Health Effects of Overweight and Obesity in 195 Countries Over 2 2017

new england
The
journal of medicine
established in 1812 July 6, 2017 vol. 377 no. 1
Health Effects of Overweight and Obesity in 195 Countries

over 25 Years
The GBD 2015 Obesity Collaborators*
a bs t r ac t
BACKGROUND
Although the rising pandemic of obesity has received major attention in many *The names, academic degrees, and af-
countries, the effects of this attention on trends and the disease burden of obe- filiations of the authors, who are mem-
bers of the Global Burden of Disease
sity remain uncertain. (GBD) 2015 Obesity Collaborators, are
listed in the Appendix. The authors as-
METHODS sume responsibility for the content and
We analyzed data from 68.5 million persons to assess the trends in the prevalence integrity of this article. Address reprint
requests to Dr. Murray at the Institute
of overweight and obesity among children and adults between 1980 and 2015. Using for Health Metrics and Evaluation, Uni-
the Global Burden of Disease study data and methods, we also quantified the versity of Washington, 2301 5th Ave.,
burden of disease related to high body-mass index (BMI), according to age, sex, Suite 600, Seattle, WA 98121, or at
cjlm@uw.edu.
cause, and BMI in 195 countries between 1990 and 2015.
This article was published on June 12,
RESULTS 2017, at NEJM.org.
In 2015, a total of 107.7 million children and 603.7 million adults were obese. This is the New England Journal of Medi-
Since 1980, the prevalence of obesity has doubled in more than 70 countries and cine version of record, which includes all
has continuously increased in most other countries. Although the prevalence of Journal editing and enhancements. The
Author Final Manuscript, which is the au-
obesity among children has been lower than that among adults, the rate of in- thor’s version after external peer review
crease in childhood obesity in many countries has been greater than the rate of and before publication in the Journal, is
increase in adult obesity. High BMI accounted for 4.0 million deaths globally, available under a CC BY license at
PMC5477817.
nearly 40% of which occurred in persons who were not obese. More than two
thirds of deaths related to high BMI were due to cardiovascular disease. The dis- N Engl J Med 2017;377:13-27.
DOI: 10.1056/NEJMoa1614362
ease burden related to high BMI has increased since 1990; however, the rate of this Copyright © 2017 Massachusetts Medical Society.
increase has been attenuated owing to decreases in underlying rates of death from
cardiovascular disease.
CONCLUSIONS
The rapid increase in the prevalence and disease burden of elevated BMI highlights
the need for continued focus on surveillance of BMI and identification, implemen-
tation, and evaluation of evidence-based interventions to address this problem.
(Funded by the Bill and Melinda Gates Foundation.)
n engl j med 377;1 nejm.org July 6, 2017 13

The New England Journal of Medicine
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Copyright © 2017 Massachusetts Medical Society. All rights reserved.
The n e w e ng l a n d j o u r na l of m e dic i n e
T
he prevalence of overweight and and disability-adjusted life-years, a composite
obesity is increasing worldwide.1 Epidemio- metric computed as the sum of years lived with
logic studies have identified high body- disability and years of life lost due to high BMI.
mass index (BMI, the weight in kilograms di- In this analysis, we used the distribution of BMI
vided by the square of the height in meters) as a according to age, sex, country, and year; the ef-
A Quick Take
is available at risk factor for an expanding set of chronic dis- fect size of the change in BMI on disease end
NEJM.org eases, including cardiovascular disease,2,3 diabe- points; the BMI associated with the lowest risk
tes mellitus, chronic kidney disease,2 many can- of death from all causes; and disease-specific
cers,4 and an array of musculoskeletal disorders.5,6 mortality and morbidity according to age, sex,
As the global health community works to develop country, and year.
treatments and prevention policies to address
obesity, timely information about levels of high Global Distribution of BMI
BMI and health effects at the population level is We systematically searched Medline for studies
needed. that provide nationally or subnationally represen-
In recent years, increasing efforts have been tative estimates of BMI, overweight, or obesity
made to assess the trends in BMI within and among children or adults. We included studies if
across nations.7,8 Other studies have quantified they used standard cutoff points of BMI to de-
the potential effects of high BMI on a variety of fine overweight (BMI, 25 to 29) and obesity
health outcomes.2,4 These efforts, while useful, (BMI, ≥30) among adults or standards of the
did not consider the relationship of high BMI International Obesity Task Force to define over-
with broader socioeconomic development; they weight and obesity among children. The search
also excluded many data sources, focused exclu- terms, selection criteria, and flow diagrams of
sively on adults, inadequately captured the skewed screening are provided in the Methods section in
distribution of BMI, did not capture emerging the Supplementary Appendix, available with the
evidence on additional outcomes, and did not full text of this article at NEJM.org. In addition,
assess the effect of epidemiologic and demo- we searched the Global Health Data Exchange
graphic transition on disease burden. The BMI (http://ghdx.healthdata.org) for multicountry sur-
that is associated with the lowest risk of death vey programs, national surveys, and longitudinal
has also been questioned.9,10 studies that provide self-reported or measured
To address these gaps in knowledge, we sys- data on height and weight for children or adults.
tematically evaluated the trends in the prevalence With respect to data regarding adults, we
of overweight and obesity as well as the patterns identified 1276 unique data sources (855 mea-
of deaths and disability-adjusted life-years related sured and 421 self-report) from 176 countries
to high BMI, according to age and sex, in 195 that provide data on BMI, 1333 sources (802
countries. This analysis supersedes all previous measured and 531 self-report) from 176 countries
results from the Global Burden of Disease study that provide data on overweight, and 1514 sources
with respect to high BMI by comprehensively (713 measured and 801 self-report) from 174
reanalyzing all data from 1990 through 2015 countries that provide data on obesity. With re-
using consistent methods and definitions. spect to data regarding children, we identified
1211 unique data sources (800 measured and
411 self-report) from 173 countries that provide
Me thods
data on BMI, 1236 sources (832 measured and
Prevalence and Disease Burden 404 self-report) from 174 countries that provide
of Overweight and Obesity data on overweight, and 1437 sources (928 mea-
We systematically estimated the prevalence of sured and 509 self-report) from 175 countries
overweight and obesity among children (<20 years that provide data on obesity. Using mixed-effects
of age) and adults between 1980 and 2015. Using linear-regression models, we separately estimated
the comparative-risk-assessment approach from and corrected for self-reporting bias among men
the Global Burden of Disease study, we also and women according to geographic region and
quantified the burden of disease related to high age group. We characterized the age and sex pat-
BMI during the period from 1990 through 2015. terns for BMI, overweight, and obesity and ap-
The burden of disease was assessed by deaths plied these patterns to split aggregated data into
14 n engl j med 377;1 nejm.org July 6, 2017

5-year age groups according to sex (see the epidemiologic evidence supporting the causal re-
Methods section in the Supplementary Appendix). lationship between high BMI and various disease
We used spatiotemporal Gaussian process re- end points among adults 25 years of age or older.13
gression to estimate the mean prevalence of obe- We found convincing or probable evidence for an
sity and overweight.11 To improve our estimates association with 20 health outcomes (Table S1 in
in data-sparse countries, we tested a wide range the Supplementary Appendix). For each outcome,
of covariates with plausible relationships to over- we obtained the relative risk from a dose–response
weight and obesity. We selected three country- meta-analysis of prospective observational stud-
level covariates with best fit and coefficients in ies (Table S2 in the Supplementary Appendix).
the expected direction, as have been used in Using pooled analyses of prospective cohort
other studies.8 These factors included 10-year studies, we estimated the relative risk associated
lag-distributed energy intake (i.e., time-weighted with a change of five units of BMI in 5-year age
average of daily energy intake) per capita, the groups for ischemic heart disease, ischemic stroke,
absolute latitude of the country, and the propor- hemorrhagic stroke, hypertensive heart disease,
tion of persons living in urban areas. To estimate and diabetes mellitus. For breast cancer, we cal-
the mean BMI, we first used mixed-effects linear culated the relative risk for premenopausal and
regression to characterize the relationship be- postmenopausal women according to region (as
tween BMI, overweight, and obesity in sources specified in the Global Burden of Disease study)
containing information on all three measures. because of evidence that overweight and obesity
We applied the coefficients of this regression to have a protective effect against breast cancer in
the prevalence of overweight and of obesity gen- premenopausal women in all countries except for
erated through spatiotemporal Gaussian process the Asia–Pacific regions,14,15 whereas a positive
regression to estimate the mean BMI for each association between high BMI and the incidence
country, according to age, sex, and year. Among of postmenopausal breast cancer has been ob-
the 195 countries and territories that are included served worldwide.15
in the present study, data regarding overweight,
obesity, or BMI were unavailable for only 8: The Lowest-Risk BMI
Antigua and Barbuda, Bermuda, Brunei, Northern We used the most recent pooled analysis of pro-
Mariana Islands, Saint Vincent and the Grena- spective observational studies to determine the
dines, the Bahamas, Turkmenistan, and Vene- BMI associated with the lowest overall risk of
zuela. The estimates in these countries were death.9 To address the limitations of previous
constructed purely from the covariates used in studies on this topic, which have included re-
the estimation of the linear model and the weight- sidual confounding among smokers and reverse
ed and smoothed residuals from data for neigh- causation due to preexisting chronic diseases,10
boring countries. the analysis was restricted to never-smokers
To identify the appropriate distribution of without identified chronic diseases who survived
BMI at the population level, we examined how 5 years after recruitment. The lowest overall risk
various distributions (i.e., log-normal, gamma, of death was observed for a BMI of 20 to 25.
inverse Gaussian, and beta) approximated the
distribution of actual data from national surveys Statistical Analysis
in six countries; the best fit was provided by the
To quantify the burden of disease related to high
beta distribution.12 We characterized the shape BMI for each disease end point, we calculated
of the beta distribution on the basis of the mean
the population attributable fraction according to
BMI and the prevalence of overweight and obe- country, age, sex, and year.16 We computed the
sity in each country according to age, sex, and numbers of deaths and disability-adjusted life-
year. Details of this approach have been de- years related to high BMI for each country, ac-
scribed previously.12 cording to age, sex, year, and cause, by multiply-
ing the population attributable fraction by the
Effect of High BMI on Health Outcomes total number of deaths or disability-adjusted life-
We used Bradford Hill’s criteria for causation years, as estimated in the Global Burden of Dis-
and the evidence-grading criteria of the World ease study for that country, age, sex, year, and
Cancer Research Fund to systematically evaluate cause. We calculated the total disease burden

related to high BMI as the sum of disease-specific Figure 1 (facing page). Prevalence of Obesity at the Global
burdens. To understand where in the distribu- Level, According to Sociodemographic Index (SDI).
tion of BMI most of the burden occurs, we es- Shown is the age-specific prevalence of obesity at
timated population attributable fractions for the global level and according to SDI quintile in 2015
three ranges of BMI (20 to 24, 25 to 29, and ≥30) (Panel A) and age-standardized prevalence trends at
and for five groups of disease end points (car- the global level and according to SDI quintile from 1980
through 2015 among children (Panel B) and adults
diovascular disease, diabetes mellitus, chronic (Panel C).
kidney disease, cancers, and musculoskeletal dis-
orders).
Using the methods developed by Das Gupta,17 among adults. Among adults, the prevalence of
we broke down the change in the numbers of obesity was generally higher among women than
deaths and the numbers of disability-adjusted among men in all age brackets (Fig. 1). The peak
life-years that are attributed to high BMI be- in the prevalence of obesity was observed between
tween population growth, population age struc- the ages of 60 and 64 years among women and
ture, risk exposure to high BMI, and rates of between the ages of 50 and 54 years among
risk-deleted mortality and disability-adjusted life- men. The rates of increase in obesity between
years. (Risk-deleted rates are the burden of dis- 1980 and 2015 did not differ significantly be-
ease in the absence of the risk factor — for ex- tween women and men in any age bracket; for
ample, rates of death from cardiovascular disease both groups, the rates of increase were highest
that would have been observed if everyone had in early adulthood. Among children, the preva-
been at the lowest-risk BMI.) lence of obesity in 2015 decreased with age until
We computed 95% uncertainty intervals for the age of 14 years and then increased; no sex
all results using Monte Carlo simulations, keep- differences were observed in obesity prevalence
ing 1000 draws of each quantity of interest to before the age of 20 years. Between 1980 and
propagate uncertainty into final estimates. The 2015, the rates of increase in global childhood
model included uncertainty from examination obesity were equal for boys and girls in all age
surveys, the relative risks for each outcome from brackets.
the pooled analyses or meta-analyses of cohorts,
the lowest-risk BMI, and the number of deaths SDI Level
and disability-adjusted life-years estimated for In 2015, at all SDI levels and for all age groups,
each country, age, sex, year, and outcome from the prevalence of obesity was generally higher for
the Global Burden of Disease 2015 study. Ac- women than for men, with the highest preva-
cording to the methods outlined in that study, lence among women between the ages of 60 to 64
we used a sociodemographic index (SDI) — a years living in countries with a high SDI (Fig. 1).
summary measure of lag-distributed income per In general, the prevalence of obesity among both
capita, average educational attainment among women and men increased with the increase in
persons over the age of 15 years, and total fertil- the SDI across all age groups. An exception was
ity rate — to position countries on the develop- the prevalence of obesity among women living in
ment continuum. We then generated quintiles of countries with a low SDI, since after the age of
SDI to categorize countries as low, low-middle, 55 years, the prevalence was higher than that
middle, high-middle, and high development level observed for women in countries with a low-
(Table S3 in the Supplementary Appendix).13 middle SDI (Fig. 1). During the period from 1980
to 2015, the most rapid relative increase in the
prevalence of obesity occurred among men be-
R e sult s
tween the ages of 25 and 29 years who were
Prevalence of Obesity (1980–2015) living in countries with a low-middle SDI —
Global Level from 1.1% (uncertainty interval, 0.9 to 1.5) in
In 2015, we estimated that 107.7 million children 1980 to 3.8% (95% uncertainty interval, 3.1 to
(uncertainty interval, 101.1 to 115.1) and 603.7 mil- 4.8) in 2015. During the same time period, the
lion adults (uncertainty interval, 592.9 to 615.6) prevalence of obesity increased by a factor of 1.7
were obese worldwide. The overall prevalence of among both men and women in countries with
obesity was 5.0% among children and 12.0% a low-middle SDI.

Male Female Global Low SDI Low-middle SDI Middle SDI High-middle SDI High SDI
A Obesity According to Age Group

30
25
20
Prevalence (%)
15
10
0
0 2–4 5–9 10–14 15–19 20–24 25–29 30–34 35–39 40–44 45–49 50–54 55–59 60–64 65–69 70–74 75–79 80+
Age Group (yr)
B Obesity in Children According to Year

9
6
Prevalence (%)
0
1980 1985 1990 1995 2000 2005 2010 2015
Year
C Obesity in Adults According to Year
20
15
Prevalence (%)
10
0
1980 1985 1990 1995 2000 2005 2010 2015
Year

Prevalence of Obesity <0.05 0.05–0.09 0.1–0.149 0.15–0.199 0.2–0.249 0.25–0.299 0.3–0.349 >0.35
18
A Men B Women
The
Caribbean LCA SYC Caribbean SYC

Persian Gulf Persian Gulf
Prevalence of Obesity <0.01 0.01–0.029

0.01
0.0 1 – 0.029 0.03–0.049
0.03
0.0 3 – 0.049 0.05–0.069
0.05
0.0 5 – 0.069 0.07–0.089
0.07
0.07 – 0.089 0.09–0.109
0.09
0.09 – 0.109 >0.11
n engl j med 377;1

C Boys D Girls
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Caribbean LCA SYC Caribbean LCA TTO SYC
Persian Gulf SGP Persian Gulf
Figure 2 (facing page). Age-Standardized Prevalence

vizhub.healthdata.org/obesity/). Here we high-
of Obesity Worldwide in 2015. light the findings related to obesity in the most
Shown is the age-standardized prevalence of obesity populous countries (Fig. 2).
among adults (Panel A [men] and Panel B [women]) In 2015, among the 20 most populous coun-
and among children (Panel C [boys] and Panel D [girls]) tries, the highest level of age-standardized adult
in 2015. Children were defined as being under the age obesity was observed in Egypt (35.3%; 95% un-
of 20 years. Values for prevalence are provided as deci-
mals. ATG denotes Antigua and Barbuda, BRB Barbados,
certainty interval, 33.6 to 37.1), and the highest
COM Comoros, DMA Dominica, E. Med. Eastern Medi- level of age-standardized childhood obesity was
terranean, FJI Fiji, FSM Federated States of Micronesia, observed in the United States (12.7%; 95% un-
GRD Grenada, KIR Kiribati, LCA Saint Lucia, MDV Mal- certainty interval, 12.2 to 13.2). The prevalence
dives, MHL Marshall Islands, MLT Malta, MUS Mauritius, was lowest among adults in Vietnam (1.6%; 95%
SGP Singapore, SLB Solomon Islands, SYC Seychelles,
TLS Timor-Leste, TON Tonga, TTO Trinidad and Tobago,
uncertainty interval, 1.4 to 2.0) and among chil-
VCT Saint Vincent and the Grenadines, VUT Vanuatu, dren in Bangladesh (1.2%; 95% uncertainty in-
W. Africa Western Africa, and WSM Samoa. terval, 0.9 to 1.7). Between 1980 and 2015, the
age-standardized prevalence of obesity increased
by a factor of 2 or more in 13 of the 20 coun-
Among children, the prevalence of obesity tries; only the Democratic Republic of Congo
was greater in countries with higher SDI levels had no increase (Figs. S1 and S2 in the Supple-
(Fig. 1). At most SDI levels, the prevalence of mentary Appendix). In 2015, China and India
obesity was lowest among both boys and girls had the highest numbers of obese children,
between ages of 10 and 14 years. In countries whereas the United States and China had the
with high and high-middle SDI levels, the preva- highest numbers of obese adults.
lence was generally greater among boys than
among girls, although this difference reversed Burden of Disease Related to High BMI
beginning with late adolescence (Fig. 1). Between (1990–2015)
1980 and 2015, there was a significant relative Global Level
increase of 20.0% (95% uncertainty interval, 5.5 In 2015, high BMI contributed to 4.0 million
to 35.3) in the prevalence of obesity in countries deaths (95% uncertainty interval, 2.7 to 5.3),
with a low SDI among both girls and boys. Dur- which represented 7.1% (95% uncertainty inter-
ing that period, the highest rates of increase val, 4.9 to 9.6) of the deaths from any cause; it
were observed in countries with a middle SDI also contributed to 120 million disability-adjust-
among both girls and boys. ed life-years (95% uncertainty interval, 84 to
158), which represented 4.9% (95% uncertainty
National Level interval, 3.5 to 6.4) of disability-adjusted life-
The prevalence of obesity among children and years from any cause among adults globally. A
adults has doubled in 73 countries since 1980 total of 39% of the deaths and 37% of the dis-
and has shown a continuous increase in most ability-adjusted life-years that were related to
other countries. Although the prevalence of high BMI occurred in persons with a BMI of less
childhood obesity has been lower than the than 30 (Fig. 3).
prevalence of adult obesity, the rate of increase Cardiovascular disease was the leading cause
in childhood obesity in many countries has been of death and disability-adjusted life-years related
greater than the rate of increase in adult obesity. to high BMI and accounted for 2.7 million
The estimated age-standardized prevalence of deaths (95% uncertainty interval, 1.8 to 3.7) and
overweight and obesity among children and 66.3 million disability-adjusted life-years (95%
adults for all 195 countries and territories is uncertainty interval, 45.3 to 88.5) (Table S4 in
provided in Table S3 in the Supplementary Ap- the Supplementary Appendix). Globally, 41% of
pendix. A complete data set of all results for BMI-related deaths and 34% of BMI-related dis-
each country according to age, sex, and year is ability-adjusted life-years were due to cardiovas-
available on the Global Health Data Exchange cular disease among obese persons. Diabetes
website (http://ghdx.healthdata.org/), and an in- was the second leading cause of BMI-related
teractive data visualization of the prevalence of deaths in 2015 and contributed to 0.6 million
overweight and obesity is provided online (https:// deaths (95% uncertainty interval, 0.4 to 0.7) and

20
Musculoskeletal Disorders Cardiovascular Diseases Cancers Chronic Kidney Disease Diabetes Mellitus
A Disability-Adjusted Life-Years in 1990 B Disability-Adjusted Life-Years in 2015

10 10
1.6%
8 8
2.8%
6 6
1.6%
2.1%
18.7% 33.7%
(in millions)
(in millions)
4 25.6% 4
0.2%
35.4% 4.2%
Disability-Adjusted Life-Years
Disability-Adjusted Life-Years
2.9%
The
0.3%
2 2
3.3% 2.5% 18.0%
3.4% 6.4%
4.1% 0.4%
5.8% 11.5%
0.6%
0.8% 0.3% 2.1% 3.1% 0.8% 0.3% 2.8% 4.7%
0 0
20 25 30 35 40 45 50 20 25 30 35 40 45 50
Body-Mass Index Body-Mass Index
n engl j med 377;1

C Deaths in 1990 D Deaths in 2015
0.4 0.4
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23.9%
Deaths (in millions)

Deaths (in millions)
41.4%
0.1 30.1% 0.1

41.5% 3.8% 5.4%
3.3% 4.7%
2.5%
4.7% 3.7% 4.2%
1.9% 2.8% 0.6%
0.7%
0.3% 0.6% 3.3% 6.2% 0.4% 0.5% 4.0% 9.5%
0.0 0.0
20 25 30 35 40 45 50 20 25 30 35 40 45 50
Body-Mass Index Body-Mass Index
Figure 3 (facing page). Global Disability-Adjusted Life- A Disability-Adjusted Life-Years

Years and Deaths Associated with a High Body-Mass Change due to risk-deleted DALY rate Change due to population growth
Index (1990–2015). Change due to population aging Change due to risk exposure
Shown are the number of global disability-adjusted life- ● Total percent change
years (in millions) related to a high body-mass index
(BMI) among adults according to the cause and the High SDI ●
level of BMI in 1990 (Panel A) and in 2015 (Panel B) High-middle SDI ●

and the number of global deaths (in millions) related
to high BMI in 1990 (Panel C) and in 2015 (Panel D). Global ●
The two vertical lines mark the BMI thresholds for over-
weight (25 to 29) and for obesity (≥30). The percentages Middle SDI ●
indicate the proportion of the total number of disability- Low SDI ●

adjusted life-years or deaths that were contributed by
each of the listed disorders. Low-middle SDI ●
–50 0 50 100 150 200
30.4 million disability-adjusted life-years (95% Percent Change

uncertainty interval, 21.5 to 39.9); among all
B Deaths
BMI-related deaths that were due to diabetes, Change due to risk-deleted death rate Change due to population growth
9.5% occurred at a BMI of 30 or more and 4.5% Change due to population aging Change due to risk exposure
occurred at a BMI of less than 30. Chronic kid- ● Total percent change
ney disease was the second leading cause of
High SDI ●
BMI-related disability-adjusted life-years in 2015;
●
18.0% of disability-adjusted life-years occurred High-middle SDI ●

●
at a BMI of 30 or more and 7.2% at a BMI of less Global ● ●
than 30. Chronic kidney disease and cancers

Middle SDI
each accounted for less than 10% of all BMI-re- ●
●
lated deaths in 2015, whereas cancers, diabetes, Low SDI ●

●
and musculoskeletal disorders each contributed Low-middle SDI ●

●
less than 10% of BMI-related disability-adjusted

life-years (Fig. 3). –50 0 50 100 150 200
High BMI also accounted for 28.6 million years Percent Change
lived with disability (95% uncertainty interval,
Figure 4. Percent Changes and Drivers of Change in Disability-Adjusted
17.8 to 41.4), which accounted for 3.6% (95%
Life-Years and Deaths at the Global Level, According to SDI (1990–2015).
uncertainty interval, 2.7 to 4.6) of years lived
Shown is a breakdown in percent changes from 1990 to 2015 in disability-
with disability due to any cause globally. Diabe- adjusted life-years (DALYs) from any cause (Panel A) and deaths (Panel B)
tes was the leading cause of years lived with related to a high BMI, according to whether the changes were attributed to
disability related to BMI (17.1 million; 95% uncer- population aging, population growth, exposure to high BMI, or risk-deleted
tainty interval, 10.6 to 24.4), followed by musculo- rates of disability-adjusted life-years or death. (Risk-deleted rates are the
underlying rates of disease that would have occurred in the absence of the
skeletal disorders (5.7 million; 95% uncertainty
risk factor.) The percent changes have been estimated according to SDI
interval, 3.4 to 8.8) and cardiovascular disease as well as at the global level. The black circles indicate the total percent
(3.3 million; 95% uncertainty interval, 2.0 to 4.9). change.
From 1990 through 2015, there was a relative
increase of 28.3% in the global rate of death
related to high BMI, from 41.9 deaths per the rate of BMI-related disability-adjusted life-
100,000 population in 1990 to 53.7 deaths per years, from 1200 per 100,000 population to 1630
100,000 population in 2015. However, there was per 100,000 population, whereas there was no
no significant change in age-standardized rates significant change in age-standardized rates.
of death during this period, with a rate of 64.0 Globally, the increases in BMI-related deaths and
(95% uncertainty interval, 41.7 to 89.7) per disability-adjusted life-years due to population
100,000 population in 1990 and 60.2 (95% un- growth, population aging, and increasing risk
certainty interval, 41.4 to 81.5) per 100,000 exposure were partially offset by reductions in
population in 2015. Similarly, during the same underlying rates of death and disability-adjusted
period, there was a relative increase of 35.8% in life-years (Fig. 4). Of the disease end points that

were considered in this study, decreases in risk- National Level

deleted rates of death from cardiovascular disease In 2015, among the 20 most populous countries,
contributed the most to this pattern. Changes that the highest rates of BMI-related death and dis-
were due to the risk of exposure to elevated BMI ability-adjusted life-years were observed in Russia,
and aging of the population were roughly equal in and the lowest rates were observed in the Demo-
terms of their contribution to the percent changes cratic Republic of Congo (Fig. S3 in the Supple-
in BMI-related deaths and disability-adjusted life- mentary Appendix). Between 1990 and 2015, the
years globally from 1990 through 2015. greatest percent changes in age-standardized BMI-
related deaths and disability-adjusted life-years
SDI Level occurred in Bangladesh, with relative increases
In 2015, the age-standardized rates of BMI-related of 133.6% (95% uncertainty interval, 66.3 to
deaths and disability-adjusted life-years were 265.7) and 139.4% (95% uncertainty interval,
greatest in countries with high-middle SDI levels, 77.2 to 273.0), respectively. During the same
with a rate of death of 68.1 (95% uncertainty period, Turkey had the largest significant de-
interval, 47.1 to 91.6) per 100,000 population crease in age-standardized BMI-related burden,
and a rate of disability-adjusted life-years of with a decrease of 43.7% (95% uncertainty interval,
1890 (95% uncertainty interval, 1330 to 2460) 36.9 to 49.8) in deaths and 37.2% (95% uncertainty
per 100,000 population. The rates of both mea- interval, 29.9 to 44.0) in disability-adjusted life-
sures were lowest in countries with high SDI years (Table S6 in the Supplementary Appendix).
levels, with a rate of death of 52.6 (95% uncer-
tainty interval, 38.7 to 67.9) per 100,000 popula- Discussion
tion and a rate of disability-adjusted life-years of
1530 (95% uncertainty interval, 1160 to 1920) In our systematic evaluation of the health effects
per 100,000 population. The rate of BMI-related of high BMI, we found that excess body weight
deaths increased between 1990 and 2015 at all accounted for about 4 million deaths and 120
SDI levels, with the highest observed rate of 90.6 million disability-adjusted life-years worldwide in
(95% uncertainty interval, 65.8 to 117.3) per 2015. Nearly 70% of the deaths that were related
100,000 population occurring in countries with to high BMI were due to cardiovascular disease,
a high SDI in 2005. The age-standardized rates and more than 60% of those deaths occurred
of death in countries with high or high-middle among obese persons. The prevalence of obesity
SDI decreased between 1990 and 2015; in the has increased during the past three decades and
lowest quintiles of SDI, age-standardized BMI- at a faster pace than the related disease burden.
related rates of death increased. With increasing However, both the trend and magnitude of the
SDI levels, the contribution of risk-deleted mortal- BMI-related disease burden vary widely across
ity to the percent change in BMI-related deaths countries.
increased, whereas the contribution of popula- Among the leading health risks that were
tion growth to the percent change in BMI-related assessed in the Global Burden of Disease 2015
deaths decreased (Fig. 4). The contribution of risk study, high BMI continues to have one of the
exposure to the percent change in BMI-related highest rates of increase. Across levels of devel-
deaths was also generally inversely related to the opment, the prevalence of obesity has increased
SDI. Patterns in the breakdown of the sources of over recent decades, which indicates that the
change in BMI-related disability-adjusted life- problem is not simply a function of income or
years were parallel to those observed for mortal- wealth.13 Changes in the food environment and
ity. In a disease-specific breakdown, risk-deleted food systems are probably major drivers.18 In-
mortality and disability-adjusted life-years showed creased availability, accessibility, and affordabil-
a declining trend for most causes across all SDI ity of energy-dense foods, along with intense
levels (Table S5 in the Supplementary Appendix). marketing of such foods, could explain excess
The largest decreases in the risk-deleted rates of energy intake and weight gain among different
death and disability-adjusted life-years were ob- populations.18 The reduced opportunities for phys-
served for cardiovascular disease, whereas can- ical activity that have followed urbanization and
cers and musculoskeletal disorders showed the other changes in the built environment have also
least decline. been considered as potential drivers; however,

these changes generally preceded the global in- disease burden related to high BMI. A recent
crease in obesity and are less likely to be major pooled cohort analysis involving 1.8 million par-
contributors.18 ticipants showed that nearly half the excess risk
During the past decade, researchers have pro- for ischemic heart disease and more than 75%
posed a range of interventions to reduce obe- of the excess risk for stroke that was related to
sity.19 Among such interventions are restricting high BMI were mediated through a combination
the advertisement of unhealthy foods to children, of raised levels of blood pressure, total serum
improving school meals, using taxation to re- cholesterol, and fasting plasma glucose.23 To-
duce consumption of unhealthy foods and pro- gether, these findings suggest that clinical inter-
viding subsidies to increase intake of healthy ventions to reduce the underlying rate of cardio-
foods, and using supply-chain incentives to in- vascular disease could substantially reduce the
crease the production of healthy foods.19 How- burden of disease related to high BMI, although
ever, the effectiveness, feasibility of widespread maintaining a normal body weight remains nec-
implementation, and sustainability of such inter- essary to achieve full benefit.
ventions need to be evaluated in various settings. Globally, 39% of deaths and 37% of disability-
In recent years, some countries have started to adjusted life-years that were related to high BMI
implement some of these policies,1 but no major occurred among nonobese persons. Although
population success has yet been shown. Many of some studies have suggested that overweight is
the countries with the highest increases in the associated with a lower risk of death from any
prevalence of obesity are those that have a low cause than is a normal range of BMI (18 to
or middle SDI and simultaneously have high rates 25),2,10 recent evidence from a meta-analysis14 and
of other forms of malnutrition. These countries pooled analysis9 of prospective observational
generally have limited financial resources for studies showed a continuous increase in the risk
nutrition programs and mostly rely on external of death associated with a BMI of more than 25.
donors whose programs often preferentially tar- These studies are particularly notable since they
get undernutrition; consequently, food security addressed major sources of bias in previous stud-
frequently takes precedence over obesity in these ies (i.e., residual confounding due to smoking
countries.20 In 2013, the World Health Organiza- and reverse causation due to preexisting chronic
tion (WHO) called for zero increase in the preva- disease) by restricting the analysis to persons
lence of overweight among children and in the who had never smoked and who did not have
prevalence of obesity among adults.21 However, chronic diseases. In addition, the pooled-cohort
given the current pace of increase and the exist- analysis controlled for the same set of covariates,
ing challenges in implementing food policies, provided cause-specific relative risks, and evalu-
achieving this goal appears unlikely in the near ated the relationship between BMI and mortality
future. across different regions. The balance of evidence
Our study showed a greater increase in the thus supports our minimum risk level of 20 to
rate of exposure to high BMI than in the rate of 25 for BMI. At the same time, to date, there re-
the related disease burden. This difference was mains insufficient evidence to support the argu-
driven mainly by the decline in risk-deleted mor- ment that the most beneficial level of BMI should
tality, particularly for cardiovascular disease; fac- vary according to geographic location or ethnic
tors such as improved treatment or changes in group9 because of differences in the relationship
other risks have resulted in decreases in the rate between BMI and body-fat distribution.
of cardiovascular disease despite increases in BMI. We found that 5% of the disability-adjusted
Existing evidence-based policies, even if fully life-years that were related to high BMI were
implemented, are unlikely to rapidly reduce the from musculoskeletal disorders. Although high
prevalence of obesity. Clinical interventions, how- BMI is a major risk factor contributing to years
ever, have proved to be effective in controlling lived with disability globally, and the economic
high levels of systolic blood pressure, cholesterol, costs associated with treatment are substantial,24
and fasting plasma glucose — the major risk these nonfatal but debilitating health outcomes
factors for cardiovascular disease.22 The expand- have received comparatively little policy attention.
ed use of such interventions among overweight Weight loss is beneficial in the prevention and
and obese persons could effectively reduce the treatment of musculoskeletal pain.25 A combina-

tion of modest weight loss and moderate exer- The potential limitations of our study should
cise provides better overall improvement in mus- also be considered. We used both self-reported
culoskeletal pain than either intervention alone26; and measured data with respect to height and
however, surgical interventions may be most weight and corrected the bias in self-reported
effective for the morbidly obese.27 data using measured data at each age, sex, and
Our systematic evaluation of prospective ob- geographic region. To apply a consistent defini-
servational studies showed sufficient evidence tion for childhood overweight and obesity across
supporting a causal relationship between high sources, we used the definition of the Interna-
BMI and cancers of the esophagus, colon and tional Obesity Task Force and excluded studies
rectum, liver, gallbladder and biliary tract, pan- that used the WHO definition. We did not propa-
creas, breast, uterus, ovary, kidney, and thyroid, gate the uncertainty in the age pattern and sex
along with leukemia. A recent review by the Inter- pattern that were used to split the aggregated
national Agency for Research on Cancer (IARC)4 data. We did not incorporate the uncertainty of
comes to largely similar conclusions, except with the BMI regression coefficients in our analysis.
respect to leukemia. (We included leukemia on Data were sparse for some locations, particularly
the basis of a systematic review and meta-analy- in earlier years, and estimates in these locations
sis of 21 prospective cohort studies.28) In addition, were based on country-level covariates and re-
even though the IARC report acknowledged con- gional data. We did not identify a consistent
sistent inverse associations between BMI and the pattern in the relationship between nationally
risk of premenopausal breast cancer, inconsistent representative data and data representing only
findings from studies that evaluated the effect urban or rural areas and were not able to correct
of waist circumference or body-weight gain re- those data for potential bias. We did not evaluate
sulted in the exclusion of premenopausal breast the trends in other measures of adiposity that
cancer from its list. However, since high BMI may better relate to specific health outcomes,
was the exposure of interest in our analysis, we including waist circumference and waist-to-hip
included the protective effect of high BMI on ratio. Since we obtained the effect size of BMI
breast cancer in premenopausal women. We did on health outcomes from prospective observa-
not evaluate the effect of high BMI on gastric tional studies, the possibility of confounding by
cancer (cardia) and meningioma because of a lifestyle habits cannot be excluded. Our estima-
lack of sufficient data to separately estimate the tion of relative risks did not capture possible
incidence and mortality of these cancers at the differences owing to ethnic group and did not
population level. account for the possibility of geographic varia-
Our study has several important strengths. tion in relative-risk curves or the lowest-risk
We have addressed the major limitations of pre- BMI. In addition, these studies generally ex-
vious studies by including more data sources cluded people with prevalent chronic diseases
and quantifying the prevalence of obesity among from the analysis of relative-risk estimation.
children. We also systematically evaluated the Thus, our estimates represent the effect of BMI
strength of evidence for the causal relationship among persons without underlying diseases.
between high BMI and health outcomes and in- This issue might be particularly important for
cluded all BMI–outcome pairs for which suffi- older age groups, in which the prevalence of
cient evidence with respect to causal relationship chronic disease increases. Finally, other prob-
was available. We used a beta distribution to able complications or forms of BMI-related bur-
characterize the distribution of BMI at the popu- den (e.g., disease burden in children) were not
lation level, a method that captures the propor- included.
tion of the population with high BMI more accu- In conclusion, our study provides a compre-
rately than other distributions.12 We used the best hensive assessment of the trends in high BMI
available evidence to determine the lowest-risk and the associated disease burden. Our results
BMI. We quantified the trends in high BMI and show that both the prevalence and disease bur-
the associated disease burden across levels of den of high BMI are increasing globally. These
development and estimated the contribution of findings highlight the need for implementation
demographic transition and epidemiologic tran- of multicomponent interventions to reduce the
sition to changes in BMI-related burden. prevalence and disease burden of high BMI.

Supported by a grant (OPP1070441) from the Bill and Melinda Disclosure forms provided by the authors are available with
Gates Foundation. the full text of this article at NEJM.org.
Appendix
The authors’ full names and academic degrees are as follows: Ashkan Afshin, M.D., Sc.D., Mohammad H. Forouzanfar, Ph.D., M.D.,
Marissa B. Reitsma, B.S., Patrick Sur, B.A., Kara Estep, M.P.A., Alex Lee, B.A., Laurie Marczak, Ph.D., Ali H. Mokdad, Ph.D., Maziar
Moradi‑Lakeh, M.D., Ph.D., Mohsen Naghavi, M.D., Ph.D., Joseph S. Salama, M.Sc., Theo Vos, Ph.D., Kalkidan H. Abate, M.S., Cris-
tiana Abbafati, Ph.D., Muktar B. Ahmed, M.P.H., Ziyad Al‑Aly, M.D., Ala’a Alkerwi, Ph.D., Rajaa Al‑Raddadi, Ph.D., Azmeraw T. Amare,
M.P.H., Alemayehu Amberbir, Ph.D., Adeladza K. Amegah, Ph.D., 0000-0001-9647-0047Erfan Amini, M.D., Stephen M. Amrock, M.D.,
Ranjit M. Anjana, M.D., Ph.D., Johan Ärnlöv, Ph.D., Hamid Asayesh, Ph.D., Amitava Banerjee, D.Phil., Aleksandra Barac, M.D., Ph.D.,
Estifanos Baye, M.P.H., Derrick A. Bennett, Ph.D., Addisu S. Beyene, M.P.H., Sibhatu Biadgilign, M.P.H., Stan Biryukov, B.S., Espen
Bjertness, Ph.D., Dube J. Boneya, M.P.H., Ismael Campos‑Nonato, M.D., Juan J. Carrero, Ph.D., Pedro Cecilio, M.S., Kelly Cercy, B.A.,
Liliana G. Ciobanu, M.S., Leslie Cornaby, B.S., Solomon A. Damtew, M.P.H., Lalit Dandona, M.D., Rakhi Dandona, Ph.D., Samath D.
Dharmaratne, M.D., Bruce B. Duncan, Ph.D., Babak Eshrati, Ph.D., Alireza Esteghamati, M.D., Valery L. Feigin, M.D., Ph.D., João C.
Fernandes, Ph.D., Thomas Fürst, Ph.D., Tsegaye T. Gebrehiwot, M.P.H., Audra Gold, M.Sc., Philimon N. Gona, Ph.D., Atsushi Goto,
M.D., Ph.D., Tesfa D. Habtewold, M.S., Kokeb T. Hadush, M.P.H., Nima Hafezi‑Nejad, M.D., Simon I. Hay, D.Sc., Masako Horino,
M.P.H., Farhad Islami, M.D., Ph.D., Ritul Kamal, M.Sc., Amir Kasaeian, Ph.D., Srinivasa V. Katikireddi, Ph.D., Andre P. Kengne, Ph.D.,
Chandrasekharan N. Kesavachandran, Ph.D., Yousef S. Khader, Sc.D., Young‑Ho Khang, M.D., Ph.D., Jagdish Khubchandani, Ph.D.,
Daniel Kim, M.D., Dr.P.H., Yun J. Kim, M.D., Ph.D., Yohannes Kinfu, Ph.D., Soewarta Kosen, M.D., Tiffany Ku, B.A., Barthelemy
Kuate Defo, Ph.D., G. Anil Kumar, Ph.D., Heidi J. Larson, Ph.D., Mall Leinsalu, Ph.D., Xiaofeng Liang, M.D., Stephen S. Lim, Ph.D.,
Patrick Liu, B.A., Alan D. Lopez, Ph.D., Rafael Lozano, Ph.D., Azeem Majeed, M.D., Reza Malekzadeh, M.D., Deborah C. Malta, Ph.D.,
Mohsen Mazidi, Ph.D., Colm McAlinden, M.D., Ph.D., Stephen T. McGarvey, Ph.D., Desalegn T. Mengistu, M.S., George A. Mensah,
M.D., 0000-0001-6268-5998Gert B.M. Mensink, Ph.D., Haftay B. Mezgebe, M.S., Erkin M. Mirrakhimov, Ph.D., Ulrich O. Mueller,
M.D., Ph.D., Jean J. Noubiap, M.D., Carla M. Obermeyer, D.C.A., Felix A. Ogbo, M.P.H., M.D., Mayowa O. Owolabi, Dr.Med., George C.
Patton, M.D., Farshad Pourmalek, M.D., Ph.D., Mostafa Qorbani, Ph.D., Anwar Rafay, M.S., Rajesh K. Rai, M.P.H., Chhabi L. Ranabhat,
Ph.D., Nikolas Reinig, B.S., Saeid Safiri, Ph.D., Joshua A. Salomon, Ph.D., Juan R. Sanabria, M.D., Itamar S. Santos, M.D., Ph.D., Benn
Sartorius, Ph.D., Monika Sawhney, Ph.D., Josef Schmidhuber, Ph.D., Aletta E. Schutte, Ph.D., Maria I. Schmidt, M.D., Sadaf G. Sepan-
lou, M.D., Ph.D., Moretza Shamsizadeh, M.P.H., Sara Sheikhbahaei, M.D., Min‑Jeong Shin, Ph.D., Rahman Shiri, Ph.D., Ivy Shiue,
Ph.D., Hirbo S. Roba, M.P.H., Diego A.S. Silva, Ph.D., Jonathan I. Silverberg, M.D., Ph.D., Jasvinder A. Singh, M.D., Saverio Stranges,
M.D., Ph.D., Soumya Swaminathan, M.D., Rafael Tabarés‑Seisdedos, Ph.D., M.D., Fentaw Tadese, M.P.H., Bemnet A. Tedla, B.S.,
Balewgizie S. Tegegne, M.P.H., Abdullah S. Terkawi, M.D., J.S. Thakur, M.D., Marcello Tonelli, M.D., Roman Topor‑Madry, Ph.D.,
Stefanos Tyrovolas, Ph.D., Kingsley N. Ukwaja, M.D., Olalekan A. Uthman, Ph.D., Masoud Vaezghasemi, Ph.D., Tommi Vasankari,
M.D., Ph.D., Vasiliy V. Vlassov, M.D., Stein E. Vollset, M.D., Dr.P.H., Elisabete Weiderpass, Ph.D., Andrea Werdecker, Ph.D., Joshua
Wesana, M.P.H., Ronny Westerman, Ph.D., Yuichiro Yano, M.D., Ph.D., Naohiro Yonemoto, M.P.H., Gerald Yonga, M.D., Zoubida
Zaidi, Ph.D., M.D., Zerihun M. Zenebe, M.S., Ben Zipkin, B.S., and Christopher J.L. Murray, M.D., D.Phil.
The authors’ affiliations are as follows: the University of Washington, Institute for Health Metrics and Evaluation, Seattle (A. Afshin,
M.H.F., M.B.R., P.S., K.E., A.L., L.M., A.H.M., M.M.-L., M.N., J.S.S., T. Vos, S. Biryukov, K.C., L.C., L.D., R.D., V.L.F., A. Gold, S.I.H.,
T.K., H.J.L., S.S.L., P.L., N.R., S.E.V., B.Z., C.J.L.M.); Jimma University, Jimma (K.H.A., M.B.A., T.T.G.), Wollo University, Department
of Public Health, Dessie (E. Baye, F.T.), Haramaya University, College of Health and Medical Sciences, Harar (A.S.B., H.S.R., B.S.T.),
Independent Public Health Consultants (S. Biadgilign), Addis Ababa University (S.A.D.), Addis Ababa, Wolaita Sodo University, College
of Health Sciences and Medicine, Wolaita (S.A.D.), Ambo University, Ambo (K.T.H.), Debre Markos University, Department of Public
Health, Debre Markos (D.J.B.), Mekelle University, Mekelle (D.T.M., H.B.M., Z.M.Z.), University of Gondar, Gondar (B.A.T.), Debre
Berhan University, Debre Berhan (T.D.H.), and Bahir Dar University, College of Medicine and Health Sciences, Bahir Dar (A.T.A.) — all
in Ethiopia; Sapienza University of Rome (C.A.), and Food and Agriculture Organization, Global Perspective Studies Unit (J. Schmidhu-
ber), Rome; Washington University School of Medicine, St. Louis (Z.A.-A.); Luxembourg Institute of Health, Department of Population
Health, Strassen (A. Alkerwi, S. Stranges); Joint Program of Family and Community Medicine, Jeddah (R.A.-R.), and King Fahad Medi-
cal City, Department of Anesthesiology, Riyadh (A.S.T.) — both in Saudi Arabia; the University of Adelaide, School of Medicine, Ade-
laide, SA (A.T.A., L.G.C.), University of Canberra, Centre for Research and Action in Public Health, Canberra, ACT (Y.K.), University of
Melbourne, Melbourne School of Population and Global Health, Melbourne, VIC (A.D.L.), University of Melbourne, Department of
Pediatrics, Murdoch Childrens Research Institute, Melbourne, VIC (G.C.P.), Western Sydney University, Centre for Health Research–
School of Medicine, Sydney, NSW (F.A.O.), James Cook University, Cairns, QLD (B.A.T.), and Monash University, School of Public
Health and Preventive Medicine, Melbourne, VIC (E. Baye) — all in Australia; University of Cape Coast, Cape Coast, Ghana (A.K.A.);
Tehran University of Medical Sciences, Uro-Oncology Research Center (E.A.), Endrocrinology and Metabolism Population Sciences
Institute (A.K.), Endocrinology and Metabolism Research Center (A.E., N.H.-N., S. Sheikhbahaei), Digestive Diseases Research Institute
(R.M., S.G.S.), Non-Communicable Diseases Research Center (E.A.), Hematology-Oncology and Stem Cell Transplantation Research
Center (A.K.), Iran University of Medical Sciences, Department of Community Medicine, Gastrointestinal and Liver Disease Research
Center, Preventative Medicine and Public Health Research Center (M.M.-L.), Tehran, Qom University of Medical Sciences, Department
of Medical Emergency, Qom (H.A.), Arak University of Medical Sciences, Arak (B.E.), Shiraz University of Medical Sciences, Non-
Communicable Diseases Research Center, Shiraz (R.M.), Alborz University of Medical Sciences, Non-Communicable Diseases Research
Center, Karaj (M.Q.), Maragheh University of Medical Sciences, Managerial Epidemiology Research Center, Department of Public
Health, School of Nursing and Midwifery, Maragheh (S. Safiri), and Hamadan University of Medical Sciences, Department of Medical
Surgical Nursing, School of Nursing and Midwifery, Hamadan (M. Shamsizadeh) — all in Iran; Dignitas International, Zomba, Malawi
(A. Amberbir); Oregon Health and Science University, Portland (S.M.A.); Madras Diabetes Research Foundation, Chennai (R.M.A.), Dr.
Mohans Diabetes Specialities Centre, Chennai (R.M.A.), Public Health Foundation of India, Gurgaon (L.D., R.D., G.A.K., ), Indian
Council of Medical Research, Chennai (S. Swaminathan), CSIR-Indian Institute of Toxicology Research, Epidemiology Division,
Lucknow (R.K., C.N.K.), Society for Health and Demographic Surveillance, Suri (R.K.R.), and Post Graduate Institute of Medical Educa-
tion and Research, School of Public Health, Chandigarh (J.S.T.) — all in India; Dalarna University, School of Health and Social Sci-
ences, Falun (J.Å.), Karolinska Institutet, Department of Medical Epidemiology and Biostatistics (J.J.C., E.W.), Karolinska Institutet,

Department of Neurobiology, Care Sciences and Society, Division of Family Medicine and Primary Care (J.Å.), Stockholm, Södertörn
University, Stockholm Center for Health and Social Change, Huddinge (M.L.), Umeå University, Department of Public Health and
Clinical Medicine, Umea (M.V.) — all in Sweden; University College London, Farr Institute of Health Informatics Research (A. Banerjee),
Imperial College London, Department of Primary Care and Public Health ( A.M.), Imperial College London, Department of Infectious
Disease Epidemiology (T.F.), and London School of Hygiene and Tropical Medicine, Department of Infectious Disease Epidemiology
(H.J.L.), London, University of Oxford, Nuffield Department of Population Health (D.A.B.), and University of Oxford, Oxford Big Data
Institute, Li Ka Shing Centre for Health Information and Discovery (S.I.H.), Oxford, University of Glasgow, MRC/CSO Social and Public
Health Sciences Unit, Glasgow (S.V.K.), University Hospitals Bristol NHS Foundation Trust, Bristol (C.M.), Public Health Wales, Swan-
sea (C.M.), Northumbria University, Faculty of Health and Life Sciences, Newcastle upon Tyne (I.S.), University of Edinburgh, Alzheimer
Scotland Dementia Research Centre, Edinburgh (I.S.), and University of Warwick, Warwick Centre for Applied Health Research and
Delivery, Division of Health Sciences, Warwick Medical School Coventry (O.A.U.) — all in the United Kingdom; University of Belgrade,
Faculty of Medicine, Belgrade, Serbia (A. Barac); Nevada Division of Public and Behavioral Health, Bureau of Child, Family and Com-
munity Wellness, Carson City (M.H.); University of Oslo, Department of Community Medicine and Global Health (E. Bjertness), and
Institute of Population-Based Cancer Research, Department of Research, Cancer Registry of Norway (E.W.), Oslo, Norwegian Institute
of Public Health and Department of Global Public Health and Primary Care, University of Bergen (S.E.V.), Bergen, and University of
Tromsø, Arctic University of Norway, Department of Community Medicine, Tromsø (E.W.) — all in Norway; National Institute of
Public Health, Cuernavaca, Mexico (I.C.-N., R.L.); Universidade do Porto, Departamento de Ciências Biológicas, Faculdade de Farmácia
(P.C.), Catholic University of Portugal, Center for Biotechnology and Fine Chemistry–Associate Laboratory, Faculty of Biotechnology
(J.C.F.), and Independent Collaborator (P.C.) — all in Porto, Portugal; University of Peradeniya, Department of Community Medicine,
Faculty of Medicine, Peradeniya, Sri Lanka (S.D.D.); Universidade Federal do Rio Grande do Sul, Porto Alegre (B.B.D., M.I.S.), Univer-
sidade Federal de Minas Gerais, Minas Gerais (D.C.M.), University of São Paulo, São Paulo (I.S.S.), and Federal University of Santa
Catarina, Florianopolis (D.A.S.S.) — all in Brazil; National Institute for Stroke and Applied Neurosciences, Auckland University of
Technology, Auckland, New Zealand (V.L.F.); University of Massachusetts Boston (P.N.G.), Northeastern University, Department of
Health Sciences (D.K.), and Harvard University, Harvard T.H. Chan School of Public Health (I.C.-N.), Department of Global Health and
Population (J.A. Salomon) — all in Boston; National Cancer Center, Division of Epidemiology, Center for Public Health Sciences, Tokyo
(A. Goto), and Kyoto University, Department of Biostatistics, School of Public Health, Kyoto (N.Y.) — both in Japan; University of
Groningen (T.D.H.), University Medical Centrum Groningen (B.S.T.), Groningen, the Netherlands; American Cancer Society, Surveil-
lance and Health Services Research, Atlanta (F.I.); South African Medical Research Council (A.P.K., A.E.S., B.S.), Groote Schuur Hos-
pital and University of Cape Town (J.J.N.), University of Cape Town (A.P.K.), Cape Town, North-West University, Hypertension in Af-
rica Research Team, Potchefstroom (A.E.S.), and University of KwaZulu-Natal, Public Health Medicine, School of Nursing and Public
Health, Durban (B.S.) — all in South Africa; Jordan University of Science and Technology, Department of Community Medicine, Public
Health and Family Medicine, Irbid, Jordan (Y.S.K.); Seoul National University College of Medicine, Department of Health Policy and
Management (Y.-H.K.) and Seoul National University Medical Center, Institute of Health Policy and Management (Y-.H.K.) and Korea
University, Department of Public Health Sciences (M.-J.S.), Seoul, and Yonsei University, Department of Preventative Medicine, Wonju
College of Medicine, Wonju (C.L.R.) — all in South Korea; Ball State University, Department of Nutrition and Health Science, Muncie,
IN (J.K.); Southern University College, Faculty of Chinese Medicine, Johor, Malaysia (Y.J.K.); National Institute of Health Research and
Development, Jakarta, Indonesia (S.K.); University of Montreal, Departments of Social and Preventive Medicine, and Demography and
the Public Health Research Institute, School of Public Health, Montreal (B.K.D.), University of British Columbia, Vancouver (F.P.),
Western University, Department of Epidemiology and Biostatistics, Schulich School of Medicine and Dentistry, London, ON (S. Strang-
es), and University of Calgary, Calgary, AB (M.T.) — all in Canada; Chinese Academy of Sciences, Key State Laboratory of Molecular
Developmental Biology, Institute of Genetics and Developmental Biology (M.M.), Chinese Center for Disease Control and Prevention
(X.L.), Beijing; Brown University School of Public Health, Providence, RI (S.T.M.); National Institutes of Health, Center for Translation
Research and Implementation Science, National Heart, Lung, and Blood Institute, Bethesda, MD (G.A.M.); Robert Koch Institute, De-
partment of Epidemiology and Health Monitoring, Berlin (G.B.B.M.), and Federal Institute for Population Research, Wiesbaden
(U.O.M., A.W., R.W.) — both in Germany; National Center of Cardiology and Internal Disease and Kyrgyz State Medical Academy,
Bishkek, Kyrgyzstan (E.M.M.); American University of Beirut, Center for Research on Population and Health, Faculty of Health Sci-
ences, Beirut, Lebanon (C.M.O.); University of Ibadan, Department of Medicine, and Blossom Specialist Medical Center, Ibadan
(M.O.O.), and Federal Teaching Hospital, Department of Internal Medicine, Abakaliki (K.N.U.) — both in Nigeria; Contech School of
Public Health, Lahore, Pakistan (A.R.); Case Western Reserve University School of Medicine, Comprehensive Cancer Center (J.R.S.), and
Cleveland Clinic, Outcomes Research Consortium (A.S.T.), Cleveland; the Department of Public Health (M. Sawhney), and the Joan C.
Edwards School of Medicine (J.R.S.), Marshall University, Huntington, WV; Finnish Institute of Occupational Health (R.S.) and Folkhäl-
san Research Center, Genetic Epidemiology Group (E.W.), Helsinki, and the UKK Institute for Health Promotion Research, Tampere
(T. Vasankari) — all in Finland; Feinberg School of Medicine (J.I.S.) and Department of Preventive Medicine, Northwestern University
(Y.Y.), Chicago; University of Alabama at Birmingham, Birmingham (J.A. Singh); University of Valencia, Department of Medicine, Valen
cia (R.T.-S.), and Universitat de Barcelona, CIBERSAM, Parc Sanitari Sant Joan de Deu, Fundació Sant Joan de Déu, Barcelona (S.T.)
— both in Spain; Department of Anesthesiology, University of Virginia, Charlottesville (A.S.T.); Jagiellonian University Medical College,
Institute of Public Health, Faculty of Health Sciences, Krakow, and Wroclaw Medical University, Faculty of Health Sciences, Wroclaw
(R.T.-M.) — both in Poland; National Research University Higher School of Economics, Moscow (V.V.V.); Ghent University, Faculty of
Bioscience Engineering, Ghent, Belgium (J.W.); Aga Khan University, East Africa, NCD Research to Policy Unit, Nairobi, Kenya (G.Y.);
University Hospital, Setif, Algeria (Z.Z.); Swiss Tropical and Public Health Institute, Department of Epidemiology and Public Health,
and University of Basel, Basel (T.F.) — both in Switzerland; National Institute for Health Development, Tallinn, Estonia (M.L.); and
Health Science Foundation and Study Center, Kathmandu, Nepal (C.L.R.).

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Health Effects of Overweight and Obesity in 195 Countries

n engl j med 377;1 nejm.org July 6, 2017 13

14 n engl j med 377;1 nejm.org July 6, 2017

The New England Journal of Medicine

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The New England Journal of Medicine

A Obesity According to Age Group

B Obesity in Children According to Year

C Obesity in Adults According to Year

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Caribbean LCA SYC Caribbean SYC

Prevalence of Obesity <0.01 0.01–0.029

n engl j med 377;1

The New England Journal of Medicine

Copyright © 2017 Massachusetts Medical Society. All rights reserved.

Figure 2 (facing page). Age-Standardized Prevalence

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A Disability-Adjusted Life-Years in 1990 B Disability-Adjusted Life-Years in 2015

n engl j med 377;1

The New England Journal of Medicine

Copyright © 2017 Massachusetts Medical Society. All rights reserved.

Deaths (in millions)

0.1 30.1% 0.1

Figure 3 (facing page). Global Disability-Adjusted Life- A Disability-Adjusted Life-Years

level of BMI in 1990 (Panel A) and in 2015 (Panel B) High-middle SDI ●

indicate the proportion of the total number of disability- Low SDI ●

–50 0 50 100 150 200

30.4 million disability-adjusted life-years (95% Percent Change

18.0% of disability-adjusted life-years occurred High-middle SDI ●

at a BMI of 30 or more and 7.2% at a BMI of less Global ● ●

than 30. Chronic kidney disease and cancers

lated deaths in 2015, whereas cancers, diabetes, Low SDI ●

and musculoskeletal disorders each contributed Low-middle SDI ●

less than 10% of BMI-related disability-adjusted

n engl j med 377;1 nejm.org July 6, 2017 21

were considered in this study, decreases in risk- National Level

22 n engl j med 377;1 nejm.org July 6, 2017

The New England Journal of Medicine

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24 n engl j med 377;1 nejm.org July 6, 2017

The New England Journal of Medicine

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26 n engl j med 377;1 nejm.org July 6, 2017

The New England Journal of Medicine

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