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Metabolic And Mechanical Cost Of Sedentary And Physical Activities In Obese Children And Adolescents

Metabolic And Mechanical Cost Of Sedentary And
Physical Activities In Obese Children And Adolescents
Stefano Lazzer
Department of Medical and Biological Sciences, University of Udine, Italy
Grace O’Malley
Physiotherapy Department, Childhood Obesity Service, Temple Street Children’s University Hospital,
Dublin, Ireland
Michel Vermorel
Energy and Lipid Metabolism Research Unit, INRA Theix, Saint-Genès Champanelle, France
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Obesity often results from an imbalance between energy intake and energy expenditure. Daily energy
intake can be determined both quantitatively and qualitatively. By contrast, estimation of daily energy
expenditure in free-living conditions requires qualified personnel and sophisticated technical methods.
Daily energy expenditure (EE) can be distributed between a number of interdependent factors including:
basal metabolic rate (BMR) extrapolated to a 24-hour period; EE associated with alimentation (thermic
effect of food, TEF); growth (in children); healing; thermoregulation (but in developed countries the
effects of cold are minimized by adjustment of clothing, housing and heating, (1); and physical activity.
In addition, for practical purposes the increase in EE associated with physical activities must be
partitioned between sedentary behaviour and actual physical activities (Fig. 1).
Figure 1 : Main components of daily energy expenditure (EE) (modified from (2)).
BMR: basal metabolic rate; SMR: sleeping metabolic rate; WMR: wakefulness metabolic rate; TEF:
thermic effect of food EE; SA: sedentary activity EE; PA: physical activity EE.
The objectives of this chapter are:
1) to review the influential factors on the main components of daily EE;
2) to investigate the association between mechanical parameters of walking and running gait with the
obese and post-obese state in adolescents;
3) to describe the physical activity ratio corresponding to various sedentary behaviours and physical
activities for children and adolescents who are obese and finally
4) to suggest methods for estimating daily energy expenditure adolescents who are obese.
% Daily EE
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Main Components Of Daily Energy Expenditure
Basal metabolic rate
Basal metabolic rate (BMR) is the energy expended by the body to maintain basic physiologic functions
(e.g. cellular activity and organ functions, heartbeat, muscle contraction and function, and respiration) in
an individual who is awake. Due to the increased energy demands of the brain and muscle compartments
when awake, the BMR is approximately 5% higher than the metabolic rate expended during sleep (the
minimum level of energy expended by the body to sustain life).
BMR can be measured after a 12-hour fast while the subject is resting in a thermo-neutral and quiet
environment. BMR occurs in a continuous process throughout the 24-hour daily cycle and remains
relatively constant within individuals over time. It is the largest component of daily EE since it
contributes, on average, 60% to daily EE, ranging from 45-50% in very active subjects to about 70% in
sedentary subjects. Therefore, it depends on the mass and metabolic rate (EE g-1 of tissue min-1) of
tissues and organs.
However, the metabolic rate (MR) of tissues and organs is highly variable. For instance, it is about 10, 15,
20, 30, and 35 times higher in the digestive tract, liver, brain, heart, and kidney compared to resting
muscle. In contrast the MR in white adipose tissue is only about 1/3 that of resting muscle (3).
Consequently, while organs account for about 7% of body weight, they contribute about 60% to BMR,
whereas skeletal tissues and adipose tissues account for 35-40% of BW and contribute only 18-22 % and
3-4 % to BMR, respectively (4) (Fig. 2).
Figure 2 : Contribution of organs and tissues to body weight and basal metabolic rate.
Due to lack of information on organ mass and metabolic rate in individuals, for practical purposes the
main significant determinant of BMR is FFM (R2 = 0.65-0.80). FM is a significant determinant only in
individuals who are obese (R2 < 0.04) (5)
% Body weight
Kidneys 0.4%
Heart 0.5%
Brain 2.0 %
Liver 2.6 %
Digestive system 1.7% Fat mass
% Basal metabolic rate
Fat mass
16% 3%
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In absolute values, BMR is higher in individuals who are obese compared to those who are lean due to
higher levels of FFM and FM. However, when adjusted for body composition, BMR is not significantly
different suggesting that tissue and organ metabolic rate is not significantly different between those who
are obese and those who are lean. BMR expressed as per kg of FFM is significantly higher in boys than in
girls, by 3% and 6% in prepubertal and pubertal subjects, respectively (6). Higher levels of BMR are
observed in pubertal children due to higher proportions of skeletal glycolytic fibers (7), higher Na+-K+
ATPase activity (8), and changes in hormonal status (9).
Collectively, FFM, FM, age, gender, and physical activity explain 70-80% of the variance in BMR (10,
11). The remaining 20-30% may be due to genetic factors or other factors such as differences in gut flora
metabolism (12).
The ability to predict BMR accurately in persons who are obese is of utmost importance for adequate
dietary therapy as it provides the basis to calculate a desired level of energy deficit. The gold-standard
method for the measurement of BMR is indirect calorimetry, however its regular use in clinical settings
(for both diagnostic and prognostic purposes) is limited due to its complex nature, the lack of skilled
staff, and the high cost of equipment. Several authors have tried to address the problem by developing
equations for predicting BMR in children and adolescents on the basis of anthropometric and body
composition parameters (13, 14).
The equations based on anthropometric parameters [Equation 1] or body composition [Equation 2] allow
an accurate estimation of BMR in children and adolescents who are obese (10, 11):
BMR = (Gender x 213) (Age x 28) + (Body Weight x 13) + (Stature x 434) + 355
R2 = 0.66 and SE = 246 kcal [Equation 1]
BMR = (Gender x 217) (Age x 26) + (FFM x 16) + (FM x 13) + 868
R2 = 0.66 and SE = 247 kcal [Equation 2]
where Gender = 1 for males and 0 for females, BMR is expressed in kcal, Age in years, Body Weight in
kg, Stature in m, FFM and FM in kg.
Thermic effect of food
The thermic effect of food includes increases in EE observed during the ingestion and digestion of food.
It lasts over an extended period of at least five hours and averages 10% of energy intake. The energy
expenditure associated with food ingestion is influenced primarily by the composition of the food
consumed and is relatively stable over time within individuals (15). The increase in metabolic rate after
food ingestion is lower for lipids and carbohydrates (3 and 5 % of energy intake, respectively, over 3-4
hour periods) than for protein (20-25 %).
Although children require additional energy for growth, the contribution of growth to total energy needs
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is negligible except within the first few months of life. During the growth period energy is stored in the
body as protein and lipids (5.5 and 9.5 kcalg-1, respectively). Assuming a 50-70% efficiency of energy
utilization for growth (depending on the proportion of energy stored as lipids) growth would contribute 2
to 4% of daily energy requirements in adolescents despite a major growth spurt (16).
During adolescence, the relative increase in FM is 13 % in girls while the levels in boys decrease by 4 %.
Adolescent boys have on average 20 kg more FFM than girls. These changes in body composition explain
that EE at rest and during physical activity in boys becomes much higher than in girls at similar total BW.
Following injury or surgical procedures increased energy and protein are required by the body to support
the immune response and repair. The body makes substrates readily available and in turn, resting energy
expenditure rises (17).
Energy expenditure during sedentary and physical activities
Because of their higher body weight including a greater FFM, children and adolescents who are obese
have higher daily EE, BMR and activity energy expenditure compared to non-obese subjects (2).
However, obese children are known to spend less time in physical activities and more time in sedentary
activities than their age-matched counterparts (18).
Daily EE and energy expenditures associated with usual sedentary and physical activities were assessed in
50 non-obese adolescents, and 27 obese adolescents aged 14.0 ± 0.3 y (2). As expected, BMI, FFM and
FM were higher in obese subjects: 34.1 vs 18.8 kgm-2, 52.4 vs 39.9 kg, and 43.1 vs 19.7 kg, respectively.
Excess weight was composed of 27 % FFM and 73 % FM, on average. Sleeping and sedentary activity
EE, were 19% higher in those who were obese compared to those who were non-obese but similar after
adjustment for body composition. Energy expenditure during walking at the same speeds on a treadmill in
whole-body calorimeters was 81% higher in those who were obese compared to those who were non-
obese. After adjustment for body weight, it was still 25% higher (P<0.001), probably because of greater
difficulty of walking observed in severely obese subjects (19-21).
DEE in free-living conditions were 2.26 MJ higher in those who were obese compared to those who were
non-obese (Fig. 3, P < 0.001). After adjustment for body composition, sleeping, sedentary activities and
daily energy expenditures were not significantly different between obese and non-obese subjects, but
energy expenditure associated with physical activities was 61 % lower in obese adolescents (P<0.001) in
spite of the higher energy cost of physical activities. In fact, the obese adolescents spent 47 mind-1 more
at light physical activities (slow walking and housework) and 53 mind-1 less at moderate physical
activities (walking at a normal speed and recreational activities) than the non-obese subjects (22).
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Figure 3. Least-squares mean (± SE) energy expenditure (EE) of and time devoted to the main activities
by non-obese (
; n = 50) and obese (; n = 27) adolescents in free-living conditions. Significant effects
of obesity: *P < 0.05, ***P < 0.001.
Significant effects of obesity: *P < 0.05, ***P < 0.001.
The inter-individual variability in EE was high and gender dependent in obese adolescents. After
adjustment for differences in FFM, it averaged ± 10.1 % in boys and ± 12.4 % in girls for EE during
sedentary activities in standardized conditions (whole-body calorimeter). Similarly, after adjustment for
body weight, the inter-individual variability in EE during walking at 5 km h-1 on a treadmill was ± 21.3
% in boys and ± 12.9 % in girls (22), which suggests differences in walking efficiency.
Effects of reduction of obesity on energy expenditure
The major objectives of weight reduction programs are: 1) to decrease FM in order to reduce metabolic
disorders which predispose obese adolescents to metabolic complications and severe morbidities such as
hypertension, cardiovascular diseases and diabetes; 2) to enhance skills, physical capacities, pleasure and
motivation to practice physical activities; 3) to preserve or increase FFM in order to enhance daily EE and
improve long-term weight regulation; and 4) to change food and behaviour in order to improve energy
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balance. All programmes should aim to increase well-being, encourage social integration and promote
mental blossoming which are mandatory conditions to maintain a long-term effect.
Severe energy restrictions in adolescents resulted in significant decreases in FM and FFM (23), which
may slow down growth and induce reductions in energy expenditure, favouring subsequent body weight
regain. On the contrary, physical training, without energy restriction preserved FFM or allowed increases
in FFM, physical capacities and energy expenditures, but with a lower reduction in FM (24, 25). Weight
reduction programs offer the possibility to combine medical, psychological and physical therapy,
nutritional education and dietetic follow-up, and adapted progressive physical training.
A study following this model was conducted with 26 obese adolescents (12 boys and 14 girls), aged 12-
16 years, over a 9-months period. Body weight loss averaged 18.4 kg (- 20 %) in boys, including 18.0 kg
FM (- 51 %) but only 0.4 kg FFM (- 0.7 %). Mean BMI decrease was 8.1 and 6.3 kg/m² (s.e.m.: 0.38
kg/m2) in boys and girls respectively. Body weight loss averaged 15.6 kg (- 17 %), including 12.5 kg FM
(- 31 %) and 3.2 kg FFM (- 6 %). EE was affected by weight loss. BMR, sleeping EE, and sedentary EE
were significantly lower at the end of the 9-month weight reduction program, both in absolute values (-
8.3, -14.0, and -14.0%, respectively; p< 0.001) and after adjustment for FFM (-6.3, -12.6, and -11.7%,
respectively; p<0.001). The energy cost of walking at the same speeds also decreased significantly (-24%
and -22% in boys and girls, respectively), even after adjustment for BW (-17.6% in boys; p<0.004). As a
consequence, with the same activity program, daily EE was significantly lower (11.67 vs. 13.96 MJ/d;
p<0.001) after the weight reduction period, even after adjustment for FFM (11.84 vs. 13.76 MJ/d;
p<0.001) (26).
The weight reduction program, also resulted in a continuous increase in walking speed during the 9-
month period: +2.9 km.h-1 in boys and +1.8 km.h-1 in girls. The working capacity of arms and legs was
increased threefold. Cardiovascular capacities improved: heart rate decreased 11-18 beats per minute
(bpm) during sleep and sedentary activities, and 20-25 bpm during walking at 4-5 and 6 km.h-1 (Fig. 3,
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Figure 4. Relationship between heart rate (HR) and energy expenditure (EE) as measured by whole-body
calorimetry, before (- - -) and after (
) the weight-reduction program (mean values of all subjects) (26).
During the 4-month period following the weight reduction program, 12 of the 26 adolescents maintained
their body weight, while 10 others gained 6.6 kg body weight, including 5.8 kg FFM (27).
The results of this study confirm and demonstrate that a multidisciplinary weight reduction program in a
specialized institution induces numerous beneficial effects in obese adolescents, but reductions in EE
were observed, especially during sleep and sedentary activities (which account for about 80 % daily EE).
These phenomena contribute to the frequent FM and body weight regains after a weight reduction
In addition, for adolescents who are obese and limited in their functional capacity by impaired exercise
performance, it is optimal to devise a form of physical activity which promotes considerable EE. This
should ideally promote substantial fat oxidation with the minimal subjective perception of effort and
exercise intensity, which could ultimately allow a better tolerance and adherence to physical activity
protocols. Previous studies, suggest that adolescents who are obese exhibited maximal fat oxidation rates
at 41% V’O2max, which corresponded to 58% HRmax (28). Similarly, walking entails the advantages of
enhancing fat utilization over cycling at an intensity requiring similar EE (29). It should be noted
however, that in children who are obese, walking and jogging may be associated with joint pain and as
such, non-weight bearing activity (e.g. cycling or walking in a swimming pool) may be initially
40 60 80 100 120 140 160 180
HR (bpm)
EE (kJ/min)
40 60 80 100 120 140 160 180
HR (bpm)
EE (kJ/min)
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Physical Activity Ratio For Various Sedentary And Physical Activities
Professionals caring for children and adolescents who are obese need information on the type, energy
cost and duration of their usual physical activities in order to prescribe appropriate individual dietary
treatments and activity guidelines.
In clinical practice the questionnaire is the most common method used to estimate the physical activity
level of subjects (30). From this, sedentary and physical activity recalls can be converted to daily EE
using the factorial method with previously determined metabolic equivalents (MET) (31). It should be
noted, that the Compendium values were obtained mainly from studies in normal-weight adults and the
authors defined the MET as the ratio of work metabolic rate to a standard resting metabolic rate of 1.0 (4.184 kJkg-1h-1).
On the basis of previous studies (2, 32, 33), the measured energy cost of walking at 3.5 kmh-1 was on
average 16% higher than the predicted MET EE (31). In addition, for all physical activities, including
walking or body movements, considered in this study, the energy expenditure were on average 15-35%
higher than that predicted by MET (31).
These data suggest the use of the appropriate Physical Activity Ratios (PARs) values (PAR = EE of
activity (kcalmin-1) / BMR (kcalmin-1)) to determine daily energy expenditure by the factorial method
in adolescents who are obese. These PARs values (2, 32, 33) allow more precision in the estimation of
daily energy expenditure of obese who are obese when using the factorial method (Fig. 5).
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Figure 5. Physical activity ratios (PAR) corresponding to various sedentary and physical activities
(modified from (2, 32, 33)
All values are mean ± SD; PAR: Physical activity ratio = PAR = EE of activity (kcal
min-1) / BMR
0 1 2 3 4 5 6 7 8 9
Basal metabolic rate
Sitting, card playing, playing board games
Reading a book, listening to music
Sitting watching television
Transport by train, car or bus
Eat sitting
Performing video games (sitting)
Bathing, dressing, undressing
Recreation at school (standing and talking)
Table soccer
Gymnastics, general
Cleaning a room (dusting, sweeping)
Walking 2.0 km/h - 0% slope
Bicycling stationary, 25 watts
Swimming, sport participation in the class
Table tennis
Bicycling stationary, 50 watts
Walking 3.3 km/h - 0% slope
Cleaning a room (changing linen)
Aerobic stepping, low impact
Non-competitive soccer, volley-ball and tennis
Walking 3.3 km/h - 3% slope
Bicycling stationary, 75 watts
Walking 4.3 km/h - 3% slope
Walking upstairs
Bicycling stationary, 100 watts
Bicycling stationary, 125 watts
Walking 4.8 km/h - 6% slope
Bicycling stationary, 150 watts
Walking 4.8 km/h - 9% slope
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Estimation Of Daily Energy Expenditure
Daily energy expenditure of subjects is often evaluated from subjects’ diaries or recalls during the
previous weeks (26). The activities reported are then evaluated for frequency, duration, and intensity to
evaluate mean daily energy expenditure (kcal). The latter can be calculated by using the following
[Equation 3]
where N corresponds to the number of activities, BMR (Equation 1 and 2) is expressed in kcalmin-1,
PAR (Table 1) is a dimensionless measure, and duration of activity in min.
On this basis, a boy (14 y, body weight 93 kg, height 1.62 m) has a predicted basal metabolic rate of
1.46 (kcalmin-1, Eq. 1)). If he sleeps for 540 min (PAR: 0.93), dresses for 60 min (PAR: 2.05), eats for
120 min (PAR: 1.75), stays at school for 420 min (PAR: 1.65), watches television for 180 min (PAR:
1.57), walks for 60 min (PAR: 5.46) and cycles for 60 min (PAR: 3.75), his daily energy expenditure
can be estimated to 3441 kcalday-1.
Mechanical Cost Of Walking And Running
In normal-weight subjects
It has been suggested that children who are obese experience a greater mechanical cost during standing
and walking. In particular greater loading of the lower limb joints is observed compared to those of
normal weight and such, persistent loading may predispose the child to pathological gait patterns.
Generally, human locomotion is characterized by two principal gaits, walking and running. The basic
features of the two modes of progression are the same: each step presents one phase of stance and one of
swing, but then they differ, as the leg controllers have two separate modes of operation for walking and
running. The timing of the events in the cycles are different, the stance of each foot being longer in
walking and shorter in running, whilst the swing shows the opposite trend. In walking there is always at
least one foot on the ground, while in running there is a period during which both feet are off the ground,
and the amplitudes of the contractions of the flexor and the extensor muscles during the two phases of the
step are different.
The mechanical energy changes (i.e. the work) required to maintain the overall motion have received
considerable attention because they affect the metabolic EE. Total work (WTOT) is defined as WINT+WEXT
where the work done to raise and accelerate the body centre of mass within the environment is the
external work (WEXT) and the work associated with the acceleration of body segments (mainly limbs) with
respect to the body centre of mass is the internal work (WINT) (34, 35). The WINT tends to be an increasing
function of speed (34), stride frequency (35), segment mass and duty factor (36) and constitutes 25 - 40%
of WTOT in humans (34).
duration) PAR (BMR EEDaily
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The ratio between WTOT and EE yields the efficiency η = WTOTEE-1100, where WTOT and EE must be
expressed in the same units (J, Jm-1 or Jm-1kg-1), therefore efficiency is a dimensionless measure,
expressed in percentage (34). In normal-weight adolescents η increased from 15 to 21 % when the
walking speed increased from 0.75 to 1.50 ms-1 (21).
Despite legged locomotion being the result of the coordinated actions of dozens of muscles, many of them
being bi-articular, exerting force via tendons and producing the movement of a multitude of bones and
body segments, each gait can be described by a model which helps understand the overall mechanics of
the progression along the ground. More specifically, the model elucidate for each gait the interplay among
the three fundamental energies associated to the body centre of mass, namely the potential energy (EP,
mgh), the kinetic energy (EK, 0.5 mv-2), and the elastic energy (EEL), where g is acceleration due to
gravity (9.81 ms-2), m is body weight (37), h is the vertical coordinate above an arbitrary reference level
(m) and v is the speed (ms-1) of the body centre of mass.
Then WEXT can be expressed as WEXT = ΔEP + ΔEK
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Figure 6: Comparisons of walking and running mechanics (modified from Bramble and Lieberman
A. Kinematics of walking (left) and running (right). During walking, the centre of mass are lowest near
toe-off (TO) and highest at mid-stance (MS) where the leg is relatively straight. During running, the head
and centre of mass are highest during the aerial phase and lowest at MS, when the hip, knee and ankle
are flexed; the trunk is also more inclined and the elbow more flexed.
B. Biomechanical contrasts between human gaits. During walking, an inverted pendulum mechanism
exchanges forward kinetic energy (EK) for gravitational potential energy (EP) between heelstrike (HS)
and MS; the exchange is reversed between MS and TO. During running, a mass-spring mechanism causes
EP and EK to be in phase, with both energies declining rapidly to minima between footstrike (FS) and MS.
Leg tendons and ligaments partially convert decreases in EP and EK to elastic energy (EEL) during the
first half of the stance, which is subsequently released through recoil between MS and TO.
Walking has been classically described by an inverted pendulum (Fig. 6, (39)). In those models potential
energy (EP) and kinetic energy (EK) continuously exchange, resulting in a total mechanical energy (TE,
where TE is the sum of EP and EK) with a smaller change over the stride with respect to the two
components taken separately. Such a mechanism minimizes the net energy needed to drive the moving
system. The energy recovery is a parameter which aims at quantifying the ability to save mechanical
energy by using a pendulum-like model. While in ideal (straight) pendulums the energy exchange is
complete (energy recovery is 100%), the path of the centre of mass of the body in walking resembles the
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motion of an inverted pendulum (40), with losses associated both with the deviation from an ideal system
and with the transition from one (inverted) swing to the next (35). The energy recovery is moderately high
(up to 60%) and depends on stride length (41) and walking speed (42). While recent literature has
suggested some elastic energy contribution to walking mechanics, through elastic energy storage and
release in the Achilles tendon (43) and possibly through the bending of the arch of the foot (44), the
pendulum-like model still explains most of the energy interplay within the stride.
In contrast to walking, during running, potential energy (EP) and kinetic energy (EK) change in phase
during the stride (thus no exchange between EP and EK occurs during ground contact). In this gait elastic
energy (EEL) has a crucial role in exchanging with the sum of the other two energy types. Part of the total
mechanical energy (TE) of the system during the flight phase is transformed into elastic energy (EEL)
during the first half of the contact phase, via tendon stretch. In the second half of the phase a consistent
part of the stored energy is given back to the system via tendon recoil, in the preparation for the next
While WEXT is a reliable estimate of the mechanical work done by muscles in walking, the values
obtained for running overestimate muscle work because of the inherent inability to take elastic energy
(EEL) into account. In fact, part of the decrease and increase of total mechanical energy (TE) in running
are not caused by the eccentric and concentric contractions of muscle, but by tendon stretch and recoil,
Effects of obesity on mechanical cost of walking and running
In individuals who are obese the mass distribution is different from that of non-obese subjects, the thigh
dimension being generally increased in disproportion to the general increase of the rest of the body.
External work of walking was higher in obese, but after adjustment for body weight, the external work
was not significantly different between obese and non-obese adolescents; consequently the efficiency (η)
was on average 23 % lower in obese than in non-obese adolescents, and the difference decreased from 30
to 20 % when the walking speed increased (21). The mechanical walking pattern differs between obese
and non-obese adolescents, in particular a greater mediolateral center of mass displacement is greater and
associated with greater step widths, especially at the lowest speeds, probably due to reduced postural
stability. It did not induce a greater external work (WEXT) as measured in the study. The greater net energy
cost of walking in obese subjects may be partially explained by the increased step-to-step transition cost
(i.e., the internal work occurring during the double contact phase) associated with wide gait.
Gushue et al. (45) proposed that overweight children have altered knee joint kinematics due to higher
peak knee adduction moments (73-100% higher than normal weight children). The authors proposed that
gait adaptation may increase medial compartment loading of the lower limbs and contribute to the
development of varus/valgus deformities and osteoarthritic wear and tear. This assertion was supported by
Davids et al (46) who demonstrated that the dynamic gait deviations seen in obese children resulted in
pathologic compressive forces in the medial compartment on the knee. High joint loading across the
medial tibiofemoral compartment is believed to play an important role in the pathogenesis of articular
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injury and osteoarthritis of the knee ((47, 48, 49., 50). Similarly, shearing forces at the hip and a reduced
femoral neck anteversion angle may lead to the development of slipped upper femoral epiphysis(51, 52).
It is reasonable to assert that excess adiposity increases the energy cost of movement and can contributed
to biomechanical inefficiency and postural instability. McGraw and colleagues (2000) and Colne et
al.,(20, 53) found that those who were obese spent significantly longer in the dual stance phase of gait
compared to those who were lean. Obesity was also associated with greater postural sway and slower
preferred gait cadence when compared to normal weight participants. Postural instability in the medio-
lateral plane are corrected by stabilizing responses occurring mainly around the hip (20). These responses
can influence a slower progression of gait as reported by Colne et al. (20, 53).
Additionally, the external work (WEXT) and the net energy cost of running and efficiency (η) in obese and
normal-weight adolescents and adults running at 8 km.h-1 (Taboga et al.2012) were independent of body
mass of the subjects. Elastic tissues of obese subjects seem to adapt (e.g. by thickening) to the increased
mass of the body, thus maintaining their ability to store elastic energy, at least at 2.2 ms-1 speed, at the
same level as in the lean subjects.
Effects of reduction of obesity on mechanical cost of walking
After a 3-month multidisciplinary weight reduction program, adolescents who were obese lost on average
6 % of body mass, 15 % of FM without significant changes in lean body mass (54). After weight loss, the
net metabolic cost of walking at 1.25 ms-1, decreased in association with the biomechanical parameters of
walking: stride length increased by 3.5 %;lateral leg swing and the variation of the medio-lateral kinetic
energy decreased by 18 % and variation in potential energy by 6 %. Consequently the net energy cost of
walking, adjusted for body mass, decreased by 9 %, whereas the external work (Wext) did not vary
The decrease in the net energy cost of walking were correlated with the decreases in body weight, FM and
percent of gynoid mass, but not with the lateral leg swing after weight loss. The main determinant was the
decrease in body weight, which in turn reduced the leg muscle work required to raise and accelerate the
center of mass as well as to support body weight and maintain body equilibrium (55) during walking.
Indeed, as vertical motions allow a pendulum-like exchange between potential and kinetic energy,
weight-reduced individuals could reduce the potential energy available (hence vertical motions) because
of the decrease in medio-lateral kinetic energy fluctuations. The reduction in FM in the gynoid region,
independently of the decrease in total body FM, is related to the decrease in net cost of walking (55).
Reductions in hip and knee moments proportional to weight loss have also been observed following
bariatric procedures (56).
Practical Applications
High cardiorespiratory fitness during childhood and adolescence has been associated with a lower
percentage of body fat and a healthier cardiovascular profile (57, 58), while childhood adiposity is
associated with an unfavourable lipid profile (59). Studies of the available evidence (60) indicated that
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increased physical activity and decreased sedentary behaviour protect against weight gain in childhood
and adolescence.
From a public health perspective, the focus should be on preventing of weight gain and regain after
weight loss (61, 62). Physical activity is recognized as a major component of the management of
overweight or obesity. The importance or magnitude of the beneficial effects of physical activity in this
context differs according to the outcome examined. Physical activity appears essential for weight
maintenance after diet-induced weight loss, rather than for weight loss per se. It is also important for the
preservation of fat-free mass during weight loss. Physical activity has beneficial effects on fitness and
reducing obesity-related complications, such as cardiovascular diseases and diabetes. Most data suggest
that total volume of physical activity, rather than its intensity, is important for managing weight.
Amount of physical activity needed to prevent obesity
There is no definite consensus on the amount of physical activity required to prevent weight gain at the
population level, and the shape of the dozen the amount is not clear. This is a complex issue, especially in
view of the difficulty of matching energy intake with energy expenditure in times of readily available
food and low levels of habitual physical activity (61, 62).
The U.S. Department of Health and Human Services 2008 Physical Activity Guidelines for Americans
(63) recommend that children and teens be physically active for at least 60 minutes on most, if not all,
days, including:
Aerobic: Most of the 60 or more minutes a day should be either moderate- or vigorous-intensity aerobic
physical activity (running, hopping, skipping, jumping rope, swimming, dancing, and bicycling are all
examples of aerobic activities), and should include vigorous-intensity physical activity at least 3 days a
week. Aerobic activities increase cardiorespiratory fitness.
Muscle-strengthening: As part of their 60 or more minutes of daily physical activity, children and
adolescents should include muscle-strengthening physical activity on at least 3 days of the week. Muscle-
strengthening activities can be unstructured and part of play, such as playing on playground equipment,
climbing trees, and playing tug-of-war. Or these activities can be structured, such as lifting weights or
working with resistance bands.
Bone-strengthening: As part of their 60 or more minutes of daily physical activity, children and
adolescents should include bone-strengthening physical activity on at least 3 days of the week. Produce a
force on the bones that promotes bone growth and strength. This force is commonly produced by impact
with the ground. Running, jumping rope, basketball, tennis, and hopscotch are all examples of bone
strengthening activities.
It is important to encourage young people to participate in physical activities that are appropriate for their
age, that are enjoyable, and that offer variety.
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Amount of physical activity needed to weight loss
The amount of physical activity needed to weight loss is related to negative balance between daily energy
intake and daily energy expenditure. Energy intake can be calculated as 1.2 or 1.3 times basal metabolic
rate (32). While, energy expenditure can be calculated as suggested previously. As well as physical
activity must to consider the following suggestions:
Endurance exercise
Frequency: For moderate-intensity activities, accumulate at least up to 60 min·d-1 in bouts of at least 15
min each, at least 2030 min·d-1 or more of vigorous-intensity activities, an equivalent combination of
moderate and vigorous activity.
Intensity: On a scale of 0 to 10 for level of physical exertion, 5 to 6 for moderate-intensity and 7 to 8 for
vigorous intensity. It has been demonstrated in adolescents that fat oxidation is at a maximum during
moderately intense physical activity (50% V’O2peak, 65% maximum heart rate, ~130 bpm) (29) walking
speed 5 km·h-1. However, short bouts (30-60 s) at 100% VO2peak or 100% heart rate favours
improvements also on aerobic power (64).
Duration: For moderate-intensity activities, accumulate at least 45 min·d-1 in bouts of at least 15 min each
of continuous activity for vigorous-intensity activities.
Type: Any modality that does not impose excessive orthopaedic stress; walking or running is the most
common type of activity. Stationary cycle exercise may be advantageous for those with limited tolerance
for weight bearing activity.
Frequency: At least 2 d·w-1.
Intensity: Between moderate- (56) and vigorous- (78) intensity on a scale of 0 to 10.
Type: Progressive weight training program or weight bearing calisthenics (810 exercises involving the
major muscle groups of 812 repetitions each), stair climbing, and other strengthening activities that use
the major muscle groups.
Frequency: At least 4 d·w-1.
Intensity: Moderate (56) intensity on a scale of 0 to 10.
Type: Any activities that maintain or increase flexibility using sustained stretches for each major muscle
group and static rather than ballistic movements.
The progression of activities should be individual and tailored to tolerance and preference; a conservative
approach may be necessary for the most deconditioned and physically limited obese children and
adolescents. Obese children and adolescents should exceed the recommended minimum amounts of
! !
physical activity if they desire to improve their fitness.
Amount of physical activity needed to preventing weight regain
While consensus is lacking on the amount of physical activity needed to prevent weight regain, there is an
indication that children and adolescents would need 60 or more minutes of daily of physical activity
needed to prevent weight regain, there intense activity, to avoid regaining weight (65, 66). This physical
activity also can be done in smaller chunks of time over the day. Engage in more than 1 h of daily
physical activity promoting walking or cycling to school, suggesting activities that involve parents or
friends and promote even small amounts of moderate to vigorous activities. Particularly promote
enjoyable and fun activities.
As well, discourage sedentary behaviour remain a simple ways to increase physical activity.
Daily energy expenditure, basal metabolic rate and energy expenditure corresponding to the various
sedentary and physical activities are significantly higher in the obese than in the non-obese adolescents,
but none except walking was significantly different after adjustment for FFM or BW. The mechanical
walking pattern differs between adolescents who are obese compared to lean peers. In particular a greater
mediolateral center of mass displacement is greater and associated with greater step widths, especially at
the lowest speeds, probably due to reduced postural stability. The greater net energy cost of walking in
obese subjects may be partially explained by the increased step-to-step transition cost (i.e., the internal
work occurring during the double contact phase) associated with wide gait. Increased energy costs and
greater joint loading may predispose the developing musculoskeletal system of children and adolescents
who are obese to injury and abnormal development. In addition, these factors may influence the child’s
interest or affinity to being physically active.
Children who are obese spent more time at light physical activities but much less time at moderate and
sports activities than did the non-obese subjects. The energy expenditure for sports activities did not differ
significantly, which indicates that the obese subjects engaged in less intense activities. Consequently, the
energy expenditure of the obese subjects for moderate and sports activities amounted to 20% and 25% of
those of the non-obese subjects, respectively.
A multidisciplinary weight-reduction program has numerous beneficial effects but induces reduction in
energy expenditures during sleeping and sedentary activities. These decreases do not result only from the
reductions in FM and FFM, but probably also from the reductions in size and metabolic rate of organs
associated with the energy deficit. These phenomena explain the frequent FM and body weight regains. It
is therefore essential for the adolescents to follow scrupulously the dietary recommendations and to
practice daily moderate physical activities to maintain the beneficial effects of the weight reduction
program. In addition, it is recommended that age-appropriate and enjoyable physical activity which
promotes substantial fat oxidation be prescribed. Such activity might be tolerated better in this cohort and
might improve adherence to physical activity protocols. Previous studies, suggest that obese adolescents
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exhibited maximal fat oxidation rates at 41% V’O2max, which corresponded to 58% HRmax. Finally,
walking enhances fat utilization over cycling (at an intensity requiring similar EE) though such weight-
bearing activity may initially be uncomfortable in those who are severely obese.
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~ About the Authors ~
Stefano Lazzer
Stefano Lazzer received a Bachelor in Sport Sciences at the University of
Padova (Italy) in 1996, and a Master in Sport Sciences at the University of
Grenoble (France) in 1998. In 2003 he received a PhD in “Human Physiology
(Mentor Dott. M. Vermorel and Prof. Y. Boirie) at the Faculty of Medicine
(University of Auvergne, France) and in 2009 a PhD in “Biotechnology and
Biomedical Sciences” (Mentor Prof. PE di Prampero) at the University of Udine,
Italy. From 2000 to 2005 he worked at the Centre for Human Nutrition in
Clermont-Ferrand (France) as a PhD student and post-doctoral student, and since 2005 he has been
working as a consultant in the Italian Auxology Institute of Verbania, studying energy metabolism in
obese subjects during and after weight reduction programs. Since September 2009 he is Assistant
Professor on Sport Physiology at the School of Sport Science (University of Udine). His main fields of
interest are the physiology of muscular contraction, bioenergetics and cardio-respiratory adaptations to
muscular exercise in obese subjects, elderly and athletes. He has 50 scientific publications, 28 invited
lectures to congresses. H-index: 17; nr of citations: 837.
Grace O’Malley
Grace O’Malley is a Senior Chartered Physiotherapist working as part of the obesity management team
at Temple Street Children’s University Hospital. She completed a PhD in Epidemiology and Public
Health at University College Cork. This work focused on the design, implementation and evaluation of
multi-disciplinary interventions for adolescent obesity. She received a 2008 Fulbright award to Yale
University School of Medicine, where she undertook clinical research into the pathophysiology of type 2
diabetes in children who are obese. She graduated with a BSc Physiotherapy in 2004 and MSc 2006 from
the University of Dublin, Trinity College. Her clinical interests include: paediatric obesity assessment,
treatment strategies and the impact of obesity on the health of the developing child.
Research interests include the effect of obesity on the musculoskeletal health of the child and the use of
web 2.0 technologies to optimise care of children who are obese.
She is the elected Irish representative of the European Childhood Obesity Group and the European
Childhood Obesity Task Force and Chairs the Association for the Study of Obesity on the Island of
Ireland. For further details see:
! !
Michel Vermorel
Michel Vermorel is engineer in Agronomics (National Agronomy Institute,
1962 Paris) and has a MSc degree in Nutrition Physiology (University of
Paris la Sorbonne, 1963). He is emeritus research director of the French
National Institute for agricultural Research. During 30 years his research first
on energy metabolism and nutrition of farm animals (149 indexed scientific
publications). Then he shifted to the study of energy metabolism and
nutrition in adolescents (healthy, obese and top athletes) at the Auvergne
Nutrition Research Center (Clermont Ferrand, France) where he published
47 indexed scientific publications. He was Research Director of 12 PhD.
! !
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To compare two modalities of exercise training (i.e., Endurance Training [ET] and High-Intensity Interval Training [HIT]) on health-related parameters in obese children aged between 8 and 12 years. Thirty obese children were randomly allocated into either the ET or HIT group. The ET group performed a 30 to 60-minute continuous exercise at 80% of the peak heart rate (HR). The HIT group training performed 3 to 6 sets of 60-s sprint at 100% of the peak velocity interspersed by a 3-min active recovery period at 50% of the exercise velocity. HIT sessions last ~70% less than ET sessions. At baseline and after 12 weeks of intervention, aerobic fitness, body composition and metabolic parameters were assessed. BOTH THE ABSOLUTE (ET: 26.0%; HIT: 19.0%) and the relative VO(2) peak (ET: 13.1%; HIT: 14.6%) were significantly increased in both groups after the intervention. Additionally, the total time of exercise (ET: 19.5%; HIT: 16.4%) and the peak velocity during the maximal graded cardiorespiratory test (ET: 16.9%; HIT: 13.4%) were significantly improved across interventions. Insulinemia (ET: 29.4%; HIT: 30.5%) and HOMA-index (ET: 42.8%; HIT: 37.0%) were significantly lower for both groups at POST when compared to PRE. Body mass was significantly reduced in the HIT (2.6%), but not in the ET group (1.2%). A significant reduction in BMI was observed for both groups after the intervention (ET: 3.0%; HIT: 5.0%). The responsiveness analysis revealed a very similar pattern of the most responsive variables among groups. HIT and ET were equally effective in improving important health related parameters in obese youth.
The construct validity and the test-retest reliability of a self-administered questionnaire about habitual physical activity were investigated in young males (n = 139) and females (n = 167) in three age groups (20 to 22, 25 to 27, and 30 to 32 yr) in a Dutch population. By principal components analysis three conceptually meaningful factors were distinguished. They were interpreted as: 1) physical activity at work; 2) sport during leisure time; and 3) physical activity during leisure time excluding sport. Test-retest showed that the reliability of the three indices constructed from these factors was adequate. Further, it was found that level of education was inversely related to the work index, and positively related to the leisure-time index in both sexes. The subjective experience of work load was not related to the work index, but was inversely related to the sport index, and the leisure-time index in both sexes. The lean body mass was positively related to the work index, and the sport index in males, but was not related to the leisure-time index in either sex. These differences in the relationships support the subdivision of habitual physical activity into the three components mentioned above.
Striding bipedalism is a key derived behaviour of hominids that possibly originated soon after the divergence of the chimpanzee and human lineages. Although bipedal gaits include walking and running, running is generally considered to have played no major role in human evolution because humans, like apes, are poor sprinters compared to most quadrupeds. Here we assess how well humans perform at sustained long-distance running, and review the physiological and anatomical bases of endurance running capabilities in humans and other mammals. Judged by several criteria, humans perform remarkably well at endurance running, thanks to a diverse array of features, many of which leave traces in the skeleton. The fossil evidence of these features suggests that endurance running is a derived capability of the genus Homo, originating about 2 million years ago, and may have been instrumental in the evolution of the human body form.
Objective: The adduction moment at the knee during gait is the primary determinant of medial-to-lateral load distribution. If the adduction moment contributes to progression of osteoarthritis (OA), then patients with advanced medial tibiofemoral OA should have higher adduction moments. The present study was undertaken to investigate the hypothesis that the adduction moment normalized for weight and height is associated with medial tibiofemoral OA disease severity after controlling for age, sex, and pain level, and to examine the correlation of serum hyaluronan (HA) level with disease severity and with the adduction moment in a subset of patients. Methods: Fifty-four patients with medial tibiofemoral OA underwent gait analysis and radiographic evaluation. Disease severity was assessed using the Kellgren-Lawrence (K-L) grade and medial joint space width. In a subset of 23 patients with available sera, HA was quantified by sandwich enzyme-linked immunosorbent assay. Pearson correlations, a random effects model, and multivariate regression models were used. Results: The adduction moment correlated with the K-L grade in the left and right knees (r = 0.68 and r = 0.60, respectively), and with joint space width in the left and right knees (r = -0.45 and r = -0.47, respectively). The relationship persisted after controlling for age, sex, and severity of pain. The partial correlation between K-L grade and adduction moment was 0.71 in the left knees and 0.61 in the right knees. For every 1.0-unit increase in adduction moment, there was a 0.63-mm decrease in joint space width. In the subset of patients in whom serum HA levels were measured, HA levels correlated with medial joint space width (r = -0.55), but not with the adduction moment. Conclusion: There is a significant relationship between the adduction moment and OA disease severity. Serum HA levels correlate with joint space width but not with the adduction moment. Longitudinal studies will be necessary to determine the contribution of the adduction moment, and its contribution in conjunction with metabolic markers, to progression of medial tibiofemoral OA.
This study examines the effects of a radical bariatric surgery-induced weight loss on the gait of obese subjects. We performed a three-dimensional motion analysis of lower limbs, and collected force platform data in the gait laboratory to calculate knee and hip joint moments. Subjects (n=13) performed walking trials in the laboratory before and 8.8 months (SD 4.2) after the surgical procedure at two gait speeds (1.2m/s and 1.5m/s). The average weight loss was 26.7kg (SD 9.2kg), corresponding to 21.5% (SD 6.8%) of the initial weight. We observed a decrease in step width at both gait speeds, but no changes in relative double support or swing time or stride length. A significant decrease was noted in the absolute values of peak knee abductor, peak knee flexor and peak hip extensor moments. However, the moment values normalized by the body weight and height remained unchanged in most cases. Thus, we conclude that weight loss reduces hip and knee joint moments in proportion to the amount of weight lost.