EDITORIAL
of the authors and JAMA and
Fifth Phase of the Epidemiologic Transition
The Age of Obesity and Inactivity
J. Michael Gaziano, MD, MPH
I
N 1900, HENRY FORD UNVEILED THE FIRST CAR MADE IN
Detroit, the International Ladies’ Garment Workers
Union was founded in New York, and San Francisco was
placed under a federal quarantine to prevent the spread
of bubonic plague. Infectious disease was a major concern,
and the most common causes of death in the United States
and in many parts of the world at the time were pneumo-
nia and tuberculosis. Today, most individuals die of car-
diovascular disease or cancer. This dramatic shift in the ill-
nesses that cause the majority of death and disability has
been divided into 4 stages known as the epidemiologic tran-
sition.1,2 In the last 2 decades, however, a fifth stage, marked
by an alarming increase in overweight and obesity and con-
tinued decreases in physical activity, has emerged. This on-
going trend is addressed by 2 articles3,4 in this issue of JAMA.
The first stage, which dominated most of human history,
was characterized by pestilence and famine, when infectious
disease and malnutrition kept average life expectancy at about
30 years. In the second stage, occurring in the late 19th and
early 20th centuries in the United States and Europe, indus-
trialization and urbanization led to increasing wealth and a cor-
responding increase in the availability of food, an era termed
receding pandemics. As the century continued, public health
systems and cleaner water supplies and sewage systems com-
bined with better nutrition drove down deaths from infectious
disease and malnutrition, leading to declining infant and child
mortality and an increased life expectancy. The third stage, de-
generative and human-made diseases, characterized by increas-
ing mortality from cardiovascular disease and cancer, emerged
in the mid 20th century. Smoking, decreased activity levels in
theworkplaceandathome,andincreasedintakeofanimalprod-
ucts and fats resulted in increasing prevalence of elevated blood
pressure and cholesterol levels. Age-adjusted cardiovascular
disease and cancer rates were at their peak.
By the mid 1960s, the United States had entered the fourth
stage of delayed degenerative diseases. Cardiovascular dis-
ease mortality declined, related to preventive strategies such
as smoking cessation programs and effective blood pres-
sure control, acute coronary care units, and technological
advances that included coronary artery bypass surgery.5
Despite the many advances in preventive medicine and
treatment that reduced cardiovascular disease, the new stage
See also pp 235 and 242.
©2010 American Medical Association. All rights reserved.
Downloaded From: http://jama.jamanetwork.com/ by a Fudan University User on 05/12/2015
Editorials represent the opinions
not those of the American Medical Association.
of the epidemiologic transition, the age of obesity and in-
activity, emerged to threaten the progress made in postpon-
ing illness and death to later in adult life spans. The steady
gains made in both quality of life and longevity by address-
ing risk factors such as smoking, hypertension, and dyslip-
idemia are threatened by the obesity epidemic.
Over the last 40 years, the proportion of the US popula-
tion considered to be overweight (body mass index [BMI]
ⱖ25.0) and obese (BMI ⱖ30.0) has steadily increased. In the
1960-1962 National Health Examination Survey, an esti-
mated 31.6% of men and women met the definition for “pre-
obesity” (BMI between 25.0 and 29.9), and 13.4% were obese.6
The latest prevalence and trends in obesity data from the Na-
tional Health and Nutrition Examination Survey (NHANES),
reported by Flegal and colleagues3 in this issue of JAMA, show
that in 2007-2008, 68.0% of US adults were overweight, of
whom 33.8% were obese. More men than women were over-
weight or obese, 72.3% compared with 64.1%.
If the increase in obesity were to continue on the same track,
researchers recently predicted that by 2020 almost half of US
adults would meet the World Health Organization criteria for
obesity.7 Compared with the previous 10-year period, the lat-
est NHANES data suggest that the steady upward trend in over-
weight and obesity may have slowed.3 Even though this find-
ing is certainly good news, the statistics are still staggering—
mostAmericansareoverweightandathirdareobese—asobering
situation, given the wide variety of deleterious health effects
strongly linked to excess weight. These include increased risk
of coronary heart disease, ischemic stroke, hypertension, dys-
lipidemia, type 2 diabetes, joint disease, cancer, sleep apnea,
asthma, and a host of other chronic conditions.
Analyses from a national survey of almost 10 000 US adults
suggest that obesity is associated with more chronic disorders
and poorer health-related quality of life than smoking or prob-
lem drinking.8 If left unchecked, overweight and obesity have
the potential to rival smoking as a public health problem, po-
tentially reversing the net benefit that declining smoking rates
have had on the US population over the last 50 years.7 Excess
weight carries not only an enormous personal burden but an
economic one as well. Medical spending for obesity-related con-
ditions accounted for an estimated 10% of total annual US medi-
Author Affiliations: Massachusetts Veterans Research and Information Center
(MAVERIC), VA Boston Healthcare System, Boston, Massachusetts; and Divisions
of Cardiology, Aging, and Preventive Medicine, Department of Medicine, Brigham
and Women’s Hospital, Boston. Dr Gaziano is also Contributing Editor, JAMA.
Corresponding Author: J. Michael Gaziano, MD, MPH, Massachusetts Veterans
Research and Information Center (MAVERIC) (151MAV), VA Boston Healthcare
System, 150 S Huntington Ave, Boston, MA 02130 (jmgaziano@partners.org).
(Reprinted) JAMA, January 20, 2010—Vol 303, No. 3 275
 EDITORIAL
cal expenses in 2008, or $147 billion, according to the Centers
for Disease Control and Prevention (CDC).9
These adverse lifestyle habits apparently have been passed
on to the next generations. The prevalence of overweight and
obesityinchildrenandadolescentshasincreasedinparallelwith
that in adults, and obese children often become obese adults.
Based on the 2007-2008 NHANES data, the report by Ogden
et al4 indicates that almost 17% of school-aged children and
adolescents are obese, defined as BMI for age at or above the
previously established 95th percentile, and almost 32% are cat-
egorized as at or above the 85th percentile of BMI for age, the
lowest CDC cut point. It appears that the prevalence of high
BMI among children and adolescents reached a plateau between
1999and2006.However,1group,theveryheaviestboys(ⱖ97th
percentile) aged 6 through 19 years, has not followed this trend
but rather seems to be getting heavier over time.
Early obesity strongly predicts later cardiovascular disease,
and excess weight may explain the dramatic increase in type 2
diabetes, a major risk factor for cardiovascular disease. A large
Swedish study found that being overweight in late adolescence
was comparable with light smoking (fewer than 11 cigarettes
perday)inincreasingtheriskofprematuredeath.10 Inthatstudy
population, being obese in late adolescence was as hazardous
as heavy smoking in increasing the risk of dying over a 38-year
period. Efforts such as revamping school lunches to be healthier
and ensuring daily physical activity as part of the school cur-
riculum are under way in some areas, but much more needs
to be done to stem the tide of childhood obesity.
Even the developing world is seeing dramatic increases in
obesity in children as well as adults. Many countries may ex-
periencetheobesity“epidemic”theUnitedStatescurrentlyfaces
earlier in their epidemiologic transitions. For instance, more
than 20% of Chinese children between the ages of 7 and 17 years
living in large cities are now overweight,11 and 1 in 5 Chinese
adults is overweight or obese.12 Other data indicate that as many
as 60% of South African women may be overweight or obese.13
Unlike cigarette smoking, hypertension, and dyslipidemia,
there is little consensus on the ideal approach to weight man-
agement. Numerous safe and effective therapies are available
to lower blood pressure and cholesterol levels, and various over-
the-counter products as well as prescription-only medication
can be used for smoking cessation. These interventions have
contributedtothedeclineinratesofcardiovasculardiseaseevents.
In contrast, no large-scale, longer-term trials have demonstrated
reduction in clinical events through any weight management
strategy. Recent clinical trials suggest that pharmacotherapy
and bariatric surgery may hold some promise in promoting
weight loss, but long-term success and long-term risks as well
as cost-effectiveness have not been fully evaluated.14 Thus, the
centerpiece of weight management is lifestyle changes; how-
ever, promoting lifestyle changes to encourage weight reduc-
tion has been disappointing.
Although 25% of US men and 43% of US women may attempt
to lose weight in any given year, failure rates are exceedingly
high. Effective treatment strategies generally involve a multi-
276 JAMA, January 20, 2010—Vol 303, No. 3 (Reprinted)
Downloaded From: http://jama.jamanetwork.com/ by a Fudan University User on 05/12/2015
facetedapproach,includingdietarycounseling,behavioralmodi-
fication, increased physical activity, and psychosocial support
that promotes long-term changes rather than fad diets that of-
fer short-term weight reduction, only to return the individu-
als to their previous habits after the short-term goal is achieved.
The reports by Flegal et al3 and Ogden et al4 in this issue of
JAMA offer a glimmer of hope that in the United States at least,
the steady, decades-long increases in overweight and obesity
may have slowed or perhaps reached a plateau. But even if these
trends can be maintained, 68% of US adults are overweight or
obese, and almost 32% of school-aged US children and adoles-
cents are at or above the 85th percentile of BMI for age. Given
theriskofobesity-relatedmajorhealthproblems,amassivepub-
lic health campaign to raise awareness about the effects of over-
weight and obesity is necessary. Such campaigns have been suc-
cessful in communicating the dangers of smoking, hyperten-
sion, and dyslipidemia; educating physicians, other clinicians,
and the public has yielded significant returns. Major research
initiatives are needed to identify better management and treat-
ment options. The longer the delay in taking aggressive action,
the higher the likelihood that the significant progress achieved
in decreasing chronic disease rates during the last 40 years will
be negated, possibly even with a decrease in life expectancy.
Published Online: January 13, 2010 (doi:10.1001/jama.2009.2025).
Financial Disclosures: Dr Gaziano reported receiving investigator-initiated re-
search funding from the National Institutes of Health, the Veterans Administra-
tion, and Veroscience and pills and packaging for a research study from BASF, DSM,
and Wyeth. He reported serving as a consultant to Bayer and having served as a
medical expert for Merck.
REFERENCES
1. Omran AR. The epidemiologic transition: a theory of the epidemiology of popu-
lation change. Milbank Mem Fund Q. 1971;49(4):509-538.
2. Olshansky SJ, Ault AB. The fourth stage of the epidemiologic transition: the
age of delayed degenerative diseases. Milbank Q. 1986;64(3):355-391.
3. Flegal KM, Carroll MD, Ogden CL, Curtin LR. Prevalence and trends in obesity
among US adults, 1999-2008 [published online January 13, 2010]. JAMA. 2010;
303(3):235-241.
4. Ogden CL, Carroll MD, Curtin LR, Lamb MM, Flegal KM. Prevalence of high
body mass index in US children and adolescents, 2007-2008 [published online Janu-
ary 13, 2010]. JAMA. 2010;303(3):242-249.
5. Ergin A, Muntner P, Sherwin R, He J. Secular trends in cardiovascular disease
mortality, incidence, and case fatality rates in adults in the United States. Am J
Med. 2004;117(4):219-227.
6. 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(1):39-47.
7. Stewart ST, Cutler DM, Rosen AB. Forecasting the effects of obesity and smok-
ing on US life expectancy. N Engl J Med. 2009;361(23):2252-2260.
8. Sturm R, Wells KB. Does obesity contribute as much to morbidity as poverty or
smoking? Public Health. 2001;115(3):229-235.
9. Finkelstein EA, Trogdon JG, Cohen JW, Dietz W. Annual medical spending at-
tributable to obesity: payer- and service-specific estimates. Health Aff (Millwood).
2009;28(5):w822-w831.
10. Neovius M, Sundstrom J, Rasmussen F. Combined effects of overweight and
smoking in late adolescence on subsequent mortality: nationwide cohort study.
BMJ. 2009;338:b496.
11. Wang L, Kong L, Wu F, Bai Y, Burton R. Preventing chronic diseases in China.
Lancet. 2005;366(9499):1821-1824.
12. Wu Y. Overweight and obesity in China. BMJ. 2006;333(7564):362-363.
13. Balkau B, Deanfield JE, Despres JP, et al. International Day for the Evaluation
of Abdominal Obesity (IDEA): a study of waist circumference, cardiovascular dis-
ease, and diabetes mellitus in 168,000 primary care patients in 63 countries.
Circulation. 2007;116(17):1942-1951.
14. Manson JE, Skerrett PJ, Greenland P, VanItallie TB. The escalating pandemics
of obesity and sedentary lifestyle: a call to action for clinicians. Arch Intern Med.
2004;164(3):249-258.
©2010 American Medical Association. All rights reserved.