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MEDICINE AND PUBLIC ISSUES

Body Weight, Health, and Longevity


ARTEMIS P. SIMOPOULOS, M.D.; and THEODORE B. VAN ITALLIE, M.D.; Bethesda, Maryland; and
New York, New York

In the United States, the weight associated with the the United States.
greatest longevity tends to be below the average weight of Despite the availability of new information, wide-
the population under consideration, if such weights are
not associated with a history of significant medical spread confusion exists about the terminology applied to
impairment. Overweight persons tend to die sooner than "body weight standards." T h e scientific literature
average-weight persons, especially those who are abounds with inadequately defined terms, such as ideal
overweight at younger ages. The effect of being body weight and desirable body weight, resulting in the
overweight on mortality is delayed and may not be seen in
short-term studies. Cigarette smoking is a potential
publication of data that are difficult to interpret and im-
confounder of the relationship between obesity and possible to compare with data from other sources.
mortality. Studies on body weight, morbidity, and mortality Early in 1982, a workshop on body weight, health, and
must be interpreted with careful attention to the longevity was held in Bethesda, Maryland, sponsored by
definitions of obesity or relative weight used, preexisting
morbid conditions, the length of follow-up, and
the Nutrition Coordinating Committee of the National
confounders in the analysis. The terminology of body Institutes of Health and the Centers for Disease Control.
weight standards should be defined more precisely and The meeting was attended by physicians, epidemiologists,
cited appropriately. An appropriate database relating body biostatisticians, anthropologists, public health workers,
weight by sex, age, and possibly frame size to morbidity and scientists who are involved in biomedical research on
and mortality should be developed to permit the
preparation of reference tables for defining the desirable obesity and its complications. Because of the growing na-
range of body weight based on morbidity and mortality tional concern about the high prevalence of obesity (23-
statistics. 25) in the United States and the many health hazards
attributable to this condition, particularly its association
THE BUILD STUDY 1979 (1, 2), based on data collected with elevated blood pressure and incidence of diabetes
from 1950 to 1972 from 4.2 million insurance-policies, mellitus, the meeting was believed to be particularly
has been published recently by the Association of Life timely.
Insurance Medical Directors of America and the Society The workshop attempted to collate and put into per-
of Actuaries. These new data have afforded an opportuni- spective new information about body weight, health, and
ty to update the 1959 Metropolitan Life Insurance Com- longevity; to ascertain the reliability of the available data
pany Desirable Weight Table and have once more fo- and the data's relation to health and longevity; to exam-
cused attention on the many problems associated with ine the relation of body weight to body composition and
setting desirable weight standards for Americans. In ad- "frame size"; and to clarify the terminology and concepts
dition to that in the Build Study 1979, new data on the about body weight in a way that might be helpful to
relation of body weight to health and longevity are avail- practicing physicians, public health workers, and clinical
able from the 1959 to 1972 American Cancer Society investigators.
Study (3) (755 502 persons), the Framingham Heart
Study (4, 5) (5209 persons), and other recent reports (6- Definitions
20). BODY W E I G H T S T A N D A R D S

Three national health surveys (National Health Exam- The terminology of body weight standards needs to be
ination Survey, 1960 to 1962; National Health and Nutri- defined precisely and cited appropriately by authors. For
tion Examination Survey I, 1971 to 1974; and National example, in scientific reports, the weights of patients are
Health and Nutrition Examination Survey II, 1976 to often described in relation to "ideal body weight" with-
1980) have provided normative data on weight, height, out explaining this expression. The term "ideal weight"
skinfold thickness, other anthropometric indices, and was used in the Statistical Bulletin, published by the Met-
several biochemical indices in statistically valid samples ropolitan Life Insurance Company in 1942 (26) and
of the U.S. population (21-24). Information from these 1943 ( 2 7 ) , which dealt with body weight of men and
surveys indicates that the weights of the Framingham women. The ideal weight table was developed to encour-
cohort are similar to those in the general population in age people to keep their weight below the average for the
insured population examined.
From the Nutrition Coordinating Committee, National Institutes of Health, The term "desirable weight" was used by Metropolitan
Bethesda, Maryland; and the Department of Medicine, College of Physicians and
Surgeons, Columbia University at St. Lukes-Roosevelt Hospital Center, N e w
Life in 1959 to indicate weight associated with the lowest
York, N e w York. mortality. However, the National Center for Health Sta-
Annalsof Internal Medicine. 1984;100:285-295. 285

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tistics created its own definition of desirable weight that BODY MASS I N D E X
was derived from the average weight of men and women Another approach for estimating the prevalence of
20 to 29 years old included in the National Health and obesity is the use of the weight-height index, represented
Nutrition Examination Survey I (24). Obviously, the by the ratio of weight ( W ) to height ( H ) squared ( W /
various uses of these terms have resulted in ambiguity in H 2 = k g / m 2 ) . The commonest method has been to use a
discussions of body weight. power function of 2 for both men and women. Recently,
a power function of 1.5 has been suggested to be more
METROPOLITAN R E L A T I V E W E I G H T appropriate for women. Thus, this question requires fur-
An index used in the Framingham Heart Study, Met- ther investigation. The body mass index has a relatively
ropolitan relative weight, is based on the midpoint of the high correlation with the amount of body fat (as estimat-
desirable weight range for a person of medium frame (as ed from body density), particularly when age is taken
given in the 1959 Metropolitan Life Table) chosen as the into consideration (29), and a relatively low correlation
reference weight for a given height. The Metropolitan with height. In the absence of skinfold measurements,
relative weight is computed for each person by forming this parameter is the most satisfactory index of obesity
the ratio of that person's body weight to the reference based on weight and height that is available (30).
weight for that person's height. This ratio is expressed as When the weight and height data of the 1959 Metro-
a percentage. The average Framingham man has a Met- politan Life Desirable Weight Table are converted to a
ropolitan relative weight of 115% to 121%, depending on "desirable" body mass index, the mean value for the mid-
the specific height group. Most adult American men have point of medium-frame men of all heights is 22 k g / m 2
a Metropolitan relative weight above 120% ( 5 ) . (range, 21.9 to 22.4), which equals a Metropolitan rela-
tive weight of 100; the range for all heights and frames is
F R A M E SIZE 19.8 to 25.7 kg/m 2 . For women, the mean desirable body
Frame size is an index in the 1959 Metropolitan Life mass index for the midpoint of medium-frame women of
Desirable Weight Table that distinguishes between per- all heights is 21.5 kg/m 2 (range, 21.3 to 22.1), and the
sons of small, medium, and large frame. The division of range for women of all heights and frames is 19.0 to 26.0
frame size in the Metropolitan Life Table was not based kg/m 2 . These figures are adjusted for the height of shoes
on any anthropometric measurement of the persons but, by subtracting 0.025 and 0.051 m from the height, and
rather, represents an arbitrary division of the population for the weight of garments by subtracting 2.3 and 1.4 kg
into the lowest (small frame), middle two (medium from the weight of men and women, respectively. The
frame), and highest quartiles (large frame). As stated by body mass index of Olympic champion sprinters is about
White (28), "The area bounded by the lower and upper 23 kg/m 2 , and that of Olympic marathon runners, 20 k g /
limits of weight in the Metropolitan Table fell within lim- m 2 (31).
its indicated by lines representing one probable error For men, a Metropolitan relative weight of 100 equals
above and below the line of mean weights, based upon a body mass index of 22.1 0.25 ( S D ) k g / m 2 for all
either chest breadth or bi-iliac diameter." In theory, heights combined. Thus, a Metropolitan relative weight
frame size reflects differences between persons of the of 110 equals a body mass index of 24.4 kg/m 2 , and a
same sex and height in regard to such factors as chest weight of 120 equals 26.6 kg/m 2 .
breadth, hip width, bone thickness, and length of trunk The mean body mass indices (and 1 SD, where avail-
relative to total height. "Frame" is a skeletal concept. able) are given in Table 1 for men and women in the
The main determinants of body frame are genetics, nutri- three age groups: 30 to 39, 40 to 49, and 50 to 62 years of
tion, and level of physical activity. Few systematic stud- age. The indices are calculated from the weight and
ies have been made to assess frame size as a factor affect- height data of the populations included in Health Exami-
ing body weight independently of height and body fat nation Survey, National Health and Nutrition Examina-
content. Moreover, many indices of body frame size are tion Surveys I and II, Build and Blood Pressure Study
too complex and cumbersome to use in routine examina- 1959, Build Study 1979, American Cancer Society Study,
tions. and the Framingham Heart Study.
Preliminary studies, including information from the The data show that none of the groups are at the desir-
National Health and Nutrition Examination Survey I able body mass index, except women in the age group 30
(21), have shown elbow breadth to be a useful measure- to 39 years in the Build Study 1979 and the American
ment for distinguishing frame size in men and women. Cancer Society Study, whose mean body mass index
This concept was taken into consideration during the de- (22.7 and 22.6 kg/m 2 , respectively) approaches the de-
velopment of the 1983 Metropolitan Height and Weight sirable body mass index (21.5 k g / m 2 ) . In all other
Tables, although the data on which the tables were based groups, including women in the older age groups (40 to
did not include any physical measurements of the frame 49 and 50 to 62 years), the mean body mass index ex-
size of the policy holders. Measurement of wrist breadth ceeds the desirable body mass index.
and wrist circumference also may have similar value in
the assessment of frame size. The independent effect of SKINFOLD THICKNESS
frame size, however defined, on morbidity and mortality Measurement of skinfold thickness is a more direct in-
and the relation of frame size to body composition have dex of obesity. Hubert and colleagues (4) have reported
yet to be ascertained. that in Framingham men, subscapular skinfold measure-
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ments were significantly and independently associated Table 1. Mean Body Mass Index for Men and Women in Various
with an increased risk of myocardial infarction, whereas Study Populations
Metropolitan relative weight was not. It is possible that Study* Men Women
relative weight represents a somewhat different measure
of body mass in each sex, because excess weight results kg/mlf
from muscularity more often in men than in women. Age group, 30-39 yrs
National Health Examination 25.2 (3.84) 24.1 (5.12)
Study
History of Weight Tables
NHANES I 26.0 (4.40) 2 4 . 7 ( 5 . 7 1 )
In the United States, the use of weight tables linked to N H A N E S II 25.6 (3.96) 24.9 (5.79)
life expectancy dates back, at least, to the Medico-Actu- Build and Blood Pressure Study, 24.3 23.1
arial Mortality Investigation (32), published in 1913, 1959
Build Study 1979 25.0 22.7
which covered data from 1885 to 1909, when tuberculosis American Cancer Society Study 24.6 22.6
and pneumonia were the leading causes of death. That Framingham Heart Study 25.8 (3.7) 24.2 (4.3)
study showed that the lowest mortality rates by build Age group, 40-49 yrs
were found in persons whose weight at younger ages was National Health Examination 25.5 (3.78) 25.2 (5.49)
somewhat over the average weight for the insured popu- Study
NHANES I 26.1 (3.93) 2 5 . 7 ( 5 . 6 1 )
lation, and in persons whose weight at older ages was N H A N E S II 26.4 (3.93) 25.7 (6.07)
under the average. Build and Blood Pressure Study, 24.9 24.2
However, mortality investigations conducted by life in- 1959
Build Study 1979 25.4 23.6
surance companies after 1913 showed that, in general,
American Cancer Society Study 24.9 23.5
persons whose weights were below average lived longer Framingham Heart Study 26.1 (3.5) 25.7 (4.6)
than those whose weights were above average. In 1942 Age group, 50-62 yrs
and 1943, Metropolitan Life developed an ideal weight National Health Examination 25.5 (4.03) 26.7 (5.24)
table (26, 27) to encourage people to keep their weight Study
NHANES I 25.9 (4.36) 26.4 (5.69)
below the average for the insured population examined. N H A N E S II 2 6 . 2 ( 3 . 9 1 ) 26.5 (5.56)
Because no one set of weights was believed to be Build and Blood Pressure Study, 25.1 25.2
"ideal" for all persons of a given height, it was proposed, 1959
for practical purposes, that a distinction be made between Build Study 1979 25.5 24.3
persons of small, medium, and large frame. A simple ta- American Cancer Society Study 24.9 24.4
Framingham Heart Study 26.3 (3.5) 27.5 (5.0)
ble, suitable for general use, was wanted that did not "Desirable*' body mass indexj
involve the computation of adjustments based on various Mean 22.0 21.5
factors (age included) associated with body weight. In- Range 20-25 19-26
deed, it was contemplated that the ideal weight table Olympic sprinters 23.0
Olympic marathon runners 20.0
could be printed on the backs of weight slips provided by
penny scales located in shopping areas. The table was not * NHANES I and II = National Health and Nutrition Examination Surveys I
necessarily designed for use in physicians' offices, sur- and II, respectively.
fNumbers in parentheses equal 1 SD (where available).
veys, or metabolic experiments. X Data from 1959 Metropolitan Life Insurance Company Desirable Weight
Table. Values are the mean of the midpoint of persons with a medium frame, and
When the Build and Blood Pressure Study 1959 (33) the range of all heights and frames, for all ages.
was completed in 1959, the ideal weight table originally Data taken from Garrow (31).
developed by Metropolitan Life was revised to conform
to the latest data. This new table, called the desirable million policy holders are compiled in the Build Study
weight table, was the first to be derived directly from 1979 (1, 2). The span of time covered by this study was
weights associated with the lowest mortality rates. This 22 years (1950 to 1972). The average length of time from
table has received worldwide recognition and has been issuance of policy until death, cancellation of policy, or
used for many purposes. end of the study was 6.6 years ("duration"), and the
Over the years, other weight tables have been devel- total number of policies terminated by deaths was almost
oped for various purposes, including to assess deviations 106 000. According to the results of the study, the ad-
from normal growth and development and to provide verse effects of being overweight on mortality appear to
standards for special groups, such as college students, be delayed, sometimes up to 10 or more years. In con-
flight attendants, participants in weight loss programs, trast, the adverse effects of being underweight manifest
and members of the armed services. Some other tables themselves relatively soon.
represent adaptations of the 1959 Metropolitan Life De- In the Build Study 1979, mortality ratios (the number
sirable Weight Table: for example, Table 2 in Recom- of deaths in a group compared with the number expected
mended Dietary Allowances (34) and those summarized in a group composed of otherwise similar persons who
in Obesity in Perspective (35). were acceptable at standard premium rates) (36) by du-
ration among men increased with increasing degrees of
Studies Based on Life Insurance Statistics weight in excess of 15% above the average weight of the
BUILD STUDY 1979 insured population. The ratios were lower in men weigh-
Data derived from persons insured by 25 U.S. and Ca- ing between 5% to 15% above and 5% to 15% below the
nadian life insurance companies and including almost 4.2 average weight, and began to increase again in men
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weighing 15% or more below average. Thus, the relation the 1983 Metropolitan Height and Weight Tables.
of relative weight to mortality is U- or J-shaped. Data from the Build Study 1979 are based on middle-
The upward trend in mortality ratios by duration class persons in ostensibly good health. These people do
among overweight persons (25% to 45% above average not constitute a cross-section of the entire population but
weight) was most pronounced among men, particularly are primarily a sample of the middle class. These persons
those who were markedly overweight (55% to 65% over have been screened for serious medical impairments. In
average weight). The upward trend was steeper for over- constructing a table of desirable weight, persons in poor
weight men who were issued policies at ages 15 to 39 health, who would be included in a probability sample of
years than for similarly overweight men who were issued the entire population, are excluded; otherwise, instead of
policies at ages 40 to 69 years. Among underweight men, measuring the effects of weight on mortality, one would
the downward trend in mortality ratios with increasing really be measuring the effects of weight in combination
weight was steeper at ages 40 to 69 years than at ages 15 with various health impairments. This screening is espe-
to 39 years, with the lowest mortality rate in both age cially important for underweight persons, because many
groups occurring in men 5% to 15% underweight. of these persons may have an underlying disease not
Among overweight women, the general pattern of mor- manifested by other symptoms. The most significant as-
tality ratios by duration was similar to that seen in men, pect of the 1983 Metropolitan Height and Weight Tables
except that the increase in mortality with duration was is that they are based on the lives of ostensibly healthy
pronounced only in markedly overweight women (55% persons and show, once again, that persons whose
to 65% over average weight). weights are below average for the population under con-
Because the experiences in the Build Study 1979 and sideration live longer, despite advances in health care,
the Build and Blood Pressure Study, 1959 were concen- early diagnosis, and treatment of hypertension and other
trated in the short durations, the mortality rates for all degenerative diseases.
durations combined give too much emphasis to the mor-
tality in the short durations. This concentration of experi- P R O V I D E N T M U T U A L LIFE S T U D Y
ence in the short duration has the effect of understating A mortality investigation (6) of build among male pol-
the long-term mortality risk for all durations combined icy holders, done by Provident Mutual Life from 1947 to
among overweight persons, and of overstating the long- 1964, divided the men into five groups by their deviation
term mortality for underweight ones. from "standard" weight. The "standard" weight used
The most impressive aspect of the tables based on life was the average weight at age 37 years obtained from the
insurance statistics is the large number of persons on Medico-Actuarial Mortality Investigation (32). The re-
which they are basedalmost 4.5 million people during sults were analyzed for various policy-year duration
the period 1935 to 1954 and 4.2 million people during groups, ranging from 16 to 34 years. In every duration
1950 to 1972. However, note that a life insurance study group, the mortality rate increased with weight. For ex-
that covers a 20-year span (1935 to 1954) does not in- ample, in the 31 to 34 policy-year group, men 10.4 kg or
volve a 20-year follow-up of more than 4 million people. more below the standard weight had a mortality ratio of
As mentioned earlier, the average length of follow-up of 89%; those within 3.2 kg of standard, 94%; and those
individual persons during the 20-year study was less than 10.4 kg over standard weight, 146%.
7 years. Assuming that the risk of disease associated with
obesity increases with the duration of being obese, one Prospective Studies
would expect that the effect of obesity on the mortality of A M E R I C A N CANCER SOCIETY S T U D Y
persons followed for 15 to 20 years would be greater than In 1959, the American Cancer Society began a follow-
that on persons followed for 5 to 10 years. The latest up study (3) of about 1 million men and women. Of
analysis of data from the Framingham Study ( 4 ) sup- these people, some 750 000 were free of serious disease
ports this assumption. and had not reported any marked loss in weight at the
Mortality rates by duration can be adjusted to reflect time of their entry into the study. This group was traced
the proportion of exposures by duration that would result to 1973, and the mortality findings were analyzed accord-
if all the policies had been issued at the beginning of the ing to variations in weight (by height) from the average
study, with mortality being the only decrement. In the weight for the population studied. The lowest mortality
Build Study 1979, the mortality rates for men and wom- rates occurred in persons weighing 80% to 89% of the
en were so adjusted and are below average for men average weight, who did not smoke cigarettes. The
weighing 25% below to 5% above the average weight, American Cancer Society study also showed higher death
and for women weighing 15% below to 5% above aver- rates in very lean ( < 80% of average weight) cigarette
age weight. smokers. In this study, data on heavy smokers, nonsmok-
The 1983 Metropolitan Height and Weight Tables de- ers, and other groups could be examined separately, ac-
veloped by Metropolitan Life Insurance Company are cording to variations in weight. This analysis showed that
based on data from the Build Study 1979. The tables are within each category of smoking habits, the lowest mor-
not a representative sample of the entire U.S. population tality generally occurred among those persons slightly be-
and thus are not to be considered desirable weight tables. low average weight.
This fact was recognized by the Metropolitan Life Insur- The persons studied by the American Cancer Society
ance Company, and thus the new tables are simply called were predominantly middle-class Americans in good
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health. The volunteer workers who interviewed these per- reference weight reported never having used tobacco,
sons and completed the questionnaires were overwhelm- compared with 20% in the overweight group. Thus, the
ingly middle-class women; thus, persons in the lowest high proportion of cigarette smokers among persons with
socioeconomic segments and nonwhite, itinerant, and in- a low Metropolitan relative weight almost completely
stitutionalized persons were grossly underrepresented in confounds the effect of cigarette smoking and low Metro-
the study. The study excluded persons who were sick; politan relative weight on mortality in this study. Among
had a history of heart disease, stroke, or cancer; or had nonsmokers, persons with a Metropolitan relative weight
lost 4.5 kg or more in the preceeding year. The popula- of 100% to 109% had a total mortality rate that was
tion studied by the American Cancer Society therefore 72%, 50%, and 3 1 % lower than that for the modal
resembles, in social characteristics and health status, group (Metropolitan relative weight, 120% to 129%) for
those populations studied by the life insurance compa- ages 30 to 39, 40 to 49, and 50 to 62 years, respectively.
nies. However, it should be noted that these persons were Thus, even men of average weight (about 20% above the
neither examined nor interviewed by professionals, and reference weight) had appreciably elevated mortality
that all data were self-reported. rates. This finding contradicts a widely held view that
being moderately, average, or slightly overweight carries
FRAMINGHAM HEART STUDY no increased risk.
A cohort of 5209 men and women, who were first ex- However, although Metropolitan relative weight, age,
amined in 1949, has been subsequently examined every 2 and cigarette smoking are easily measured "markers" for
years in the Framingham Heart Study. Carefully docu- mortality, other attributes, including physical activity
mented information about cardiovascular disease mor- level, alcohol ingestion, and dietary patterns, are proba-
bidity and mortality is available on all but a few of the bly related to both mortality and each other. These other
original participants. factors were not included in this analysis.
A recent study (4) has examined the relationship be-
tween the degree of obesity and the incidence of cardio- MANITOBA STUDY
vascular disease. The index of obesity chosen to charac-
In the Manitoba Study ( 7 ) , comprising a cohort of
terize the population was Metropolitan relative weight.
3983 men with a mean age at entry of 30.8 years, initial
Desirable weight for each sex was derived from the 1959
measurements of body weight, represented by body mass
Metropolitan Desirable Weight Table by taking the mid-
index, were correlated with the 26-year incidence of
point of the weight range for persons of medium build at
ischemic (coronary) heart disease. After adjustment was
a specified height. Results of multiple logistic regression
made for the effects of age and blood pressure, the body
analyses showed that all values of Metropolitan relative
mass index was found to be a significant predictor of the
weight (including the group from 110% to 130%) on
390 cases of ischemic heart disease. The association with
initial examination were positively related to the
weight was most apparent in men less than 40 years old
differences in the 26-year incidence of coronary disease,
and was not evident until after 16 years of follow-up. A
congestive heart failure, and coronary death in men,
high body mass index was significantly associated with
independently of age, cholesterol level, systolic pressure,
the development of myocardial infarction, sudden death,
cigarette smoking, left ventricular hypertrophy, and glu-
and coronary insufficiency. The authors concluded that
cose intolerance. Over the same period, higher Metropol-
obesity, per se, occurring in young adults (20 to 40 years
itan relative weight (including the group from 110% to
of age), is a risk factor with a latent period of more than
130%) in women also was associated with an increasing
16 years.
incidence of coronary disease, stroke, congestive heart
These findings agree with the results of the Build and
failure, and death from coronary and cardiovascular dis-
Blood Pressure Study 1959 (33) and the Framingham
ease. These results indicate the importance of obesity as
Study ( 4 ) , which show the increase in the cardiovascular
an independent, long-term predictor of cardiovascular
disease mortality rate by duration for overweight per-
disease.
sons. The association of greatest longevity with a body-
Like the Build Study 1979 ( 1 ) , the Framingham Heart weight below the average is a constant finding of the
Study shows a U- or J-shaped univariate relationship be- Provident Mutual Life Study, Build Study 1979, Ameri-
tween total mortality from all causes and relative weight can Cancer Society Study, Manitoba Study, and Fram-
( 5 ) . Thus, for persons at the underweight and over- ingham Heart Study (Table 2 ) .
weight ends of the relative weight distribution, mortality
rates are well above the average. A recent analysis (5) of
the Framingham data indicates that the rise in mortality CHICAGO PEOPLE'S GAS C O M P A N Y S T U D Y
rates among underweight men was, in large part, due to A population of 1233 persons was followed prospec-
the mortality risks associated with cigarette smoking. tively for 14 years in the Chicago People's Gas Company
The proportion of men who smoked cigarettes at the time Study (18). Although this study does not support the
of their first examination ranged from 55% in the most association of below-average body weight and greater life
overweight group to more than 80% in those who were expectancy, the study did not exclude persons with
less than the reference weight. There was also a higher health impairments at entry, nor did it consider their
proportion of former smokers in the lower weight groups. smoking habits. Thus, the results of this study are diffi-
Only 12 of the 258 men (5%) who were less than the cult to interpret.
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Table 2. Studies That Relate Overweight to Mortality

Author Patients Deaths Follow- Age at Smoking Evaluation of Population Other


(Reference) Men Women up Entry Considered Health Group Considerations
Status*
< n yrs
Build Study 3 700 OOOf 500 000t 106 OOOf 6.6 15-69 No RR U.S. insurance
1979(1,2) policy holders
Lew and Gar- 336 442 419 060 107 323 6 >30 Yes* SR U.S. self-selected Middle class
finkel (3) (American
Cancer Society
Study)
Blair and 0 5408f 34 15-65 No RR U.S. policy holders 5274f of the
Haines (6) insured by Prov- deaths occurred
ident Mutual after 16 or more
years
Hubert and 2252 2818 658|| 26 28-62 Yes RR Framingham, Original cohort
colleagues Massachusetts,
(4) residents
Rabkin and 3983 0 199 26 25-34 No RR Pilots Royal Canadian
colleagues Air Force
(7)
Garrison and 1977 0 729 26 30-62 Yes RR Framingham, Original cohort
colleagues Massachusetts,
(5) residents
* RR = medical record review/examination; SR = self-reported.
t Number of insurance policies issued.
X Smoking not considered as confounding factor with weight.
All standard-rate life and endowment policies issued in 1930 to 1934.
|| Deaths from cardiovascular disease only.

SEVEN COUNTRIES STUDY out three major national surveys that have included mea-
The Seven Countries Study (9) has reported that when surements of weight and height. The Health and Exami-
risk factors such as hypertension, hyperglycemia, and hy- nation Survey (23) was done in 1960 to 1962; the Na-
perlipidemia are dissociated from obesity, obesity per se tional Health and Nutrition Examination Survey I (24,
ceases to be a risk factor for premature cardiovascular 37), in 1971 to 1974; and the National Health and Nutri-
disease. However, the duration of the Seven Countries tion Examination Survey II (25), in 1976 to 1980. Both
Study was 10 years (as compared with the 26-year fol- the National Health and Nutrition Examination Surveys
low-up of the Framingham Study). The groups in this I and II collected data from a national probability sample
study were drawn from different European countries and representative of the U.S. civilian, noninstitutionalized
represent cultures that often differ substantially from population, 1 to 74 years of age.
each other and from that of the United States. The popu- The greatest strength of the National Health and Nu-
lations studied were leaner than the U.S. population. N o trition Examination Surveys I and II is that the data gen-
effort was made to ensure that the populations studied erated by the program are based on measured health indi-
were limited to healthy individuals, nor were smokers cators obtained by standardized examinations, the most
distinguished from nonsmokers in the analysis of the ef- accurate and objective means available for ascertaining
fect of weight on mortality. health status. The examination consisted of a general
medical examination and screening by a physician to
OTHER S T U D I E S OF SPECIAL GROUPS identify symptoms and physical evidence of disease or
Several other studies reported in the literature (8-19) abnormality; a complete medical history; body measure-
also have contradicted the theory that life expectancy is ments such as height, weight, and skinfold thickness; a
enhanced in otherwise healthy adults under age 50 years, dietary interview covering the types and quantities of
who are somewhat below average weight. Pertinent fea- foods eaten during the 24 hours before the examination
tures of these studies are given in Table 3. Only 5 of the (tabulated for calories, protein, calcium, iron, and vita-
12 studies have been carried out in the United States, and mins A and C); and a food-frequency questionnaire. It
1 of these, the study by Borhani and colleagues (11), was should be mentioned that survey participants knew, in
limited to longshoremen. These studies all covered rela- advance, that they would be asked to report their food
tively short periods; all but 2 include follow-ups of 10 intake. The following biochemical tests were done: hema-
years or less, during which time the effects of obesity on tocrit, hemoglobin, serum iron, percent transferrin satu-
longevity would not be expected to manifest themselves. ration, total protein, albumin, and vitamin A.
None of these studies considered smoking in the analysis Data from the Health and Examination Survey and the
of the effect of weight on mortality. National Health and Nutrition Examination Surveys I
and II permit assessment of body weight trends among
Cross-Sectional Health Surveys Americans from 1960 to 1962, 1971 to 1974, and 1976 to
The National Center for Health Statistics has carried 1980. A comparison of mean heights and weights of
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Table 3. Studies That Found No Relation Between Obesity and Mortality

Author Subjects Deaths Follow- Age at Smoking Evaluation of Population Other


(Reference) Men Women up Entry Considered Health Group Considerations
Status*
< n yrs
Rose and col- 18 403 0 277f 5 40-64 YesJ CD Civil servants Great Britain
leagues ( 8 )
Keys (9) 11250 0 1247 10 40-59 No RR Rural and urban 15 areas in Europe
residents and 1 in the
United States
Kozarevic and col- 11 121 0 95t 7 35-62 YesJ CD Rural and urban Yugoslavia; weight
leagues (10) residents is a risk factor in
urban residents
only
Borhani and col- 3994 0 655 10 14-65 + YesJ RR Longshoremen United States
leagues (11)
Westlund and Ni- 3751 0 190 10 40-49 No RR Industrial workers Norway
colaysen (12)
Bottiger and 3486 0 531 14.5 0-70 + YesJ RR Workers Sweden
Carlson (13)
Rosenman and 3154 0 257f 8.5 39-59 No "Initially well" Company San Francisco
colleagues (14) employees
Chapman and 1859 393 43f 10 21-70 YesJ CD Civil servants Los Angeles
Massey (15)
Paul and col- 2036 0 13t 4 40-55 YesJ RR Employees of United States
leagues (16) Western Electric
Co.
Noppa and col- 0 1462 52 10 38-60 No RR Sample of town Sweden
leagues (17)
Dyer and col- 1233 0 246 14 40-59 Yes* CD Employees of Chi- All causes of death
leagues (18) cago Peoples
Gas
Tibblin and col- 855 0 61 10 50 No RR Industrial town Sweden
leagues (19)
* RR = Medical record review/examination; CD = examined for heart disease only.
t Deaths from cardiovascular disease only.
% Smoking not considered as a confounding factor with weight.
Totals for 16 cohorts in 7 countries (64 to 298 deaths per country).

adults aged 18 to 74 years in the three surveys (Table 4) and mortality fail to show that overall obesity leads to
shows that both men and women were taller and heavier greater risk." Keys (38) has stated that obesity in the
in 1971 to 1974 and 1976 to 1980 than they were in 1960 absence of related risk factors, such as hypertension, dia-
to 1962. As noted earlier, the Survey data are based on a betes, or hyperlipidemia, is not a risk factor for the pre-
national probability sample and are normative. The use mature development of cardiovascular disease. These
or designation of the average weight at 20 to 29 years as analyses have been useful in stimulating critical examina-
"desirable" weight is probably inappropriate, because data tion of the data and the pitfalls involved in their interpre-
from epidemiologic and other longitudinal studies indicate tation. With the recent publication of the long-term find-
a continuous increase in weight during that age period, ings in the Framingham population (4), including
that leads to an overestimation of desirable weight and an consideration of the confounding role of different smok-
underestimation of obesity in the population. ing habits on obese and nonobese persons (5), it has be-
The National Center of Health Statistics has published come possible to analyze the disparate views of the com-
the data (tables and graphs) from its survey of character- plex relationship between obesity and mortality.
istics of the growth of children in the United States. The
children studied represented a cross-section of ethnic and CIGARETTE SMOKING A N D SUBCLINICAL ILLNESS
socioeconomic groups. Because genetic, ethnic, and so- Only a few prospective studies are large enough to per-
cioeconomic differences are imbedded in the final data, mit stratification by cigarette smoking. Prospective stud-
the derived charts are regarded by pediatricians not as ies that do not exclude or consider smokers or persons
descriptions of any single racial, social, economic, or nu- who suffer from subclinical illness are likely to yield data
tritional group, but simply as reference standards. that are distorted by factors other than the status of
weight relative to height. Cigarette smoking is a potential
Pitfalls in Interpretation of Life-Expectancy Data confounder of the relationship between obesity and mor-
During the past decade, apparently conflicting inter- tality. Statistical control for this factor in all studies of
pretations have been published of the results of studies of mortality requires careful consideration.
the effect of obesity on life expectancy. For example, An- Life insurance statistics have not been adjusted to al-
dres (20) has concluded, "Population studies of obesity low for the effects of cigarette smoking or other con-
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Table 4 . Mean Weights and Heights by Age and Sex in Three Populations*

Age Group Men Women

HES NHANES I N H A N E S II HES NHANES I N H A N E S II

Weight, kg
18-24 yrs 71.7 74.8 73.9 57.6 59.9 60.8
25-34 yrs 72.6 79.8 78.5 60.8 63.5 64.4
35-44 yrs 77.1 80.7 80.7 64.4 67.1 67.1
45-54 yrs 77.1 79.4 80.7 65.8 67.6 68.0
55-64 yrs 74.4 77.6 78.9 68.0 67.6 68.0
65-74 yrs 71.7 74.4 74.8 65.3 66.2 66.7
18-74 yrs 75.3 78.0 78.0 63.5 64.9 65.3
Height, /73
18-24 yrs 1.74 1.77 1.77 1.62 1.63 1.63
25-34 yrs 1.76 1.77 1.77 1.62 1.63 1.63
35-44 yrs 1.74 1.76 1.76 1.61 1.63 1.63
45-54 yrs 1.73 1.75 1.75 1.60 1.62 1.61
55-64 yrs 1.71 1.73 1.74 1.58 1.60 1.60
65-74 yrs 1.70 1.71 1.71 1.56 1.58 1.58
18-74 yrs 1.73 1.75 1.76 1.60 1.62 1.62

* The three populations are from the National Health Examination Survey ( H E S ) , 1960 to 1962 ( 2 3 ) , and the National Health and Nutrition Examination Surveys
( N H A N E S ) I, 1971 to 1974 ( 2 4 ) , and II, 1976 to 1980 ( 2 5 ) . T w o pounds were deducted from HES data to allow for weight of clothing; total weight of all clothing for
N H A N E S I and II ranged from 0.1 to 0.3 kg and was not deducted from weights in table. Height was measured without shoes. Data are preliminary. Age-adjusted mean
values and estimates of variation (standard error) about the mean estimates are not currently available.

founding factors. As already mentioned, evidence shows Study, only 8% of men and 18% of women in the highest
that persons below average weight are more likely to be weight class were free ofriskfactors. When findings such
smokers than are overweight persons. If this is the case as these are taken into account, it is likely that many
for the persons considered in the Society of Actuaries' discrepancies between studies of populations with differ-
mortality studies, lack of any adjustment to allow for the ent ages, different initial health statuses, and different fol-
effects of smoking could distort the data on underweight low-ups can be resolved.
and overweight persons, thus exaggerating the risk of be-
ing underweight and understating the risk of being over- Conclusions
weight. In the United States, studies based on life insurance
data (for example, the Build and Blood Pressure Study,
D U R A T I O N OF OBESITY 1959; Build Study 1979; Provident Mutual Life Study),
If persons are followed for a sufficient length of time, the American Cancer Society Study, and other long-term
being obese at the time of entry into a prospective study studies, such as the Framingham Heart Study and Mani-
is an independent risk factor predicting premature car- toba Study, indicate that below-average weights tend to
diovascular morbidity and reduced life expectancy. This be associated with the greatest longevity, if such weights
fact does not exclude the possibility that obesity may gen- are not associated with concurrent illness or a history of
erate, or be associated with, other risk factors at a subse- significant medical impairment. Overweight persons tend
quent time. Also apparent is that when obesity develops to die sooner than average-weight persons, particularly
at an early age in adults, and is sustained, its effect on life those who are overweight at younger ages. The effect of
expectancy is different from the effect of obesity that de- obesity on mortality is delayed, so that it is not seen in
velops in middle age. short-term studies; the extensive data from the Build
In the past, obesity was considered to be associated Study 1979 show this delayed effect particularly well.
with coronary heart disease through its impact on the The recent analyses of the Framingham Heart Study data
cardiovascular risk factors, such as hyperlipidemia and emphasize that obesity is a significant independent pre-
hypertension (39). However, findings from the Manitoba dictor of cardiovascular disease, with smoking having a
(7) and Provident (6) Studies, along with findings from separate effect. Furthermore, the concept of "desirable
the recent analyses of the Framingham Heart Study (4), weight" developed by the Metropolitan Life Insurance
suggest that the duration of being obese has an important Company in 1959 has been validated by a recent long-
bearing on the putative relationship of body weight and term study (5). In addition to the age range of the popu-
longevity. Thus, when data from the Framingham Study lation studied, the interpretation of studies on body
were analyzed using a longer time interval between mea- weight, morbidity, and mortality must also carefully con-
surement of obesity and subsequent outcome, obesity sider the definition of obesity used, preexisting illnesses in
clearly was a significant predictor for cardiovascular dis- persons, the length of follow-up, and any confounding
ease, independent of age, cholesterol level, systolic blood risk factors.
pressure, cigarette smoking, left ventricular hypertrophy,
and glucose intolerance. D E F I N I T I O N S OF OBESITY OR R E L A T I V E W E I G H T

The practicality of attempting to dissociate obesity Body weight, by itself, is not a measure of obesity.
from the risk factors that often accompany this condition Therefore, when it is used to define obesity, weight must
has been questioned. For example, in the Framingham be related to more appropriate measures of body fat.
2 9 2 February 1984 Annals of Internal Medicine Volume 100 Number 2

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Therefore, several indices of body weight have been de- tween relative weight and mortality may be shown to be
veloped on the basis of varying relationships with total of little value if an easily measured third variable (for
body fat. Most of these indices have used body weight in example, smoking) is found to be strongly related to both
some combination with height. In children, this index has relative weight and mortality. Controlling the analysis for
most commonly been the use of weight for height distri- such a variable increases the chance for showing a valid
butions (percentiles), whereas in adults the common in- relationship between relative weight and mortality.
dex has been based on the quotient of weight divided by The most recent analysis of the Framingham data (5)
height to the nth power (W/H 71 ). Although a number of has shown strong evidence that body weights in excess of
different values for n have been suggested for use in dif- those recommended as desirable by the 1959 Metropoli-
ferent populations, the most commonly used power func- tan Life Insurance Table are associated with increased
tion has been 2, as in the body mass index, kg/m 2 . mortality. Although not all the mechanisms or casual
Other approaches have defined some measure of pathways linking increased mortality and obesity have
weight at a given age (such as median or mean) as the been documented, an emphasis on prevention of obesity
"standard" and have related all other weights to this ar- through diet and exercise is clearly warranted. The need
bitrarily denned standard. Some other approaches have for such initiatives is especially compelling when one con-
defined the standard within the population being studied siders the enormity of the "morbid load" from obesity on
and have related all other weights to that value (for ex- the U.S. population. Latest data from the Framingham
ample, Metropolitan relative weight and the 1959 Metro- Heart Study show that more than 80% of men above the
politan Life Insurance Desirable Weight Table). age of 40 years and about 70% of women are in this
The use of a relative weight index depends on the pop- elevated risk category (Metropolitan relative weight
ulation on which it is based; therefore, such an index can > 110%; >24.4 kg/m 2 ). Furthermore, the latest infor-
only be understood in relation to the weight distribution mation from both the National Health and Nutrition Ex-
in that specific population. However, body mass indices amination Survey II (25) and the Framingham Heart
are independent of specific population distributions and Study indicate that these percentages are continuing to
can be understood in terms of the value itself and the rise in women at higher weights, and are rising in men at
relation of different values to the risk of disease incidence younger ages.
and prevalence.
This conference (see below) has recommended that all
reports present data in terms of the body mass index (kg/ Recommendations
m2) in addition to any other method of presentation An appropriate database that relates body weight by
used. Ultimately, the use of this or any other index will age, sex, and possibly frame size to morbidity and mortal-
have to be evaluated in a number of populations in rela- ity should be developed to permit the preparation of ref-
tion to the specific morbidity and mortality outcomes. erence tables for defining the range of desirable body
weight from morbidity and mortality statistics. Ideally,
EXCLUSION FOR PREEXISTING MORBID CONDITIONS reference data should consider appropriate attributes
Persons studied should be carefully assessed for the (such as physical activity level and nature of diet) as well
presence of morbid conditions, because such conditions as possible changes in the attributes. These changes will
are likely to cause weight loss and are themselves associ- require new observational studies to measure, in study
ated with increased mortality rates. Inclusion of such populations, the relation of such factors to morbidity and
persons in surveys is likely to understate the risk of being mortality. Therefore, it is recommended that, at a mini-
overweight and overstate the risk of being underweight. mum, the following are needed to develop a reference data
Because elderly persons are difficult to screen for preex- table that relates body weight to health and longevity:
isting, occult, pathologic conditions, mortality studies of The population studied should be representative
the effects of weight in elderly persons occasionally have of the healthy population to which the reference
found the lowest mortality rate to occur among those data will be applied.
who are of average weight or even slightly overweight. Data on weight and height should be analyzed
and presented separately by sex, age, and duration
T H E L E N G T H OF OBSERVATION of follow-up, with age divided by decades. This pro-
If persons with morbid conditions or unhealthy habits cedure takes into account age-related changes in
are not excluded, then the length of observation of the weight and permits establishment of age-related de-
persons becomes a key factor in the interpretation of re- sirable weight goals.
sults. Because the extra mortality associated with various Data on weight and height should also be ex-
morbid conditions or unhealthy habits is generally high- pressed as the body mass index with a median,
est in the short duration but decreases with time (40), range, and standard deviation presented for each
awareness of the proportions and the kinds of persons age and sex group. Data so presented can be con-
with various morbid conditions or unhealthy habits is verted into tables relating weight and height, al-
important in order to make valid interstudy comparisons. though questions remain regarding the validity of
the body mass index for estimating body fat in per-
C O N F O U N D E R S IN T H E A N A L Y S I S sons outside the groups for which the index was
A strictly univariate assessment of the relationship be- originally derived. Consequently, caution must be
Simopoulos and Van Itallie Body Weight and Longevity 2 9 3

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7. RABKIN SW, MATHEWSON FAL, H S U PH. Relation of body weight t o .
used in comparing the body mass index between development of ischemic heart disease in a cohort of young North
groups with standards not validated on the groups American men after a 26 year observation period: the Manitoba Study.
under consideration. Am J Cardiol. 1977;39:452-8.
8. ROSE G, HAMILTON PS, K E E N H, R E I D D D , M C C A R T N E Y P, JAR-
Efforts should be made to develop uncomplicated RETT RJ. Myocardial ischaemia, risk factors and death from coronary
indices that correlate with the body fat content bet- heart-disease. Lancet. 1977;1:105-9.
ter than body mass index does. 9. KEYS A. Seven Countries: A Mutivariate Analysis of Death A Coronary
Heart Disease. Cambridge: Harvard University Press; 1980.
All statements regarding the ranges in which 10. KOZAREVIC D, PIRC Z, RACIC Z, D A W B E R TR, GORDON T, Z U K E L
the morbidity and mortality rates are lowest should WJ. The Yugoslavia Cardiovascular Disease Study: II. Factors in the
be based on statistically significant differences in incidence of coronary heart disease. Am J Epidemiol. 1976;104:133-40.
11. BORHANI NO, HECHTER HH, BRESLOW L. Report of a ten-year follow-
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The range should be broad enough to encompass ed to serum cholesterol: a follow-up of 3,751 men aged 40-49. Scand J
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