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Brief Report |

Trends and Correlates of Class 3 Obesity in the United States From 1990 Through 2000 FREE

David S. Freedman, PhD; Laura Kettel Khan, PhD; Mary K. Serdula, MD; Deborah A. Galuska, PhD; William H. Dietz, MD, PhD
[+] Author Affiliations

Author Affiliations: Division of Nutrition and Physical Activity, Centers for Disease Control and Prevention, Atlanta, Ga.


JAMA. 2002;288(14):1758-1761. doi:10.1001/jama.288.14.1758.
Text Size: A A A
Published online

Context Although the prevalence of obesity has markedly increased among US adults, health risks vary according to the severity of obesity. Persons with class 3 obesity (body mass index [BMI] ≥40) are at greatest risk, but there is little information about this subgroup.

Objective To examine correlates of class 3 obesity and secular trends.

Design, Setting, and Participants Adults (aged ≥18 years) in the United States who participated in the Behavioral Risk Factor Surveillance System telephone survey between 1990 (75 600 persons) and 2000 (164 250 persons).

Main Outcome Measure Body mass index calculated from self-reported weight and height.

Results The prevalence of class 3 obesity increased from 0.78% (1990) to 2.2% (2000). In 2000, class 3 obesity was highest among black women (6.0%), persons who had not completed high school (3.4%), and persons who are short. During the 11-year period, the median BMI level increased by 1.2 units and the 95th percentile increased by 3.2 units.

Conclusion The prevalence of class 3 obesity is increasing rapidly among adults. Because these extreme BMI levels are associated with the most severe health complications, the incidence of various diseases will increase substantially in the future.

Figures in this Article

The prevalence of obesity, defined as a body mass index (BMI) of 30 or more, has markedly increased during the last 3 decades in the United States13 and other countries.46 Between 1976-1980 and 1999, for example, the prevalence of obesity increased from 13% to 27% among US adults.1,7

There are few epidemiologic investigations, however, of more extreme BMIs. Based on differences in treatment and health risks, obesity has been categorized as class 1 (BMI, 30-34.9), class 2 (BMI, 35-39.9), and class 3 (BMI, ≥40).811 Persons with class 3 obesity, also termed morbid or extreme obesity, are potential candidates for antiobesity surgery12 and have a 2-fold higher risk for all-cause mortality than persons with BMIs of 30 to 31.9.13

The prevalence of class 3 obesity increased from 1% to 3% between 1960-1962 and 1988-1994 and is highest among black women.1,2 The objectives of the current study are to determine if trends have continued through 2000 and to examine various correlates of class 3 obesity.

Behavioral Risk Factor Surveillance System

We analyzed data from the Behavioral Risk Factor Surveillance System (BRFSS), a multistage survey that uses random-digit dialing to obtain a representative sample of adults (≥18 years old) in each state.14 Several steps were taken to ensure quality control in BRFSS, and the current analyses are based on data collected from 1990 (44 states) through 2000 (50 states).

The questionnaire focuses on behaviors associated with disease risks,15 and the data have been used to examine secular trends in overweight and obesity (cutpoints of 27-32).3,16 Because height was recorded in inches and weight in pounds, these units are used throughout the text; BMI was calculated as the weight in kilograms divided by the squared height in meters.

More than 1 million persons participated in the BRFSS between 1990 and 2000. Approximately 4% of participants did not report weight or height, and the current analyses are limited to non-Hispanic whites, non-Hispanic blacks, and Hispanics. Other race/ethnic groups (approximately 4%) are excluded, as are pregnant women (approximately 2%) and persons (n = 364) with extreme values of weight or height (eg, weight >560 lb). Yearly totals for the current analyses ranged from 75 600 (1990) to 164 250 persons (2000).

Statistical Methods

All analyses accounted for the unequal selection probabilities.17 Statistical testing is not emphasized in this large sample, but SEs were calculated using SUDAAN to account for the design.17

Trends in various BMI categories are examined according to sex, race/ethnicity, age, educational achievement, and height. The independent relation of these characteristics to class 3 obesity (and possible interactions) was examined in logistic regression analyses.17 Differences in the BMI distributions in 1990-1991 vs 2000 were examined using a percentile comparison plot.18

The mean BMI increased from 24.9 (1990) to 26.5 (2000), and Figure 1 illustrates trends in 5 BMI categories. Although the prevalence of all BMI categories greater than 25 increased during the study period, the most striking increases were in the extreme BMI categories, with class 3 obesity increasing from 0.78% to 2.2%.

Figure 1. Secular Trends in Body Mass Index
Graphic Jump Location
Secular trends from 1990 through 2000 in the prevalence of normal weight (body mass index [BMI], <25), overweight (BMI, 25-29.9), class 1 obesity (BMI, 30-34.9), class 2 obesity (BMI, 35-39.9), and class 3 obesity (BMI, ≥40). BMI was calculated as weight in kilograms divided by squared height in meters.

The prevalence of class 3 obesity according to various characteristics is examined in Table 1. (Because of the smaller number of persons interviewed in 1990, data for 1990 and 1991 have been combined.) In each year, the prevalence of class 3 obesity was approximately 2-fold higher among women than men, with the highest prevalence among black women (6% in 2000). Among men, there was little difference in class 3 obesity by race/ethnicity in 1990-1991, but the prevalence in 2000 was highest among blacks (2.4%). Although secular increases were seen in all age groups, the largest proportional increase (0.4% to 1.2%) was among 18- to 29-year-olds. The prevalence of class 3 obesity also increased within all categories of educational achievement, with the prevalence highest among persons who did not complete high school.

Table Graphic Jump LocationTable 1. Secular Trends in Class 3 Obesity According to Various Characteristics*

Additional analyses indicated that although mean levels of weight increased by 9 to 12 lb during the 11 years, these weight increases varied only slightly by height. We therefore examined the prevalence of class 3 obesity within various height categories (Table 1, bottom). Among both men and women, the prevalence of class 3 obesity was about 2-fold higher among short persons than among taller persons (eg, <67 vs ≥74 inches among men).

Logistic regression analyses indicated that each characteristic in Table 1, including year of study, was independently associated with the prevalence of class 3 obesity. For example, educational achievement was inversely associated with class 3 obesity among 30- to 69-year-olds in each race-sex group, with the prevalence highest (12% in 2000) among black women who did not complete high school (Table 2). Additional analyses indicated that the association with educational achievement was stronger among women than men.

Table Graphic Jump LocationTable 2. Prevalence of Class 3 Obesity Among 30- to 69-Year-Olds According to Year of Study, Race, Sex, and Educational Achievement*

All percentiles of BMI were higher in 2000 than in 1990-1991, but the increases were larger at high BMI levels (Figure 2). For example, although the 10th percentile of BMI increased by 0.6 units, the 95th percentile increased by 3.2 units (36.9 − 33.7 = 3.2).

Figure 2. Comparison of Body Mass Index Percentiles
Graphic Jump Location
Percentile comparison plot of body mass indexes (BMIs) between 1990-1991 and 2000 among 30- to 69-year-old white and black adults. Various percentiles of BMI are plotted, and points would lie on the diagonal line if there had been no secular increase. The distance above the line represents the BMI increase at each percentile.

Most studies of secular trends in obesity have focused on mean BMIs or on BMIs of 30 or higher, but our results indicate that the prevalence of BMIs of 40 or higher increased almost 3-fold between 1990 and 2000. These trends will greatly increase the risk for various diseases and premature mortality.13,19 Approximately 75% of adults with class 3 obesity have at least one comorbid condition, such as high blood pressure or diabetes mellitus.20 Furthermore, a BMI of 40 or higher is associated with a 2-fold higher risk for all-cause mortality than are BMIs of 30 to 31.9.13

Despite these consequences, relatively little is known about the distribution of class 3 obesity. We found the highest prevalence among black women and among persons with low levels of educational achievement. Although an inverse association between social class and less extreme obesity has consistently been found among women, a review21 of articles before 1990 concluded that the association among men was inconsistent. Our observations suggest that the (inverse) association among men may have become stronger during the last decade. In agreement with this possibility, several recent studies2224 have found that obesity (BMI >30) is inversely associated with social class among men. However, the sex differences before 1990 may also reflect the greater stigmatization of obesity among women.

An unexpected finding was the high prevalence of class 3 obesity among shorter adults. Although it is generally assumed that height and BMI are uncorrelated, an inverse association (r = −0.10) has been reported,25 and others26,27 have found a relatively high prevalence of obesity among short adults. It is possible that the association between BMI and height may be influenced by characteristics, such as dietary intake and physical activity, that vary only slightly by height.

In agreement with the trends observed between 1966-1970 and 1988-199428 is our finding that increases in BMI were most striking at high BMIs. Although all BMI percentiles increased between 1990 and 2000, the median increased by 1.2, whereas the 95th percentile increased by 3.2. We also found that 18- to 29-year-olds showed a large proportional increase in class 3 obesity, possibly reflecting the increases in childhood BMI (particularly at the upper percentiles) that have occurred since 1975.28,29

An important limitation of the current study is the use of self-reported rather than measured weight and height. The BMIs based on self-reported and measured data are highly correlated (r>0.95), and self-reported data have been used in cohort studies13,30,31 and in studies of secular trends.3,5,16 However, because height is overreported and weight is underreported, BMIs based on self-reported data are biased downward.3235 This bias increases at higher BMIs,3234 and the sensitivity of self-reported data to detect a BMI of 30 or higher ranges from 63% to 74%.32,33,36 This underreporting likely accounts for the approximately 50% lower prevalence of class 3 obesity that we observed in 1995 (1% for men and 1.6% for women) than the estimates of 2% to 4% reported by others.1,2 However, if these biases remained fairly constant during the study, our observed trends and subgroup differences would parallel those calculated from measured data. The proportional increase in class 3 obesity that we observed between 1990 and 2000 is similar to those reported (based on measured data) from 1976-1980 to 1988-19941 and from 1985 to 1995.2

Although the optimum BMI remains uncertain,37 the trends in class 3 obesity will result in substantial increases in morbidity and premature mortality. Additional studies are needed to elucidate future trends and to identify other characteristics that may be associated with class 3 obesity, such as repeated weight increases during pregnancy among women with more than 3 children.38,39 Because weight loss is difficult to maintain, the prevention of obesity should be emphasized.

Flegal KM, Carroll MD, Kuczmarski RJ, Johnson CL. Overweight and obesity in the United States: prevalence and trends, 1960-1994.  Int J Obes Relat Metab Disord.1998;22:39-47.
Lewis CE, Jacobs Jr DR, McCreath H.  et al.  Weight gain continues in the 1990s: 10-year trends in weight and overweight from the CARDIA study (Coronary Artery Risk Development in Young Adults).  Am J Epidemiol.2000;151:1172-1181.
Mokdad AH, Bowman BA, Ford ES, Vinicor F, Marks JS, Koplan JP. The continuing epidemics of obesity and diabetes in the United States.  JAMA.2001;286:1195-1200.
Flegal KM. The obesity epidemic in children and adults: current evidence and research issues.  Med Sci Sports Exerc.1999;31(suppl 11):S509-S514.
Maillard G, Charles MA, Thibult N.  et al.  Trends in the prevalence of obesity in the French adult population between 1980 and 1991.  Int J Obes Relat Metab Disord.1999;23:389-394.
Martorell R, Khan LK, Hughes ML, Grummer-Strawn LM. Obesity in women from developing countries.  Eur J Clin Nutr.2000;54:247-252.
 Prevalence of overweight and obesity among adults: United States, 1999. Available at: http://www.cdc.gov/nchs/products/pubs/pubd/hestats/obese/obse99.htm. Accessed May 8, 2002.
WHO Expert Committee on Physical Status: the Uses and Interpretation of Anthropometry.  Physical Status: The Use and Interpretation of Anthropometry: Report of a WHO Expert Committee. Geneva, Switzerland: World Health Organization; 1995. World Health Organization Technical Report Series 854.
Bray GA, Bouchard C, James WPT. Definitions and proposed current classification of obesity. In: Bray GA, Bouchard C, James WPT, eds. Handbook of Obesity. New York, NY: Marcel Dekker Inc; 1997:31-40.
National Heart, Lung, and Blood Institute.  Clinical Guidelines on the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults: The Evidence ReportBethesda, Md: National Institutes of Health; 1998. NIH publication 98-408. Available at: http://www.nhlbi.nih.gov/guidelines/ obesity/ob_gdlns.pdf. Accessed November 7, 2001.
Kuczmarski RJ, Flegal KM. Criteria for definition of overweight in transition: background and recommendations for the United States.  Am J Clin Nutr.2000;72:1074-1081.
National Institutes of Health Consensus Development Conference.  Gastrointestinal surgery for severe obesity: proceedings of a National Institutes of Health Consensus Development Conference.  Am J Clin Nutr.1992;55(2 suppl):615S-619S.
Calle EE, Thun MJ, Petrelli JM, Rodriguez C, Heath Jr CW. Body-mass index and mortality in a prospective cohort of US adults.  N Engl J Med.1999;341:1097-1105.
Gentry EM, Kalsbeek WD, Hogelin GC.  et al.  The behavioral risk factor surveys, II: design, methods, and estimates from combined state data.  Am J Prev Med.1985;1:9-14.
Remington PL, Smith MY, Williamson DF, Anda RF, Gentry EM, Hogelin GC. Design, characteristics, and usefulness of state-based behavioral risk factor surveillance: 1981-87.  Public Health Rep.1988;103:366-375.
Galuska DA, Serdula M, Pamuk E, Siegel PZ, Byers T. Trends in overweight among US adults from 1987 to 1993: a multistate telephone survey.  Am J Public Health.1996;86:1729-1735.
Shah BV, Barnwell BG, Bieler GS. SUDAAN User's Manual. Release 7.5. Research Triangle Park, NC: Research Triangle Institute; 1997.
Cleveland WS. The Elements of Graphing DataMurray Hill, NJ: Wadsworth Inc; 1985:135-143.
Sjostrom LV. Morbidity of severely obese subjects.  Am J Clin Nutr.1992;55(2 suppl):508S-515S.
Must A, Spadano J, Coakley EH, Field AE, Colditz G, Dietz WH. The disease burden associated with overweight and obesity.  JAMA.1999;282:1523-1529.
Sobal J, Stunkard AJ. Socioeconomic status and obesity: a review of the literature.  Psychol Bull.1989;105:260-275.
Gutierrez-Fisac JL, Regidor E, Rodriguez C. Trends in obesity differences by educational level in Spain.  J Clin Epidemiol.1996;49:351-354.
Rahkonen O, Lundberg O, Lahelma E, Huuhka M. Body mass and social class: a comparison of Finland and Sweden in the 1990s.  J Public Health Policy.1998;19:88-105.
Lauderdale DS, Rathouz PJ. Body mass index in a US national sample of Asian Americans: effects of nativity, years since immigration and socioeconomic status.  Int J Obes Relat Metab Disord.2000;24:1188-1194.
Welborn TA, Knuiman MW, Vu HT. Body mass index and alternative indices of obesity in relation to height, triceps skinfold and subsequent mortality: the Busselton health study.  Int J Obes Relat Metab Disord.2000;24:108-115.
Billewicz WZ, Kemsley WFF, Thomas AM. Indices of adiposity.  Br J Prev Soc Med.1962;16:183-195.
Freeman JV, Power C, Rodgers B. Weight-for-height indices of adiposity: relationships with height in childhood and early adult life.  Int J Epidemiol.1995;24:970-976.
Flegal KM, Troiano RP. Changes in the distribution of body mass index of adults and children in the US population.  Int J Obes Relat Metab Disord.2000;24:807-818.
Freedman DS, Srinivasan SR, Valdez RA, Williamson DF, Berenson GS. Secular increases in relative weight and adiposity among children over two decades: the Bogalusa Heart Study.  Pediatrics.1997;99:420-425.
Lee IM, Manson JE, Hennekens CH, Paffenbarger Jr RS. Body weight and mortality: a 27-year follow-up of middle-aged men.  JAMA.1993;270:2823-2828.
Folsom AR, French SA, Zheng W, Baxter JE, Jeffery RW. Weight variability and mortality: the Iowa Women's Health Study.  Int J Obes Relat Metab Disord.1996;20:704-709.
Stewart AW, Jackson RT, Ford MA, Beaglehole R. Underestimation of relative weight by use of self-reported height and weight.  Am J Epidemiol.1987;125:122-126.
Nieto-Garcia FJ, Bush TL, Keyl PM. Body mass definitions of obesity: sensitivity and specificity using self-reported weight and height.  Epidemiology.1990;1:146-152.
Rowland ML. Self-reported weight and height.  Am J Clin Nutr.1990;52:1125-1133.
Kuczmarski MF, Kuczmarski RJ, Najjar M. Effects of age on validity of self-reported height, weight, and body mass index: findings from the Third National Health and Nutrition Examination Survey, 1988-1994.  J Am Diet Assoc.2001;101:28-34.
Bowlin SJ, Morrill BD, Nafziger AN, Lewis C, Pearson TA. Reliability and changes in validity of self-reported cardiovascular disease risk factors using dual response: the Behavioral Risk Factor Survey.  J Clin Epidemiol.1996;49:511-517.
Strawbridge WJ, Wallhagen MI, Shema SJ. New NHLBI clinical guidelines for obesity and overweight: will they promote health?  Am J Public Health.2000;90:340-343.
Lederman SA. The effect of pregnancy weight gain on later obesity.  Obstet Gynecol.1993;82:148-155.
Lahmann PH, Lissner L, Gullberg B, Berglund G. Sociodemographic factors associated with long-term weight gain, current body fatness and central adiposity in Swedish women.  Int J Obes Relat Metab Disord.2000;24:685-694.

Figures

Figure 1. Secular Trends in Body Mass Index
Graphic Jump Location
Secular trends from 1990 through 2000 in the prevalence of normal weight (body mass index [BMI], <25), overweight (BMI, 25-29.9), class 1 obesity (BMI, 30-34.9), class 2 obesity (BMI, 35-39.9), and class 3 obesity (BMI, ≥40). BMI was calculated as weight in kilograms divided by squared height in meters.
Figure 2. Comparison of Body Mass Index Percentiles
Graphic Jump Location
Percentile comparison plot of body mass indexes (BMIs) between 1990-1991 and 2000 among 30- to 69-year-old white and black adults. Various percentiles of BMI are plotted, and points would lie on the diagonal line if there had been no secular increase. The distance above the line represents the BMI increase at each percentile.

Tables

Table Graphic Jump LocationTable 1. Secular Trends in Class 3 Obesity According to Various Characteristics*
Table Graphic Jump LocationTable 2. Prevalence of Class 3 Obesity Among 30- to 69-Year-Olds According to Year of Study, Race, Sex, and Educational Achievement*

References

Flegal KM, Carroll MD, Kuczmarski RJ, Johnson CL. Overweight and obesity in the United States: prevalence and trends, 1960-1994.  Int J Obes Relat Metab Disord.1998;22:39-47.
Lewis CE, Jacobs Jr DR, McCreath H.  et al.  Weight gain continues in the 1990s: 10-year trends in weight and overweight from the CARDIA study (Coronary Artery Risk Development in Young Adults).  Am J Epidemiol.2000;151:1172-1181.
Mokdad AH, Bowman BA, Ford ES, Vinicor F, Marks JS, Koplan JP. The continuing epidemics of obesity and diabetes in the United States.  JAMA.2001;286:1195-1200.
Flegal KM. The obesity epidemic in children and adults: current evidence and research issues.  Med Sci Sports Exerc.1999;31(suppl 11):S509-S514.
Maillard G, Charles MA, Thibult N.  et al.  Trends in the prevalence of obesity in the French adult population between 1980 and 1991.  Int J Obes Relat Metab Disord.1999;23:389-394.
Martorell R, Khan LK, Hughes ML, Grummer-Strawn LM. Obesity in women from developing countries.  Eur J Clin Nutr.2000;54:247-252.
 Prevalence of overweight and obesity among adults: United States, 1999. Available at: http://www.cdc.gov/nchs/products/pubs/pubd/hestats/obese/obse99.htm. Accessed May 8, 2002.
WHO Expert Committee on Physical Status: the Uses and Interpretation of Anthropometry.  Physical Status: The Use and Interpretation of Anthropometry: Report of a WHO Expert Committee. Geneva, Switzerland: World Health Organization; 1995. World Health Organization Technical Report Series 854.
Bray GA, Bouchard C, James WPT. Definitions and proposed current classification of obesity. In: Bray GA, Bouchard C, James WPT, eds. Handbook of Obesity. New York, NY: Marcel Dekker Inc; 1997:31-40.
National Heart, Lung, and Blood Institute.  Clinical Guidelines on the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults: The Evidence ReportBethesda, Md: National Institutes of Health; 1998. NIH publication 98-408. Available at: http://www.nhlbi.nih.gov/guidelines/ obesity/ob_gdlns.pdf. Accessed November 7, 2001.
Kuczmarski RJ, Flegal KM. Criteria for definition of overweight in transition: background and recommendations for the United States.  Am J Clin Nutr.2000;72:1074-1081.
National Institutes of Health Consensus Development Conference.  Gastrointestinal surgery for severe obesity: proceedings of a National Institutes of Health Consensus Development Conference.  Am J Clin Nutr.1992;55(2 suppl):615S-619S.
Calle EE, Thun MJ, Petrelli JM, Rodriguez C, Heath Jr CW. Body-mass index and mortality in a prospective cohort of US adults.  N Engl J Med.1999;341:1097-1105.
Gentry EM, Kalsbeek WD, Hogelin GC.  et al.  The behavioral risk factor surveys, II: design, methods, and estimates from combined state data.  Am J Prev Med.1985;1:9-14.
Remington PL, Smith MY, Williamson DF, Anda RF, Gentry EM, Hogelin GC. Design, characteristics, and usefulness of state-based behavioral risk factor surveillance: 1981-87.  Public Health Rep.1988;103:366-375.
Galuska DA, Serdula M, Pamuk E, Siegel PZ, Byers T. Trends in overweight among US adults from 1987 to 1993: a multistate telephone survey.  Am J Public Health.1996;86:1729-1735.
Shah BV, Barnwell BG, Bieler GS. SUDAAN User's Manual. Release 7.5. Research Triangle Park, NC: Research Triangle Institute; 1997.
Cleveland WS. The Elements of Graphing DataMurray Hill, NJ: Wadsworth Inc; 1985:135-143.
Sjostrom LV. Morbidity of severely obese subjects.  Am J Clin Nutr.1992;55(2 suppl):508S-515S.
Must A, Spadano J, Coakley EH, Field AE, Colditz G, Dietz WH. The disease burden associated with overweight and obesity.  JAMA.1999;282:1523-1529.
Sobal J, Stunkard AJ. Socioeconomic status and obesity: a review of the literature.  Psychol Bull.1989;105:260-275.
Gutierrez-Fisac JL, Regidor E, Rodriguez C. Trends in obesity differences by educational level in Spain.  J Clin Epidemiol.1996;49:351-354.
Rahkonen O, Lundberg O, Lahelma E, Huuhka M. Body mass and social class: a comparison of Finland and Sweden in the 1990s.  J Public Health Policy.1998;19:88-105.
Lauderdale DS, Rathouz PJ. Body mass index in a US national sample of Asian Americans: effects of nativity, years since immigration and socioeconomic status.  Int J Obes Relat Metab Disord.2000;24:1188-1194.
Welborn TA, Knuiman MW, Vu HT. Body mass index and alternative indices of obesity in relation to height, triceps skinfold and subsequent mortality: the Busselton health study.  Int J Obes Relat Metab Disord.2000;24:108-115.
Billewicz WZ, Kemsley WFF, Thomas AM. Indices of adiposity.  Br J Prev Soc Med.1962;16:183-195.
Freeman JV, Power C, Rodgers B. Weight-for-height indices of adiposity: relationships with height in childhood and early adult life.  Int J Epidemiol.1995;24:970-976.
Flegal KM, Troiano RP. Changes in the distribution of body mass index of adults and children in the US population.  Int J Obes Relat Metab Disord.2000;24:807-818.
Freedman DS, Srinivasan SR, Valdez RA, Williamson DF, Berenson GS. Secular increases in relative weight and adiposity among children over two decades: the Bogalusa Heart Study.  Pediatrics.1997;99:420-425.
Lee IM, Manson JE, Hennekens CH, Paffenbarger Jr RS. Body weight and mortality: a 27-year follow-up of middle-aged men.  JAMA.1993;270:2823-2828.
Folsom AR, French SA, Zheng W, Baxter JE, Jeffery RW. Weight variability and mortality: the Iowa Women's Health Study.  Int J Obes Relat Metab Disord.1996;20:704-709.
Stewart AW, Jackson RT, Ford MA, Beaglehole R. Underestimation of relative weight by use of self-reported height and weight.  Am J Epidemiol.1987;125:122-126.
Nieto-Garcia FJ, Bush TL, Keyl PM. Body mass definitions of obesity: sensitivity and specificity using self-reported weight and height.  Epidemiology.1990;1:146-152.
Rowland ML. Self-reported weight and height.  Am J Clin Nutr.1990;52:1125-1133.
Kuczmarski MF, Kuczmarski RJ, Najjar M. Effects of age on validity of self-reported height, weight, and body mass index: findings from the Third National Health and Nutrition Examination Survey, 1988-1994.  J Am Diet Assoc.2001;101:28-34.
Bowlin SJ, Morrill BD, Nafziger AN, Lewis C, Pearson TA. Reliability and changes in validity of self-reported cardiovascular disease risk factors using dual response: the Behavioral Risk Factor Survey.  J Clin Epidemiol.1996;49:511-517.
Strawbridge WJ, Wallhagen MI, Shema SJ. New NHLBI clinical guidelines for obesity and overweight: will they promote health?  Am J Public Health.2000;90:340-343.
Lederman SA. The effect of pregnancy weight gain on later obesity.  Obstet Gynecol.1993;82:148-155.
Lahmann PH, Lissner L, Gullberg B, Berglund G. Sociodemographic factors associated with long-term weight gain, current body fatness and central adiposity in Swedish women.  Int J Obes Relat Metab Disord.2000;24:685-694.
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