a | | Effects of physical inactivity and obesity on i morbidity and mortality: current evidence and research issues STEVEN N. BLAIR and SUZANNE BRODNEY The Cooper Institute, Dallas TX 75230 ABSTRACT i BLAIR. S, N. and. BRODNEY. Effects of physica! inatvity and obesity on morbidity and morality: cument evidence and research i. ‘asus. Med. Set. Sports Exere, Vol 1, No.1, Suppl pP- S646-S662, 1999. Purpose: The purpose ofthis review was to address / tree specific questions. 1) Do higher levels of physical activity atenuate the increased health isk normaly observed in overweight | ‘or obese individuals? 2) Do obese but ative individuals actualy havea lower morbidity snd morality risk than noma weight persons t ‘vo ae sedentry? 3) Which is a more impotant predictor of mortality, overweight or inetivty? Methods: We inital densified | ‘more thin 700 arteles that ncladed information onthe exposure variables of body habits (body mass index, body composition, or ‘body fu pte) and physical activity habits, and on outcomes sah as morbidity or matali. Tobe included inthe review, we required that an article include an analysis of one of our outcomes by strats ofthe eno exposure variables, We excluded review ates and { repors of cross-sectional analyses, We used an evdence-baod approsch to value the quality of the pblished data Results: We | summarized results fom 24 aciles that met all clusion criteria. Data were avilable forthe outcomes of a-cause mortality, } cardiovascular disease morality, coronary art disease (CHD), hypertension, type 2 diabetes mellius, and canes. Summary rests forall outcomes excep cancer were generally consistent in showing th active of: women and men appeared to be protected against ‘he hazards of overweight or obesity. This apparent protesve effect was often suonger in obese individuals than in those of noma eight or who were overweight. There were 100 fe dats on cance to permit ny contusions. Cnlustons: Thace ae no randomized linc rials onthe topes addressed in tis review. All studies reviewed were prospective observational studies, 0 all conclusions are based on Evidence Category C. The conclusions forthe three questions addressed in the review te: 1) egulr physical activity clearly ‘ Menuates many ofthe beath risks associat with overeight or obey 2) physiealacvty appears to not oly atenuate the beslth i risks of overweight and obesity, bat active obese individuals actually have lower morbidity and morality than normal weight individuals who are sedentary, and3) nativity and low earioresptatory tess re as important as overweight and obesity as mortality predictors. Research needs include extending cutent observations to more diverse populations, nclding more studies in women, the { ‘ldery, and minoiy groups, asesinet methods need to be improved, and randomized clinical wils addressing the questions ‘iscussd in this review should be undertaken. Owing to size, complex, and cot, these ils will need o be designed with valid noninvasive measures of subclinical ditease processes as outcomes. Key Words: PHYSICAL ACTIVITY, CARDIORESPIRATORY FITNESS, BODY MASS INDEX, OVERWEIGHT, OBESITY, BODY FAT DISTRIBUTION, EPIDEMIOLOGY verweght and obey are dey eae 19 O= ok of seven eicnc cae and in pied physical function, whereas piety and carrot fines are mow tn ivery se Sac wt since sks 5.8 In seer States bah overight and abesiy ae coca wi Dhyscl activity and eariorspitary fies, with stem thy and uf pons having peter weight fo ght, body ‘mass index (BMI, kgm”), and percent body fat (2,5~ $1114 131732), Dat om contd cna Was ave Shon tn Inceses in pial acy sean weg fs and changes in boy composiion and fat st tuon (49.16353680~1), Thu publ at some, per 0195.9131/99/3101.061600 MEDICINE & SCIENCE IN SPORTS & EXERCISE Copyright © 1999 by the American College of Spors Medicine Roundtable eld February 47,1998, Indianapolis, IN. 646 haps much, of the overweight and obesity seen in U.S. populations is caused by a sedentary, physically inactive lifestyle. This topic is reviewed in detail elsewhere in these proceedings. Its difficult to know how much of the higher morbidity and mortality seen in overweight or obese individuals re- sulls from the elevated weight and how much results from inactivity, Whereas most observational studies of the rela- tionship between physical activity or cardiorespiratory fit- ness and morbidity or mortality include adjustment for some aspect of body composition, many of the studies of over ‘weight or obesity and morbidity and mortality have not included data on physical activity Barlow et al. (2) published the first report that included analyses specifically designed to evaluate the relation of cardiorespiratory fitness to mortality in individuals classi- fied as normal, overweight, or obese based on their BMI Based on their results these investigators suggested thehypothesis that moderate to high levels of cardiorespiratory fitness protect against much, if not most, of the increased ‘mortality that accompanies overweight and obesity. This hypothesis is the basis for this review of the aveilable wvidence, ‘The material presented in this review addresses three specific questions: |. Do higher levels of physical activity or cardiorespira- tory fitness attenuate the increased risk of morbidity and mortality in overweight or obese persons? If the evidence supports the hypothesis that higher levels of physical activity and cardiorespiratory fitness attenuate the increased risk associated with overweight and obesity, do overweight or obese individuals who are physically active or fit actually have a lower risk of morbidity and mortality than normal weight individu- als who are sedentary (i.e, what is the magnitude of the protective effect of activity or fitness in overweight and obese individuals)? 3. Which is a more important predictor of mortality in individuals, overweight and obesity or inactivity and low fitness? METHODS AND DEFINITIONS ‘We evaluated several different measures of health, over- weight or obesity, and sedentary habits. Outcome variables considered for this report include all-cause mortality, the presence or development of cardiovascular disease, hyper- tension, stroke, CHD, type 2 diabetes mellitus, cancer, and functional health status. We found no articles on stroke or funetional health status that met the inclusion eriteria de- scribed below, and these variables are not mentioned fur ther. Exposure variables included body habitus (BMI or body composition as estimated by hydrostatic weighing or skinfold thickness, and fat distribution as estimated by waist slrth), and evidence of a sedentary life style (low levels of self-reported occupational or leisure-time physical activity or low Ievels of cardiorespiratory fitness as determined by objective laboratory assessment). These exposure variables have limitations. Cusrent opinion holds that it is the amount tnd distribution of body fat that are the principal causes of, high rates of chronic disease seen in overweight or obese individuals, but few studies have included direct measure- tent of these parameters. Physical activity is difficult to ‘quantify, and self-report of activity patterns is the most ‘common measurement approach used in studies of physical ‘activity and health. Although many of the activity question- naires and procedures have established validity, the amount of variance explained in criterion measures of energy ex- Ppenditure by these methods is low to moderate (27). Car- sliorespiratory fitness is assessed objectively, but it is rela- tively expensive and logistically complicated to perform in epidemiological studies. Limitations of cardiorespiratory Fitness assessments are that these measurements only reflect tctivity over recent months before the assessment and are at least partly determined by heredity PHYSICAL INACTIVITY AND OBESITY AND MORBIDITY AND MORTALITY neat Rett ett SEES EO ETTORE Identifying Source Material Our objective was to identity all published reports that were from prospective investigations and included one of the outcome measures listed above, in which results were presented in strata of body habitus cross-tabulated by cate gories of physical activity or cardiorespiratory fitness. We excluded reports in which outcomes were given by strata of body habitus with adjustment for activity or fitness oF by strata of activity of fitness with adjustment for body habitus, Such report typically did not include sufficient information that would allow us to fully charscterize the independent effect of one exposure variable across the full rge of the other. We also excluded review articles and erose-sectional analyses. ‘Another problem that arises in considering the questions under review in this report is that many ofthe major studies on obesity and health did not include measurement of phys- ical activity or fitness. In reports on obesity and health in Which investigators indicated tha they adjusted for physical activity, there i often no, or at best an incomplete, descrip- tion of how the physical activity was measured, In other instances activity was assessed so crudely, perhaps with a single global question, that litle confidence could be placed in the measurement. In these circumstances determination of the true independent effects of body habitus and energy expenditure on outcomes is impossible because of the great difference in the reliability of assessment of the two expo- sure variables. For these reasons, we believe that the most valid approach to evaluate the independent contributions of body habitus and energy expenditure to health is 10 use objective and valid measures of each. Measurement of body habitus and cardiorespiratory fitness ina laboratory or clin- ical setting meets this criterion, although we also include reports in which physical activity was measured with a standardized method that has been shown to have a strong and graded association with health outcomes. We began with papers identified inthe 1996 publication, Physical Activity and Health: A Report of the Surgeon General (38). Next, we performed computer searches with keywords related to our identified outcome measures in combination with keywords related to energy expenditure (physical fitness, cardiorespratory fitness, exertion, exer- cise, oF physical activity) and body habitus (BMI, over- weight, obesity, or fat distribution). We also searched our personal files and reference lists in identified published auticles. We initially identified more than 700 potentially relevant articles. After exclusions based on the above crite- tia this process identified 24 articles that are included in this report. Critical Analysis of Published Articles. Both au- thors reviewed each article onthe final ist. We summarized results from the articles in Tables 1-6, witha different table for each outcome measure. Each table includes the study reference; a brief description of the study population; the method of assessing physical activity or fitness; the method of assessing body habitus; a description of outcomes, the number of events, and the length of follow-up (where Medicine & Science in Sports & Exercises S647wou syousoou pu seus (agz-a01) ze ~ 00 ii-ur0) eo} = e (@ei-ev0) 960 ~ ssayo ye = fA i ruz>-082 ne A y9 = ana vay eae soe w se = wa Paci) 2 Tgavaih ‘etz>-0s2 0sz>-08 f-151 wane on Tyo ues ena ced re 84 batho Cun 52 tuyous| vou es og poe au 96312 = \ag0-pz0 oro 99 = 8 ‘ooo ne Igoe) so-izo) we = ssa ut igeel 9z0-1e0) Gr = ssa een, ") 0) ~ Su AD ou ne i ie) ut pig = 000 m0 euow-ge> me voueze a ay = Sah tht 690 = dag ue ‘aygeele a= Aeon any 6a = donope wen pore vororn w1a> na a 0 para pana sions) ‘on uu 252 = seg step qu st coun po URL pap ) 98 nou ‘acy, (zu0u) y= see see te oss. eee (aa) 8 = toa erp aaa nara 008 pops oh ae evo ey a Pon (ave om vou not a as “ea vase “ag waned “noe wa 0 Sa KO IrepalAwwwmssecrg ‘S648 Official Journal of he American Coleg of Spots Medicine