Chapter 16 / Physical Activity and Obesity

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Physical Activity and Obesity

John M. Jakicic, PhD, Amy D. Otto, PhD, RD, LDN, Kristen Polzien, PhD, and Kelli K. Davis, MS
CONTENTS
INTRODUCTION CONTRIBUTION OF PHYSICAL ACTIVITY TO TOTAL ENERGY EXPENDITURE CAN PHYSICAL ACTIVITY PREVENT WEIGHT GAIN? PHYSICAL ACTIVITY FOR WEIGHT LOSS AND PREVENTION OF WEIGHT REGAIN DEVELOPMENT OF EXERCISE PRESCRIPTION FOR WEIGHT CONTROL CONCLUSION ACKNOWLEDGMENTS REFERENCES

Summary
There is an increasing prevalence of overweight and obesity in the United States and other developed countries. This can have significant public health implications because of the association of excess body weight with increased risk of chronic diseases. It has been suggested that the increasing prevalence of excess body weight (overweight and obesity) and related diseases also has a significant impact on health care costs. Physical activity can significantly affect weight control and can also have an independent effect on associated chronic disease risk factors. However, physical activity participation is less than optimal. Thus, it is important for health care professionals to understand the role of physical activity in weight loss, the prevention of weight gain, and the prevention of weight regain, and to understand how to provide accurate and meaningful information to their patients. Key Words: Exercise; overweight; fitness; weight control.

INTRODUCTION
Obesity, physical activity, and poor dietary behaviors have been linked to increased health risk, which may contribute to 300,000 to 400,000 additional deaths per year in the United States (1). This may in part be a result of the increasing prevalence of overweight (body mass index [ BMI] 25.0 kg/m2) and obesity (BMI 30.0 kg/m2), with these rates estimated to be approx 65% and 30% in adults, respectively (2,3). Moreover, it is estimated that 16% of children and adolescents ages 6 to 19 yr are obese (4). The increasing prevalence of overweight and obesity results in associated health risks from an increase
From: Contemporary Endocrinology: Treatment of the Obese Patient Edited by: R. F. Kushner and D. H. Bessesen Humana Press Inc., Totowa, NJ

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in numerous chronic diseases that include heart disease, diabetes, and various forms of cancer (1). These increased obesity-related health risks may contribute to more than $ 100 billion in annual health care costs. Thus, the development and implementation of interventions that result in weight loss, prevention of weight gain, and prevention of weight regain can significantly reduce the health burden and have an impact on public health. It has been demonstrated that a reduction in body weight and an increase in physical activity may facilitate the management of body weight and reduce the risk and onset of obesity-related diseases (1). However, it is estimated that only 20% of adults in the United States participate in adequate levels of physical activity to improve their health (5), and it is clear that most children do not participate in adequate amounts of physical activity (5). Thus, it is important for health care professionals to understand the role of physical activity in the prevention of weight gain, weight loss, and the prevention of weight regain, and to understand how to provide accurate and meaningful information to their patients.

CONTRIBUTION OF PHYSICAL ACTIVITY TO TOTAL ENERGY EXPENDITURE

Whether body weight remains stable, increases, or decreases is ultimately dependent on the balance or imbalance between energy intake (calories consumed) and energy expenditure. To reduce body weight, energy expenditure must exceed energy intake, whereas to prevent weight gain or to maintain weight loss, energy expenditure must equal energy intake. Thus, the effect of an increase in energy expenditure on body weight is also dependent on the relative contribution of energy intake to energy balance. This section will focus on the contribution of the components of energy expenditure on energy balance. There are three basic component of energy expenditure: resting energy expenditure (REE), thermic effect of food (TEF), and voluntary physical activity (Fig. 1). Although it is recognized that REE can vary among individuals, and there are physiological, metabolic, and genetic influences on REE, the REE within a given individual remains relatively stable, provided that weight and health status remain stable. Moreover, despite the large contribution of REE to total energy expenditure, limited studies have shown the ability of lifestyle interventions to increase REE; this is especially true during weight loss when REE tends to decrease (6,7). Thus, it appears that interventions targeting an increase in REE will have a small and limited impact on total energy expenditure for most individuals, which will result in a limited impact on body weight. TEF is the increase in energy expenditure resulting from the food that is consumed to allow for the necessary components of digestion. Ravussin et al. (8) have suggested that TEF is approx 10% of total daily energy expenditure. Moreover, TEF is influenced by the macronutrient content of the food that is consumed. Despite the potential increase in TEF based on dietary composition, this increase in energy expenditure is relatively small compared with the total daily energy expenditure. Moreover, this would require a significant increase in a specific macronutrient content sustained over a relatively long period of time to significantly and independently affect body weight. Thus, attempting to affect body weight solely through an increase in TEF is not practical and will likely result in minimal impact. A more detailed discussion of this issue is not within the scope or focus of this chapter.

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Fig. 1. Contribution of varying levels of leisure-time physical activity (LTPA) to total energy expenditure (TEE) for a fix resting energy expenditure (REE - 1800 kcal/d) and thermic effect of a metal (TEM = 180 kcal/d).

Leisure-time physical activity (LTPA) is the most variable component of energy expenditure. LTPA can occur in the form of structured exercise, lifestyle activity, or other forms of activity that contribute to an increase in energy expenditure. The amount of the increase in energy expenditure varies based on the amount of LPTA that is performed. For example, an individual who is relatively inactive will expend approx 30% more calories above what is expended in REE, with this increasing to approx 50% or 80% for individuals participating in moderate or higher amounts of LTPA, respectively (see Fig, 1). Thus, it is important to understand the contribution of an increase in total daily energy expenditure resulting from LTPA on energy balance, which can affect the prevention of weight gain, weight loss, the prevention of weight regain following weight loss.

CAN PHYSICAL ACTIVITY PREVENT WEIGHT GAIN?

Close examination of prevalence data indicates the need to focus intervention efforts on the prevention of weight gain. If effective, this will decrease the likelihood of a transition from normal weight to overweight or obesity, and decrease the transition from overweight to obesity. There is some evidence that LTPA can play a significant role in the prevention of weight gain; this is mostly likely a result of the increase in energy expenditure resulting from an increase in LTPA. For example, there are data from prospective observation studies that appear to support this hypothesis. Lee and Paffenbarger (9) concluded that participants in the Harvard Alumni Study who reported levels of physical activity consistent with approx 30 min of moderate-intensity physical activity had a lower body weight when compared with individuals reporting lower levels of physical activity. When change in cardiorespiratory fitness is used as a surrogate for change in LTPA, the data reported by DiPietro et al. (10) demonstrate the inverse association between change in fitness and change in body weight, which also supports the importance of physical activity in the prevention of weight gain in adults.

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The application of these prospective, observational findings need to be apply to interventions to have a meaningful impact on weight gain prevention. In fact, Sherwood et al. (11) reported that an increase in physical activity was predictive of prevention of weight gain. Moreover, preliminary data are available from an ongoing clinical trial that is being conducted in our research center. Results indicated that an increase in physical activity (150 to 300 min/wk) resulted in prevention of weight gain or modest weight loss (12 kg) in approx 60% of overweight adults (BMI = 25.029.9), with change in fitness predictive of prevention of weight gain (unpublished data). These findings are important when considered in context of the recommendations for physical activity in the prevention of weight gain that appeared in the 2005 US Dietary Guidelines, which stated that to prevent weight gain there is a need for individuals to engage in approximately 60 minutes of moderate- to vigorous-intensity activity on most days of the week while not exceeding caloric intake requirements. Clinicians should consider individually tailoring these recommendations based on the response of the participant. For example, it has been established that approx 30 min of moderateintensity physical activity per day on most days of the week can result in a significant reduction in the risk of chronic diseases. Thus, individuals should increase to this level of activity and determine whether this level of physical activity is sufficient to prevent weight gain. If it is not, the recommended level of physical activity can gradually be increased (e.g, 30 to 35 min/wk, 35 to 40 min/wk, etc.) until weight gain ceases. This is illustrated in the flow chart provided in Fig. 2.

PHYSICAL ACTIVITY FOR WEIGHT LOSS AND PREVENTION OF WEIGHT REGAIN Short-Term Weight Loss
It has been clearly established that effective behavioral weight-loss interventions result in approximately a 10% weight loss compared to initial body weight within 6 mo of initiating an intervention (12). These results appear to be achievable with the combination of a reduction in energy intake and an increase in energy expenditure (1). However, the contributions of each of these components (reduction in energy intake and increase in energy expenditure) are not equal, with the majority of weight loss resulting from a reduction in energy intake. In response to a 12-wk intervention, Hagan et al. (13) reported a reduction in body weight of 8.4% in males and 5.5% in females, with Wing et al. (14) reporting 9.1% in response to a 24-wk intervention, with energy intake ranging from 1000 to 1500 kcal/d. The addition of exercise to a reduction in energy intake resulted in weight loss of 11.4% and 7.5%, respectively in males and females (13), with Wing et al. (14) reporting weight loss of 10.4%. In these studies, exercise alone resulted in weight loss of 0.3, 0.6, and 2.1%, respectively (13,14). These findings support the conclusions of the clinical guidelines developed by the National Institutes of Health that recommend the combination of a reduction in energy intake and an increase in energy expenditure to maximize weight loss in response to a behavioral intervention (1).

Long-Term Weight Loss and Weight-Loss Maintenance

Despite the minimal effect of exercise on short-term weight loss, exercise appears to be an important component of long-term interventions. This is supported by the 2005 US Dietary Guidelines (15), the Institute of Medicine (16), and extensive reviews of the

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Fig. 2. Example of exercise progression to prevent weight gain or weight regain.

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literature (17,18). However, a common conclusion that appears to be supported by crosssectional data, prospective observational data, and data from clinical trials is that physical activity equivalent to 2000 kcal/wk or approx 250 to 300 min/wk is associated with improved long-term weight loss at 12 to 24 mo (1924). These results appear to support the recommendation of the US Dietary Guidelines that 60 to 90 min/d is required to prevention weight regain following significant weight loss (15). It appears that adequate levels of physical activity do not act alone to control body weight long-term, but rather work in synergy with appropriate levels of energy intake. For example, Jakicic et al. (25) reported that the combination of increased levels of physical activity combined with reduced levels of energy intake were predictive of longterm weight-loss outcomes following an 18-mo intervention. Similar findings were reported by McGuire et al. (26) based on data from the National Weight Control Registry. Thus, these data appear to support the importance of maintaining adequate levels of energy balance (energy intake and energy expenditure) to enhance long-term weight loss and prevent weight regain following weight loss. Thus, it is important for clinicians to address these components of energy balance equally when providing interventions for overweight and obese adults.

DEVELOPMENT OF EXERCISE PRESCRIPTION FOR WEIGHT CONTROL Exercise Mode

The majority of clinical trials have incorporated aerobic forms of physical activity (i.e., brisk walking) into the weight loss interventions; overweight/obese individuals report that walking is the self-selected mode of physical activity for 80 to 90% of activity sessions (20). This may be a result of ease of participation for most individuals, the low cost of participation, and lack of need for special skills to participate in this form of physical activity. Despite these findings, additional forms of physical activity have been examined for weight control with mixed results. For example, a review of the scientific literature revealed no apparent improvement in weight loss with the addition of resistance exercise (27), and preliminary data from our laboratory appear to support this conclusion (35). Moreover, Jannsen et al. (28) reported no significant improvement in risk factors with the addition of resistance exercise when compared with weight loss resulting from diet alone. However, there is initial evidence, that despite these findings, that resistance exercise has been associated with a reduction in all-cause mortality (29). Moreover, resistance exercise will improve muscular strength (30,31), which may affect physical function of overweight and obese adults (32). Despite these potential benefits, resistance exercise has not been shown to be more effective for weight loss or the maintenance of weight loss compared with other forms of physical activity. Thus, although more research is needed to understand the role of resistance exercise for weight control, this form of exercise may be appropriate when used as a complement to other forms of physical activity such as walking. Because of the potential functional limitations of overweight and obese adults, alternative forms of physical activity may need to be considered. Yoga has been shown to improve range of motion and physical function, while reducing pain (33,34). However, there are limited data to support the addition of yoga to interventions to improve weight

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loss. Results from a 12-mo weight-loss intervention that included yoga as a complement to aerobic forms of physical activity and a reduction in energy intake demonstrate no improvement in weight loss when compared with interventions not including yoga (35). Another popular recommendation is to include aquatic forms of physical activity for overweight adults, as this may overcome functional limitations in overweight and obese individuals. Again, the limited data in this area of research do not indicate that weight loss is improved with the addition of aquatic exercise compared with other forms of physical activity (36). These factors should be considered by clinicians when recommending physical activity to overweight and obese adults when weight loss is the primary outcome, and used to enhance LTPA and energy expenditure for individuals who find these activities enjoyable.

Physical Activity Intensity vs Volume

Current recommendations for physical activity to control body weight appear to indicate that approx 60 to 90 min/d may be required to prevent weight gain or improve long-term weight loss (15). Moreover, although the accumulation of at least 10,000 steps per day, measured using a pedometer, may be associated with improvements in healthrelated parameters (37), it has been suggested that it may be necessary to progressively increase daily steps to levels above 10,000 steps per day to improve weight loss (38). Thus, clinicians should focus on progressively increasing the total volume of physical activity to maximize energy expenditure in overweight and obese adults. This could involve increasing duration by 10 min/d or by 1000 steps/d at approximately 4-wk intervals until the desired level of physical activity is attained. The total volume of physical activity, expressed as energy expenditure, may be more important for weight control than the intensity of the physical activity that is performed. For example, Duncan et al. (39) have demonstrated that when total volume of physical activity is held constant, there is no difference in the effect on body weight across different intensities of physical activity. Similar results have been reported by Jakicic et al. (20), who demonstrated that the magnitude of weight loss was affected by volume of physical activity rather than the intensity of physical activity within a 12-mo clinical trial. Even though total volume of physical activity may be more important than the intensity of physical activity for promoting weight control, this does not suggest that an adequate intensity of physical activity to improve cardiorespiratory fitness is not important. In fact, there is a growing body of literature to support the need for sufficient improvements in cardiorespiratory fitness independent of body weight, with higher levels of fitness reducing health-related risk even in overweight and obese adults (4043). Moreover, this may also result in a reduction in all-cause mortality independent of body weight (44). However, these data appear to only apply to individuals with a BMI <35, as there are limited data to support the independent effects of physical activity on health-related outcomes and mortality for individuals above this level of BMI. An additional factor when considering the volume of physical activity is whether this needs to be done in a continuous manner to have an effect on the desired outcomes. In fact, there are numerous studies to support that intermittent exercise performed in multiple bouts of at least 10 min in duration can significantly improve desired outcomes. These outcomes can include cardiorespiratory fitness (4547) and selected risk factors (46). Moreover, intermittent physical activity may provide an effective strategy for

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improving initial adoption of physical activity in overweight and obese adults (21,47). This may provide a strategy for clinicians when addressing physical activity for individuals who are resistant to traditional forms of physical activity that require continuous exercise for periods ranging from 20 to 60 min per session.

CONCLUSION
Excessive body weight that results in overweight or obesity has been linked to significant health risks for numerous chronic conditions (1). A continuing challenge for clinicians is to address the increasing prevalence of weight gain in patients to prevent overweight or obesity, and to prevent weight regain following initial weight loss. However, it appears that physical activity can contribute to a significant increase in energy expenditure, which will facilitate long-term weight control provided that a sufficient dose of physical activity is performed. It appears that the level of physical activity necessary for prevention of weight gain and to enhance long-term weight loss maintenance ranges from approx 30 to 60 min/d (15,1720). Therefore, clinicians should encourage patients to progressively increase physical activity to this range (see Fig. 2) in addition to maintaining a complementary level of energy intake. This may require clinicians to individually tailor these recommendations to the needs of the patient in a progressive and systematic manner to enhance both weight control and health-related outcomes in overweight and obese adults.

ACKNOWLEDGMENTS
The efforts of Dr. Jakicic, Dr. Otto, Dr. Polzien, and Ms. Davis are supported by research funding from the National Institutes of Health (HL70257, HL67826, DK066150). Dr. Jakicic is on the scientific advisory boards for the Coca-Cola Beverage Institute for Health and Wellness, the Calorie Control Council, and BodyMedia, Inc.

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