex.

Global

The global picture is as troubling as the US situation. As mentioned earlier, the number of obese children in developing countries now exceeds those malnourished. The International Obesity Taskforce is an excellent source of information on the global problem.  Table 7 provides a listing of the countries with the highest obesity rates.

Table 7. – Countries with Highest Obesity Rates*

Country	Obesity %
Egypt	46.60
Iraq	32.20
United States	32.15
Argentina	26.90
Mexico	23.35
Turkey	22.70
United Kingdom	22.65
New Zealand	22.55
Croatia	22.15
Greece	22.10

Source: World Health Organization

* Countries with populations over 1 million

 Table 8 provides a listing of the countries with the lowest obesity rates.

Table 7. – Countries with Lowest Obesity Rates*

Country	Obesity %
Ethiopia	0.70
Nepal	0.90
Madagascar	1.00
Loas	1.15
Cambodia	1.20
Rwanda	1.30
Chad	1.50
Eritrea	1.60
India	2.05
Indonesia	2.35

Source: World Health Organization

* Countries with populations over 1 million

 While the countries with the lowest obesity rates are very poor, there is no correlation between per capita income and poverty overall. It is also interesting to look at obesity rates by region, and this is done in Table 8.

Table 8. – Obesity Rates by Region

Location	Obesity	Population
Asia	2.62	2,991,635,283
Africa	5.01	680,794,177
Western Europe	13.26	403,134,039
Latin America	16.16	473,226,361
Eastern Europe	16.39	397,776,584
Oceania	17.42	25,476,059
North America	30.45	340,699,331
Middle East	31.19	180,510,773

The differences here are truly striking. There is considerable poverty in both Africa and Asia, but that does not explain Asia’s low obesity rate. Japan and South Korea have high per capita incomes, but their obesity rates are 3.1% and 3.5%, respectively. Latin America also has poverty, but its obesity problems are growing rapidly. In this table Oceania includes Australia and New Zealand, both high meat consumption countries. Western Europe, Japan, and the US, have the highest per capita incomes in the world, but note the difference in obesity.

Looking Ahead

It is difficult to know if governments can make any difference as this epidemic grows. I am skeptical: in the past, US nutrition advice has been developed primarily by food industry lobbyists. Other countries have launched better health, lower weight initiatives, and there is the International Obesity Taskforce mentioned earlier. But without effective government intervention, the future is bleak.

Childhood obesity is growing worldwide. Children now get caught up in their video games and they can do most of their schoolwork on their computers. In essence, they can sit in one place all day…. And increasingly, we hear horror stories such as the mother of a 555 pound 14 year old boy being arrested for neglect. A 555 pound 14 year old boy!!!!

It can be anticipated that resentment of overweight people will grow more recognize their very high medical costs. Already, doctors and educators have become frustrated. Recent self-report studies show that doctors view obese patients as lazy, lacking in self-control, non-compliant, unintelligent, weak-willed, and dishonest. Educators view overweight students as untidy, more emotional, less likely to succeed on homework….

 ANNEX

 State – Region Groupings

Bible Belt - West Virginia, Tennessee, Kentucky

Mid-Atlantic – District of Columbia, Delaware, New Jersey, Maryland, Pennsylvania, Virginia, New York

Solid South – Louisiana, Mississippi, Alabama, Arkansas

Midwest – Wisconsin, Missouri, Illinois, Michigan, Ohio, Indiana

West – Alaska, Hawaii, Oregon, Washington, California

Southwest – New Mexico, Arizona, Texas, Oklahoma

Farm – North Dakota, Minnesota, South Dakota, Nebraska, Iowa, Kansas

South Atlantic – Florida, South Carolina, Georgia, North Carolina

New England – New Hampshire, Vermont, Massachusetts, Rhode Island, Maine, Connecticut

Mountain – Nevada, Wyoming, Montana, Colorado, Idaho, Utah