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ARTICLE
Effects of functional training and 2 interdisciplinary
interventions on maximal oxygen uptake and weight loss of
women with obesity: a randomized clinical trial
Cauê Vazquez La Scala Teixeira, Danielle Arisa Caranti, Lila Missae Oyama, Ricardo da Costa Padovani,
Maria Gabriela Soria Cuesta, Amanda dos Santos Moraes, Letícia Andrade Cerrone,
Luiz Henrique Lima Affonso, Silvandro dos Santos Gil, Ronaldo V. Thomatieli dos Santos,
and Ricardo José Gomes
Abstract: Our aim was to analyze and compare functional training, interdisciplinary therapy, and interdisciplinary education
on cardiorespiratory fitness (CF) and anthropometric characteristics of women with obesity. Forty-four women (age = 39.7 ±
5.9 years, body mass index (BMI) = 35.5 ± 2.8 kg/m
2
) completed 30 weeks of intervention randomly assigned to 3 groups:
functional training (FT) (n= 14), interdisciplinary therapy (IT) (n= 19), and interdisciplinary education (IE) (n= 11). The FT group
participated in the training program (3/week), the IT group received the same training intervention plus nutrition (1/week) and
psychology advice (1/week) and physical therapy (1/week). The IE group participated in interdisciplinary lectures on topics related
to health promotion (1/month). CF (ergospirometry), anthropometry, and body composition (electrical bioimpedance) were
measured pre-intervention (Pre) and post-intervention (Post). CF increased (p≤ 0.05) significantly (Pre vs. Post) in the FT (7.5%) and
IT (10.8%) groups, but not in the IE group (1.8%). Body mass (BM), BMI, relative fat mass, and waist circumference significantly
(p≤ 0.05) decreased (Pre vs. Post) in IT (−4.4%, −4.4%, −2.3%, and −5.1%, respectively). The IE group showed a significant decrease
in BM (−3.7%), BMI (−3.7%), and waist circumference (−3.5%), whereas the FT group promoted significant decrease in waist
circumference (−3.4%). In conclusion, functional training increased CF but only interdisciplinary interventions improved the
anthropometric profile of women with obesity.
Novelty
•Interdisciplinary therapy provided more comprehensive adaptations in women with obesity, including morphological vari-
ables and CF.
•Functional training increased CF but reduced only abdominal obesity.
•Interdisciplinary education provided benefits on morphological variables, but it does not increase CF.
Key words: obesity, overweight, integrated training, combined training, multimodal training, interdisciplinary therapy,
multicomponent training.
Résumé : Notre objectif est d’analyser et de comparer l’effet de l’entraînement fonctionnel, de la thérapie interdisciplinaire et
de la formation interdisciplinaire sur l’aptitude cardiorespiratoire (« CF ») et les caractéristiques anthropométriques des femmes
obèses. Quarante-quatre femmes (âge = 39,7 ± 5,9 ans, indice de masse corporelle « BMI » = 35,5 ± 2,8 kg/m
2
) se soumettent à
30 semaines d’intervention assignée au hasard dans trois groupes : entraînement fonctionnel (« FT ») (n= 14), thérapie interdis-
ciplinaire (« IT ») (n= 19) et formation interdisciplinaire (« IE ») (n= 11). Le groupe FT participe au programme d’entraînement
(3/semaines), le groupe IT reçoit la même intervention en entraînement plus la nutrition (1/semaines), les conseils psy-
chologiques (1/semaines) et la physiothérapie (1/semaines). Le groupe IE assiste à des conférences interdisciplinaires sur des sujets
liés à la promotion de la santé (1/mois). Avant et après l’intervention, on évalue la CF (ergospirométrie), les caractéristiques
anthropométriques et la composition corporelle (bioimpédance électrique). La CF augmente (p≤ 0,05) significativement (pré vs
post) dans les groupes FT (7,5 %) et IT (10,8 %), mais pas dans le groupe IE (1,8 %). La masse corporelle (« BM »), BMI, la masse grasse
Received 14 October 2019. Accepted 9 January 2020.
C.V. La Scala Teixeira, A.S. Moraes, L.H.L. Affonso, and S.S. Gil. Obesity Study Group, Interdisciplinary Laboratory of Metabolic Diseases, Federal
University of São Paulo, Santos, SP 11045-301, Brazil; Post Graduate Program of Interdisciplinary Health Sciences, Federal University of São Paulo,
Santos, SP 11015-020, Brazil.
D.A. Caranti and R.J. Gomes. Obesity Study Group, Interdisciplinary Laboratory of Metabolic Diseases, Federal University of São Paulo, Santos,
SP 11045-301, Brazil; Post Graduate Program of Interdisciplinary Health Sciences, Federal University of São Paulo, Santos, SP 11015-020, Brazil;
Department of Bioscience, Federal University of São Paulo, Santos, SP 11015-020, Brazil.
L.M. Oyama. Department of Physiology, Paulista School of Medicine, Federal University of São Paulo, SP 04023-900, Brazil.
R.C. Padovani. Obesity Study Group, Interdisciplinary Laboratory of Metabolic Diseases, Federal University of São Paulo, Santos, SP 11015-020, Brazil;
Post Graduate Program of Interdisciplinary Health Sciences, Federal University of São Paulo, Santos, SP 11015-020, Brazil; Department of Health,
Education and Society, Federal University of São Paulo, Santos, SP 11015-020, Brazil.
M.G.S. Cuesta and L.A. Cerrone. Obesity Study Group, Interdisciplinary Laboratory of Metabolic Diseases, Federal University of São Paulo, Santos,
SP 11045-301, Brazil.
R.V.T. dos Santos. Department of Bioscience, Federal University of São Paulo, Santos, SP 11015-020, Brazil.
Corresponding author: Cauê Vazquez La Scala Teixeira (email: contato@caueteixeira.com.br).
Copyright remains with the author(s) or their institution(s). Permission for reuse (free in most cases) can be obtained from copyright.com.
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relative et le tour de taille diminuent (p≤ 0,05) significativement (pré et post) dans le groupe IT (−4,4 %, −4,4 %, −2,3 % et −5,1 %,
respectivement). Le groupe IE affiche une diminution significative de la BM (−3,7 %), de BMI (−3,7 %) et de tour de taille (−3,5 %),
tandis que le groupe FT présente une diminution significative de tour de taille (−3,4 %). En conclusion, l’entraînement fonction-
nel suscite une augmentation de la CF mais seules les interventions interdisciplinaires améliorent le profil anthropométrique
des femmes obèses. [Traduit par la Rédaction]
Les nouveautés
•La thérapie interdisciplinaire procure des adaptations plus complètes chez les femmes obèses, dont celles des variables
morphologiques et de l’aptitude cardiorespiratoire.
•L’entraînement fonctionnel engendre une augmentation de l’aptitude cardiorespiratoire mais ne réduit que l’obésité abdominale.
•La formation interdisciplinaire procure des avantages sur les variables morphologiques, mais elle n’augmente pas l’aptitude
cardiorespiratoire.
Mots-clés : obésité, surcharge pondérale, entraînement intégré, entraînement combiné, entraînement multimodal, thérapie
interdisciplinaire, formation à composantes multiples.
Introduction
Obesity is a serious fast-growing global public health problem.
According to the World Health Organization (2000), more than
300 million people worldwide are obese, of which over one-third
suffer from obesity-related health problems.
Excessive accumulation of adipose tissue compromises the bal-
ance in the production of pro- and anti-inflammatory adipokines,
creating a state of chronic subclinical inflammation that favors
the development of heart, metabolic, musculoskeletal, and men-
tal comorbidities (Schelbert 2009). Thus, there is a growing inter-
est in strategies that promote weight- and fat mass-loss, including
physical exercise (Thompson 2018) and multi- or interdisciplinary
interventions (Donini et al. 2009;Sanches et al. 2016).
Considering that obesity is a multifactorial disease, interven-
tions that address more than 1 factor (e.g., physical exercise +
nutrition) generally provide better results for weight loss than
isolated physical exercise programs (Johns et al. 2014). In this
sense, studies using face-to-face multi- or interdisciplinary ther-
apy for obesity treatment —combination of interventions in dif-
ferent areas —observed significant weight loss in patients with
obesity (Carvalho-Ferreira et al. 2012;Leite et al. 2017). Other studies
using interventions from different areas but based on information
sharing through obese patient education programs (e.g., interdisci-
plinary education) were also effective in promoting weight loss in
people with obesity (Lagger et al. 2010).
In isolated exercise programs, the weight loss is discrete and
sometimes nonexistent (Swift et al. 2014). However, exercise can
help in maintaining lean body mass (BM) and resting metabolic
rate in weight loss programs (Donnelly et al. 2009). Additionally,
physical exercise has benefits on cardiorespiratory fitness in peo-
ple with obesity (Sanches et al. 2016) and, regardless of changes in
BM, provides reduction in viscera/abdominal fat (Verheggen et al.
2016). It is noteworthy that both low cardiorespiratory fitness and
excess visceral/abdominal fat are independently associated with
the risk of early mortality (Ekelund et al. 2015;McAuley et al.
2010).
Regarding the type of physical exercise, aerobic and resistance
exercises are already widely investigated (Ismail et al. 2012;Wewege
et al. 2018), but there are few studies analyzing the effects of func-
tional training in people with obesity, and there is a gap regarding
the comparison of this “new” type of training being performed by
itself or with interdisciplinary therapies in patients with obesity.
Functional training has been understood as the use of strength
training (and other techniques) to promote multisystem adapta-
tions (e.g., strength, balance, coordination, agility, among others),
using multiarticular, multisegmental, multiplanar, integrated, un-
stable, and acyclic exercises. Some previous studies have shown ben-
eficial effects of this type of training on anthropometric variables
and body composition with overweight women (body mass index
(BMI) < 30 kg/m
2
)(Neves et al. 2014,2017). Additionally, it should
be considered that functional training, as it presents itself as one
of the main fitness worldwide trends (Thompson 2018) and as it
uses high-complexity exercises that seem to increase energy ex-
penditure (La Scala Teixeira et al. 2019), has attracted people with
obesity, justifying this research.
Thus, the aim of the study was to analyze and compare the
effects of functional training with 2 distinct formats of interdisci-
plinary interventions on cardiorespiratory fitness and anthropo-
metric characteristics and body composition of women with
obesity. We hypothesized that 3 interventions would produce
beneficial health outcomes (including anthropometric variables
and cardiorespiratory fitness), but at different magnitudes.
Materials and methods
Experimental design
The present study had a randomized clinical trial format. To
verify and compare the effects of 3 different obesity treatments on
cardiorespiratory fitness and anthropometric profiles, 44 women
with obesity were randomly (through Microsoft Excel specific func-
tion) assigned to 3 groups: functional training (aerobic + functional
resistance training − 3×/week), interdisciplinary therapy (aerobic +
functional resistance training − 3×/week; nutrition − 1×/week;
psychology − 1×/week; physical therapy − 1×/week), and interdisci-
plinary education (lectures on topics related to general health
promotion − 1×/month). Before and after 30 weeks of intervention,
all volunteers underwent maximal oxygen uptake (V
˙O
2max
), an-
thropometry, and body composition assessments. Results were
compared within and between groups. The study was conducted
at the Interdisciplinary Laboratory of Metabolic Diseases of the
Federal University of São Paulo, Santos, Brazil, and is registered at
clincialtrials.gov (no. NCT02573688).
Subjects
The invitation to participate was made through social media,
institutional Websites, and local newspapers. Inclusion criteria
were women aged between 30 and 50 years, BMI between 30.0 and
39.9 kg/m
2
and having a recent medical certificate and electrocar-
diogram. Volunteers were excluded if they had any skeletal mus-
cle restrictions to practice resistance and aerobic exercises, were
using ergogenic, stimulant substances and/or weight loss sub-
stances, were pregnant, or had already undergone bariatric sur-
gery. Volunteers who presented comorbidities were not excluded
because it is a common condition for people with obesity. In total,
78 adult women with obesity were randomized into 3 groups:
functional training (FT) group (n= 28), interdisciplinary therapy
(IT) group (n= 24), and interdisciplinary education (IE) group (n= 26).
After 30 weeks, 44 women (FT = 14; IT = 19; IE = 11) reached the
minimum number of interventions (70%) and were included in
the analyses. The reasons reported for drop-out or noninclusion in
the data analysis were as follows: pregnancy (n= 1), surgery (n= 1),
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job opportunities (n= 2), nonattendance at reevaluations (n= 12),
personal reasons (n= 8), and insufficient attendance (n= 12). The
study was previously approved by the UNIFESP Research Ethics
Committee (CAAE: 57101616.6.0000.5505).
Cardiorespiratory fitness assessment – V
˙O
2max
For the aerobic fitness assessment, an ergospirometric test of
increasing loads on a treadmill (TRX 600; Total Health, Jabotica-
bal, Brazil) was performed until exhaustion. The protocol was
adapted from previous studies of our group (Cerrone et al. 2017.
Sanches et al. 2018). The protocol used to perform the ergospi-
rometric test had an initial speed of 3 km/h and inclination set at
1%, with speed increasing 1 km/h every 2 min until the volunteer’s
exhaustion. Volunteers were verbally encouraged to continue the
exercise for as long as possible. The test was interrupted when
subjects reported inability to continue the activity. During the
test, a facemask connected to Gas Analyzer (FITMATE-PRO;
COSMED, Rome, Italy) was used. For safe test execution, heart rate
and blood pressure were measured during each stage. Concomi-
tantly, the rating of perceived exertion (RPE) (Borg 1998) was re-
ported at the end of each stage and test results that showed RPE ≥
18 and heart rate compatible with the expected maximum at the
time of discontinuation were considered valid. The relative
V
˙O
2max
(absolute V
˙O
2max
/ body mass) and the intensity (km/h)
corresponding to V
˙O
2max
(iV
˙O
2max
) were recorded.
Anthropometry
BM was measured using a digital scale (Toledo, São Bernardo do
Campo, Brazil) with 200 kg as maximum capacity and 50 g of
accuracy, with the volunteers wearing light clothes and standing
with their backs to the scales. Height was measured by a profes-
sional stadiometer (Sanny, São Bernardo do Campo, Brazil), accu-
rate to 1 mm. BMI was calculated by the ratio of BM (kg) to the
square of height (m).
Anthropometric tape (Sanny) with a precision of 1 mm was used
to measure waist circumference. Waist circumference was mea-
sured with the tape being placed horizontally over the midpoint
between the iliac crest and the last costal arch at the end of normal
exhalation (Kaminsky and American College of Sports Medicine
2013). The median of 3 measurements was considered. To calculate
waist-to-height ratio (WHtR), the waist circumference value (cm) was
divided by height (cm).
Body composition
Participants were submitted to the bioelectrical impedance pro-
tocol using tetrapolar equipment (Maltron BF-906, Rayleigh, UK)
to evaluate body fat (BF) percentage, which has been used in some
previous studies of women with obesity (Carroll et al. 2012;
Steckling et al. 2016). The assessment was made after4hoffasting
period, following the manufacturer’s recommendations. To calcu-
late body composition by calculating fat free mass (FFM), an equa-
tion was used, as previously proposed by Segal et al. (1988), that is
specific for women with obesity.
Physical activity level
To estimate physical activity level, the International Physical
Activity Questionnaire (IPAQ) was applied in its short version
(Matsudo et al. 2001), comprising 4 questions about the weekly
time of sedentary, mild, moderate, and vigorous physical activi-
ties. In this study, the 5 possible IPAQ classifications were divided
into 2 physical activity levels: unsatisfactory = “sedentary” +
“irregularly active A” + “irregularly active B”; satisfactory = “active” +
“very active”.
FT group
The FT group underwent a face-to-face training protocol that
consisted of performing exercises to enhance different physical
capacities in an integrated, synergistic, and balanced approach, as
suggested by La Scala Teixeira et al. (2017). The intervention was
conducted in a climate-controlled environment (⬃20 to 22 °C) that
was equipped with ergometers (bicycle and treadmills) and equip-
ment and accessories for resistance training. The volunteers un-
derwent functional training program 3 times a week (Monday,
Wednesday, and Thursday), including aerobic and functional re-
sistance exercises. The training session lasted 60 min and was
structured as follows: 5 min of warm-up, followed by 25 min of
aerobic exercise plus 25 min of functional resistance exercises
(not necessarily in this order), ending with 5 min of relaxation.
Aerobic exercises were performed on an ergometer (treadmill
or bicycle) at an intensity equivalent to the rating of perceived
exertion (RPE) of 13–14 on the Borg scale (Borg 1998). Resistance
training was performed in a circuit scheme, with 3 passes in
8 stations. Each pass consisted of execution for 40 s interleaved
with 20 s of passive rest interval. Table 1 shows intensity control
by the RPE using the CR-10 scale (Borg 1998). In total, 4 different
circuits were elaborated, which were rotated in monthly cycles.
For overload, the exercises used free weights (bars, plates, dumb-
bells, poles), elastic bands, and bodyweight, except for the fourth
circuit, which was based on manual resistance training, as sug-
gested by La Scala Teixeira (2017) (Table 2).
IT group
The IT group underwent a training program identical to the FT
group. However, on each physical training day, interventions
were added in the fields of nutrition (once a week, Tuesday), psy-
chology (once a week, Thursday), and physical therapy (once a
week, Friday) based on an interdisciplinary approach. Further-
more, once a month an intervention was developed between 2 or
more fields to strengthen the interdisciplinary character of the
proposed treatment.
The nutrition interventions were conducted with the main
objective of raising awareness about diet and eating behavior,
allowing volunteers to make positive changes in their lifestyles,
helping to reduce obesity and its comorbidities. The interventions
were based on the dietary guide for the Brazilian population
(Brasil 2014) and the principles of behavioral nutrition (Alvarenga
et al. 2015), as well as specific knowledge of nutrition, food, and
dietetics. These were structured in weekly themes and lasted
60 min, during which mainly expository and talking methods
were used to convey the contents covered. Moreover, practical
classes in experimental cooking were held every 2 months to
enrich the practical knowledge of participants, and so they could
live some experiences in the area of gastronomy and nutrition. At
the beginning of the therapy, an individualized dietary plan was
also proposed for each volunteer according to their energetic and
Table 1. Characteristic of the functional training group intervention component.
Variable Characteristic
Activities conducted Integrated resistance exercises, including simultaneous upper and lower limb, multiplanar
movements, high demand for core stability, motor coordination, and balance
Intensity Weeks 1 to 10: RPE 6–7 (0–10)
Weeks 11 to 20: RPE 7–8 (0–10)
Weeks 21 to 30: RPE 8–9 (0–10)
Volume/duration/method Circuit with 8 stations (exercises), 40 s of execution, 20 s apart, 3 passes, totaling 25 min
Note: RPE, rating of perceived exertion.
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nutritional needs, seeking to serve as a guide for those who had
greater difficulty regarding the quantities and portion sizes of
food, thus helping in the daily food choices.
Psychology interventions were performed once a week, lasting
60 min per session. The theoretical approach that guided psycho-
logical intervention was cognitive behavioral therapy (CBT). In
this model, cognition has an important role in expression of feel-
ings and behavior. The individual learns how to identify and re-
spond to dysfunctional thoughts in a more realistic and adaptive
perspective, which leads to feeling better emotionally and to be-
have more adaptively to one’s environment. The CBT emphasizes
the importance of collaborative relation and active participation
in solving problems (Beck 2011). The cognitive behavioral model
was adopted to help individuals modify the way they deal with
eating, physical activity, and exercise.
Physical therapy interventions aimed to improve the volun-
teers’ functional capacity. Each session lasted 60 min and involved
postural exercises, lumbopelvic stabilization (core training), dy-
namic balance, and flexibility exercises.
IE group
The protocol adopted in the IE group was conducted as monthly
lectures. Volunteers received guidance on lifestyle changes through
7 lectures on the following key topics: (i) motivation to behavior
change; (ii) emotional eating; (iii) healthy eating; (iv) physical ther-
apy care in obesity and in the weight loss process; (v) obesity-
associated diseases; (vi) physical exercise in promoting health and
weight loss; and (vii) bariatric surgery. During the investigation,
group members were connected to each other by social networks
(WhatsApp group chat) to share information about therapy and
feedback on lectures/meetings.
Statistical analysis
Data normality was verified using the Shapiro–Wilk test. Data
are presented as means and SD for the analyzed variables at pre-
intervention (Pre) and post-intervention (Post). Baseline character-
istics were compared by 1-way ANOVA test. Inferential analysis to
verify interaction in time (Pre vs. Post) and the relationship be-
tween time and intervention (FT vs. IT vs. IE) was performed using
mixed ANOVA for repeated measures with Bonferroni’s post hoc
application for multiple pairwise comparison. To correct any sta-
tistical problems, nonparametric data were transformed into log-
arithms prior to ANOVA analysis of repeated measures. The
significance level considered was 5% (p≤ 0.05). Additionally, per-
centage changes (⌬%) and effect size (ES) by Cohen’s dwere calcu-
lated. Inferential analysis of categorical variables of physical
activity level was performed using
2
test. The analyses were per-
formed using SPSS version 20 (IBM Corp., Armonk, N.Y., USA).
Results
Table 3 presents the characteristics of subjects who completed
the interventions in the 3 groups.
Cardiorespiratory fitness – V
˙O
2max
In V
˙O
2max
, ANOVA showed interaction in the time factor (F=
12.441, p= 0.001), but not in the relationship between time and
intervention (F= 1.841, p= 0.172). The post hoc test showed a
significant increase in V
˙O
2max
in the FT (p= 0.014, 95% confidence
interval (CI) = 0.469 to 3.902, ⌬% = 7.5 ± 10.7, ES = 0.47) and IT
(p= 0.001, 95% CI = 1.169 to 4.115, ⌬% = 10.8 ± 14.1, ES = 0.74)
interventions, with no change in the IE intervention (p= 0.699,
95% CI = −1.564 to 2.309, ⌬% = 1.8 ± 9.8, ES = 0.12) (Table 4).
Table 2. Circuit protocol adopted in monthly functional training cycles.
Week Exercise
Type of
exercise
1, 5, 9, 13, 17, 21, 25, 29 1. Sit-to-stand with elbow flexion FW, BW
2. Push-ups BW
3. Crunches with rotation BW
4. Dumbbell swing FW
5. Front pulldown with squat EL
6. “Good morning” FW
7. Side-lying hip abduction FW
8. Airplane BW
2, 6, 10, 14, 18, 22, 26, 30 1. Upright row with sumo squat FW
2. Dumbbell fly with pelvic elevation FW
3. Elastic trunk rotation EL
4. Front raise with side lunge FW, BW
5. Suspended row BW
6. Knee flexion with elbow flexion FW
7. Trunk lateral flexion FW
8. Single leg balance with eyes closed BW
3, 7, 11, 15, 19, 23, 27 1. Squat thruster FW
2. Hip flexion with elbow flexion PL
3. Ball crunch BW
4. Side lateral raise with lunge FW, BW
5. Horizontal row EL
6. Stiff leg deadlift FW
7. Bench press FW
8. Single leg balance with eyes closed BW
4, 8, 12, 16, 20, 24, 28 1. Standing bench press MRT
2. Sumo squat MRT
3. Horizontal row MRT
4. Crunch BW
5. Push forward MRT
6. Hips extension MRT
7. Shoulder abduction/adduction MRT
9. Trunk rotation MRT
Note: BW, bodyweight (calisthenic exercises); EL, elastic bands; FW, free weights; MRT, manual
resistance training.
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In iV
˙O
2max
, ANOVA showed interaction in the time factor (F=
56.843, p< 0.001) but not in the relationship between time and
intervention (F= 1.414, p= 0.255). The post hoc test showed a
significant increase in all interventions (IE: p= 0.014, 95% CI =
0.007, ⌬% = 9.1 ± 14.7, ES = 0.65 to 0.062; FT: p< 0.001, 95% CI = 0.038
to 0.087, ⌬% = 15.7 ± 8.0, ES = 1.22; IT: p< 0.001, 95% CI = 0.038 to
0.079, ⌬% = 15.1 ± 12.3, ES = 1.45), with no difference between
groups (Table 4).
Anthropometric variables and body composition
For both BM and BMI, mixed ANOVA showed interaction in
time (BM: F= 17.719, p< 0.001; BMI: F= 18.708, p< 0.001) but not in
the relationship between time and intervention (BM: F= 1.218,
p= 0.306; BMI: F= 1.274, p= 0.291). The post hoc test showed a
significant decrease in BM and BMI in IE (BM: p= 0.029, 95% CI =
0.363 to 6.228, ⌬% = −3.7 ± 6.1, ES = 0.85; BMI: p= 0.022, 95% CI =
0.197 to 2.347, ⌬% = −3.7 ± 6.1, ES = 1.62), and IT (BM: p< 0.001,
95% CI = 2.145 to 6.608, ⌬% = −4.4 ± 5.3, ES = 1.44; BMI: p< 0.001,
95% CI = 0.812 to 2.448, ⌬% = −4.4 ± 5.3, ES = 2.67) interventions,
without change in FT (BM: p= 1.187, 95% CI = −0.871 to 4.288, ⌬%=
−1.8 ± 2.2, ES = 0.49; BMI: p= 0.183, 95% CI = −0.314 to 1.592, ⌬%=
−1.8 ± 2.2, ES = 0.86) (Table 5).
For WC and WHtR, mixed ANOVA showed interaction in time
(WC: F= 31.534, p< 0.001; WHtR: F= 32.264, p< 0.001) but not in
the relationship between time and intervention (WC: F= 0.757,
p= 0.476; WHtR: F= 0.749, p= 0.479). The post hoc test showed
significant decrease in WC and WHtR in IE (WC: p= 0.022, 95% CI =
0.538 to 6.407, ⌬% = −3.5 ± 4.4, ES = 1.25; WHtR: p= 0.014, 95% CI =
0.003 to 0.028, ⌬% = −3.5 ± 4.4, ES = 0.40), FT (WC: p= 0.007,
95% CI = 1.084 to 6.287, ⌬% = −3.4 ± 3.8, ES = 1.54; WHtR: p= 0.009,
95% CI = 0.004 to 0.026, ⌬% = −3.4 ± 3.8, ES = 0.40), and IT (WC:
p< 0.001, 95% CI = 3.157 to 7.622, ⌬% = −5.1 ± 5.0, ES = 2.57; WHtR:
p< 0.001, 95% CI = 0.014 to 0.033, ⌬% = −5.1 ± 5.0, ES = 1.00)
interventions (Table 5), with no difference between the groups.
In the body composition analysis, the relative BF showed inter-
action in time (F= 11.192, p= 0.002) but not in the relationship
between time and intervention (F= 1.644, p= 0.206). In the post
hoc test, relative BF significantly reduced only in the IT group
(p= 0.001, 95% CI = 0.451 to 1.662, ⌬% = −2.3 ± 2.9, ES = 0.68), with
no changes in the IE (p= 0.065, 95% CI = −0.048 to 1.544; ⌬% = −1.7 ±
4.1, ES = 0.54) and FT (p= 0.527, 95% CI = −0.483 to 0.928, ⌬% = −0.5 ±
1.3, ES = 0.11) groups. Similarly, absolute BF presented interaction
in time (F= 14.849, p< 0.001), but not in the relationship between
time and intervention (F= 1.384, p= 0.262), showing significant
decrease only in the IT group (p< 0.001, 95% CI = 1.394 to 4.460,
⌬% = −7.3 ± 10.0, ES = 0.38), tendency to decrease in the IE group
(p= 0.052, 95% CI = −0.022 to 4.007, ⌬% = −3.7 ± 14.7, ES = 0.33), and
no changes in the FT group (p= 0.269, 95% CI = −0.794 to 2.777,
⌬% = 0.1 ± 5.5, ES = 0.15). Relative FFM showed interaction in time
(F= 11.192, p= 0.002) but not in the relationship between time and
intervention (F= 1.644, p= 0.206) (Table 5). IT was the only inter-
vention that showed a significant increase in relative FFM
(p= 0.001, 95% CI = 0.451 to 1.662, ⌬% = 1.9 ± 2.5, ES = 0.68), without
changes in the IE (p= 0.065, 95% CI = −0.048 to 1.544, ⌬% = 1.3 ± 3.2,
ES = 0.54) and FT (p= 0.527, 95% CI = −0.483 to 0.928, ⌬% = 0.4 ± 1.0,
ES = 0.11) interventions. Regarding absolute FFM, there was inter-
action in time (F= 22.470, p< 0.001) but not in the relationship
between time and intervention (F= 0.851, p= 0.434). The post hoc
test showed a significant decrease in absolute FFM in the IT
(p< 0.001, 95% CI = 0.714 to 2.185, ⌬% = −2.7 ± 3.3, ES = 0.21) and IE
(p= 0.009, 95% CI = 0.336 to 2.269, ⌬% = −2.6 ± 3.1, ES = 0.24)
interventions but not in the FT intervention (p= 0.090, 95% CI =
−0.120 to 1.594, ⌬% = −1.4 ± 1.9, ES = 0.12) (Table 5).
Physical activity level
Based on the percentage of subjects distributed in the IPAQ
classifications, physical activity levels increased in all groups. In
the IT group, the number of subjects with satisfactory physical
activity level (“active” + “very active”) increased from 5 to 14 (⌬%=
180.2%). In FT group, it increased from 3 to 11 (⌬% = 267.3%). In the
IE group, it increased from 4 to 7 (⌬% = 74.7%). The
2
test revealed
an association between physical activity level (unsatisfactory and
satisfactory) and intervention at both Pre (
2
= 5.830, p= 0.054) and
Post (
2
= 5.830, p= 0.054).
Discussion
To the best of our knowledge, this is the first study to investi-
gate functional training effects on people with obesity, as well as
being the first to compare it with interdisciplinary therapy (gold
standard) and an interdisciplinary education program. Our main
finding was that while interdisciplinary therapy was the only in-
tervention that improved all parameters evaluated, functional train-
ing and interdisciplinary education promoted positive changes in
some variables, which confirms our hypothesis in part.
As expected, interdisciplinary therapy promoted positive
changes in all variables investigated, including a decrease in BM,
BMI, relative and absolute fat mass, waist circumference and
WHtR, as well as an increase in cardiorespiratory fitness and rel-
ative FFM. These findings confirm the results of previous studies
(Bischoff et al. 2012;Leite et al. 2017;Sanches et al. 2016) and
corroborate what the literature suggests as the “gold standard”
for obesity treatment (Jensen et al. 2014;Tsigos et al. 2008). More-
over, the drop-out rate over the 30 weeks was low for interdisci-
plinary therapy (⬃20%), confirming the effectiveness of the
intervention.
However, considering the high cost of long-term interdisciplinary
therapy for both the subject with obesity (end-user) and health
services, this study analyzed the effects of cheaper interventions
and thus accessible to large populations. Although these data
were not presented in the results, the cost of interdisciplinary
therapy was approximately 5 and 14 times higher than the cost of
functional training and interdisciplinary education, respectively.
This information needs to be considered in view of the possibility
of practical application of these therapy models for obesity treat-
ment.
Regarding the interdisciplinary education program, the results
showed a positive effect on several anthropometric variables in
the sample that remained until the end of the intervention. As
observed in the results, the number of subjects with satisfactory
physical activity level in the IE group increased by 74%, which may
have helped, in part, in the reduction of anthropometric measure-
ments. Moreover, although the specific procedures adopted by
each volunteer that aimed to lose weight during the intervention
period were not recorded, it is possible that the information
shared in the lectures motivated attitudes related to behavior
changes —mainly regarding the adoption of a healthier eating
pattern, eating behavior, and physical activity level. This is a hy-
pothesis that must be confirmed in future studies.
In a study that considered 35 systematic reviews and meta-
analyses results (covering 360 studies in total), Lagger et al. (2010)
found that 64% of the studies showed positive effects related to
programs based on education of the patient with obesity (similar
to the IE group), corroborating our findings. Although the IE
group had a positive effect on anthropometry, the drop-out rate
over the intervention period was high (58%), which classifies the
Table 3. Sample characterization of subjects who completed the
interventions.
Variable IE FT IT
n11 14 19
Age (y) 41.0±6.3 39.7±6.6 39.0±5.5
BMI (kg/m
2
)36.3±2.7 34.5±2.6 35.8±3.0
Frequency of participation (%) 77.9±11.7 78.0±9.3 75.7±10.7
Note: Values are presented as means ± SD. BMI, body mass index; FT, functional
training; IE, interdisciplinary education; IT, interdisciplinary intervention.
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strategy as effective for weight loss for those who remain until the
end of the study but the probability of permanence is small (⬃42%
of users).
The functional training program provided a decrease only in
waist circumference and WHtR, without changes in BM, body fat,
and FFM. Although some previous studies have observed a posi-
tive effect of functional training on anthropometric variables and
body composition of overweight postmenopausal women (Neves
et al. 2014,2017), some of the literature shows that training-based
interventions of physical exercise in subjects with obesity has
little or no effect on weight loss (Johns et al. 2014;Swift et al. 2014).
However, even without observing weight loss, studies suggest
that physical training can reduce visceral fat (Verheggen et al.
2016), a fact that has been confirmed in this study. We must note
that abdominal obesity is considered an isolated risk factor for
morbidity and death (Ekelund et al. 2015) and its reduction is
important for reducing cardiometabolic risk.
In addition to functional training providing positive changes in
waist circumference and WHtR, cardiorespiratory fitness also im-
proved significantly in this group. Considering that (i) low cardio-
respiratory fitness is associated with high mortality rate in
overweight and subjects with obesity, (ii) its improvement alters
the obesity paradox (McAuley et al. 2010), and (iii) physical inactiv-
ity kills at least 2 times more than obesity (Ekelund et al. 2015),
functional training presents itself as another physical exercise
option and can be encouraged for women with obesity. However,
given the low efficacy in promoting positive changes on anthro-
pometric variables and body composition, in addition to the high
drop-out rate over the intervention period (50%), its association
with nutrition, psychology, and physical therapy interventions is
necessary, especially in an interdisciplinary approach. However,
it should be emphasized that although functional training did not
promote significant weight loss, the results observed at Post did
not present significant differences between the groups.
Although the overall drop-out rate seems high (⬃44%), it is
similar or lower than rates observed in previous studies of our
group with long-term interventions in people with obesity (Leite
et al. 2017;Sanches et al. 2016). The highest drop-out rates were
observed in the IE and FT groups. Specifically in the IE group, the
low frequency of lectures may have contributed to the higher
drop-out rates, because another study that used a similar format,
but more frequently at the beginning of the intervention, ob-
served a low drop-out rate (⬃16%) after 6 months of treatment
(Minniti et al. 2007). In the FT group, the results corroborate a
previous study that showed Brazilians with obesity have a drop-
out rate close to 50% in isolated physical training programs (Costa
et al. 2009). In the IT group, the interdisciplinary character of
therapy, with the purpose of promoting behavior change, associ-
ated with the high frequency of interventions (3/week) may have
contributed to attenuate the drop-out rate.
Our results obviously have to be interpreted in light of some
limitations. The main limitation of this study was the large sam-
ple drop-out rate over the intervention period, especially in the IE
and FT groups. However, as mentioned, previous studies show
that the drop-out rate of overweight and people with obesity in
exercise programs and other interventions for weight loss is high,
being higher than that of nonobese individuals (Burgess et al.
2017;Costa et al. 2009); thus, this is a challenge that requires
greater attention from investigators and professionals dealing
with this population. Another important limitation is the method
used to evaluate body composition, although it was highly corre-
lated with the gold standard method in the study (Segal et al. 1988)
that proposed the equation used in the present. Also, the analysis
of the physical activity level through a questionnaire also has
limitations and questions.
Finally, it is important to highlight that, although the interven-
tions applied in the present study provided statistically significant
changes in several of the analyzed variables, some observations
should be considered. Interdisciplinary therapy and interdisci-
plinary education provided significant weight loss, but percent-
age reductions did not reach 5%–10% of initial weight, which is
recommended by the World Health Organization and other enti-
ties (World Health Organization 2000). Similarly, oxygen uptake
increased significantly in functional therapy and interdisciplinary
therapy, but Post mean ratings were “regular” according to pa-
rameters for Brazilian women (Herdy and Caixeta 2016).
In conclusion, isolated functional training promotes improve-
ment in cardiorespiratory fitness, but only interdisciplinary ther-
apy improved both cardiorespiratory fitness and anthropometric
profile of women with obesity. Considering that concomitant im-
provement in anthropometric variables and cardiorespiratory fit-
ness is desirable in these women, functional therapy should be
encouraged, but whenever possible should be associated with nu-
Table 4. Maximum oxygen uptake (V
˙O
2max
) and V
˙O
2max
intensity (iV
˙O
2max
) before (Pre) and after (Post) moments in
different interventions.
Variable
IE FT IT
Pre Post Pre Post Pre Post
V
˙O
2max
(mL·kg
−1
·min
−1
)25.9±3.4 26.3±3.5 28.8±4.7 31.0±6.2* 26.8±3.5 29.4±3.7*
iV
˙O
2max
(km/h) 7.8±1.0 8.5±0.9* 7.5±0.9 8.6±0.9* 7.6±0.8 8.7±0.9*
Note: Values are presented as means ± SD. FT, functional training; IE, interdisciplinary education; IT, interdisciplinary intervention.
*p≤ 0.05 versus Pre.
Table 5. Anthropometric variables before (Pre) and after (Post) the different interventions.
Variable
IE FT IT
Pre Post Pre Post Pre Post
BM (kg) 97.5±3.9 94.2±4.1* 91.2±3.5 89.5±3.6 95.9±3.0 91.6±3.1*
BMI (kg/m
2
)36.3±0.8 35.0±1.0* 34.5±0.7 33.9±0.9 35.8±0.6 34.2±0.7*
BF (%) 45.4±1.4 44.6±2.8 44.3±2.0 44.1±1.8 45.2±1.6 44.2±1.8*
BF (kg) 44.3±6.0 42.3±8.6 40.6±6.8 39.6±6.4 43.6±7.6 40.6±7.6*
FFM (%) 54.7±1.4 55.4±2.8 55.7±2.0 55.9±1.8 54.8±1.6 55.8±1.8*
FFM (kg) 53.2±5.4 51.9±6.2* 50.6±6.1 49.9±5.9 52.4±6.8 50.9±6.6*
WC (cm) 101.9±2.8 98.4±2.8* 103.9±2.4 100.2±2.5* 105.2±2.1 99.8±2.1*
WHtR 0.62±0.05 0.60±0.06* 0.64±0.05 0.62±0.04* 0.65±0.04 0.61±0.05*
Note: Values are presented as means ± SD. BF, body fat; BM, body mass; BMI, body mass index; FFM, fat free mass; FT, functional
training; IE, interdisciplinary education; IT, interdisciplinary intervention; WC, waist circumference; WHtR, waist-to-height ratio.
*p≤ 0.05 versus Pre.
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trition, psychology, and physical therapy interventions, prefera-
bly in an interdisciplinary approach.
Conflict of interest statement
The authors have no conflicts of interest to report.
Acknowledgements
The authors thank the volunteers and investigating staff. This
work was supported by the Fundação de Amparo à Pesquisa do
Estado de São Paulo (FAPESP) (2015/06630-1, 2011/51723-7, 2015/
00953-3) and Conselho Nacional de Desenvolvimento Científico e
Tecnológico (CNPq) (471108/2011-1). L.M.O. is recipient of CNPq fel-
lowship.
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