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
greatest longevity tends to be below the average weight of
the population under consideration, if such weights are
not associated with a history of significant medical
impairment. Overweight persons tend to die sooner than
average-weight persons, especially those who are
overweight at younger ages. The effect of being
overweight on mortality is delayed and may not be seen in
short-term studies. Cigarette smoking is a potential
confounder of the relationship between obesity and
mortality. Studies on body weight, morbidity, and mortality
must be interpreted with careful attention to the
definitions of obesity or relative weight used, preexisting
morbid conditions, the length of follow-up, and
confounders in the analysis. The terminology of body
weight standards should be defined more precisely and
cited appropriately. An appropriate database relating body
weight by sex, age, and possibly frame size to morbidity
and mortality should be developed to permit the
preparation of reference tables for defining the desirable
range of body weight based on morbidity and mortality
statistics.
THE BUILD STUDY 1979 (1, 2), based on data collected
from 1950 to 1972 from 4.2 million insurance-policies,
has been published recently by the Association of Life
Insurance Medical Directors of America and the Society
of Actuaries. These new data have afforded an opportuni-
ty to update the 1959 Metropolitan Life Insurance Com-
pany Desirable Weight Table and have once more fo-
cused attention on the many problems associated with
setting desirable weight standards for Americans. In ad-
dition to that in the Build Study 1979, new data on the
relation of body weight to health and longevity are avail-
able from the 1959 to 1972 American Cancer Society
Study (3) (755 502 persons), the Framingham Heart
Study (4, 5) (5209 persons), and other recent reports (6-
20).
Three national health surveys (National Health Exam-
ination Survey, 1960 to 1962; National Health and Nutri-
tion Examination Survey I, 1971 to 1974; and National
Health and Nutrition Examination Survey II, 1976 to
1980) have provided normative data on weight, height,
skinfold thickness, other anthropometric indices, and
several biochemical indices in statistically valid samples
of the U.S. population (21-24). Information from these
surveys indicates that the weights of the Framingham
cohort are similar to those in the general population in
From the Nutrition Coordinating Committee, National Institutes of Health,
Bethesda, Maryland; and the Department of Medicine, College of Physicians and
Surgeons, Columbia University at St. Lukes-Roosevelt Hospital Center, N e w
York, N e w York.
Annalsof Internal Medicine. 1984;100:285-295.
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the United States.
Despite the availability of new information, wide-
spread confusion exists about the terminology applied to
"body weight standards." T h e scientific literature
abounds with inadequately defined terms, such as ideal
body weight and desirable body weight, resulting in the
publication of data that are difficult to interpret and im-
possible to compare with data from other sources.
Early in 1982, a workshop on body weight, health, and
longevity was held in Bethesda, Maryland, sponsored by
the Nutrition Coordinating Committee of the National
Institutes of Health and the Centers for Disease Control.
The meeting was attended by physicians, epidemiologists,
biostatisticians, anthropologists, public health workers,
and scientists who are involved in biomedical research on
obesity and its complications. Because of the growing na-
tional concern about the high prevalence of obesity (23-
25) in the United States and the many health hazards
attributable to this condition, particularly its association
with elevated blood pressure and incidence of diabetes
mellitus, the meeting was believed to be particularly
timely.
The workshop attempted to collate and put into per-
spective new information about body weight, health, and
longevity; to ascertain the reliability of the available data
and the data's relation to health and longevity; to exam-
ine the relation of body weight to body composition and
"frame size"; and to clarify the terminology and concepts
about body weight in a way that might be helpful to
practicing physicians, public health workers, and clinical
investigators.
Definitions
BODY W E I G H T S T A N D A R D S
The terminology of body weight standards needs to be
defined precisely and cited appropriately by authors. For
example, in scientific reports, the weights of patients are
often described in relation to "ideal body weight" with-
out explaining this expression. The term "ideal weight"
was used in the Statistical Bulletin, published by the Met-
ropolitan Life Insurance Company in 1942 (26) and
1943 ( 2 7 ) , which dealt with body weight of men and
women. The ideal weight table was developed to encour-
age people to keep their weight below the average for the
insured population examined.
The term "desirable weight" was used by Metropolitan
Life in 1959 to indicate weight associated with the lowest
mortality. However, the National Center for Health Sta-
285
 tistics created its own definition of desirable weight that
was derived from the average weight of men and women
20 to 29 years old included in the National Health and
Nutrition Examination Survey I (24). Obviously, the
various uses of these terms have resulted in ambiguity in
discussions of body weight.
METROPOLITAN R E L A T I V E W E I G H T
An index used in the Framingham Heart Study, Met-
ropolitan relative weight, is based on the midpoint of the
desirable weight range for a person of medium frame (as
given in the 1959 Metropolitan Life Table) chosen as the
reference weight for a given height. The Metropolitan
relative weight is computed for each person by forming
the ratio of that person's body weight to the reference
weight for that person's height. This ratio is expressed as
a percentage. The average Framingham man has a Met-
ropolitan relative weight of 115% to 121%, depending on
the specific height group. Most adult American men have
a Metropolitan relative weight above 120% ( 5 ) .
F R A M E SIZE
Frame size is an index in the 1959 Metropolitan Life
Desirable Weight Table that distinguishes between per-
sons of small, medium, and large frame. The division of
frame size in the Metropolitan Life Table was not based
on any anthropometric measurement of the persons but,
rather, represents an arbitrary division of the population
into the lowest (small frame), middle two (medium
frame), and highest quartiles (large frame). As stated by
White (28), "The area bounded by the lower and upper
limits of weight in the Metropolitan Table fell within lim-
its indicated by lines representing one probable error
above and below the line of mean weights, based upon
either chest breadth or bi-iliac diameter." In theory,
frame size reflects differences between persons of the
same sex and height in regard to such factors as chest
breadth, hip width, bone thickness, and length of trunk
relative to total height. "Frame" is a skeletal concept.
The main determinants of body frame are genetics, nutri-
tion, and level of physical activity. Few systematic stud-
ies have been made to assess frame size as a factor affect-
ing body weight independently of height and body fat
content. Moreover, many indices of body frame size are
too complex and cumbersome to use in routine examina-
tions.
Preliminary studies, including information from the
National Health and Nutrition Examination Survey I
(21), have shown elbow breadth to be a useful measure-
ment for distinguishing frame size in men and women.
This concept was taken into consideration during the de-
velopment of the 1983 Metropolitan Height and Weight
Tables, although the data on which the tables were based
did not include any physical measurements of the frame
size of the policy holders. Measurement of wrist breadth
and wrist circumference also may have similar value in
the assessment of frame size. The independent effect of
frame size, however defined, on morbidity and mortality
and the relation of frame size to body composition have
yet to be ascertained.
2 8 6 February 1984 Annals of Internal Medicine Volume 100
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BODY MASS I N D E X
Another approach for estimating the prevalence of
obesity is the use of the weight-height index, represented
by the ratio of weight ( W ) to height ( H ) squared ( W /
H 2 = k g / m 2 ) . The commonest method has been to use a
power function of 2 for both men and women. Recently,
a power function of 1.5 has been suggested to be more
appropriate for women. Thus, this question requires fur-
ther investigation. The body mass index has a relatively
high correlation with the amount of body fat (as estimat-
ed from body density), particularly when age is taken
into consideration (29), and a relatively low correlation
with height. In the absence of skinfold measurements,
this parameter is the most satisfactory index of obesity
based on weight and height that is available (30).
When the weight and height data of the 1959 Metro-
politan Life Desirable Weight Table are converted to a
"desirable" body mass index, the mean value for the mid-
point of medium-frame men of all heights is 22 k g / m 2
(range, 21.9 to 22.4), which equals a Metropolitan rela-
tive weight of 100; the range for all heights and frames is
19.8 to 25.7 kg/m 2 . For women, the mean desirable body
mass index for the midpoint of medium-frame women of
all heights is 21.5 kg/m 2 (range, 21.3 to 22.1), and the
range for women of all heights and frames is 19.0 to 26.0
kg/m 2 . These figures are adjusted for the height of shoes
by subtracting 0.025 and 0.051 m from the height, and
for the weight of garments by subtracting 2.3 and 1.4 kg
from the weight of men and women, respectively. The
body mass index of Olympic champion sprinters is about
23 kg/m 2 , and that of Olympic marathon runners, 20 k g /
m 2 (31).
For men, a Metropolitan relative weight of 100 equals
a body mass index of 22.1 0.25 ( S D ) k g / m 2 for all
heights combined. Thus, a Metropolitan relative weight
of 110 equals a body mass index of 24.4 kg/m 2 , and a
weight of 120 equals 26.6 kg/m 2 .
The mean body mass indices (and 1 SD, where avail-
able) are given in Table 1 for men and women in the
three age groups: 30 to 39, 40 to 49, and 50 to 62 years of
age. The indices are calculated from the weight and
height data of the populations included in Health Exami-
nation Survey, National Health and Nutrition Examina-
tion Surveys I and II, Build and Blood Pressure Study
1959, Build Study 1979, American Cancer Society Study,
and the Framingham Heart Study.
The data show that none of the groups are at the desir-
able body mass index, except women in the age group 30
to 39 years in the Build Study 1979 and the American
Cancer Society Study, whose mean body mass index
(22.7 and 22.6 kg/m 2 , respectively) approaches the de-
sirable body mass index (21.5 k g / m 2 ) . In all other
groups, including women in the older age groups (40 to
49 and 50 to 62 years), the mean body mass index ex-
ceeds the desirable body mass index.
SKINFOLD THICKNESS
Measurement of skinfold thickness is a more direct in-
dex of obesity. Hubert and colleagues (4) have reported
that in Framingham men, subscapular skinfold measure-
Number 2
 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
Simopoulos and Van Itallie Body Weight and Longevity 2 8 7

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 weighing 15% or more below average. Thus, the relation
of relative weight to mortality is U- or J-shaped.
The upward trend in mortality ratios by duration
among overweight persons (25% to 45% above average
weight) was most pronounced among men, particularly
those who were markedly overweight (55% to 65% over
average weight). The upward trend was steeper for over-
weight men who were issued policies at ages 15 to 39
years than for similarly overweight men who were issued
policies at ages 40 to 69 years. Among underweight men,
the downward trend in mortality ratios with increasing
weight was steeper at ages 40 to 69 years than at ages 15
to 39 years, with the lowest mortality rate in both age
groups occurring in men 5% to 15% underweight.
Among overweight women, the general pattern of mor-
tality ratios by duration was similar to that seen in men,
except that the increase in mortality with duration was
pronounced only in markedly overweight women (55%
to 65% over average weight).
Because the experiences in the Build Study 1979 and
the Build and Blood Pressure Study, 1959 were concen-
trated in the short durations, the mortality rates for all
durations combined give too much emphasis to the mor-
tality in the short durations. This concentration of experi-
ence in the short duration has the effect of understating
the long-term mortality risk for all durations combined
among overweight persons, and of overstating the long-
term mortality for underweight ones.
The most impressive aspect of the tables based on life
insurance statistics is the large number of persons on
which they are basedalmost 4.5 million people during
the period 1935 to 1954 and 4.2 million people during
1950 to 1972. However, note that a life insurance study
that covers a 20-year span (1935 to 1954) does not in-
volve a 20-year follow-up of more than 4 million people.
As mentioned earlier, the average length of follow-up of
individual persons during the 20-year study was less than
7 years. Assuming that the risk of disease associated with
obesity increases with the duration of being obese, one
would expect that the effect of obesity on the mortality of
persons followed for 15 to 20 years would be greater than
that on persons followed for 5 to 10 years. The latest
analysis of data from the Framingham Study ( 4 ) sup-
ports this assumption.
Mortality rates by duration can be adjusted to reflect
the proportion of exposures by duration that would result
if all the policies had been issued at the beginning of the
study, with mortality being the only decrement. In the
Build Study 1979, the mortality rates for men and wom-
en were so adjusted and are below average for men
weighing 25% below to 5% above the average weight,
and for women weighing 15% below to 5% above aver-
age weight.
The 1983 Metropolitan Height and Weight Tables de-
veloped by Metropolitan Life Insurance Company are
based on data from the Build Study 1979. The tables are
not a representative sample of the entire U.S. population
and thus are not to be considered desirable weight tables.
This fact was recognized by the Metropolitan Life Insur-
ance Company, and thus the new tables are simply called
2 8 8 February 1984 Annals of Internal Medicine Volume 100
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the 1983 Metropolitan Height and Weight Tables.
Data from the Build Study 1979 are based on middle-
class persons in ostensibly good health. These people do
not constitute a cross-section of the entire population but
are primarily a sample of the middle class. These persons
have been screened for serious medical impairments. In
constructing a table of desirable weight, persons in poor
health, who would be included in a probability sample of
the entire population, are excluded; otherwise, instead of
measuring the effects of weight on mortality, one would
really be measuring the effects of weight in combination
with various health impairments. This screening is espe-
cially important for underweight persons, because many
of these persons may have an underlying disease not
manifested by other symptoms. The most significant as-
pect of the 1983 Metropolitan Height and Weight Tables
is that they are based on the lives of ostensibly healthy
persons and show, once again, that persons whose
weights are below average for the population under con-
sideration live longer, despite advances in health care,
early diagnosis, and treatment of hypertension and other
degenerative diseases.
P R O V I D E N T M U T U A L LIFE S T U D Y
A mortality investigation (6) of build among male pol-
icy holders, done by Provident Mutual Life from 1947 to
1964, divided the men into five groups by their deviation
from "standard" weight. The "standard" weight used
was the average weight at age 37 years obtained from the
Medico-Actuarial Mortality Investigation (32). The re-
sults were analyzed for various policy-year duration
groups, ranging from 16 to 34 years. In every duration
group, the mortality rate increased with weight. For ex-
ample, in the 31 to 34 policy-year group, men 10.4 kg or
more below the standard weight had a mortality ratio of
89%; those within 3.2 kg of standard, 94%; and those
10.4 kg over standard weight, 146%.
Prospective Studies
A M E R I C A N CANCER SOCIETY S T U D Y
In 1959, the American Cancer Society began a follow-
up study (3) of about 1 million men and women. Of
these people, some 750 000 were free of serious disease
and had not reported any marked loss in weight at the
time of their entry into the study. This group was traced
to 1973, and the mortality findings were analyzed accord-
ing to variations in weight (by height) from the average
weight for the population studied. The lowest mortality
rates occurred in persons weighing 80% to 89% of the
average weight, who did not smoke cigarettes. The
American Cancer Society study also showed higher death
rates in very lean ( < 80% of average weight) cigarette
smokers. In this study, data on heavy smokers, nonsmok-
ers, and other groups could be examined separately, ac-
cording to variations in weight. This analysis showed that
within each category of smoking habits, the lowest mor-
tality generally occurred among those persons slightly be-
low average weight.
The persons studied by the American Cancer Society
were predominantly middle-class Americans in good
Number 2
 health. The volunteer workers who interviewed these per-
sons and completed the questionnaires were overwhelm-
ingly middle-class women; thus, persons in the lowest
socioeconomic segments and nonwhite, itinerant, and in-
stitutionalized persons were grossly underrepresented in
the study. The study excluded persons who were sick;
had a history of heart disease, stroke, or cancer; or had
lost 4.5 kg or more in the preceeding year. The popula-
tion studied by the American Cancer Society therefore
resembles, in social characteristics and health status,
those populations studied by the life insurance compa-
nies. However, it should be noted that these persons were
neither examined nor interviewed by professionals, and
that all data were self-reported.
FRAMINGHAM HEART STUDY
A cohort of 5209 men and women, who were first ex-
amined in 1949, has been subsequently examined every 2
years in the Framingham Heart Study. Carefully docu-
mented information about cardiovascular disease mor-
bidity and mortality is available on all but a few of the
original participants.
A recent study (4) has examined the relationship be-
tween the degree of obesity and the incidence of cardio-
vascular disease. The index of obesity chosen to charac-
terize the population was Metropolitan relative weight.
Desirable weight for each sex was derived from the 1959
Metropolitan Desirable Weight Table by taking the mid-
point of the weight range for persons of medium build at
a specified height. Results of multiple logistic regression
analyses showed that all values of Metropolitan relative
weight (including the group from 110% to 130%) on
initial examination were positively related to the
differences in the 26-year incidence of coronary disease,
congestive heart failure, and coronary death in men,
independently of age, cholesterol level, systolic pressure,
cigarette smoking, left ventricular hypertrophy, and glu-
cose intolerance. Over the same period, higher Metropol-
itan relative weight (including the group from 110% to
130%) in women also was associated with an increasing
incidence of coronary disease, stroke, congestive heart
failure, and death from coronary and cardiovascular dis-
ease. These results indicate the importance of obesity as
an independent, long-term predictor of cardiovascular
disease.
Like the Build Study 1979 ( 1 ) , the Framingham Heart
Study shows a U- or J-shaped univariate relationship be-
tween total mortality from all causes and relative weight
( 5 ) . Thus, for persons at the underweight and over-
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
rates among underweight men was, in large part, due to
the mortality risks associated with cigarette smoking.
The proportion of men who smoked cigarettes at the time
of their first examination ranged from 55% in the most
overweight group to more than 80% in those who were
less than the reference weight. There was also a higher
proportion of former smokers in the lower weight groups.
Only 12 of the 258 men (5%) who were less than the
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reference weight reported never having used tobacco,
compared with 20% in the overweight group. Thus, the
high proportion of cigarette smokers among persons with
a low Metropolitan relative weight almost completely
confounds the effect of cigarette smoking and low Metro-
politan relative weight on mortality in this study. Among
nonsmokers, persons with a Metropolitan relative weight
of 100% to 109% had a total mortality rate that was
72%, 50%, and 3 1 % lower than that for the modal
group (Metropolitan relative weight, 120% to 129%) for
ages 30 to 39, 40 to 49, and 50 to 62 years, respectively.
Thus, even men of average weight (about 20% above the
reference weight) had appreciably elevated mortality
rates. This finding contradicts a widely held view that
being moderately, average, or slightly overweight carries
no increased risk.
However, although Metropolitan relative weight, age,
and cigarette smoking are easily measured "markers" for
mortality, other attributes, including physical activity
level, alcohol ingestion, and dietary patterns, are proba-
bly related to both mortality and each other. These other
factors were not included in this analysis.
MANITOBA STUDY
In the Manitoba Study ( 7 ) , comprising a cohort of
3983 men with a mean age at entry of 30.8 years, initial
measurements of body weight, represented by body mass
index, were correlated with the 26-year incidence of
ischemic (coronary) heart disease. After adjustment was
made for the effects of age and blood pressure, the body
mass index was found to be a significant predictor of the
390 cases of ischemic heart disease. The association with
weight was most apparent in men less than 40 years old
and was not evident until after 16 years of follow-up. A
high body mass index was significantly associated with
the development of myocardial infarction, sudden death,
and coronary insufficiency. The authors concluded that
obesity, per se, occurring in young adults (20 to 40 years
of age), is a risk factor with a latent period of more than
16 years.
These findings agree with the results of the Build and
Blood Pressure Study 1959 (33) and the Framingham
Study ( 4 ) , which show the increase in the cardiovascular
disease mortality rate by duration for overweight per-
sons. The association of greatest longevity with a body-
weight below the average is a constant finding of the
Provident Mutual Life Study, Build Study 1979, Ameri-
can Cancer Society Study, Manitoba Study, and Fram-
ingham Heart Study (Table 2 ) .
CHICAGO PEOPLE'S GAS C O M P A N Y S T U D Y
A population of 1233 persons was followed prospec-
tively for 14 years in the Chicago People's Gas Company
Study (18). Although this study does not support the
association of below-average body weight and greater life
expectancy, the study did not exclude persons with
health impairments at entry, nor did it consider their
smoking habits. Thus, the results of this study are diffi-
cult to interpret.
Simopoulos and Van Itallie Body Weight and Longevity 2 8 9
 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
The Seven Countries Study (9) has reported that when
risk factors such as hypertension, hyperglycemia, and hy-
perlipidemia are dissociated from obesity, obesity per se
ceases to be a risk factor for premature cardiovascular
disease. However, the duration of the Seven Countries
Study was 10 years (as compared with the 26-year fol-
low-up of the Framingham Study). The groups in this
study were drawn from different European countries and
represent cultures that often differ substantially from
each other and from that of the United States. The popu-
lations studied were leaner than the U.S. population. N o
effort was made to ensure that the populations studied
were limited to healthy individuals, nor were smokers
distinguished from nonsmokers in the analysis of the ef-
fect of weight on mortality.
OTHER S T U D I E S OF SPECIAL GROUPS
Several other studies reported in the literature (8-19)
also have contradicted the theory that life expectancy is
enhanced in otherwise healthy adults under age 50 years,
who are somewhat below average weight. Pertinent fea-
tures of these studies are given in Table 3. Only 5 of the
12 studies have been carried out in the United States, and
1 of these, the study by Borhani and colleagues (11), was
limited to longshoremen. These studies all covered rela-
tively short periods; all but 2 include follow-ups of 10
years or less, during which time the effects of obesity on
longevity would not be expected to manifest themselves.
None of these studies considered smoking in the analysis
of the effect of weight on mortality.
Cross-Sectional Health Surveys
The National Center for Health Statistics has carried
2 9 0 February 1984 Annals of Internal Medicine Volume 100
out three major national surveys that have included mea-
surements of weight and height. The Health and Exami-
nation Survey (23) was done in 1960 to 1962; the Na-
tional Health and Nutrition Examination Survey I (24,
37), in 1971 to 1974; and the National Health and Nutri-
tion Examination Survey II (25), in 1976 to 1980. Both
the National Health and Nutrition Examination Surveys
I and II collected data from a national probability sample
representative of the U.S. civilian, noninstitutionalized
population, 1 to 74 years of age.
The greatest strength of the National Health and Nu-
trition Examination Surveys I and II is that the data gen-
erated by the program are based on measured health indi-
cators obtained by standardized examinations, the most
accurate and objective means available for ascertaining
health status. The examination consisted of a general
medical examination and screening by a physician to
identify symptoms and physical evidence of disease or
abnormality; a complete medical history; body measure-
ments such as height, weight, and skinfold thickness; a
dietary interview covering the types and quantities of
foods eaten during the 24 hours before the examination
(tabulated for calories, protein, calcium, iron, and vita-
mins A and C); and a food-frequency questionnaire. It
should be mentioned that survey participants knew, in
advance, that they would be asked to report their food
intake. The following biochemical tests were done: hema-
tocrit, hemoglobin, serum iron, percent transferrin satu-
ration, total protein, albumin, and vitamin A.
Data from the Health and Examination Survey and the
National Health and Nutrition Examination Surveys I
and II permit assessment of body weight trends among
Americans from 1960 to 1962, 1971 to 1974, and 1976 to
1980. A comparison of mean heights and weights of
Number 2

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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)
shows that both men and women were taller and heavier
in 1971 to 1974 and 1976 to 1980 than they were in 1960
to 1962. As noted earlier, the Survey data are based on a
national probability sample and are normative. The use
or designation of the average weight at 20 to 29 years as
"desirable" weight is probably inappropriate, because data
from epidemiologic and other longitudinal studies indicate
a continuous increase in weight during that age period,
that leads to an overestimation of desirable weight and an
underestimation of obesity in the population.
The National Center of Health Statistics has published
the data (tables and graphs) from its survey of character-
istics of the growth of children in the United States. The
children studied represented a cross-section of ethnic and
socioeconomic groups. Because genetic, ethnic, and so-
cioeconomic differences are imbedded in the final data,
the derived charts are regarded by pediatricians not as
descriptions of any single racial, social, economic, or nu-
tritional group, but simply as reference standards.
Pitfalls in Interpretation of Life-Expectancy Data
During the past decade, apparently conflicting inter-
pretations have been published of the results of studies of
the effect of obesity on life expectancy. For example, An-
dres (20) has concluded, "Population studies of obesity
and mortality fail to show that overall obesity leads to
greater risk." Keys (38) has stated that obesity in the
absence of related risk factors, such as hypertension, dia-
betes, or hyperlipidemia, is not a risk factor for the pre-
mature development of cardiovascular disease. These
analyses have been useful in stimulating critical examina-
tion of the data and the pitfalls involved in their interpre-
tation. With the recent publication of the long-term find-
ings in the Framingham population (4), including
consideration of the confounding role of different smok-
ing habits on obese and nonobese persons (5), it has be-
come possible to analyze the disparate views of the com-
plex relationship between obesity and mortality.
CIGARETTE SMOKING A N D SUBCLINICAL ILLNESS
Only a few prospective studies are large enough to per-
mit stratification by cigarette smoking. Prospective stud-
ies that do not exclude or consider smokers or persons
who suffer from subclinical illness are likely to yield data
that are distorted by factors other than the status of
weight relative to height. Cigarette smoking is a potential
confounder of the relationship between obesity and mor-
tality. Statistical control for this factor in all studies of
mortality requires careful consideration.
Life insurance statistics have not been adjusted to al-
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
that persons below average weight are more likely to be
smokers than are overweight persons. If this is the case
for the persons considered in the Society of Actuaries'
mortality studies, lack of any adjustment to allow for the
effects of smoking could distort the data on underweight
and overweight persons, thus exaggerating the risk of be-
ing underweight and understating the risk of being over-
weight.
D U R A T I O N OF OBESITY
If persons are followed for a sufficient length of time,
being obese at the time of entry into a prospective study
is an independent risk factor predicting premature car-
diovascular morbidity and reduced life expectancy. This
fact does not exclude the possibility that obesity may gen-
erate, or be associated with, other risk factors at a subse-
quent time. Also apparent is that when obesity develops
at an early age in adults, and is sustained, its effect on life
expectancy is different from the effect of obesity that de-
velops in middle age.
In the past, obesity was considered to be associated
with coronary heart disease through its impact on the
cardiovascular risk factors, such as hyperlipidemia and
hypertension (39). However, findings from the Manitoba
(7) and Provident (6) Studies, along with findings from
the recent analyses of the Framingham Heart Study (4),
suggest that the duration of being obese has an important
bearing on the putative relationship of body weight and
longevity. Thus, when data from the Framingham Study
were analyzed using a longer time interval between mea-
surement of obesity and subsequent outcome, obesity
clearly was a significant predictor for cardiovascular dis-
ease, independent of age, cholesterol level, systolic blood
pressure, cigarette smoking, left ventricular hypertrophy,
and glucose intolerance.
Study, only 8% of men and 18% of women in the highest
weight class were free ofriskfactors. When findings such
as these are taken into account, it is likely that many
discrepancies between studies of populations with differ-
ent ages, different initial health statuses, and different fol-
low-ups can be resolved.
Conclusions
In the United States, studies based on life insurance
data (for example, the Build and Blood Pressure Study,
1959; Build Study 1979; Provident Mutual Life Study),
the American Cancer Society Study, and other long-term
studies, such as the Framingham Heart Study and Mani-
toba Study, indicate that below-average weights tend to
be associated with the greatest longevity, if such weights
are not associated with concurrent illness or a history of
significant medical impairment. Overweight persons tend
to die sooner than average-weight persons, particularly
those who are overweight at younger ages. The effect of
obesity on mortality is delayed, so that it is not seen in
short-term studies; the extensive data from the Build
Study 1979 show this delayed effect particularly well.
The recent analyses of the Framingham Heart Study data
emphasize that obesity is a significant independent pre-
dictor of cardiovascular disease, with smoking having a
separate effect. Furthermore, the concept of "desirable
weight" developed by the Metropolitan Life Insurance
Company in 1959 has been validated by a recent long-
term study (5). In addition to the age range of the popu-
lation studied, the interpretation of studies on body
weight, morbidity, and mortality must also carefully con-
sider the definition of obesity used, preexisting illnesses in
persons, the length of follow-up, and any confounding
risk factors.
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.
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 Therefore, several indices of body weight have been de-
veloped on the basis of varying relationships with total
body fat. Most of these indices have used body weight in
some combination with height. In children, this index has
most commonly been the use of weight for height distri-
butions (percentiles), whereas in adults the common in-
dex has been based on the quotient of weight divided by
height to the nth power (W/H 71 ). Although a number of
different values for n have been suggested for use in dif-
ferent populations, the most commonly used power func-
tion has been 2, as in the body mass index, kg/m 2 .
Other approaches have defined some measure of
weight at a given age (such as median or mean) as the
"standard" and have related all other weights to this ar-
bitrarily denned standard. Some other approaches have
defined the standard within the population being studied
and have related all other weights to that value (for ex-
ample, Metropolitan relative weight and the 1959 Metro-
politan Life Insurance Desirable Weight Table).
The use of a relative weight index depends on the pop-
ulation on which it is based; therefore, such an index can
only be understood in relation to the weight distribution
in that specific population. However, body mass indices
are independent of specific population distributions and
can be understood in terms of the value itself and the
relation of different values to the risk of disease incidence
and prevalence.
This conference (see below) has recommended that all
reports present data in terms of the body mass index (kg/
m2) in addition to any other method of presentation
used. Ultimately, the use of this or any other index will
have to be evaluated in a number of populations in rela-
tion to the specific morbidity and mortality outcomes.
EXCLUSION FOR PREEXISTING MORBID CONDITIONS
Persons studied should be carefully assessed for the
presence of morbid conditions, because such conditions
are likely to cause weight loss and are themselves associ-
ated with increased mortality rates. Inclusion of such
persons in surveys is likely to understate the risk of being
overweight and overstate the risk of being underweight.
Because elderly persons are difficult to screen for preex-
isting, occult, pathologic conditions, mortality studies of
the effects of weight in elderly persons occasionally have
found the lowest mortality rate to occur among those
who are of average weight or even slightly overweight.
T H E L E N G T H OF OBSERVATION
If persons with morbid conditions or unhealthy habits
are not excluded, then the length of observation of the
persons becomes a key factor in the interpretation of re-
sults. Because the extra mortality associated with various
morbid conditions or unhealthy habits is generally high-
est in the short duration but decreases with time (40),
awareness of the proportions and the kinds of persons
with various morbid conditions or unhealthy habits is
important in order to make valid interstudy comparisons.
C O N F O U N D E R S IN T H E A N A L Y S I S
A strictly univariate assessment of the relationship be-
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tween relative weight and mortality may be shown to be
of little value if an easily measured third variable (for
example, smoking) is found to be strongly related to both
relative weight and mortality. Controlling the analysis for
such a variable increases the chance for showing a valid
relationship between relative weight and mortality.
The most recent analysis of the Framingham data (5)
has shown strong evidence that body weights in excess of
those recommended as desirable by the 1959 Metropoli-
tan Life Insurance Table are associated with increased
mortality. Although not all the mechanisms or casual
pathways linking increased mortality and obesity have
been documented, an emphasis on prevention of obesity
through diet and exercise is clearly warranted. The need
for such initiatives is especially compelling when one con-
siders the enormity of the "morbid load" from obesity on
the U.S. population. Latest data from the Framingham
Heart Study show that more than 80% of men above the
age of 40 years and about 70% of women are in this
elevated risk category (Metropolitan relative weight
> 110%; >24.4 kg/m 2 ). Furthermore, the latest infor-
mation from both the National Health and Nutrition Ex-
amination Survey II (25) and the Framingham Heart
Study indicate that these percentages are continuing to
rise in women at higher weights, and are rising in men at
younger ages.
Recommendations
An appropriate database that relates body weight by
age, sex, and possibly frame size to morbidity and mortal-
ity should be developed to permit the preparation of ref-
erence tables for defining the range of desirable body
weight from morbidity and mortality statistics. Ideally,
reference data should consider appropriate attributes
(such as physical activity level and nature of diet) as well
as possible changes in the attributes. These changes will
require new observational studies to measure, in study
populations, the relation of such factors to morbidity and
mortality. Therefore, it is recommended that, at a mini-
mum, the following are needed to develop a reference data
table that relates body weight to health and longevity:
The population studied should be representative
of the healthy population to which the reference
data will be applied.
Data on weight and height should be analyzed
and presented separately by sex, age, and duration
of follow-up, with age divided by decades. This pro-
cedure takes into account age-related changes in
weight and permits establishment of age-related de-
sirable weight goals.
Data on weight and height should also be ex-
pressed as the body mass index with a median,
range, and standard deviation presented for each
age and sex group. Data so presented can be con-
verted into tables relating weight and height, al-
though questions remain regarding the validity of
the body mass index for estimating body fat in per-
sons outside the groups for which the index was
originally derived. Consequently, caution must be
Simopoulos and Van Itallie Body Weight and Longevity 2 9 3

used in comparing the body mass index between
groups with standards not validated on the groups
under consideration.
Efforts should be made to develop uncomplicated
indices that correlate with the body fat content bet-
ter than body mass index does.
All statements regarding the ranges in which
the morbidity and mortality rates are lowest should
be based on statistically significant differences in
mortality rates between the nadir of the curve and
the proposed limits of the range.
The range should be broad enough to encompass
subgroups whose life expectancy is known to differ
because of certain life styles, such as smoking, or
whose socioeconomic status or other demographic
characteristics contribute to differences in life ex-
pectancy. The expected differences contributed by
such characteristics should be explicitly noted.
The value of indices of frame size should be as-
sessed.
Because the latest Framingham data (4) show that
obesity is a significant independent predictor for cardio-
vascular disease, there is a need to investigate the ways in
which obesity becomes, or acts as, a "marker" for prema-
ture demise; identify the various types of obesity associat-
ed with specific diseases at different stages of the life cycle
(for example, upper trunk obesity with diabetes, fat cell
number and hypertension in early adulthood, and fat cell
size and hypertension in middle age); and define the ef-
fect of duration of being overweight on health to ascer-
tain the specific age (how early in life) at which obesity
becomes a marker for both morbidity and mortality.
ACKNOWLEDGMENTS: The authors thank Sherri Wisner of the Nutri-
tion Coordinating Committee office; and Sidney Abraham, Karen Donato,
Robert J. Garrison, Edward A. Lew, Milton Z. Nichaman, Frederic Seltzer,
and Thomas P. Vogl for their review of the manuscript.
This article is based on the proceedings of a workshop held on 24 to 26
January 1982 at the Linden Hill Hotel, Bethesda, Maryland, sponsored by
the Nutrition Coordinating Committee of the National Institutes of Health;
and the Centers for Disease Control. Participants in the workshop were
Sidney Abraham; Reubin Andres, M.D.; John K. Davidson, III, M.D.; Wil-
liam DeWys, M.D.; Karen A. Donato; Nancy D. Ernst; A. Roberto Frisan-
cho, Ph.D.; Robert J. Garrison; Gilman D. Grave, M.D.; Edward A. Lew;
Joseph L. Lyon, M.D.; Thomas E. Malone, Ph.D.; Maria A. Mannarino,
M.D.; Howard M. McCue, Jr., M.D.; Elizabeth A. McGuire, Ph.D.; Albert
I. MendelofT, M.D.; Milton Z. Nichaman, M.D., D.Sc; Alex Roche, M.D.;
Frederic Seltzer; Reuel A. Stallones, M.D.; and Thomas P. Vogl, Ph.D.
Requests for reprints should be addressed to Artemis P. Simopoulos,
M.D.; Nutrition Coordinating Committee, Building 31, Room 4B59, Na-
tional Institutes of Health; Bethesda, MD 20205.
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