Prevalence of Obesity With Confirmed Excess Adiposity in US Children and Adolescents

Alexandra B Palmer; Kyung Hyun Lee; Rashedeh Roshani; Elizabeth Frankel; Miryoung Lee; Mohammad Y Anwar; Heather M Highland; Kristin L Young; Mariaelisa Graff; Joseph B McCormick; Susan P Fisher-Hoch; Joyce P Samuel; Jennifer E Below; Kari E North; Penny Gordon-Larsen

doi:10.1001/jamapediatrics.2025.2991

. Author manuscript; available in PMC: 2026 May 20.

Published in final edited form as: JAMA Pediatr. 2025 Nov 1;179(11):1227–1229. doi: 10.1001/jamapediatrics.2025.2991

Prevalence of Obesity With Confirmed Excess Adiposity in US Children and Adolescents

Alexandra B Palmer ¹, Kyung Hyun Lee ², Rashedeh Roshani ³, Elizabeth Frankel ⁴, Miryoung Lee ⁵, Mohammad Y Anwar ⁶, Heather M Highland ⁷, Kristin L Young ⁸, Mariaelisa Graff ⁹, Joseph B McCormick ¹⁰, Susan P Fisher-Hoch ¹¹, Joyce P Samuel ¹², Jennifer E Below ¹³, Kari E North ¹⁴, Penny Gordon-Larsen ¹⁵

¹Department of Epidemiology, Gillings School of Global Public Health, The University of North Carolina at Chapel Hill

²The Institute for Clinical Research and Learning Health Care, The University of Texas Health Science Center at Houston

³Vanderbilt Genetics Institute, Division of Genetic Medicine, Vanderbilt University Medical Center, Nashville, Tennessee

⁴Vanderbilt Genetics Institute, Division of Genetic Medicine, Vanderbilt University Medical Center, Nashville, Tennessee

⁵Department of Epidemiology, The University of Texas Health Science Center at Houston School of Public Health, Brownsville Regional Campus

⁶Department of Epidemiology, Gillings School of Global Public Health, The University of North Carolina at Chapel Hill

⁷Department of Epidemiology, Gillings School of Global Public Health, The University of North Carolina at Chapel Hill

⁸Department of Epidemiology, Gillings School of Global Public Health, The University of North Carolina at Chapel Hill

⁹Department of Epidemiology, Gillings School of Global Public Health, The University of North Carolina at Chapel Hill

¹⁰Department of Epidemiology, The University of Texas Health Science Center at Houston School of Public Health, Brownsville Regional Campus

¹¹Department of Epidemiology, The University of Texas Health Science Center at Houston School of Public Health, Brownsville Regional Campus

¹²Department of Pediatrics, McGovern Medical School, The University of Texas Health Science Center at Houston

¹³Vanderbilt Genetics Institute, Division of Genetic Medicine, Vanderbilt University Medical Center, Nashville, Tennessee

¹⁴Department of Epidemiology, The University of Texas Health Science Center at Houston School of Public Health, Brownsville Regional Campus

¹⁵Department of Nutrition, Gillings School of Global Public Health, University of North Carolina at Chapel Hill

Author Contributions: Dr Palmer had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. Drs Below, North, and Gordon-Larsen are senior authors.

Concept and design: Palmer, McCormick, Fisher-Hoch, Below, North, Gordon-Larsen.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: Palmer, Below, North, Gordon-Larsen.

Critical review of the manuscript for important intellectual content: K. Lee, Roshani, Frankel, M. Lee, Anwar, Highland, Young, Graff, McCormick, Fisher-Hoch, Samuel.

Statistical analysis: Palmer.

Obtained funding: McCormick, Fisher-Hoch, Below, North, Gordon-Larsen.

Administrative, technical, or material support: M. Lee, McCormick, Fisher-Hoch, North, Gordon-Larsen.

Supervision: Highland, Young, Graff, McCormick, Fisher-Hoch, Below, North, Gordon-Larsen.

Additional Contributions: The authors would like to thank the Cameron County Hispanic Cohort cohort team, particularly Rocío Uribe, BE (University of Texas Health Science Center at Houston School of Public Health, Brownsville Regional Campus), who recruited and interviewed the participants; Marcela Morris, BS (University of Texas Health Science Center at Houston School of Public Health, Brownsville Regional Campus), and her teams for laboratory support; Valley Baptist Medical Center in Brownsville, Texas, for providing us space where our Center for Clinical and Translational Science Clinical Research Unit is located; and the community of Brownsville and the participants who so willingly participated in this study in their city.

^✉

Corresponding Author: Penny Gordon-Larsen, PhD, University of North Carolina at Chapel Hill, 312 South Building, Chapel Hill, NC 27514 (pglarsen@unc.edu).

PMCID: PMC12418218 NIHMSID: NIHMS2151821 PMID: 40920413

Pediatric obesity is associated with serious short- and long-term adverse health outcomes. Although body mass index (BMI) is widely used to classify obesity, BMI does not measure adiposity. A recent Lancet commission¹ recommended using additional measures beyond BMI to confirm adiposity for adult and pediatric obesity. Aryee and colleagues² reported that 98% of adults with obesity using BMI in the US National Health and Nutrition Examination Survey (NHANES) had excess adiposity, determined by waist circumference and dual-energy x-ray absorptiometry (DXA).

It is unknown whether screening for obesity using only BMI might overdiagnose pediatric obesity, which is particularly relevant in populations with disproportionate rises in obesity over the past 2 decades. It is critical to appropriately capture excess adiposity in pediatric populations, particularly those with elevated prevalence of adiposity-related metabolic disease, such as those living on the US-Mexico border.³

Methods |

The Cameron County Hispanic Cohort (CCHC) is a randomly ascertained, population-based cohort in southern Texas. We included 183 CCHC participants aged 8 to 17 years recruited between 2014 and 2023 with DXA (Hologic Inc) and anthropometric measures (weight, height, and waist circumference) (eMethods in Supplement 1). As recommended by the Lancet commission,¹ we confirmed excess adiposity among participants with obesity (BMI ≥95th US Centers for Disease Control and Prevention [CDC]/National Center for Health Statistics [NCHS] 2000 age- and sex-specific percentiles⁴). We defined excess adiposity as 1 or more of the following characteristics: elevated waist-height ratio (WHtR, >0.50), severe obesity (BMI ≥120% of the 95th percentile^4,5), or elevated fat mass index (FMI) (DXA-based total fat mass divided by height squared, FMI ≥90th sex- and age-specific NHANES 1999–2004 percentiles⁶).

We estimated prevalence of obesity with and without excess adiposity in CCHC participants and age- and sex-matched NHANES Mexican American, non-Hispanic Black, and non-Hispanic White participants from examination years 2013 to 2018. Methods were compiled according to Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guidelines.

Results |

Overall, 98 CCHC participants (53.6%) were female, 28 (15.3%) were aged 8 to 10 years, 72 (39.3%) 11 to 13 years, and 83 (45.4%) 14 to 17 years. Using BMI alone, obesity prevalence varied for CCHC and NHANES youth (CCHC: 36.1%; NHANES: 30.6% Mexican American, 23.5% non-Hispanic Black, 18.6% non-Hispanic White) (Table). Prevalence of elevated WHtR was highest in CCHC participants (56.3%), followed by NHANES Mexican American (45.4%), non-Hispanic White (31.7%), and non-Hispanic Black (30.6%) participants. Prevalence of elevated FMI was also highest in CCHC participants (32.2%), followed by NHANES Mexican American (21.9%), non-Hispanic White (12.6%), and non-Hispanic Black (12.6%) participants.

Table.

Prevalence of Excess Adiposity Among Cameron County Hispanic Cohort (CCHC) Children and Adolescents Aged 8 to 17 Years (N = 183) and Age- and Sex-Matched National Health and Nutrition Examination Survey (NHANES) 2013–2018 Participants With and Without Obesity by Body Mass Index (BMI)^a

	No. (%)
	CCHC, Mexican American	NHANES
	CCHC, Mexican American	Mexican American	Non-Hispanic Black	Non-Hispanic White
Youth without obesity (BMI <95th percentile) ^b
No.	117	127	140	149
Elevated WHtR^c	38 (32.5)	28 (22.0)	19 (13.6)	25 (16.8)
Severe obesity^d	NA	NA	NA	NA
Elevated FMI^e	4 (3.4)	1 (0.8)	0	0
Excess adiposity, confirmed via WHtR or FMI	38 (32.5)	28 (22.0)	19 (13.6)	25 (16.8)
Youth with obesity (BMI ≥95th percentile) ^b
No.	66	56	43	34
Elevated WHtR	65 (98.5)	55 (98.2)	37 (86.0)	33 (97.1)
Severe obesity	24 (36.4)	25 (44.6)	19 (44.2)	11 (32.4)
Elevated FMI	55 (83.3)	39 (69.6)	23 (53.5)	23 (67.6)
Excess adiposity, confirmed via WHtR, FMI, or severe obesity	65 (98.5)	55 (98.2)	37 (86.0)	33 (97.1)
Excess adiposity, confirmed with only anthropometry^f	65 (98.5)	55 (98.2)	37 (86.0)	33 (97.1)

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Abbreviations: FMI, fat mass index; NA, not applicable; WHtR, waist-height ratio.

^a

NHANES participants matched to CCHC participants by sex and nearest age.

^b

Obesity: ≥95th percentile per age- and sex-specific CDC/NCHS 2000 BMI reference curves.

^c

Elevated WHtR: waist measurement divided by height measurement >0.50.

^d

Severe obesity: BMI ≥120% of 95th age- and sex-specific CDC/NCHS 2000 BMI reference curves.

^e

Elevated FMI (measured via dual-energy x-ray absorptiometry): ≥90th age- and sex-specific NHANES 1999–2004 percentile.

^f

Excess adiposity confirmed via WHtR or severe obesity (anthropometry only).

We confirmed excess adiposity in nearly all participants with BMI at the 95th percentile or higher: 98.5% in CCHC participants (all except 1 male participant aged 15 years, BMI at 96th percentile), and 98.2%, 97.1%, and 86.0% in NHANES Mexican American, non-Hispanic White, and non-Hispanic Black participants, respectively. Results were similar by age (eg, confirmed excess adiposity among CCHC youth with obesity: 100% aged 8–10 years, 100% aged 11–13 years, and 96.3% aged 14–17 years). We confirmed excess adiposity using anthropometry and DXA in equal numbers overall (Figure) and in all age groups. We observed excess adiposity even among youth without obesity (CCHC: 32.5%; NHANES: 22.0% Mexican American, 13.6% non-Hispanic Black, 16.8% non-Hispanic White).

Figure. — DXA indicates dual-energy x-ray absorptiometry; FMI, fat mass index; WHtR, waist-height ratio.

^aMeasures of excess adiposity: elevated WHtR (>0.50), elevated FMI (≥90th age- and sex-specific National Health and Nutrition Examination Survey 1999–2004 percentile), severe obesity (BMI ≥120% of 95th age- and sex-specific US Centers for Disease Control and Prevention [CDC]/National Center for Health Statistics [NCHS] 2000 BMI reference curves).

^bObesity by BMI: ≥95th percentile per age- and sex-specific CDC/NCHS 2000 BMI reference curves.

Discussion |

Screening for pediatric obesity using BMI alone effectively identified excess adiposity in almost all youth with obesity and underdiagnosed adiposity in youth without obesity. Notably, nearly one-third of CCHC youth without obesity by BMI had excess adiposity. These youth would be missed in traditional screening by BMI alone, highlighting the importance of incorporating body composition measures into routine clinical care and surveillance.

Every participant with elevated FMI also had elevated WHtR. Thus, the same individuals were identified with excess adiposity whether by DXA or anthropometry alone, so anthropometry may serve as a practical, low-cost marker to confirm excess adiposity among youth.

Although we could not address pubertal status due to small sample sizes, findings were similar by age. Overall, our findings emphasize the urgent need for improved early detection strategies in high-risk pediatric populations, given high excess adiposity in youth with and without obesity.

Supplementary Material

Supplement

NIHMS2151821-supplement-Supplement.pdf^{(126.2KB, pdf)}

Funding/Support:

This study was funded in part by a Center for Clinical and Translational Sciences and a National Institutes of Health Clinical and Translational Award (grant number UL1 TR000371) from the National Center for Advancing Translational Sciences. Drs Palmer and North were supported by R01HL142302 and R01DK122503. Drs Palmer, Below, North, and Gordon-Larsen were supported by R01DK139598. Drs McCormick, Fisher-Hoch, and Below were supported by R01HL142302.

Role of the Funder/Sponsor:

The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Footnotes

Conflict of Interest Disclosures: Dr Highland reported grants from the US National Institutes of Health (NIH) during the conduct of the study and personal fees from the American Heart Association (AHA) outside the submitted work. Dr Below reported grants from the NIH during the conduct of the study and outside the submitted work and payment from the AHA for work as a senior statistical editor. Dr Gordon-Larsen reported serving as senior research officer for the University of North Carolina, on a data safety monitoring board for an unrelated study funded by the NIH, and compensated work on an advisory board for RTI International, a independent research institute. No other disclosures were reported.

Contributor Information

Alexandra B. Palmer, Department of Epidemiology, Gillings School of Global Public Health, The University of North Carolina at Chapel Hill.

Kyung Hyun Lee, The Institute for Clinical Research and Learning Health Care, The University of Texas Health Science Center at Houston.

Rashedeh Roshani, Vanderbilt Genetics Institute, Division of Genetic Medicine, Vanderbilt University Medical Center, Nashville, Tennessee.

Elizabeth Frankel, Vanderbilt Genetics Institute, Division of Genetic Medicine, Vanderbilt University Medical Center, Nashville, Tennessee.

Miryoung Lee, Department of Epidemiology, The University of Texas Health Science Center at Houston School of Public Health, Brownsville Regional Campus.

Mohammad Y. Anwar, Department of Epidemiology, Gillings School of Global Public Health, The University of North Carolina at Chapel Hill.

Heather M. Highland, Department of Epidemiology, Gillings School of Global Public Health, The University of North Carolina at Chapel Hill.

Kristin L. Young, Department of Epidemiology, Gillings School of Global Public Health, The University of North Carolina at Chapel Hill.

Mariaelisa Graff, Department of Epidemiology, Gillings School of Global Public Health, The University of North Carolina at Chapel Hill.

Joseph B. McCormick, Department of Epidemiology, The University of Texas Health Science Center at Houston School of Public Health, Brownsville Regional Campus.

Susan P. Fisher-Hoch, Department of Epidemiology, The University of Texas Health Science Center at Houston School of Public Health, Brownsville Regional Campus.

Joyce P. Samuel, Department of Pediatrics, McGovern Medical School, The University of Texas Health Science Center at Houston.

Jennifer E. Below, Vanderbilt Genetics Institute, Division of Genetic Medicine, Vanderbilt University Medical Center, Nashville, Tennessee.

Kari E. North, Department of Epidemiology, The University of Texas Health Science Center at Houston School of Public Health, Brownsville Regional Campus.

Penny Gordon-Larsen, Department of Nutrition, Gillings School of Global Public Health, University of North Carolina at Chapel Hill.

Data Sharing Statement:

See Supplement 2.

References

1.Rubino F, Cummings DE, Eckel RH, et al. Definition and diagnostic criteria of clinical obesity. Lancet Diabetes Endocrinol. 2025;13(3):221–262. doi: 10.1016/S2213-8587(24)00316-4 [DOI] [PMC free article] [PubMed] [Google Scholar]
2.Aryee EK, Zhang S, Selvin E, Fang M. Prevalence of obesity with and without confirmation of excess adiposity among US adults. JAMA. 2025;333(19):1726–1728. doi: 10.1001/jama.2025.2704 [DOI] [PMC free article] [PubMed] [Google Scholar]
3.Ramirez AG, Thompson IM, Vela L, eds. The South Texas Health Status Review: A Health Disparities Roadmap. Springer; Open; 2013. doi: 10.1007/978-3-319-00233-0 [DOI] [PubMed] [Google Scholar]
4.CDC growth charts. US National Center for Health Statistics, Centers for Disease Control and Prevention. Accessed April 23, 2025. https://www.cdc.gov/growthcharts/cdc-growth-charts.htm [Google Scholar]
5.Hales CM, Freedman DS, Akinbami L, Wei R, Ogden CL. Evaluation of alternative body mass index (BMI) metrics to monitor weight status in children and adolescents with extremely high BMI using CDC BMI-for-age growth charts. National Center for Health Statistics Vital Health Statistics. 2022;2(197). doi: 10.15620/cdc:121711 [DOI] [PubMed] [Google Scholar]
6.Weber DR, Moore RH, Leonard MB, Zemel BS. Fat and lean BMI reference curves in children and adolescents and their utility in identifying excess adiposity compared with BMI and percentage body fat. Am J Clin Nutr. 2013;98(1):49–56. doi: 10.3945/ajcn.112.053611 [DOI] [PMC free article] [PubMed] [Google Scholar]

Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Supplementary Materials

Supplement

NIHMS2151821-supplement-Supplement.pdf^{(126.2KB, pdf)}

Data Availability Statement

See Supplement 2.

[R1] 1.Rubino F, Cummings DE, Eckel RH, et al. Definition and diagnostic criteria of clinical obesity. Lancet Diabetes Endocrinol. 2025;13(3):221–262. doi: 10.1016/S2213-8587(24)00316-4 [DOI] [PMC free article] [PubMed] [Google Scholar]

[R2] 2.Aryee EK, Zhang S, Selvin E, Fang M. Prevalence of obesity with and without confirmation of excess adiposity among US adults. JAMA. 2025;333(19):1726–1728. doi: 10.1001/jama.2025.2704 [DOI] [PMC free article] [PubMed] [Google Scholar]

[R3] 3.Ramirez AG, Thompson IM, Vela L, eds. The South Texas Health Status Review: A Health Disparities Roadmap. Springer; Open; 2013. doi: 10.1007/978-3-319-00233-0 [DOI] [PubMed] [Google Scholar]

[R4] 4.CDC growth charts. US National Center for Health Statistics, Centers for Disease Control and Prevention. Accessed April 23, 2025. https://www.cdc.gov/growthcharts/cdc-growth-charts.htm [Google Scholar]

[R5] 5.Hales CM, Freedman DS, Akinbami L, Wei R, Ogden CL. Evaluation of alternative body mass index (BMI) metrics to monitor weight status in children and adolescents with extremely high BMI using CDC BMI-for-age growth charts. National Center for Health Statistics Vital Health Statistics. 2022;2(197). doi: 10.15620/cdc:121711 [DOI] [PubMed] [Google Scholar]

[R6] 6.Weber DR, Moore RH, Leonard MB, Zemel BS. Fat and lean BMI reference curves in children and adolescents and their utility in identifying excess adiposity compared with BMI and percentage body fat. Am J Clin Nutr. 2013;98(1):49–56. doi: 10.3945/ajcn.112.053611 [DOI] [PMC free article] [PubMed] [Google Scholar]

PERMALINK

Prevalence of Obesity With Confirmed Excess Adiposity in US Children and Adolescents

Alexandra B Palmer, PhD

Kyung Hyun Lee, PhD

Rashedeh Roshani, MS

Elizabeth Frankel, BS

Miryoung Lee, PhD

Mohammad Y Anwar, PhD

Heather M Highland, PhD

Kristin L Young, PhD, MS-CR

Mariaelisa Graff, PhD

Joseph B McCormick, MD

Susan P Fisher-Hoch, MD

Joyce P Samuel, MD

Jennifer E Below, PhD

Kari E North, PhD

Penny Gordon-Larsen, PhD

Methods |

Results |

Table.

Figure. Prevalence of Excess Adiposity Among Cameron County Hispanic Cohort (CCHC) Participants Aged 8 to 17 Years (N = 183) With and Without Obesity Classified Using Body Mass Index (BMI)^a,b.

Discussion |

Supplementary Material

Funding/Support:

Role of the Funder/Sponsor:

Footnotes

Contributor Information

Data Sharing Statement:

References

Associated Data

Supplementary Materials

Data Availability Statement

ACTIONS

PERMALINK

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Cite

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PERMALINK

Prevalence of Obesity With Confirmed Excess Adiposity in US Children and Adolescents

Alexandra B Palmer, PhD

Kyung Hyun Lee, PhD

Rashedeh Roshani, MS

Elizabeth Frankel, BS

Miryoung Lee, PhD

Mohammad Y Anwar, PhD

Heather M Highland, PhD

Kristin L Young, PhD, MS-CR

Mariaelisa Graff, PhD

Joseph B McCormick, MD

Susan P Fisher-Hoch, MD

Joyce P Samuel, MD

Jennifer E Below, PhD

Kari E North, PhD

Penny Gordon-Larsen, PhD

Methods |

Results |

Table.

Figure. Prevalence of Excess Adiposity Among Cameron County Hispanic Cohort (CCHC) Participants Aged 8 to 17 Years (N = 183) With and Without Obesity Classified Using Body Mass Index (BMI)a,b.

Discussion |

Supplementary Material

Funding/Support:

Role of the Funder/Sponsor:

Footnotes

Contributor Information

Data Sharing Statement:

References

Associated Data

Supplementary Materials

Data Availability Statement

ACTIONS

PERMALINK

RESOURCES

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Figure. Prevalence of Excess Adiposity Among Cameron County Hispanic Cohort (CCHC) Participants Aged 8 to 17 Years (N = 183) With and Without Obesity Classified Using Body Mass Index (BMI)^a,b.