National, state, and county estimates of adult overweight and obesity from electronic health records and kiosks in retail locations, 2024-2025
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Importance
High body mass index (BMI) is a leading cause of morbidity and mortality from non-communicable diseases and increases susceptibility to infectious diseases. Inadequate subnational geographical resolution, low response rates (23-45%), and lag of 2-3 years requires the evaluation of alternative data sources for monitoring the burden of high BMI.
Objective
To describe the prevalence of overweight and obesity among individuals aged 18 years and older using electronic health records and kiosks in retail locations.
Design
Cross-sectional analysis, January 2024-July 2025
Setting
3,144 counties from 50 states and District of Columbia
Participants
85 million patients from Epic Cosmos and 1.2 million users of Pursuant Health kiosks
Exposures
National, state, and county of residence; age, gender, race and ethnicity, urban vs rural residence
Main Outcomes and Measures
Overweight (BMI: 25-29.9 kg/m 2 ) or obesity (BMI ≥30 kg/m 2 ) were defined using height (Epic Cosmos: measured, kiosks: self-reported) and measured weight based on World Health Organization cutoffs. Prevalence was estimated directly for Epic Cosmos and using multilevel regression & post-stratification based on socio-demographic variables for kiosks. We compared these estimates with those from the National Health and Nutrition Examination Survey (NHANES) and Behavioral Risk Factor Surveillance System (BRFSS). Modeled county estimates were compared to PLACES 2024 small area estimates, based on BRFSS 2022, using Local Moran’s I and Spearman rank correlations.
Results
The analytic sample was 32.3 % aged 45 to 64 years, 30.9% aged 65 years and older, 55.8% women and 2.6% rural for Epic Cosmos. The analytic samples were 35.8% aged 45 to 64 years, 25.2% aged 65 years and older, 43.7% women and 18.2% rural for kiosks. The prevalence of overweight was 39.1% and 33.6%, and obesity was 43.7% and 43.3% in Epic Cosmos and kiosks respectively, and similar to NHANES and BRFSS. Higher prevalence was observed among NH Black adults, those aged 45 to 64 years, and rural residents for both Epic Cosmos and kiosks. County hotspots were observed across Southern and Midwestern states, and were correlated with PLACES (Cosmos = 0.64, kiosks: 0.34).
Conclusions and Relevance
In this administrative EHR and convenience kiosk samples of US adults, prevalence of overweight and obesity were high. National surveys mask substantial subnational variations in prevalence of high BMI.
KEY POINTS
Question
What is the prevalence of overweight and obesity in states and counties from samples of US adults based on electronic health records and users of health kiosks in retail stores?
Findings
Of 89 million patients in Epic Cosmos and 1.2 million users of Pursuant Health kiosks between 2024-2025, nearly three out of four had overweight or obesity. Prevalence was higher among rural and racial and ethnic minorities, as well as in counties in the South and Midwest.
Meaning
The increasing availability of data in administrative and convenience samples enable spatially granular and timely population health monitoring of the prevalence of overweight and obesity. These samples cover demographic groups traditionally underrepresented in national surveys.
