The role of physical activity and exercise in obesity and weight management: Time for critical appraisal

This is an elec onic ep in o he o iginal a icle. This ep in may di e om he o iginal in pagina ion and ypog aphic de ail. Au ho (s): Ti le: Yea : Ve sion: Please ci e he o iginal e sion: All ma e ial supplied ia JYX is p o ec ed by copy igh and o he in ellec ual p ope y igh s, and duplica ion o sale o all o pa o any o he eposi o y collec ions is no pe mi ed, excep ha ma e ial may be duplica ed by you o you esea ch use o educa ional pu poses in elec onic o p in o m. You mus ob ain pe mission o any o he use. Elec onic o p in copies may no be o e ed, whe he o sale o o he wise o anyone who is no an au ho ised use . The ole o physical ac i i y and exe cise in obesi y and weigh managemen : Time o c i ical app aisal Wiklund, Pe i Wiklund, P. (2016). The ole o physical ac i i y and exe cise in obesi y and weigh managemen : Time o c i ical app aisal. Jou nal o Spo and Heal h Science, 5(2), 151-154. h ps://doi.o g/10.1016/j.jshs.2016.04.001 2016 Re iew The ole o physical ac i i y and exe cise in obesi y and weigh managemen : Time o c i ical app aisal Pe i Wiklund * Depa men o Heal h Sciences, Uni e si y o Jy äskylä, Jy äskylä FI-40014, Finland Recei ed 15 Janua y 2016; e ised 1 Ma ch 2016; accep ed 21 Ma ch 2016 A ailable online 8 Ap il 2016 Abs ac The p e alence o o e weigh and obesi y has inc eased d ama ically du ing las 3 decades wi h de as a ing consequences o public heal h. Recommended s a egies o educe obesi y ha e ocused on heal hie die and physical ac i i y (PA). Clea ly, hese app oaches ha e no been success ul, bu whe he his is due o ailu e o es ic ene gy in ake o o main ain high le els o ene gy expendi u e has been he subjec o g ea con o e sy. Consequen ly, he e has been a g ea deal o con usion abou he ole o PA and exe cise in obesi y and weigh managemen . In his a icle, he heo e ical basis o conside ing educed PA and ene gy expendi u e as he cause o obesi y is app aised. Fu he , he ole o PA in ood in ake and weigh con ol is examined. The idea ha obesi y is caused by consis en decline in daily ene gy expendi u e is no suppo ed ei he by objec i e measu es o ene gy expendi u e o physiological heo y o weigh gain alone. Howe e , since olun a y exe cise is he mos impo an disc e iona y componen o o al daily ene gy expendi u e, i can a ec ene gy balance. The e o e, PA and exe cise hold po en ial as pa o he solu ion o he ongoing obesi y epidemic. © 2016 P oduc ion and hos ing by Else ie B.V. on behal o Shanghai Uni e si y o Spo . This is an open access a icle unde he CC BY-NC-ND license (h p://c ea i ecommons.o g/licenses/by-nc-nd/4.0/). Keywo ds: Ene gy expendi u e; Exe cise; Obesi y; O e weigh ; Physical ac i i y 1. In oduc ion The p e alence o o e weigh and obesi y has inc eased subs an ially in all socie ies ac oss he globe du ing las 3 decades (Fig. 1), and all indica ions a e ha his end is likely o con inue unaba ed in he coming yea s.1This is a majo public heal h conce n because obesi y has a eaching nega i e e ec s on heal h. The isk o ype 2 diabe es, ca dio ascula disease, ce ain ypes o cance s, and e en mo ali y a e di ec ly p opo ional o he deg ee o obesi y.2,3 Thus, i goes wi hou saying ha he e is a need o e e se his mode n epidemic. Public heal h ac ions o educe obesi y ha e mos ly ocused on indi iduals, encou aging hem o ea heal hie and o exe cise mo e. Bu so a , hese app oaches a e ailing as no a single coun y has succeeded in educing obesi y a es in he pas 30 yea s.4Whe he his is due o ailu e o es ic ene gy in ake o o main ain high le els o ene gy expendi u e has ye o be de e mined conclusi ely, and he ela i e impo ance o hese 2 elemen s has been he subjec o spa king deba e.5–7 The lack o consensus has led o a g ea deal o con usion o he use ulness o physical ac i i y (PA) in weigh loss, and he media’s messages abou he u ili y o exe cise ha e no hing bu gal anized his pe plexi y. In his a icle, I will conside he ole o PA in obesi y de elopmen and i s use ulness in weigh managemen . 2. Secula ends in occupa ional and household- ela ed PA appea o be cong uen wi h he dynamics o he popula ion weigh gain Concep ually, obesi y is a condi ion in which he amoun o body a exceeds he biological need o an indi idual. Obesi y is a mani es a ion o a posi i e ene gy balance ha has been sus ained o e an ex ended pe iod o ime. Howe e , he eason why his condi ion has sp ead inexo ably ac oss he globe o e he pas 3 decades wi h such speed is no well unde s ood. Gene ally speaking, he human genome has no changed sub- s an ially du ing his ime; he e o e, he ise in obesi y mos likely e lec s changes in he en i onmen and/o beha io . Du ing he pas hal -cen u y mechaniza ion has impinged upon Pee e iew unde esponsibili y o Shanghai Uni e si y o Spo . *E-mail add ess: [email p o ec ed] h p://dx.doi.o g/10.1016/j.jshs.2016.04.001 2095-2546/© 2016 P oduc ion and hos ing by Else ie B.V. on behal o Shanghai Uni e si y o Spo . This is an open access a icle unde he CC BY-NC-ND license (h p://c ea i ecommons.o g/licenses/by-nc-nd/4.0/). A ailable online a www.sciencedi ec .com Jou nal o Spo and Heal h Science 5 (2016) 151–154 www.jshs.o g.cn HOSTED BY ScienceDi ec ou modes o li ing in di e se ways. Consequen ly, ene gy expendi u e equi ed o daily li ing has con inuously declined. A ecen s udy showed ha in he US, daily ene gy expendi u e due o wo k ela ed PA has dec eased by mo e han 100 kcal du ing las 50 yea s in bo h men and women, and his educ ion is associa ed wi h he inc ease in mean body weigh du ing his ime ame.8Simila ends ha e also been obse ed in o he coun ies including Finland, whe e daily ene gy expendi u e du ing wo k epo edly dec eased by mo e han 50 kcal be ween 1982 and 1992 while he a e age body weigh elen - lessly c ep upwa d.9Mo e ecen s udies indica ed ha hese ends ha e con inued unaba ed up o he p esen day.10,11 Sub- s an ial educ ions in daily ene gy expendi u e ha e also occu ed in de eloping coun ies such as China and B azil, which ha e he highes absolu e and ela i e a es o decline in o al PA due o educ ions in mo emen a wo k.12 Fo his eason, i is belie ed ha he obesi y epidemic has also pen- e a ed he low-income coun ies, pa icula ly in he u ban a eas, and will con inue o sp ead o he o eseeable u u e.13 The e is also eason o assume ha domes ic mechaniza ion o daily asks (wi h he ad en o labo -sa ing de ices such as washing machines and dishwashe s) ha e educed ene gy expendi u e o e he yea s. Indeed, i was ecen ly es ima ed ha in women, daily housewo k- ela ed ene gy expendi u e has dec eased by 360 kcal in he US since he 1960s.14 The au ho s o he s udy concluded ha such educ ions in housewo k- ela ed ene gy expendi u e migh ha e been subs an ial con- ibu o s o he ise in p e alence o obesi y in women in las 5 decades. Because such labo -sa ing de ices a e habi ually used in all a luen socie ies, hei con ibu ion o popula ion ene gy balance in high-income coun ies has been conside ed subs an i e.15 Domes ic mechaniza ion has also con ibu ed o inc eased seden a iness, as ime spen in house wo k has been eplaced by seden a y ac i i ies such as wa ching ele ision and use o o he sc een based media.16 Many s udies ha e impli- ca ed seden a y beha io , including passi e anspo a ion, wi h weigh gain.17–19 On he o he hand, pa icipa ion in leisu e- ime physical ac i i y (LTPA) has p og essi ely inc eased o e he yea s;20 howe e , i appea s ha on a secula basis, his has no been enough o o se inc eased seden a y beha io , as o al PA is declining apidly ac oss he globe.12 3. Objec i e measu emen s o ene gy expendi u e con lic he idea ha obesi y epidemic is a ibu able o educ ions in daily ene gy expendi u e Based on he e idence p esen ed abo e, i seems in ui i e ha he ise in bodyweigh and obesi y is a ibu able o dec eases in daily ene gy expendi u e. Howe e , on close sc u- iny his idea seems highly imp obable, and he e is ai amoun o e idence o suppo ha con en ion. Fi s , he “labo -sa ing” cul u e has no changed subs an ially since he 1960s and 1970s, whe eas he obesi y p e alence s a ed o inc ease d a- ma ically only a ound he 1980s. Second, doubly-labeled wa e s udies (which p o ide he op imal me hod o measu e ene gy expendi u e in ee-li ing indi iduals) show ha daily ene gy expendi u e has no declined be ween 1980 and 2005 in Eu ope o No h Ame ica.21 Simila ly, ecen me a-analyses o nea ly 100 doubly-labeled wa e s udies indica ed ha popula ions in indus ialized coun ies do no ha e lowe a e o daily ene gy expendi u e compa ed wi h popula ions in de eloping coun ies.22 Clea ly, obese indi iduals ha e highe habi ual ene gy expendi u e compa ed wi h no mal weigh people23 (due o hei la ge body size and es ing me abolic a es). Leibel e al.24 demons a ed ha 10% weigh gain inc eases daily ene gy expendi u e om 370 o 530 kcal, depending on he baseline weigh . The ob ious implica ion o his is ha he a e o ene gy in ake mus also inc ease acco dingly, o he wise weigh loss will ensue. Consis en wi h his no ion, Swinbu n e al.25 examined U.S. nu i ional su eillance da a and showed ha he es ima ed daily ene gy in ake in adul s has inc eased on a e age by 500 kcal in he US be ween 1970s and 2000s. Simila indings ha e also been epo ed om se e al Eu opean coun ies.26,27 Howe e , a mo e ecen examina ion by A che e al.28 sug- ges ed ha once he measu es o die a y in ake in Na ional Heal h and Nu i ion Examina ion Su ey (NHANES) we e modi ied, no subs an ial di e ence in ene gy in ake exis ed. Ene gy in ake canno be quan i ied as p ecisely as ene gy expendi u e. The eason why daily ene gy in ake is no ably smalle han simul aneously es ima ed ene gy expendi u e28,29 may be explained by selec i e mis epo ing (o e o unde ) and ecall bias, which a e well-known ac o s ha con ound s udies in es iga ing ene gy in ake in humans.30 Popula ion ene gy in ake can also be assessed om he na ional ood a ailabili y da a. These da a show ha daily ene gy in ake in he US inc eased slowly un il he ea ly 1980s, and hen s a ed o inc eased apidly.31 Mo eo e , a ecen global analysis con- cluded ha inc eases in ood-ene gy supplies a e su icien o explain inc eases in a e age popula ion body weigh , pa icu- la ly in high-income coun ies.32 Thus, i seems unlikely ha dec emen s in daily ene gy expendi u e a e d i ing he ongoing obesi y epidemic. 4. The ole o PA in ood in ake and weigh con ol Dec eases in daily ene gy expendi u e may no be he p ima y cause o obesi y, bu ha is no o say ha PA o Fig. 1. Changes (%) in adul obesi y p e alence o e ime in selec ed coun ies a ound he wo ld.50 BMI =body mass index. Rep oduced wi h pe mission o Wo ld Obesi y Fede a ion. 152 P. Wiklund exe cise has no ole in weigh managemen and ene gy balance. One heo y holds ha ene gy balance may be easie o achie e when ene gy lux is high. This concep was o iginally de eloped by Maye e al.33 in he 1950s, and has subsequen ly been desc ibed by Blundell and King34 and Hill e al.35 Acco ding o his heo y, a h eshold o PA exis s abo e which people a e in he so called “ egula ed zone” o ene gy balance. Those who a e in he egula ed zone a e able o mee high ene gy expendi u e needs wi h ene gy in ake, hus main aining body weigh . Howe e , hose who a e below he PA h eshold ha e lowe ene gy expendi u e, and hus a e in he “un egula ed zone” wi hou he ma ching dec emen s in ene gy in ake. In o he wo ds, his heo y sugges s ha appe i e may no be app op i- a ely egula ed a low le els o PA. This was ecen ly demon- s a ed by Shook e al.;36 hey examined he ela ion be ween ene gy in ake, PA, appe i e, and weigh gain du ing a 1-yea ollow-up, and epo ed ha indi iduals wi h low PA had highe le els o c a ings o oods compa ed wi h hose who had high le els o PA. Fu he mo e, he au ho s no ed ha a h eshold o achie ing ene gy balance occu ed a an ac i i y le el co e- sponding o 7116 s eps pe day. Thus, i may be ha inc ease in seden a iness in he cou se o he yea s has allowed much s eepe ajec o y in popula ion weigh gain han wha would ha e been o he wise. Volun a y exe cise is he mos impo an disc e iona y com- ponen o o al daily ene gy expendi u e, and hus has he po en- ial o a ec ene gy balance. This has been illus a ed in a numbe o longi udinal s udies. Fo example, in a p ospec i e s udy wi h 20 yea s o ollow-up, Hankinson e al.37 showed ha main aining high le el o PA mi iga es weigh gain signi ican ly, pa icula ly in women. In ha s udy, ac i e indi iduals gained less weigh du ing he ollowed pe iod compa ed wi h hose who we e consis en ly inac i e. Simila indings ha e been epo ed om he Finnish Twin Coho , which can be consid- e ed as a na u al expe imen al app oach o in es iga e he ole o PA and genes o o he amilial ac o s on u u e mo bidi y.38 Twins who ha e been consis en ly disco dan LTPA o o e 30 yea s di e signi ican ly om each o he in e ms o body weigh and body composi ion; physically ac i e co- wins ha e signi ican ly lowe body weigh ,39 BMI,40 and a pe cen , and hey ha e much less (50%) isce al and hepa ic a 41 compa ed wi h hei inac i e co- win. This e idence clea ly shows ha pe sis en ly highe PA le el is associa ed wi h dec eased a e o weigh gain e en a e con olling o gene ic liabili y and childhood en i onmen . The e is also a weal h o e idence om con olled ials ha exe cise (o PA) ca ied ou o e long pe iods o ime can gene a e ene gy de ici and he eby induce weigh loss.42–44 Se ies o e iews,45,46 including a Coch ane Re iew47 (which is conside ed as he golden s anda d in assess- ing e idence), indica e ha exe cise induces weigh loss, and ha he weigh loss is e en g ea e when coupled wi h ene gy es ic ion. Thus, bo h die and exe cise a e impo an compo- nen s in he p og ams in ended o weigh loss. Howe e , he majo i y o he weigh loss p og ams seem o ail in he long- e m as people o en egain weigh .48 Consequen ly, a gene al pe cep ion, pa icula ly among he layman, is ha only e y ew succeed in long- e m main enance o weigh loss. Howe e , long- e m weigh loss main enance is a ques ion o beha io al adhe ence. S udies ha e clea ly shown ha con inued adhe - ence o die and exe cise s a egies a e associa ed wi h long- e m success.49 5. Conclusion The inc ease in obesi y epidemic is occu ing agains he backg ound o con inuous decline in he ene gy expendi u e equi ed o daily li ing. Howe e , he idea ha obesi y is inc easing because o consis en decline in daily ene gy expen- di u e is no suppo ed ei he by objec i e measu es o ene gy expendi u e o physiological heo y o weigh gain. Clea ly, obesi y esul s om excessi e ene gy in ake ha has sus ained o e a long pe iod o ime. Cu en ly, we do no unde s and why people consume mo e ene gy han hey expend. I may be ha PA has he abili y o egula e ood in ake, bu in he con empo- a y en i onmen ha is conduci e o seden a y beha io , his egula o y mechanism has gone as ay. Inc easing PA mos ce ainly can c ea e ene gy de ici h ough inc eased ene gy expendi u e. Fo his eason PA and exe cise hold po en ial as pa o he solu ion o he ongoing obesi y epidemic. Compe ing in e es s The au ho decla es no compe ing inancial in e es s. Re e ences 1. Finkels ein EA, Kha jou OA, Thompson H, T ogdon JG, Pan L, She y B, e al. Obesi y and se e e obesi y o ecas s h ough 2030. AmJP e Med 2012;42:563–70. 2. Lu Y, Haji a halian K, Ezza i M, Woodwa d M, Rimm EB, Danaei G. Me abolic media o s o he e ec s o body-mass index, o e weigh , and obesi y on co ona y hea disease and s oke: a pooled analysis o 97 p ospec i e coho s wi h 1.8 million pa icipan s. Lance 2014;383:970–83. 3. McGee DL. Body mass index and mo ali y: a me a-analysis based on pe son-le el da a om wen y-six obse a ional s udies. Ann Epidemiol 2005;15:87–97. 4. Ng M, Fleming T, Robinson M, Thomson B, G ae z N, Ma gono C, e al. Global, egional, and na ional p e alence o o e weigh and obesi y in child en and adul s du ing 1980–2013: a sys ema ic analysis o he Global Bu den o Disease S udy 2013. Lance 2014;384:766–81. 5. Blai SN, A che E, Hand GA. Commen a y: Luke and Coope a e w ong: physical ac i i y has a c ucial ole in weigh managemen and de e minan s o obesi y. In J Epidemiol 2013;42:1836–8. 6. Hill JO, Pe e s JC. Commen a y: physical ac i i y and weigh con ol. In J Epidemiol 2013;42:1840–2. 7. Luke A, Coope RS. Physical ac i i y does no in luence obesi y isk: ime o cla i y he public heal h message. In J Epidemiol 2013;42:1831–6. 8. Chu ch TS, Thomas DM, Tudo -Locke C, Ka zma zyk PT, Ea nes CP, Roda e RQ, e al. T ends o e 5 decades in U.S. occupa ion- ela ed physical ac i i y and hei associa ions wi h obesi y. PLoS One 2011; 6:e19657. doi: 10.1371/jou nal.pone.0019657 9. Fogelholm M, Mannis o S, Va iainen E, Pie inen P. De e minan s o ene gy balance and o e weigh in Finland 1982 and 1992. In J Obes Rela Me ab Diso d 1996;20:1097–104. 10. Bo odulin K, Ha ald K, Jousilah i P, Laa ikainen T, Mannis o S, Va iainen E. Time ends in physical ac i i y om 1982 o 2012 in Finland. Scand J Med Sci Spo s 2016;26:93–100. 11. Bo odulin K, Va iainen E, Pel onen M, Jousilah i P, Juole i A, Laa ikainen T, e al. Fo y-yea ends in ca dio ascula isk ac o s in Finland. Eu J Public Heal h 2015;25:539–46. 12. Ng SW, Popkin BM. Time use and physical ac i i y: a shi away om mo emen ac oss he globe. Obesi y Re 2012;13:659–80. 153Physical ac i i y and obesi y 13. P en ice AM. The eme ging epidemic o obesi y in de eloping coun ies. In J Epidemiol 2006;35:93–9. 14. A che E, Shook RP, Thomas DM, Chu ch TS, Ka zma zyk PT, Hebe JR, e al. 45-yea ends in women’s use o ime and household managemen ene gy expendi u e. PLoS One 2013;8:e56620. doi: 10.1371/jou nal.pone. 0056620 15. Lanningham-Fos e L, Nysse LJ, Le ine JA. Labo sa ed, calo ies los : he ene ge ic impac o domes ic labo -sa ing de ices. Obes Res 2003; 11:1178–81. 16. A che E, La ie CJ, McDonald SM, Thomas DM, Hebe JR, Ta e no Ross SE, e al. Ma e nal inac i i y: 45-yea ends in mo he s’ use o ime. Mayo Clin P oc 2013;88:1368–77. 17. McCo mack GR, Vi k JS. D i ing owa ds obesi y: a sys ema ized li e a u e e iew on he associa ion be ween mo o ehicle a el ime and dis ance and weigh s a us in adul s. P e Med 2014;66:49–55. 18. Rhodes RE, Ma k RS, Temmel CP. Adul seden a y beha io : a sys ema ic e iew. AmJP e Med2012;42:e3–28. 19. Tho p AA, Owen N, Neuhaus M, Duns an DW. Seden a y beha io s and subsequen heal h ou comes in adul s a sys ema ic e iew o longi udinal s udies, 1996–2011. AmJP e Med2011;41:207–15. 20. Knu h AG, Hallal PC. Tempo al ends in physical ac i i y: a sys ema ic e iew. J Phys Ac Heal h 2009;6:548–59. 21. Wes e e p KR, Speakman JR. Physical ac i i y ene gy expendi u e has no declined since he 1980s and ma ches ene gy expendi u es o wild mammals. In J Obes (Lond) 2008;32:1256–63. 22. Dugas LR, Ha de s R, Me ill S, Ebe sole K, Shoham DA, Rush EC, e al. Ene gy expendi u e in adul s li ing in de eloping compa ed wi h indus ialized coun ies: a me a-analysis o doubly labeled wa e s udies. Am J Clin Nu 2011;93:427–41. 23. Ra ussin E, Bu nand B, Schu z Y, Jequie E. Twen y- ou -hou ene gy expendi u e and es ing me abolic a e in obese, mode a ely obese, and con ol subjec s. Am J Clin Nu 1982;35:566–73. 24. Leibel RL, Rosenbaum M, Hi sch J. Changes in ene gy expendi u e esul ing om al e ed body weigh . N Engl J Med 1995;332:621– 8. 25. Swinbu n B, Sacks G, Ra ussin E. Inc eased ood ene gy supply is mo e han su icien o explain he US epidemic o obesi y. Am J Clin Nu 2009;90:1453–6. 26. Sil en oinen K, Sans S, Tolonen H, Mon e de D, Kuulasmaa K, Kes eloo H, e al. T ends in obesi y and ene gy supply in he WHO MONICA P ojec . In J Obes Rela Me ab Diso d 2004;28:710–8. 27. Balanza R, Ga cia-Lo da P, Pe ez-Rod igo C, A ance a J, Bone MB, Salas-Sal ado J. T ends in ood a ailabili y de e mined by he Food and Ag icul u e O ganiza ion’s ood balance shee s in Medi e anean Eu ope in compa ison wi h o he Eu opean a eas. Public Heal h Nu 2007; 10:168–76. 28. A che E, Hand GA, Blai SN. Validi y o U.S. nu i ional su eillance: Na ional Heal h and Nu i ion Examina ion Su ey calo ic ene gy in ake da a, 1971–2010. PLoS One 2013;8:e76632. doi: 10.1371/jou nal.pone. 0076632 29. Black AE, P en ice AM, Goldbe g GR, Jebb SA, Bingham SA, Li ings one MB, e al. Measu emen s o o al ene gy expendi u e p o ide insigh s in o he alidi y o die a y measu emen s o ene gy in ake. JAm Die Assoc 1993;93:572–9. 30. Black AE, Cole TJ. Biased o e - o unde - epo ing is cha ac e is ic o indi iduals whe he o e ime o by di e en assessmen me hods. JAm Die Assoc 2001;101:70–80. 31. Le i sky DA, Pacanowski CR. F ee will and he obesi y epidemic. Public Heal h Nu 2012;15:126–41. 32. Vande ij e e S, Chow CC, Hall KD, Umali E, Swinbu n BA. Inc eased ood ene gy supply as a majo d i e o he obesi y epidemic: a global analysis. Bull Wo ld Heal h O gan 2015;93:446–56. 33. Maye J, Roy P, Mi a KP. Rela ion be ween calo ic in ake, body weigh , and physical wo k: s udies in an indus ial male popula ion in Wes Bengal. Am J Clin Nu 1956;4:169–75. 34. Blundell JE, King NA. Physical ac i i y and egula ion o ood in ake: cu en e idence. Med Sci Spo s Exe c 1999;31(Suppl. 11):S573–83. 35. Hill JO, Wya HR, Pe e s JC. Ene gy balance and obesi y. Ci cula ion 2012;126:126–32. 36. Shook RP, Hand GA, D enowa z C, Hebe JR, Paluch AE, Blundell JE, e al. Low le els o physical ac i i y a e associa ed wi h dys egula ion o ene gy in ake and a mass gain o e 1 yea . Am J Clin Nu 2015; 102:1332–8. 37. Hankinson AL, Da iglus ML, Boucha d C, Ca ne hon M, Lewis CE, Sch eine PJ, e al. Main aining a high physical ac i i y le el o e 20 yea s and weigh gain. JAMA 2010;304:2603–10. 38. Leskinen T, Kujala UM. Heal h- ela ed indings among win pai s disco dan o leisu e- ime physical ac i i y o 32 yea s: he TWINACTIVE s udy synopsis. Twin Res Hum Gene 2015;18:266–72. 39. Walle K, Kap io J, Kujala UM. Associa ions be ween long- e m physical ac i i y, wais ci cum e ence and weigh gain: a 30-yea longi udinal win s udy. In J Obes (Lond) 2008;32:353–61. 40. Pii ola M, Kap io J, Walle K, Heikkila K, Kosken uo M, S edbe g P, e al. Leisu e- ime physical inac i i y and associa ion wi h body mass index: a Finnish Twin S udy wi h a 35-yea ollow-up. In J Epidemiol 2016. doi: 10.1093/ije/dyw007 [Epub ahead o p in ]. 41. Leskinen T, Sipila S, Alen M, Cheng S, Pie ilainen KH, Usenius JP, e al. Leisu e- ime physical ac i i y and high- isk a : a longi udinal popula ion-based win s udy. In J Obes (Lond) 2009;33:1211–8. 42. Donnelly JE, Honas JJ, Smi h BK, Mayo MS, Gibson CA, Sulli an DK, e al. Ae obic exe cise alone esul s in clinically signi ican weigh loss o men and women: midwes exe cise ial 2. Obesi y (Sil e Sp ing) 2013;21:E219–28. 43. Jakicic JM, Ma cus BH, Lang W, Janney C. E ec o exe cise on 24-mon h weigh loss main enance in o e weigh women. A ch In e n Med 2008;168:1550–9. discussion 59–60. 44. Rosenkilde M, Aue bach P, Reichkendle MH, Ploug T, S allknech BM, Sjodin A. Body a loss and compensa o y mechanisms in esponse o di e en doses o ae obic exe cise–a andomized con olled ial in o e weigh seden a y males. Am J Physiol Regul In eg Comp Physiol 2012;303:R571–9. 45. Ballo DL, Keesey RE. A me a-analysis o he ac o s a ec ing exe cise-induced changes in body mass, a mass and a - ee mass in males and emales. In J Obes 1991;15:717–26. 46. Ca enacci VA, Wya HR. The ole o physical ac i i y in p oducing and main aining weigh loss. Na Clin P ac Endoc inol Me ab 2007; 3:518–29. 47. Shaw K, Genna H, O’Rou ke P, Del Ma C. Exe cise o o e weigh o obesi y. Coch ane Da abase Sys Re 2006;(4):CD003817. doi: 10.1002/14651858.CD003817.pub3 48. El hag K, Rossne S. Who succeeds in main aining weigh loss? A concep ual e iew o ac o s associa ed wi h weigh loss main enance and weigh egain. Obesi y Re 2005;6:67–85. 49. Wing RR, Phelan S. Long- e m weigh loss main enance. Am J Clin Nu 2005;82(Suppl. 1):S222–5. 50. T ends in Global Obesi y. A ailable a h p://www.wo ldobesi y.o g/ esou ces/obesi y-da a- eposi o y/ esou ces/ ends/12/;2014 [accessed 23.03.2016]. 154 P. Wiklund