Obesity, heavy smoking and mortality; Physical activity and academic achievement
April 2009
Shape Up America! Newsletter

Obesity is Equivalent to Heavy Smoking as a Primary Cause of Premature Death
by Barbara J. Moore, PhD
Most people would agree that 57 years old is too young to die. But a 2009 study of more than 45,000 Swedish male adolescents, followed from ages 19 to 57, found a significantly higher mortality — more than double the death rate — in those who were heavy smokers (over 10 cigarettes per day) and also in those who were obese (body mass index or BMI of 30 or higher).1

This study has caused quite a stir in the public health community because the risk of early death in obese individuals was found to be as high as it was in heavy smokers — a finding that surprised those who see smoking as the far greater threat to health. But that was what these researchers found. They also found that overweight (BMI of 25.0 to 29.9) was comparable to light smoking (1 to 10 cigarettes per day) in predicting premature mortality. The data are summarized in this table.

The strengths of this study include:

  1. The study was a large nationwide cohort study of 45,920 people who were young and otherwise likely to be in good health.
  2. It was conducted in a developed country known for rigorous data collection and control procedures.
  3. It was conducted in virtually all eligible Swedish males of the target age since registration in the military is compulsory for males.
  4. It controlled carefully for socioeconomic status.
  5. It measured height and weight in order to calculate body mass index (BMI) as an indicator of obesity/weight status, whereas the major weakness of other studies is reliance on self-reported height and weight data, which are notoriously unreliable.

The weaknesses of this study include:

  1. It was a study only of males.
  2. The study relied on self-report for smoking status.
  3. There was possible misclassification of obesity status since some highly muscular individuals have a high BMI but are not overly fat. This limitation was addressed by these researchers by evaluating muscular strength in all subjects in order to control for muscularity when the data were analyzed.
  4. Obesity or weight status and smoking status were evaluated only at the start of the study, and not thereafter, making this the most serious weakness of the study. Thus, some normal weight people may have gained weight and some obese people may have lost weight soon after initial measurement. However, this would have raised mortality in the normal weight group and lowered mortality rates in the obese group, thus minimizing differences in mortality rather than accentuating them. The same argument applies to nonsmokers who might have started smoking and to smokers who may have quit. This would also likely minimize differences in mortality rather than accentuate them. However, we agree that this weakness does make comparisons of smoking-related mortality and weight-related mortality less reliable.

In conclusion, the authors point out that in adolescents as well as adults, the two most important preventable causes of death are smoking and obesity, at least in the developed world. Whether the risk of obesity is equivalent to the risk of heavy smoking is not entirely clear, but this large study in young men is very carefully conducted and suggests that it is. We agree with the authors that obesity and smoking among adolescents are important targets for intensified public health initiatives.

Barbara J. Moore, PhD, is President and CEO of Shape Up America!

Physical Activity and Academic Achievement: Is There A Link?
by Derek Mears, PhD
Juvenal, the ancient Roman poet, first coined the phrase "a sound mind in a sound body" to summarize what he believed to be an important link between exercise and cognitive health — that is, sound mental functioning. This ancient philosophy has long been a primary concern of parents, educators and administrators throughout the US. Nonetheless, in a misguided attempt to facilitate the development of a "sound mind," physical activity opportunities for children — instructional time for physical education and recess — are being sacrificed in many school systems.

Greater emphasis on academic instruction has been proposed in order to increase student test scores.1 However, results from the Trends in International Mathematics and Science Study [TIMSS] indicate that more instructional time may not be effective in increasing academic performance.2 In comparisons of student performance, US rankings dropped from 19th to 37th in math and from 18th to 35th in science between the years of 1999 and 2008.

The "sound body" of today's youth is being compromised. Over 65% of children and adolescents fail to perform physical activity of a sufficient intensity or duration. Fully 25% are classified as sedentary and 17% are obese.3 What is the relationship between intellectual development and physical fitness?

Recent studies have shown positive relationships between higher levels of physical fitness and academic performance 4,5,6 and that increasing physical education time is not detrimental to achievement in other academic areas.7 The 2005 California Department of Education study of 884,715, fifth, seventh and ninth graders found that as the students' level of physical fitness improved so did their mean achievement level on state tests.6 Neurophysiologists have also indicated that physical activity strengthens the functioning of the basal ganglia, cerebellum and corpus callosum — key areas related to cognitive function in the brain, and that exercise enhances the brain's ability to communicate and transfer information.8-13

Physical activity is only one of many factors related to how a child will perform academically. Variables such as the learning environment, teaching methods, parental involvement, nutrition, quality of instruction in physical education, and supervision in physical activity settings should all be considered, as they all have an impact on a child's intellectual development. As parents, educators, administrators and community members concerned about the development of the "whole child," we need to look at education through a broader scope.

Learning is an inseparable partnership between the brain and the body and movement is crucial to every brain function including memory, emotion, language, and learning.14 Reducing the ability for kids to move during the school day has a negative impact on their physical health, and it impairs cognitive development, as well. As funding for physical education programs and teachers declines, Juvenal's adage of 1900 years ago is more important now than ever. Shaping the "sound minds" and "sound bodies" of the future depends on a balanced approach to education — one that acknowledges the link between physical competency and academic achievement.

Derrick Mears, Ph.D., A.T.C. is Assistant Professor of Teacher Education, Physical Education at Western Washington University in Bellingham, WA

Celebrating In Good Health
by Barbara J. Moore, PhD
A distressed young mother contacted me two years ago when her child started school. She was dismayed by the fact that hardly a week would pass without a birthday or holiday celebration at school. These celebrations always included cakes, cookies, soda or other foods or beverages she preferred her child not consume at school. Another young mother said that even sporting events for her kids were an excuse for eating chips and drinking soda (pop), and each parent was expected to take turns contributing. She reported that the pressure to adhere to low nutritional standards for these foods and beverages was intense.

Federal law requires every school district to have a wellness policy. The policy should include ALL foods and beverages available at school, but this is often not the case. As a parent, you have a right to see this policy and to determine whether it addresses school celebrations to your satisfaction. If it does not, we encourage you to join the wellness committee at your child's school to help amend the wellness policy and set appropriate nutritional standards for food and beverages served at school celebrations and other events.

Here are some ideas on healthy school celebrations appropriate for each month of the school year.

Menus for Weight Loss and Healthy Eating
Shape Up America! offers these simple, convenient 1500 calorie and 2000 calorie menus to help you eat healthfully while controlling your calories.

Recipe of the Month
Here's a healthier, reduced fat version of a favorite family dish.
Zucchini Lasagna
Makes 6 servings, 1 piece per serving


  • 1/2 lb lasagna noodles, cooked in unsalted water
  • 3/4 cup part-skim mozzarella cheese, grated
  • 1 1/2 cups fat free cottage cheese (use no salt added cottage cheese to reduce sodium)
  • 1/4 cup Parmesan cheese, grated
  • 1 1/2 cups raw zucchini, sliced
  • 2 1/2 cups no salt added tomato sauce
  • 2 tsp basil, dried
  • 2 tsp oregano, dried
  • 1/4 cup onion, chopped
  • 1 clove garlic
  • 1/8 tsp black pepper


  1. Preheat oven to 350 F. Lightly spray 9- by 13-inch baking dish with vegetable oil spray.
  2. In small bowl, combine 1/8 cup mozzarella and 1 tablespoon Parmesan cheese. Set aside.
  3. In medium bowl, combine remaining mozzarella and Parmesan cheese with all of the cottage cheese. Mix well and set aside.
  4. Combine tomato sauce with remaining ingredients. Spread thin layer of tomato sauce in bottom of baking dish. Add a third of noodles in single layer. Spread half of cottage cheese mixture on top. Add layer of zucchini.
  5. Repeat layering. Add thin coating of sauce. Top with noodles, sauce, and reserved cheese mixture. Cover with aluminum foil.
  6. Bake for 30-40 minutes. Cool for 10-15 minutes. Cut into 6 portions.

Nutritional analysis per serving: 276 calories, 5 grams total fat, 2 grams saturated fat, 11 milligrams cholesterol, 41 grams carbohydrate, 19 grams protein, 5 grams dietary fiber, 380 milligrams sodium (*196 milligrams sodium if no salt added cottage cheese is used)

Source: Keep the Beat Heart Healthy Recipes, NHLBI

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Editor: Adrienne Forman, MS, RD

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