Published by Oxford University Press on behalf of the International Epidemiological Association

The Author 2013; all rights reserved.

International Journal of Epidemiology 2013;42:18311836

doi:10.1093/ije/dyt159

DEBATEPHYSICAL ACTIVITY AND OBESITY RISK

Physical activity does not influence obesity risk:

time to clarify the public health message
Amy Luke* and Richard S Cooper
Department of Public Health Sciences, Stritch School of Medicine, Loyola University Chicago, Chicago, IL, USA
*Corresponding author. Department of Public Health Sciences, Stritch School of Medicine, Loyola University Chicago,
2160 S. First Avenue, Maywood, IL 60153, USA. E-mail: aluke@lumc.edu

Accepted

16 July 2013

Introduction
Over the past 3 decades the obesity epidemic has
spread inexorably across societies in all parts of the
globe. Unfortunately our understanding of the key factors driving body weight upward and thereby the
public health interventions required to reverse this
trend has advanced much more slowly. Since the
1980s innumerable studies have catalogued the descriptive characteristics of this epidemic and detailed
maps of obesity prevalence and the associated disease
burden have been produced.13 Until recently, however, discourse about the underlying aetiology of this
quintessential modern epidemic has been confined primarily to commentaries on bad dietary habits and low
levels of physical activity, suggesting a failure both to
restrict energy intake and to maintain high levels of
energy expenditure.4 On closer scrutiny, the empirical
data have been insufficient to support either element of
the aetiological pathway characterized in those terms,
nor is that formulation justified on theory alone.
Virchow laid the foundation for our understanding of
all human epidemics with the assertion that mass disease means society is out of joint.5 Recent work by
nutrition scientists and economists has led to the formulation of an increasingly sophisticated explanatory
model of this latest scourge based on solid data
which is firmly rooted in traditional public health
theory: Changes in the global food system, including
reductions in the time-cost of food, seem to be the
major drivers of the rise of the global obesity epidemic
during the past 34 decades.6 Although recognizing
the secondary, or conditional, role of dietary habits,
this model clearly states that individual choice has not
been the primary factor leading to the worldwide rise
in long-term positive energy balance.
Within this new phase of aetiological thinking, however, there has continued to be less clarity about the role
of low levels of physical activity.7 In this commentary

we challenge the theoretical basis for considering

reduced energy expenditure in activity as a cause of
the obesity epidemic and summarize the empirical
data to support that contention. From both perspectives
physiological theory as well as observational data and
trials as set out below energy expenditure in activity
appears to be playing no role in either causing or moderating the obesity epidemic, suggesting that current
guidelines need to be reformulated.

Long-term secular trends in

activity are not consistent with the
dynamics of the obesity epidemic
Over the past century and a half, mechanization has
markedly reduced the requirement for hard physical
labour and physically active transportation. Estimates
of a decline in energy expenditure assumed to accompany increased mechanization are indirect, however,
since no objective measurements span this time
frame. Nonetheless, these trends away from high
levels of physical activity cannot explain the increases
in relative weight that have occurred during the latter
half of the 20th century, as the labour-saving culture
was fully in place by the 1960s-70s.8 A recent econometric analysis of calorie intake in the USA demonstrated a slow relative decline through the 1950s,
which is presumed to reflect parallel decreases in
expenditure since the US population as a whole remained relatively weight stable.9 To use a term borrowed from Swinburn et al., an energy balance
flipping point appears to have been reached in the
mid-1960s; following dramatic changes in the food
supply, energy intake increased along with a parallel
increase in body mass6 (Figure 1). In the decades following this flipping point, energy intake crept slowly
upward, while expenditure remained stable,

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INTERNATIONAL JOURNAL OF EPIDEMIOLOGY

Figure 1 Food availability for the USA, 191006. There are two distinct phases, a decrease in food energy supply
(postulated to be pulled down by reduced energy expenditure requirements for daily living), followed by an increase in food
energy supply (postulated to be pushed up by increasing food access). An energy balance flipping point has been proposed
by Swinburn et al., marking the change in how the US population generally achieved energy balance.6
Figure reprinted with permission from Elsevier

normalized for body size. As a result, weight, i.e. primarily excess body stores of fat, for the average
American adult increased by 13 kg between the mid1960s and today.10,11

meta-analysis of doubly-labelled water studies concluded that neither total daily expenditure nor physical
activity level differ by degree of social and economic
development.16

Energy expenditure does not vary Energy intake increases to balance

between societies with low vs high expenditure
obesity prevalence
Energy flux is regulated by a complex neuro-humoral
Comparisons of wealthy countries like the USA and
Europe with non-industrialized societies, where subsistence agriculture remains the norm, can complement
analyses of long-term historical trends in energy expenditure. Whereas it is often stated that low rates of
obesity in rural Africa, India and China, for example, are
in part attributable to strenuous daily work routines,
this view is contradicted by the evidence. Stable isotopes provide the optimal method to measure energy
expenditure in free-living individuals.12 Recent studies
using doubly labelled water in rural Nigeria, for example, demonstrate no difference in calorie expenditure
corrected for body size as compared with US samples of
comparable age.13,14 Likewise, in another recent report,
Pontzer et al. present similar findings comparing the
Hadza, hunter-gatherers living in Tanzania, to
Westerners; Hadza women did not have higher daily
energy expenditure levels than the Western women
with much higher body masses, although Hazda men
were somewhat more active.15 In fact, a recent

system which has become increasingly well understood. Feedback mechanisms linking the gut and the
brain, with additional input from fat stores and other
metabolically more active tissues, regulate appetite and
satiety.17 As with all other organisms in their natural
environment, in the past given adequate nutritional
resources the vast majority of humans ceased gaining
weight after reaching full height, and remained weight
stable until sarcopenia intervened in old age. This lifelong weight balance was achieved unconsciously by appetite-satiety control mechanisms. Although these
regulatory pathways can be overridden, and are obviously not functioning normally in populations with a
high prevalence of obesity, they retain the capacity to
respond to increased expenditure. Thus, increases in
energy expenditure through activity, virtually independent of the baseline state of adiposity, are generally
matched over the medium range (i.e. weeks, not days)
by increases in calorie intake.18 Perhaps from an evolutionary perspective one might argue that organisms

PHYSICAL ACTIVITY AND PUBLIC HEALTH

which faced chronic, intermittent food shortage might

have no use for a feedback loop that signalled the tank
is full, but rather placed value exclusively on replacing
lost stores as soon as possible.
Illustrative examples of this process have now been
identified. Long a high profile candidate for providing
excess calories, evidence is mounting that sugar, especially when presented as a beverage, can bypass satiety
control mechanisms.1921 The beverage industry has
rebutted this assertion, and its main defence is to
claim its not just soft drinks, which is undoubtedly
true, given the rise in obesity in widely varying food
cultures. Sugar-sweetened beverages may be paradigmatic, however, and provide a crucial entry point to
the phenomenon of overeating. This initial skirmish
with a satiety-overpowering food carries other implications for those who would formulate policy aimed at
obesity control. Attempts by New York City to restrict
sales of large sugared beverages has met the predictable
resistance from the food industry;22 as with all other
public health campaigns against harmful products in
the marketplace, we can look forward to a protracted
fight over food. Succeeding in an adversarial debate, as
the role of hyper-consumption of food and drink
required to satisfy the needs of a consumer economy
is certain to be, will require great clarity and forcefulness on the part of the public health community.

1833

calorie intake and food composition. Most studies

used self-reported food intake, resulting in a body of
evidence that is fatally flawed by under-reporting of
total calories among heavier individuals.29,30 The
paradoxical result that has emerged is a negative correlation between body size and total calories a
mathematical equivalent of wishful thinking .When
energy intake is measured using stable isotopes,
however, the expected strong monotonic positive correlation between body size and actual intake is
demonstrated.31 Even with objective measurement
techniques, cross-sectional data are potentially confounded by lower volitional activity among those
who have already gained weight.32 As a result, observational studies are relevant primarily when stable
isotopes are used at baseline and weight change is
measured prospectively. Relatively limited data exist
using this design, but the entire body of evidence is
congruent. Studies conducted among a variety of
populations refute the commonly held belief that
higher levels of energy expended in free-living
physical activity translate into less weight being
gained.3235 Recent reviews on the relationship between physical activity and obesity or weight gain
conclude that there does not appear to be one.36,37

Extremely small proportions of our

society engage in levels of energy
Conflicting evidence from clinical
trials on effect of increased energy expenditure at a sufficiently high
level to impact on long-term
expenditure on weight
Consistent with the physiological evidence outlined energy balance
above, clinical trials provide generally consistent evidence that intake will rise to match expenditure
making weight loss from increased exercise difficult,
if not impossible for most people. Several carefully controlled randomized trials have shown a match of energy
intake to energy expended in exercise measured as
lack of weight change in groups undergoing supervised exercise in the absence of calorie restriction,18,23,24 although other trials have come to the
conclusion that there is variability in the degree of compensation for calories expended in exercise.2527 At the
same time, numerous trials have indicated that exercise plus calorie restriction achieves virtually the same
result in weight loss as calorie restriction alone.28

Observational studies show no

association between energy
expenditure and subsequent
weight change
Numerous epidemiological studies have attempted
to examine both cross-sectional and longitudinal relationships between relative weight and both total

Like dietary intake, self-report of energy expenditure in

activity is subject to large random and systematic bias.38
In most epidemiological research, the construct of
physical activity has been restricted primarily to moderate and vigorous leisure-time sports, although attempts have been made to capture the more difficult
occupational domain.39 Based on these data, minutes
spent in moderate or vigorous activity is often used to
determine whether an individual participant meets the
guidelines.40 There is no doubt that physical activity at
any level promotes health, and that activity at a sufficient intensity to raise heart rate and promote cardiovascular conditioning has significant value.41,42 Across
the general population in countries like the USA, however, the time spent in what are generally conceived of
as sport-like moderate-vigorous activities is extremely
small. Although some surveys, such as the Behavioral
Risk Factor Surveillance System Survey (BRFSS), report
that about 50% of individuals in the USA currently
meet the guidelines of 30 min/day moderate activity
on at least 5 days per week, the activities described include gardening, walking and golf.43 For the first
time in a national representative sample, beginning
with the 200304 survey, the National Health and
Nutrition Examination Survey (NHANES) included an

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INTERNATIONAL JOURNAL OF EPIDEMIOLOGY

objective measure of activity.40 In an analysis of data

from NHANES 200306, the average adult participant
recorded only one bout of vigorous activity lasting a
single minute. Moderate activity lasted 35 min/day
among men and 21 min/day among women, but again
75% of this activity occurred in bouts of only 1 min and
only 0.3% of participants met physical activity guidelines requiring a minimum of two 10-min blocks of
moderate activity per day.44 Although marathon running and other participatory sports have achieved
great publicity, these involve minuscule proportions of
the population. Given that an hour of vigorous activity
is required to expend roughly 500 calories, leisure-time
activity cannot be playing any noticeable role in the
energy budget of the US population.

Conclusions
First, it must be reiterated that the health-promoting
role of physical activity and the more the better
cannot be challenged on any grounds. The purpose of
this commentary is therefore not to question the
value of public health recommendations to maintain
an active lifestyle, nor do we doubt that physical activity by necessity will burn calories. The purpose of
this commentary is to present the evidence to support
two assertions:
 First, increases in physical activity of the amount
common for most individuals, such as 3 days/week
of 1 h of aerobic activity, will not lead to weight

loss, nor will it help prevent weight gain, for the

majority of the population.
 Second, variation in physical activity within the
range engaged in by the US population is not modulating obesity risk. Only reduction in calorie
intake will result in weight loss, whether done in
isolation or together with increases in exercise.
A rare contemporary instance of population-wide food
shortage demonstrates both the immediate, universal
impact of small reductions in intake, as well as the
consequent drop in diabetes and cardiovascular
diseases.45
In our view, therefore, given the evolving evidence
on this crucial aetiological question, the public health
community should re-frame the message we communicate about the obesity epidemic. A sophisticated,
coherent body of data now supports the transition
to a new food environment as the fundamental
cause: the time cost of food has been lowered, and
the inducements to eat high calorie items have
increased, leading the susceptible half of the worlds
populations to gain 0.51 kg per year from age
18 years onward. At the same time, as outlined
above, reduced energy expenditure has been removed
from the list of candidate aetiological agents. These
messages should be de-coupled and we should focus
with great urgency and vigour on the challenge of
altering the modern food environment.
Conflict of interest: None declared.

KEY MESSAGES
 Public health guidelines advocate increased physical activity as a key modality in the prevention and
treatment of obesity despite little empirical evidence to support its effectiveness.
 Secular trends in activity levels are not consistent with trends in obesity prevalence nor do data from
observational or clinical trials support a direct relationship between activity and excess weight gain.
 A complex neuro-humoral system regulates energy balance through satiety and appetite, preferentially matching intake to increased rather than decreased activity in free-living individuals.
 Physical activity is crucially important for improving overall health and fitness levels, but there is
limited evidence to suggest that it can blunt the surge in obesity.

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Published by Oxford University Press on behalf of the International Epidemiological Association

The Author 2013; all rights reserved.

International Journal of Epidemiology 2013;42:18361838

doi:10.1093/ije/dyt160

Commentary: Luke and Cooper are wrong:

physical activity has a crucial role in weight
management and determinants of obesity
Steven N Blair,1,2* Edward Archer1 and Gregory A Hand1
1

Department of Exercise Science, Arnold School of Public Health, University of South Carolina, Columbia, SC, USA and
Department of Epidemiology and Biostatistics, University of South Carolina, Columbia, SC, USA

*Corresponding author. Department of Exercise Science, Arnold School of Public Health, University of South Carolina,
921 Assembly Street, Suite 212 Columbia, SC 29208, USA. E-mail: <sblair@mailbox.sc.edu4

Accepted

1 March 2013

Introduction
Luke and Cooper claim that evidence does not support
a relationship between physical activity (PA) and
obesity, and that policy recommendations to control
the obesity epidemic should be limited to altering the
modern food environment.1 We disagree and contend
that to support their position Luke and Cooper misrepresent and/or ignore an extensive evidence base of
observational and experimental studies that clearly
support an effect of PA on obesity, as follows.

from 1971 to 2006.2 We examined household energy expenditure over the past 45 years and found decrements
of41800 kcal/week for all women and42500 kcal/week
in non-employed women.3 These results combined with
decreases in active transport4 suggest that the decrements in PA energy expenditure in multiple domains
surely must be an important cause of population increases in weight. It is implausible that the laboursaving culture1 has not changed since the 1960s70s.

Observational cohort studies

Secular trends in physical activity
In direct contradiction to claims that secular trends in
PA are not consistent with trends in obesity prevalence
and that the labour-saving culture was fully in place by
the 1960s70s,1 Church et al. examined US occupational
PA from more than 140 000 businesses and government agencies, and 4440 000 individual worksites.
They report a significant decreasing trend in occupational energy expenditure over the past 50 years.
Mathematical modelling showed that decrements in occupational PA were 140 and 120 kcal/day in men and in
women, respectively. Their model accurately predicted
changes in body mass index (BMI) (National Health and
Nutrition Examination Surveys) for men and women

There are numerous longitudinal studies showing that

PA prevents weight gain. One excellent example by
Hankinson et al. examined 3554 men and women
with seven follow-up measurements over 20 years and
concluded that maintaining high activity levels lessens
gains in weight and visceral adiposity.5 Women and
men who maintained PA at recommended levels had
smaller increases in both BMI and waist circumference
when compared with inactive individuals.

Ecological studies
Perhaps the gravest misrepresentation by Luke and
Cooper is citation of data from the Cuban economic