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Epidemiology and Population Health

Association of elevation, urbanization and ambient temperature with obesity prevalence in the United States



The macrogeographic distribution of obesity in the United States, including the association between elevation and body mass index (BMI), is largely unexplained. This study examines the relationship between obesity and elevation, ambient temperature and urbanization.

Methods and Findings:

Data from a cross-sectional, nationally representative sample of 422 603 US adults containing BMI, behavioral (diet, physical activity, smoking) and demographic (age, sex, race/ethnicity, education, employment, income) variables from the 2011 Behavioral Risk Factor Surveillance System were merged with elevation and temperature data from WorldClim and with urbanization data from the US Department of Agriculture. There was an approximately parabolic relationship between mean annual temperature and obesity, with maximum prevalence in counties with average temperatures near 18 °C. Urbanization and obesity prevalence exhibited an inverse relationship (30.9% in rural or nonmetro counties, 29.2% in metro counties with <250 000 people, 28.1% in counties with population from 250 000 to 1 million and 26.2% in counties with >1 million). After controlling for urbanization, temperature category and behavioral and demographic factors, male and female Americans living <500 m above sea level had 5.1 (95% confidence interval (CI) 2.7–9.5) and 3.9 (95% CI 1.6–9.3) times the odds of obesity, respectively, as compared with counterparts living 3000 m above sea level.


Obesity prevalence in the United States is inversely associated with elevation and urbanization, after adjusting for temperature, diet, physical activity, smoking and demographic factors.

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Matthew Gilbert provided help with Microsoft Access. Robert Smalley provided help with Microsoft Excel and suggested quantile regression. Daniel Burnett first presented and discussed BRFSS obesity maps with principal investigator and discussed the referent group. Roger Gibson reviewed the project and discussed with Principal Investigator. Cara Olsen provided biostatistical support and Tzucheg Kao provided base code for GEE in SAS. The USUHS School of Medicine Office of Research approved this study as non-human subjects research. The project was completed while the principal investigator was in training within the USUHS Public Health and General Preventive Medicine Residency.

Author contributions

Study concept and design: J Voss and P Masuoka; acquisition of data: J Voss, P Masuoka and AI Scher; analysis and interpretation of data: J Voss, P Masuoka, BJ Webber, AI Scher and RL Atkinson; drafting of the manuscript: J Voss, P Masuoka and BJ Webber; critical revision of the manuscript for important intellectual content: P Masuoka, AI Scher and RL Atkinson; statistical analysis: J Voss, P Masuoka, BJ Webber, AI Scher and RL Atkinson; administrative, technical or material support: P Masuoka and AI Scher; study supervision: AI Scher and RL Atkinson.


This work is the sole responsibility of the authors and does not represent the official views of the Uniformed Services University of the Health Sciences, Department of Defense or Virginia Commonwealth University.

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Correspondence to J D Voss.

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Supplementary Information accompanies the paper on International Journal of Obesity website

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Voss, J., Masuoka, P., Webber, B. et al. Association of elevation, urbanization and ambient temperature with obesity prevalence in the United States. Int J Obes 37, 1407–1412 (2013).

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  • altitude
  • geographic
  • GIS
  • urbanization
  • hypoxia

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