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Obesity and Physical Activity International Journal of Obesity (1999) 23, Suppl 1, 59±64 ß 1999 Stockton Press All rights reserved 0307±0565/99 $12.00 http://www.stockton-press.co.uk/ijo Obesity and physical activity KR Westerterp*1 1Department of Human Biology, Maastricht University, The Netherlands OBJECTIVES: Three aspects of obesity and physical activity are reviewed: whether the obese are inactive; how the activity level can be increased; and which are the effects of an increase in physical activity in combination with a reduction of energy intake. METHOD: The focus is on an objective approach that is, activity associated energy expenditure as measured with doubly labelled water. RESULTS: Activity associated energy expenditure increases with body mass index while the average physical activity level does not change. The majority of obese subjects is moderately active. An increase in the activity level of obese subjects is limited by the ability to perform exercise of higher intensity. Training programs obese subjects can cope with are until now not rewarded by weight loss. A possible loss in fat mass is compensated by a gain in fat-free mass. CONCLUSIONS: Obese subjects can only reach a signi®cant weight loss with an energy restricted diet. Mild energy restriction will already result in very signi®cant weight loss when one complies with the diet. An increase in physical activity is necessary to compensate for the reduction in activity induced energy expenditure and should be facilitated by the lower body mass. Keywords: energy expenditure; energy intake; doubly-labelled water; fat mass; fat-free mass Introduction Are the obese inactive? Obesity is often associated with a low level of The doubly-labelled water method allows accurate physical activity. Many people think that one of the measurement of average daily metabolic rate causes of obesity is that people sit most of the day. (ADMR) under unrestricted conditions over 1 ± 3 The ®rst question we will try to answer is whether week intervals to assess the relation between physical there is evidence for a difference in the level of activity and obesity. In Maastricht, we have applied physical activity between obese and non-obese sub- the method, since 1983, in humans.1 Table 1 shows jects. Obesity can be treated by inducing a negative characteristics of 226 subjects measured since then in energy balance, either by increasing physical activity our laboratory, excluding the following characteris- or be reducing energy intake. The second and third tics: age < 20 y and > 50 y, an intervention in energy question therefore is, respectively, how can the activ- intake, an intervention in physical activity including ity level be increased in obese subjects and what is the athletic performance, pregnancy, lactation and dis- effect of an increase in physical activity in combina- ease. Basal metabolic rate (BMR) was measured tion with a reduction of energy intake. Discussing with a ventilated hood or in a respiration chamber. obesity and physical activity needs a de®nition of both Body composition was measured with isotope dilu- items. Obesity can be quanti®ed as weight corrected tion. Figure 1 shows ADMR as a function of BMI. for height, the body mass index (BMI, kg=m2), or fat The lower limit of ADMR clearly increases with BMI mass corrected for height, the fat mass index, or fat from < 5MJ=d in somebody with the lowest BMI of mass as a fraction of body mass. Physical activity is 12.5 kg=m2 to > 15 MJ=d in the morbid obese, a not easily quanti®ed. Measures range from self report threefold difference. It is obvious from this ®gure to activity-associated energy expenditure. One obvi- that the lower limit of energy expenditure, that is, ously wants an objective approach and therefore can energy expenditure at a minimal physical activity, not rely on self report. Here, the focus is on activity- increases with body size. The upper limit is set by associated energy expenditure as measured with body size and physical capacity. Here, we see a steep doubly-labelled water. increase in the lower range of BMI from 5 MJ=din somebody with the lowest BMI of 12.5 kg=m2 to a value of about 20 MJ=d in somebody with a BMI of 22.5 kg=m2. Higher values can be reached in a selec- tion of the population, such as endurance athletes.2 The energy expenditure associated with physical *Correspondence: Dr KR Westerterp, Department of Human activity was calculated as ADMR minus diet-induced Biology, Maastricht University, PO Box 616, 6200 MD Maastricht, The Netherlands. energy expenditure, assumed to be 10% of ADMR, Email [email protected] and minus BMR. Figure 2 shows activity-associated Obesity and physical activity KR Westerterp 60 Table 1 Characteristics of the subjects Women (n 101) Men (n 125) mean s.d. range mean s.d. range Age (y) 32 8 20 ± 49 34 7 20 ± 48 Height (m) 1.67 0.06 1.54 ± 1.81 1.80 0.06 1.64 ± 1.97 Body mass (kg) 73 24 38 ± 164 82 20 58 ± 216 Body mass 26.4 8.1 12.5 ± 55.3 25.4 5.6 19.4 ± 61.7 index (kg=m2) Fat mass (kg) 26 17 1 ± 85 20 14 3 ± 129 Fat-free mass (kg) 47 8 33 ± 79 62 8 48 ± 93. BMR (MJ=d) 6.3 1.2 3.6 ± 10.8 7.7 1.3 5.4 ± 12.7 ADMR (MJ=d) 10.9 2.2 4.7 ± 18.4 13.6 2.3 9.7 ± 21.5 ADMR=BMR 1.75 0.22 1.07 ± 2.57 1.79 0.23 1.23 ± 2.57 *BMR, basal metabolic rate; ADMR, average daily metabolic rate. Figure 2 Activity associated energy expenditure (AEE) as a function of body mass index (BMI) in 226 subjects (Table 1) with the calculated linear regression line (AEE (MJ=d) 0.38 BMI (kg=m2) r 0.17, P< 0.01). increases with BMI while the PAL for the same population does not is that the latter is corrected for differences in body size by expressing ADMR as a multiple of BMR. Someone with a larger body mass needs more energy for an activity than someone with a lower body mass, especially when the activity involves movement of the body mass. It is impossible to recommend a generalisable coef®cient for adjusting energy expenditure associated with physical activity for body size.4 Dividing by body mass power 1 Figure 1 Average daily metabolic rate as a function of body de®nitely overcorrects for body size as the majority mass index in 226 subjects (Table 1). The dotted lines denote the of the activities for the average subject involve only lower and upper limits. limb movements. Prentice et al 4 calculated an expo- nent of 0.51 for a 24 h activity pattern in a respiration energy expenditure as a function of BMI. As chamber including ADL activities, stepping and expected, there is a wide scatter, the activity-induced cycling. Dividing by BMR, as done in the PAL energy expenditure being the most variable compo- calculation, probably is a justi®ed intermediate. nent of ADMR. It ranges from 1 ± 10 MJ=d and there BMR in the population of the current analysis is a slight but signi®cant increase with BMI was a function of body mass power 0.63 (P < 0.01), overweight subjects spending on average (BMR 0.443 body mass0.63, r 2 0.69). more energy for physical activity. There are at least four meta-analyses of the relation The physical activity level (PAL) of a subject can between body mass or body fatness and physical be calculated by expressing ADMR as a multiple of activity as derived from doubly-labelled water.4 ± 7 BMR (PAL ADMR=BMR) or by adjustment of Westerterp et al 5 analysed 96 existing data sets with ADMR for BMR as suggested by Carpenter et al.8 observations on body composition and PAL of healthy Figure 3 shows the physical activity level expressed in subjects age 19 ± 48 y. Fat-free mass and fat mass both ways and plotted as a function of BMI. Which- were related to PAL. In a regression analysis fat ever of the two methods is used, the physical activity mass explained 53 and 40% of the variation in fat- level is independent of BMI, a result that has been free mass in females and males, respectively. Adding con®rmed with a tri-axial accelerometer for move- PAL to the model raised the explained variation in fat- ment registration in a sub-group of the subjects in free mass in females to 62%. In contrast with females, current analysis.3 An explanation for the fact that there was an independent relationship between PAL energy expenditure associated with physical activity and fat mass in males, such that a higher PAL was Obesity and physical activity KR Westerterp 61 physical activity and it was suggested that a low physical activity is a permissive factor for obesity. Prentice et al 4 analysed 319 data sets of healthy subjects age 18 ± 64 y. Results were analysed accord- ing to four categories: < 25.0, 25.0 ± 29.9, 30.0 ± 35.0 and > 35.0 kg=m2. PAL remained constant across the three lowest BMI groups indicating similar levels of physical activity. There was a non-signi®cant decrease in PAL in the most obese men and women. Westerterp and Goran7 analysed data sets of 290 healthy subjects age 18 ± 49 y. Physical activity was quanti®ed by adjustment of ADMR for BMR as suggested by Carpenter et al.
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