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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
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
2 9 0 February 1984 Annals of Internal Medicine Volume 100 Number 2
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-
Simopoulos and Van Itallie Body Weight and Longevity 2 9 1
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