Weight Loss Strategies for Obese Adults:
Personalized Weight Management Program vs.
Standard Care
Nuala M. Byrne,* Jarrod D. Meerkin,* Raija Laukkanen,† Robert Ross,‡ Mikael Fogelholm,§ and
Andrew P. Hills*
Abstract
BYRNE, NUALA M., JARROD D. MEERKIN, RAIJA
LAUKKANEN, ROBERT ROSS, MIKAEL
FOGELHOLM, AND ANDREW P. HILLS. Weight loss
strategies for obese adults: personalized weight
management program vs. standard care. Obesity. 2006;14:
1777–1788.
Objective: The objective of this study was to evaluate the
effect of a 32-week personalized Polar weight management
program (PWMP) compared with standard care (SC) on
body weight, body composition, waist circumference, and
cardiorespiratory fitness in overweight or obese adults.
Research Methods and Procedures: Overweight or obese
(29 ⫾ 2 kg/m2) men and women (n ⫽ 74) 38 ⫾ 5 years of
age were randomly assigned into either PWMP (men ⫽ 20,
women ⫽ 21) or SC (men ⫽ 15, women ⫽ 18). Both groups
managed their own diet and exercise program after receiv-
ing the same standardized nutrition and physical activity
advice. PWMP also received a weight management system
with literature to enable the design of a personalized diet
and exercise weight loss program. Body weight and body
composition, waist circumference, and cardiorespiratory fit-
ness were measured at weeks 0, 16, and 32.
Results: Eighty percent of participants completed the 32-
week intervention, with a greater proportion of the dropouts
Received for review November 8, 2005.
Accepted in final form July 14, 2006.
The costs of publication of this article were defrayed, in part, by the payment of page
charges. This article must, therefore, be hereby marked “advertisement” in accordance with
18 U.S.C. Section 1734 solely to indicate this fact.
*School of Human Movement Studies, Queensland University of Technology, Kelvin
Grove, Australia; †Polar Electro Oy, Kempele, Finland; Department of Public Health
Science and General Practice, University of Oulu, Oulu, Finland; ‡Queen’s University,
School of Physical and Health Education, Kingston, Ontario, Canada; and §The UKK
Institute for Health Promotion Research, Tampere, Finland.
Address correspondence to Nuala M. Byrne, School of Human Movement Studies, Queens-
land University of Technology, Victoria Park Road, Kelvin Grove, Q4059 Brisbane,
Queensland, Australia.
E-mail: n.byrne@qut.edu.au
Copyright © 2006 NAASO
being women (PWMP: 2 men vs. 7 women; SC: 2 men vs.
4 women). At 32 weeks, PWMP completers had signifi-
cantly (p ⬍ 0.001) greater losses in body weight [6.2 ⫾ 3.4
vs. 2.6 ⫾ 3.6 (standard deviation) kg], fat mass (5.9 ⫾ 3.4
vs. 2.2 ⫾ 3.6 kg), and waist circumference (4.4 ⫾ 4.5 vs.
1.0 ⫾ 3.6 cm). Weight loss and fat loss were explained by
the exercise energy expenditure completed and not by
weekly exercise duration.
Discussion: More effective weight loss was achieved after
treatment with the PWMP compared with SC. The results
suggest that the PWMP enables effective weight loss
through tools that support self-monitoring without the re-
quirement of more costly approaches to program supervi-
sion.
Key words: weight loss, exercise, diet, weight manage-
ment, intention-to-treat
Introduction
The epidemic of obesity coupled with poor success of
cost-effective weight loss treatments has prompted the call
for further research to determine viable treatment options
(1). Physical activity is important but is not the sole deter-
minant of successful weight loss (2). Data from the Diabetes
Prevention Program revealed that both exercise and dietary
restraint facilitate weight loss and its long-term maintenance
(3). The frequency of monitoring dietary intake was related
to success at achieving the physical activity goal (minimum
of 150 minutes moderate exercise per week), suggesting that
adherence to one aspect of the intervention is related to
adherence in other aspects. Likewise, success at achieving
the physical activity goal was related to success at achieving
the weight loss goal (7% initial body weight) in ⬃24 weeks
and also in maintaining the reduced-weight for an average
3.2 years (3). These results support the notion that success-
ful weight loss is enabled when behavior changes cluster;
with participants who adhere to one aspect of the lifestyle
OBESITY Vol. 14 No. 10 October 2006 1777
Weight Loss: Personalized Management vs. Standard Care, Byrne et al.

regimen more likely to adhere to other aspects (4,5). Such

findings suggest the need for weight loss interventions that
link strategies for increasing physical activity levels with
monitoring dietary intake. Importantly, however, these stud-
ies included considerable support networks of research staff
to educate, prescribe, and monitor the intervention for the
participants. For instance, in obese children/adolescents,
biweekly phone contact has been shown to mediate weight
maintenance after an intensive live-in weight loss program
(6). While effective, there is a significant economic burden
in such approaches.
In contrast to research studies or professionally managed
treatments, some individuals have successful weight loss
through self-management strategies. The National Weight
Control Registry surveyed behaviors of ⬎1000 individuals
Figure 1: Flow of participants in the study.
who self-reported successful weight loss and maintenance
over a number of years (7). Approximately 45% of regis-
trants had lost weight on their own, and as shown in other
studies (8 –10), the majority of individuals reported using predicted degree of change in body composition and success
behavioral strategies such as lowering dietary fat, increasing in meeting a self-defined target weight loss.
physical activity or structured exercise programs, weekly
weighing, and self-monitoring of food intake. Self-help
Research Methods and Procedures
strategies purportedly have the additional advantage of en-
abling individuals to obtain a sense of power and the inward Participants
resources that give them more control over themselves and Seventy-four participants were recruited for the study
their environment (11). However, despite these successes, from the Brisbane metropolitan area through the public
some individuals who have lost weight and attempt to media (e.g., local radio, newspapers) and within the Uni-
versity (Figure 1). Respondents were initially screened by
maintain the weight-reduced state on their own express the
telephone, and if eligible based on self-reported height,
need for programs with ongoing support offered at low or
weight, and medical history, were invited to attend an
no cost (12). For these individuals, there is the need for
information session. Eligibility criteria were 30 to 45 years
tools, in addition to currently available resources, to assist in
of age, overweight/obese (BMI ⫽ 27 to 32 kg/m2), seden-
learning how to self-manage weight loss and long-term
tary (defined as ⬍30 minutes of intentional moderate phys-
weight maintenance.
ical activity per week over the past 12 months, including
This study was designed to evaluate whether a 32-week
work-related physical activity), weight stable (⫾2 kg) for
personalized weight management program (PWMP)1 would the last 6 months, and ambulatory. Exclusion criteria were
enhance weight loss compared with standard care (SC). It medications known to affect HR or body composition, preg-
was hypothesized that, compared with individuals given nancy or lactation, planning to get pregnant during the
standard diet and physical activity advice, overweight/obese intervention period, post-menopausal, and smoking. Addi-
individuals given exercise energy expenditure targets and tional exclusion criteria included the inability to walk on a
heart rate (HR) and dietary intake monitoring are better able treadmill or to undertake a graded test to achieve maximum
to achieve a self-defined target weight loss. A further pur- aerobic capacity. Only those respondents who identified
pose of the study was to determine whether body size, body that they were in the “ready to change” stage according to
composition, and cardiorespiratory fitness improvements the Transtheoretical Model (13) were included. Further-
gained over the first 16 weeks of intervention, which in- more, participants categorized as overweight or obese but
cluded weekly contact with research staff, could be main- otherwise healthy gained clearance from their medical prac-
tained over the second 16 weeks when there was no contact titioner before enrollment in the study. The study was ap-
with study participants. A final aim in the PWMP group, proved by the University Human Research Ethics Commit-
where objective exercise training data were available, was tee, and all participants gave written informed consent.
to determine whether adherence to the exercise prescription
Interventions
1
After baseline testing, participants were randomly as-
Nonstandard abbreviations: PWMP, personalized weight management program; SC, stan-
dard care; HR, heart rate; ITT, intention to treat; V̇O2, oxygen uptake; V̇O2max, maximum
signed to either of two intervention groups: PWMP or SC.
oxygen uptake; HRmax, maximum HR. Participants were stratified according to sex (men and

1778 OBESITY Vol. 14 No. 10 October 2006

Weight Loss: Personalized Management vs. Standard Care, Byrne et al.

Table 1. Baseline characteristics of participants by randomization group and sex

PWMP (N ⴝ 41) SC (N ⴝ 33)
PWMP SC Men Women Men Women
(N ⴝ 41) (N ⴝ 33) (N ⴝ 20) (N ⴝ 21) (N ⴝ 15) (N ⴝ 18)
Age (years) 37.6 (4.4) 38.6 (4.8) 37.4 (4.5) 37.9 (4.5) 39.8 (5.3) 37.5 (4.3)
Height (m) 1.71 (0.10) 1.69 (0.10) 1.80 (0.10) 1.63 (0.10) 1.78 (0.10) 1.62 (0.10)
Weight (kg) 87.2 (12.6) 85.7 (12.5) 97.9 (8.1) 79.2 (7.4) 96.7 (11.1) 78.8 (8.4)
BMI (kg/m2) 29.3 (1.6) 29.3 (1.8) 29.3 (1.6) 29.3 (1.8) 29.3 (1.6) 29.3 (1.8)
Body fat (%) 35.5 (6.0) 36.4 (2.1) 30.7 (4.0) 40.0 (3.4) 30.6 (5.2) 41.2 (4.2)
Waist (cm) 90.4 (8.7) 91.4 (9.2) 97.0 (5.2) 84.0 (6.3) 98.6 (5.9) 85.4 (6.8)
V̇O2max (mL/kg/min) 37.6 (7.1) 35.4 (7.8) 43.4 (4.8) 32.4 (4.1) 39.6 (7.6) 31.8 (7.3)
V̇O2max (mL/kg FFM/min) 58.6 (7.0) 55.5 (7.1) 62.8 (7.0) 54.3 (7.1) 56.8 (7.0) 54.2 (7.0)

PWMP, personalized weight management program; SC, standard care; V̇O2max, maximum oxygen uptake; FFM, fat-free mass. Data
presented as mean (standard deviation).

women), age (30 to 37 and 38 to 45 years), and BMI (27 to
29.9 and 30 to 32 kg/m2) and were randomized to enable the
intervention groups to be matched as closely as possible.
Unfortunately, there were not enough volunteers in the BMI
range willing to be randomized into the standard care group
to enable a balanced research design; time restrictions pre-
cluded further recruitment of participants. However, as
shown in Table 1, although the groups were not equal in
number, there was no difference in outcomes variables at
baseline.
SC
Participants received standard care advice on weight
management from a health professional with dual qualifi-
cations in dietetics and exercise physiology. The single
consultation included simple advice regarding ways to in-
crease physical activity levels and reduce energy intake,
with clear directions that the goal should be to lose no ⬎1
kg per week. This maximum was important to parallel the
average target rate of weight loss selected by the PWMP
group. Guidelines for physical activity participation were
consistent with the Australian National Physical Activity
Guidelines (14) for safe exercise by relatively unfit but
otherwise healthy individuals. Nutrition advice was consis-
tent with an ad libitum low-fat diet. Each week during the
first 16 weeks of the intervention, participants reported to
the University for the measurement of body weight and
waist circumference.
PWMP
In addition to the standard care treatment outlined above,
these participants were provided with an HR transmitter
belt, a receiver watch with built in weight management
program, and weight management program education re-
sources (Polar Electro Oy, Kemple, Finland). These re-
sources included an explanatory booklet with an overview
of the program, users manual, diet diary, tape measure, and
“calorie counting” book (15) that provides a comprehensive
analysis of the energy content of most of the foods and
ingredients available in Australia. The program calculates a
weight loss (or maintenance) program, including the rec-
ommendation for daily energy intake and weekly exercise
energy expenditure (defined in kilocalories). These individ-
ualized goals are based on information provided by each
subject (body weight, height, age, sex, target weight, daily
occupational activity assessment) and also on the chosen
exercise intensity (low: 110 to 130 beats/min; moderate:
130 to 160 beats/min). The program allows the user to
follow his/her progress daily in an electronic diary by track-
ing body weight, energy intake, and exercise energy expen-
diture (whenever exercising with the transmitter belt). Ad-
ditionally, the program provides weekly updates and makes
adjustments according to the progress of the individual by
giving updated daily energy intake and weekly exercise
energy expenditure values. Because the intention of the
study was to investigate the effectiveness of the PWMP in
the form that it would be provided to the general public, no
additional requirement to complete exercise or diet diaries
was deemed appropriate.
Participants were introduced to the PWMP in a training
session to ensure comprehension of all functions. In the first
few weeks of the intervention, participants were encouraged
to e-mail a member of the research team if they encountered
any problems with the program or needed assistance to
follow instructions. As did the SC group, PWMP partici-
pants reported to the University Clinic each week for the

OBESITY Vol. 14 No. 10 October 2006 1779

Weight Loss: Personalized Management vs. Standard Care, Byrne et al.
first 16 weeks of the study for the measurement of body
weight and waist circumference. For the following 16
weeks, participants had no contact with the study team. All
baseline measurements were repeated after Weeks 16 and
32 of the intervention.
Experimental Protocol
All participants attended two testing sessions at baseline
and after Weeks 16 and 32 of the intervention. On both
testing days, participants reported to the University labora-
tory a minimum of 3 hours after their last food or fluid
intake, wearing light-weight, comfortable clothing, having
abstained from physical exercise and consumption of caf-
feine or alcohol in the previous 12 hours. The first session
involved anthropometric measurements (height, body
weight, and waist circumference) and body composition
assessment by DXA (DPX-L; Lunar Radiation Corp., Mad-
ison, WI). The scans were analyzed with the ADULT soft-
ware, version 1.33 (Lunar Radiation Corp.), and body com-
position was determined as previously reported (16).
Measurements of body height (stretch stature) were taken
using a Harpenden stadiometer, body weight was recorded
on a digital scale, and BMI (weight divided height squared)
was calculated from height and weight values. Waist cir-
cumference was measured at the narrowest point below the
inferior border of the last ribs and above the iliac crest.
Subsequently, participants were familiarized with the max-
imal aerobic power test protocol, breathing apparatus, and
treadmill. Participants were familiarized with walking at 5.6
kph, the optimal walking and running speeds for the max-
imal graded exercise test were identified, and participants
were familiarized with the Borg 6 –20 scale for the rating of
perceived exertion (17,18).
On the second testing day, participants undertook a
graded exercise test to assess maximal aerobic capacity.
After being fitted with a Hans-Rudolf headset (with two-
way breathing valve and pneumotach), a nose clip, and a
Polar Coded Transmitter (Polar Electro Oy), participants
walked for 4 minutes at 0% grade and 5.6 kph and the speed
increased to an individualized speed, after which grade
increased by 2.5% per minute until volitional exhaustion.
Respiratory gases were collected throughout the test using a
Q-PLEX Gas Analysis System (Quinton Instrument Co.,
Seattle, WA). The O2 and CO2 analysers were calibrated
before each test against known gas concentrations and the
flowmeter calibrated against a 3.0-liter syringe. HR and
respiratory gases were averaged for the last 30 seconds of
each stage and the highest average value for 30 seconds
(provided respiratory exchange ratio ⱖ1.10) was recorded
as the peak value. Duplicate 0.5-mL samples of capillary
blood obtained by the finger-prick method were collected
immediately at the end of each test. Blood lactate concen-
trations were subsequently analyzed by an ultraviolet end-
1780 OBESITY Vol. 14 No. 10 October 2006
point method using the spectrophotometric assay procedure
(19). To confirm that the peak values obtained were repre-
sentative of maximal capacity, a booster test was used after
the participants had rested for 5 minutes. A “booster” test is
when the individual undertaking a test to volitional exhaus-
tion is required, after a short rest, to resume exercising at the
mechanical work they stopped at, and continue the test with
the usual mechanical work increases until again reaching a
point of volitional exhaustion. Five commonly used markers
of maximal cardiorespiratory capacity were measured, and
the data were accepted provided three of the following were
achieved in the main test: oxygen uptake (V̇O2) increase
⬍0.8 mL/kg per minute per percent grade in last stage;
respiratory exchange ratio ⱖ1.10; HR greater than predicted
maximum (220 – age) – 10 beats/min; blood lactate ⬎8
mM; and rating of perceived exertion ⱖ18.
Statistical Analyses
To determine the sample size required to detect a differ-
ence between two interventions, the power calculations
were based on prior observations of modest weight losses
through diet and exercise interventions (6% and 7% initial
weight, respectively) in obese women (20). The within-
group changes in body weight derived from a dietary inter-
vention and an exercise intervention over 14 weeks were
5.2 ⫾ 1.2 and 6.1 ⫾ 1.2 kg, respectively. To detect this
magnitude of between-group difference as statistically sig-
nificant with ␣ set at 0.05 and at a power of 0.80, 24
participants per group were required.
All statistical calculations were performed using SAS
(version 8.02) with p ⬍ 0.05 considered significant. Data
are presented as mean ⫾ standard deviation or mean ⫾
standard error as specified, and 95% confidence intervals
for the mean group differences were calculated. Differences
between characteristics of completers vs. dropouts were
tested using independent t tests. When comparing treatment
effects, data were analyzed using both completers-only data
and intention-to-treat (ITT) analysis approaches. For the
completers analyses, only data from the participants (N ⫽
59) who completed the 32-week intervention was included.
ITT analysis included all randomized participants (N ⫽ 74)
with missing values imputed by last-observation-carried-
forward method. Comparisons of outcome variables before
and after 16 and 32 weeks of the intervention were assessed
after adjusting for sex, using 2 (group) ⫻ 3 (time) repeated-
measures analysis of covariance. When significant F ratios
were obtained, Bonferroni post hoc tests were performed to
locate differences among means.
Results
The baseline characteristics of the study sample are out-
lined in Table 1. As expected, compared with women of the
same BMI, men had significantly lower percentage body fat
Weight Loss: Personalized Management vs. Standard Care, Byrne et al.

Table 2. ITT analysis of changes 关mean (standard error)兴 in weight, waist, fat mass, and V̇O2max
95% confidence
PWMP SC Group effect Difference limits for
(n ⴝ 41) (n ⴝ 33) (p value) between means group difference
Weight (kg)
Week 0 to Week 16 ⫺4.46 (0.5) ⫺2.35 (0.6) NS 2.11 ⫺4.52 0.30
Week 16 to Week 32 ⫺0.39 (0.5)*† 0.12 (0.6) NS 0.51 ⫺2.92 1.90
Week 0 to Week 32 ⫺4.84 (0.5) ⫺2.19 (0.6) ⬍0.05 2.65 ⫺5.06 ⫺0.24
Waist (cm)
Week 0 to Week 16 ⫺3.15 (0.6) ⫺1.28 (0.7) NS 1.86 ⫺4.62 0.90
Week 16 to Week 32 ⫺0.31 (0.6)*† 0.37 (0.7) NS 0.68 ⫺3.43 2.08
Week 0 to Week 32 ⫺3.44 (0.6) ⫺0.86 (0.7) 0.09 2.58 ⫺5.34 0.18
Fat mass (kg)
Week 0 to Week 16 ⫺3.99 (0.5) ⫺2.12 (0.6) NS 1.87 ⫺4.21 0.46
Week 16 to Week 32 ⫺0.65 (0.5)*† 0.21 (0.6) NS 0.85 ⫺3.18 1.48
Week 0 to Week 32 ⫺4.63 (0.5) ⫺1.87 (0.6) ⬍0.01 2.76 ⫺5.09 ⫺0.42
V̇O2max (mL/kg/min)
Week 0 to Week 16 3.14 (0.6) 2.68 (0.7) NS 0.46 ⫺2.14 3.05
Week 16 to Week 32 0.08 (0.6)*† ⫺0.74 (0.7)* NS 0.82 ⫺1.77 3.42
Week 0 to Week 32 3.21 (0.6) 1.92 (0.7) NS 1.29 ⫺1.31 3.88
V̇O2max (mL/kg FFM/min)
Week 0 to Week 16 1.90 (0.7) 2.92 (0.8) NS 1.02 ⫺2.05 4.09
Week 16 to Week 32 0.61 (0.7) ⫺1.22 (0.8)* NS 0.62 ⫺3.68 2.45
Week 0 to Week 32 1.29 (0.7) 1.70 (0.8) NS 0.41 ⫺2.66 3.47

ITT, intention to treat; PWMP, personalized weight management program; SC, standard care; FFM, fat-free mass; V̇O2max, maximum
oxygen uptake; NS, not significant.
* Significantly different (p ⬍ 0.05) from Week 0 to Week 16 within the same intervention group.
† Significantly different (p ⬍ 0.05) from Week 0 to Week 32 within the same intervention group.

and larger waist circumference. There were no differences
between groups for any of the primary outcome variables at
baseline, and no within-sex differences in body size or
composition were noted between groups. Of the starting
cohort, 80% of the participants completed the study (Figure
1). The retention rate was comparable between groups
(PWMP ⫽ 78%, SC ⫽ 81%), but greater for men (89%)
than women (72%). After adjustment for sex, examination
of the average baseline characteristics for the completers
(N ⫽ 59) compared with dropouts (N ⫽ 15) showed no
significant difference in body weight (87.0 vs. 89.5 kg; p ⫽
0.36); waist circumference (91.6 vs. 89.7 cm; p ⫽ 0.33); fat
mass (30.4 vs. 32.3 kg; p ⫽ 0.51); fat-free mass (56.4 vs.
57.0 kg; p ⫽ 0.73); relative body fat (35.5% vs. 36.3%; p ⫽
0.54); or V̇O2max (37.1 vs. 36.0 mL/kg per minute; p ⫽
0.53). Ninety percent of the participants attended at least
80% of the weekly weigh-in sessions during the first 16
weeks of the study. There was no difference between groups
in the attendance rate and no relationship between weight
loss and frequency of attendance. Reasons for dropping out
of the study were similar between groups; including per-
sonal reasons, work commitments, and unexpected require-
ment to travel overseas. However, two of the participants
dropped out in week 2 because of being disappointed with
being randomized into SC.
Table 2 outlines group and sex comparisons of changes in
body weight, waist circumference, body composition, and
maximal aerobic power from ITT analysis. Table 3 shows
the same analysis, but using only data from participants who
completed the 32-week intervention. The results of the two
analysis approaches are comparable, with the magnitude of
intervention effects defined by the ITT analyses being more
modest. In terms of the participants who completed the
32-week study, at 32 weeks, PWMP had lost 3.5 kg more
weight, 3.7 kg more fat mass, and 3.3 cm more waist
circumference than SC. However the improvement in car-
diorespiratory fitness was not appreciably greater in PWMP
than SC.

OBESITY Vol. 14 No. 10 October 2006 1781

Weight Loss: Personalized Management vs. Standard Care, Byrne et al.

Table 3. Completers analysis of changes 关mean (standard error)兴 in weight, waist, fat mass, and V̇O2max
95% confidence
PWMP SC Group effect Difference limits for
(n ⴝ 32) (n ⴝ 27) (p value) between means group difference
Weight (kg)
Week 0 to Week 16 ⫺5.66 (0.6) ⫺2.82 (0.7) ⬍0.05 2.84 ⫺5.56 ⫺0.12
Week 16 to Week 32 ⫺0.45 (0.6)*† 0.19 (0.7)* NS 0.64 ⫺3.36 2.07
Week 0 to Week 32 ⫺6.15 (0.6) ⫺2.3 (0.7) ⬍0.01 3.53 ⫺6.24 ⫺0.81
Waist (cm)
Week 0 to Week 16 ⫺3.91 (0.8) ⫺1.52 (0.7) NS 2.39 ⫺5.76 0.97
Week 16 to Week 32 ⫺0.31 (0.8)*† 0.50 (0.7) NS 0.81 ⫺4.17 2.56
Week 0 to Week 32 ⫺4.29 (0.8) ⫺1.00 (0.7) 0.06 3.29 ⫺6.65 0.08
Fat mass (kg)
Week 0 to Week 16 ⫺5.08 (0.6) ⫺2.55 (0.7) 0.07 2.53 ⫺5.18 0.12
Week 16 to Week 32 ⫺0.79 (0.6)*† 0.29 (0.7)* NS 1.09 ⫺3.74 1.56
Week 0 to Week 32 ⫺5.89 (0.6) ⫺2.25 (0.7) ⬍0.001 3.65 ⫺6.30 ⫺1.00
V̇O2max (mL/kg/min)
Week 0 to Week 16 4.03 (0.7) 3.26 (0.8) NS 0.77 ⫺2.33 3.87
Week 16 to Week 32 0.10 (0.7)*† ⫺0.93 (0.8)* NS 1.03 ⫺2.07 4.13
Week 0 to Week 32 4.12 (0.7) 2.33 (0.8) NS 1.79 ⫺1.31 4.89
V̇O2max (mL/kg FFM/min)
Week 0 to Week 16 2.41 (0.9) 3.57 (0.9) NS 1.16 ⫺4.95 2.64
Week 16 to Week 32 0.69 (0.9) ⫺1.49 (0.9)* NS 0.81 ⫺2.99 4.60
Week 0 to Week 32 1.69 (0.9) 2.08 (0.9) NS 0.39 ⫺4.19 3.40

V̇O2max, maximum oxygen uptake; PWMP, personalized weight management program; SC, standard care; FFM, fat-free mass; NS, not
significant.
* Significantly different (p ⬍ 0.05) from Week 0 to Week 16 within the same intervention group.
† Significantly different (p ⬍ 0.05) from Week 0 to Week 32 within the same intervention group.

As shown in Figure 2 and Table 3, the average weight
loss from baseline was significantly greater for PWMP
compared with SC both at Week 16 and Week 32 for the
completers analysis; but only at Week 32 for the ITT
analysis. The weight loss at Week 32 equated with a 7.1%
and 3.1% decrease from baseline values for PWMP and SC,
respectively. The self-defined weight loss “target” was com-
parable for both groups: 8.9 ⫾ 1.2 and 8.6 ⫾ 1.2 kg for
PWMP and SC, respectively. PWMP achieved a greater
proportion of the weight loss goal than SC both at Week 16
(60 ⫾ 36% vs. 34 ⫾ 41%; p ⫽ 0.01) and Week 32 (70 ⫾
51% vs. 30 ⫾ 51%; p ⫽ 0.008). As shown in Figure 3, at
Week 16, the 50th percentile for SC equated with 26% of
target weight loss, whereas for PWMP, the median was
72%. At Week 32, the 50th percentile for SC had dropped
to 18% of target weight loss, whereas the PWMP median
remained at 72%. A weight loss of ⱖ5% initial body weight
is often referenced as an important clinical outcome. More
of those in PWMP than SC achieved this relative weight
loss by Week 16 (63% and 30%, respectively); these pro-
portions were comparable at Week 32 (59% PWMP and
33% SC).
While fat loss was significant for both groups, the loss
from baseline was significantly greater at both Week 16 and
Week 32 for PWMP compared with SC (p ⬍ 0.01). Simi-
larly, waist circumference decrease from baseline was
greater on average for PWMP compared with SC at both
Week 16 and Week 32 (Figure 2). The average increase in
V̇O2max from baseline for PWMP did not differ significantly
from SC at Week 16 or Week 32 (p ⬎ 0.1). For all
measures, the change from baseline for both groups was
significant at both Week 16 and Week 32, but changes
between Week 16 and Week 32 were not significant.
Table 4 outlines the exercise prescription goals and the
exercise completed by the PWMP group. Despite a wide
range of prescribed exercise energy expenditure being com-
pleted (28% to 145%), the PWMP, on average, achieved
two thirds of the energy expenditure target over an average

1782 OBESITY Vol. 14 No. 10 October 2006

Weight Loss: Personalized Management vs. Standard Care, Byrne et al.
Figure 2: Mean weight and waist change by group (error bars indicate standard error). Between-group difference (* p ⬍ 0.05; ** p ⬍ 0.01;
§ p ⫽ 0.06).
2.8 h/wk (range: 1.3 to 5.4 h/wk) and at a mean intensity of
72% maximum HR (HRmax; 61% to 88% HRmax). There
was no difference between men and women in the average
weekly exercise training completed. Pearson correlation
analyses showed that duration of weekly exercise completed
did not explain the variance in weight loss (r ⫽ 0.21; 95%
confidence interval, ⫺0.21 to 0.57; p ⫽ 0.32) or fat loss
(r ⫽ 0.21; 95% confidence interval, ⫺0.22 to 0.57; p ⫽
0.34). In contrast, Figure 4 shows the relationship between
weight change and average weekly exercise energy expen-
diture completed. Based on the resulting prediction equa-
tion, even with no reduction in energy intake, the average
target weight loss (8.9 kg) would have been achieved with
an average exercise energy expenditure of 2341 kcal/wk.
Furthermore, after adjusting for sex, the proportion of target
exercise energy expenditure completed by PWMP partici-
pants was positively related to weight loss (r ⫽ 0.55, p ⬍
0.05) and fat loss (r ⫽ 0.49, p ⬍ 0.05).
OBESITY Vol. 14 No. 10 October 2006 1783
Weight Loss: Personalized Management vs. Standard Care, Byrne et al.

Figure 3: Cumulative frequency distribution of the target weight loss achieved by Week 16 (top) and Week 32 (bottom).

Table 4. PWMP completers exercise prescription and training data 关mean (standard deviation)兴
Total 95% confidence
PWMP Men Women Sex limits for sex
Variable (n ⴝ 32) (n ⴝ 18) (n ⴝ 14) difference difference
Target weight loss (kg) 8.9 (1.2) 9.7 (0.8) 7.8 (0.7) 1.9* 1.3 3.5
Actual weight loss (kg) 6.2 (3.7) 7.3 (3.2) 5.7 (3.9) 1.6 1.6 4.7
Proportion of target weight loss (%) 73 (40) 75 (31) 71 (50) 4 ⫺32 39
Target exercise energy expenditure (kcal/wk) 2341 (519) 2796 (234) 1846 (117) 950* 787 1114
Target exercise energy expenditure (kcal/kg/wk) 26.2 (3.3) 28.9 (1.4) 23.1 (1.5) 5.7* 4.5 7.0
Actual exercise energy expenditure (kcal/wk) 1509 (554) 1637 (562) 1369 (536) 268 ⫺209 745
Actual exercise energy expenditure (kcal/kg/wk) 16.9 (5.5) 16.9 (5.4) 17.0 (6.0) 0.1 ⫺5.0 4.9
Proportion target exercise energy expenditure (%) 66 (31) 57 (21) 74 (39) 18 ⫺45 18
Exercise time (h/wk) 2.8 (1.0) 2.5 (0.7) 3.2 (1.3) 0.7 ⫺1.5 0.2
Exercise heart rate (beats/min) 132 (13) 134 (15) 131 (11) 2.7 ⫺10 14
Exercise heart rate (%HRmax) 72 (7) 72 (8) 73 (6) 0.7 ⫺7 6

PWMP, personalized weight management program; %HRmax, percentage of maximum heart rate.
* p ⬍ 0.001.

1784 OBESITY Vol. 14 No. 10 October 2006

Weight Loss: Personalized Management vs. Standard Care, Byrne et al.
Figure 4: Weight change at 32 weeks relative to average weekly exercise energy expenditure.
Stepwise and best-subsets regression analyses were used
to determine which variables best explained the variance in
average weekly exercise energy expenditure. Average
weekly exercise energy expenditure was best explained (r ⫽
0.92, p ⬍ 0.0001) by a combination of weekly exercise dura-
tion and exercise intensity (HR or %HRmax); addition of sex
explained a further 6% of the variance.
Discussion
These study results support the hypothesis that over-
weight and obese individuals given exercise energy expen-
diture targets, HR monitoring, and calorie counting moni-
tors are better able to achieve a self-defined target weight
loss than those given standard diet and physical activity
advice. The PWMP group achieved twice the weight loss of
SC in both relative and absolute terms. Furthermore, the
PWMP group achieved, on average, twice the proportion of
the individualized weight loss goal. As expected, partici-
pants in the PWMP group achieved a greater reduction in
absolute and percentage body fat compared with SC and
significantly greater reduction in waist circumference.
The proportion of weight lost by PWMP is clinically
meaningful (21). Previous weight loss studies have shown
that waist circumference changes are matched with changes
in intra-abdominal fat. While Irwin et al. (22) found a 2-kg
weight loss in women was accompanied by a 7% reduction
in visceral fat, Slentz et al. (23) also noted a 2-kg weight
loss was accompanied by a 7% reduction in visceral fat, and
Ross et al. (20) reported a 6-kg exercise-induced weight loss
was accompanied by a 6.5-cm reduction in waist circum-
ference and a 30% reduction in visceral fat. Based on the
dose–response relationships between weight loss, waist cir-
cumference reduction, and visceral fat loss shown in these
previous studies, it can be speculated that the current 32-
week intervention resulted in greater losses in visceral fat
for PWMP compared with SC. Thus, the greater weight loss
for PWMP was accompanied by greater fat loss and impor-
tantly greater reduction in abdominal girth than SC. Collec-
tively, these findings show that weight loss over 32 weeks
is possible with both SC and PWMP; however, the addi-
tional support provided by PWMP augments the favorable
changes achieved with SC. These findings hold both in
analysis of “completers” data and ITT analyses.
The second purpose of the study was to determine
whether improvements gained over the first 16 weeks of the
intervention, which included weekly contact with research
staff, could be maintained over the second 16 weeks when
no contact was made with study participants. The results
showed that, although the changes elicited in the second
phase of the intervention were not significantly different
between groups, the pattern of change tended to reflect
further reductions in body weight and body composition for
the PWMP group. The SC group tended toward a reversal in
the improvements gained during the first phase. For some
individuals, the cessation of the weekly “conscience” meet-
ings may have resulted in lowered motivation to adhere to
diet and exercise goals. However, despite no weekly weigh-
ins, the PWMP group, in using electronic monitoring of
exercise energy expenditure and dietary intake, had contin-
ued (albeit non-significant) body size and body composition
reductions in the second 16 weeks.
OBESITY Vol. 14 No. 10 October 2006 1785
Weight Loss: Personalized Management vs. Standard Care, Byrne et al.
In a study of similar design, Heshka et al. (24) compared
weight loss achieved and maintained through self-help strat-
egies with a structured weight loss program. The self-help
group was provided with two 20-minute consultations with
a dietitian and was given publicly available printed dietary
and exercise advice, web sites, and health organization
contact details. The individuals randomized to the commer-
cial weight loss group were provided with vouchers enti-
tling them to attend Weight Watchers. The self-help group
achieved an average peak weight loss of 1.6 kg (1.7%) after
6 months of the intervention period compared with com-
mercial intervention, which, also peaking at 6 months,
achieved an average loss of 5.5 kg (5.8%). Weight losses at
16 weeks were, on average, ⬃1.5 (1.6%) and 4.5 kg (4.8%)
for the self-help and commercial groups, respectively.
These findings suggest that even with continued “con-
science” meetings, weight may be slowly regained after 24
weeks.
Recidivism in the months after weight loss elicited
through behavior modification interventions are common-
place, and, thus, strategies to assist self-management of
weight loss and weight loss maintenance in the longer term
are required. The results from this study suggest the PWMP
may provide a less costly way to enable individuals to
self-monitor their weight loss process using more objective
targets. Self-help strategies also theoretically have the ad-
ditional advantage of enabling individuals to obtain a sense
of power and the inward resources that give them more
control over themselves and their environment (11). Segal et
al. (25) argued that empowerment may be a primary prin-
ciple underlying self-help goals and that empowerment
may, in turn, increase self-efficacy, self-esteem, and the
sense that one’s own efforts can effect positive change. A
longer period of self-management without weekly weigh-
ins using PWMP and SC would be required to determine
whether the trends we observed in the second 16-week
period would reach statistical significance. Further research
to determine the impact of PWMP on self-efficacy and
self-esteem in relation to capacity to successfully self-man-
age weight loss and long-term weight management would
be valuable.
Treatment efficacy is a measure of the benefit resulting
from an intervention for a given health outcome under ideal
conditions of a study; as such, it refers to the degree to
which the intervention is shown to scientifically accomplish
the desired outcome in people who fully comply with the
intervention. In contrast, effectiveness is a measure of the
benefit resulting from an intervention under usual condi-
tions of clinical care for a particular group; hence, it con-
siders both efficacy of an intervention and its acceptance by
those to whom it is offered (26). The data discussed thus far
indicate that PWMP was more effective than SC in achiev-
ing body size and body composition improvements over 32
weeks. However, the efficacy of PWMP needs to be con-
1786 OBESITY Vol. 14 No. 10 October 2006
sidered with reference to the extent to which participants
adhered to the intervention as prescribed. The third aim of
the study was to determine whether adherence to the exer-
cise prescribed predicted magnitude of body composition
changes and success in meeting weight loss targets in par-
ticipants who finished the 32-week intervention.
Participants who finished the 32-week intervention com-
pleted, on average, two thirds of the exercise energy expen-
diture prescribed and achieved approximately three quarters
of the target weight loss. It is of interest to note that if the
average prescribed exercise energy expenditure had been
completed, the average target weight loss would have been
achieved (Figure 4). However, it is important to recognize
the relatively large standard error of the estimate of this
prediction. The average exercise energy expenditure was
1509 kcal/wk (17 kcal/kg per week), and the time commit-
ted to structured exercise was, on average, 168 min/wk
(range, 78 to 324 min/wk). An important finding was that
minutes spent exercising did not explain the variance in
weight loss or fat loss. However, absolute and relative
exercise energy expenditure completed was positively re-
lated with weight and fat mass losses. Exercise energy
expenditure was best explained by the combination of ex-
ercise duration and exercise intensity. This is an important
finding, given that in many clinical and public health set-
tings, exercise recommendations are based around time,
with vague exercise intensity prescriptions.
The Centers for Disease Control and Prevention promote
population-level recommendations of 150 minutes of exer-
cise of moderate or greater intensity per week (27). These
are comparable with the commonly cited 1000 kcal/wk
(4184 kJ/wk) additional energy expenditure through pur-
poseful physical activity or exercise recommended for
weight reduction (28). On average, participants in the
PWMP met both of these recommendations. With no con-
comitant change to dietary intake, completing 1000 kcal/wk
of exercise should result in a weight loss of ⬃2 kg over 16
weeks. This rate of weight loss is supported by the studies
of Ross et al. (29), in which, for men, a daily exercise
energy expenditure of 700 kcal and isocaloric diet over 12
weeks (55,800 kcal) elicited the predicted 7.2-kg weight
loss. Similarly, for women, a daily exercise energy expen-
diture of 500 kcal and isocaloric diet over 14 weeks (49,000
kcal) elicited the predicted 6.3-kg weight loss (20). Based
on the relationship between energy deficit and weight loss
(3500 kcal energy deficit ⫽ 0.45 kg weight loss), the
predicted average weight loss of the PWMP in the current
study would be 6.3 kg. The actual average weight loss was
6.2 kg.
Another important finding of this study was that, despite
men having a higher exercise energy expenditure target,
women and men completed the same weekly exercise en-
ergy expenditure, and this was undertaken at the same
relative intensity. Unlike many other weight loss studies, the
Weight Loss: Personalized Management vs. Standard Care, Byrne et al.
weight loss (absolute and relative) did not differ signifi-
cantly between men and women. Doucet et al. (30) noted a
difference in fat mass losses between men and women when
participants were on a moderate dietary restriction plus
exercise program and reported that the effect could be
entirely explained by the difference in the net energy cost of
the exercise. The authors suggested that this sex difference
was attributable to an exercise intensity effect (31,32), re-
porting that, despite the same exercise intensity being pre-
scribed, women exercised at a relative exercise intensity of,
on average, 19%, which is lower than for men. In this study,
the monitored exercise intensity revealed that men and
women exercised as the same physiological intensity, and
the resultant weight loss did not differ between men and
women.
According to the American College of Sports Medicine,
depending on the quantity and quality of training, improve-
ment in V̇O2max ranges from 5% to 30% (33). In this study,
the average relative change in V̇O2max (mL/kg per minute)
was ⬃10%; however, only 66% of the prescribed exercise
was completed (PWMP). Thus, although the relative im-
provements are at the lower end of the expected range, the
completed exercise was much less than prescribed in the
majority of participants. While genetics explains some of
the variance in the magnitude and rate of change in cardio-
respiratory fitness with aerobic training, initial V̇O2max may
also be a factor (34). The average baseline V̇O2max values for
the PWMP men was between the 50th and 60th percentile
and for SC men was in the 40th percentile; for women in
both groups, the average was between the 30th and 40th
percentile (33). However, the range for both sexes was from
the 10th to the 90th percentile. Therefore, there was con-
siderable variance within the cohort; and no reason to an-
ticipate that improvement in cardiorespiratory fitness would
be limited in either group. Furthermore, it is important to
note that the change in V̇O2max was not correlated with
baseline V̇O2max (r ⫽ 0.12; 95% confidence interval, ⫺0.14
to 0.37; p ⫽ 0.37). Similar findings were reported by
Skinner et al. (35) in a study in which participants were
trained on cycle ergometers for 20 weeks (3 times/wk) for
30 to 50 minutes per session at the HR associated with 55%
to 75% V̇O2max measured at baseline.
Data from 633 participants who finished 95% of the
required training sessions revealed that ⌬V̇O2max was not
related to baseline V̇O2max. However, when the baseline
values were correlated with relative (%) change in V̇O2max,
there was a significant (p ⬍ 0.01) correlation coefficient of
⫺0.37. In the current study, no relationship was found
between relative change in V̇O2max and baseline values (r ⫽
⫺0.11; 95% confidence interval, ⫺0.36 to 0.15; p ⫽ 0.41).
Therefore, the changes in V̇O2max are not lower than ex-
pected given the training completed; and the magnitude of
change was not related to initial fitness level. We would
speculate that the modest improvements in cardiorespiratory
fitness are attributed to modest training rather than evidence
of a ceiling effect.
In conclusion, this study was designed to determine the
efficacy and effectiveness of a personalized weight man-
agement strategy using biofeedback of exercise intensity
and exercise energy expenditure and dietary energy targets
compared with generalized standard care. Our ability to
more definitively attribute causality of the exercise dose on
the weight (or fat) loss is limited by not having objective
data on changes in dietary patterns or energy intake. How-
ever, despite this limitation, the data, analyzed both by
completers and ITT analysis, revealed a strong intervention
effect on the magnitude of change in outcome variables.
Compared with SC, PWMP showed greater reduction in
body weight, waist circumference, and body fat at Week 16
and after a further 16-week period without weekly weigh-in
meetings. The study showed that provision of PWMP more
than doubled the changes in body weight and body compo-
sition achieved with standard nutrition and physical activity
advice. However, individuals given the opportunity to self-
manage behavior with the aid of PWMP varied in the extent
to which they met the exercise energy expenditure and
dietary guidelines. While successful weight loss and weight
maintenance can be achieved with varying strategies, the
PWMP is a tool that more effectively assists overweight and
obese individuals to self-manage this process. It remains to
be determined whether such self-management strategies
will prove effective for longer-term weight management.
Acknowledgment
The authors thank Connie Wishart and Nigel Smith for
laboratory assistance during the study. Funding for this
study was provided by the Queensland University of Tech-
nology Industry Collaborative Grant Scheme and Polar
Electro Oy.
References
1. Bond Brill J, Perry A, Parker L, Robinson A, Burnett K.
Dose-response effect of walking exercise on weight loss. How
much is enough? Int J Obes Relat Metab Disord. 2002;26:
1484 –93.
2. Weinsier RL, Hunter GR, Desmond RA, Byrne NM, Zuck-
erman PA, Darnell BE. Free-living activity energy expendi-
ture in women successful and unsuccessful at maintaining a
normal body weight. Am J Clin Nutr. 2002;75:499 –504.
3. The Diabetes Prevention Program Research Group.
Achieving weight and activity goals among diabetes preven-
tion program lifestyle participants. Obes Res. 2004;12:1426 –
34.
4. Wadden TA, Letizia KA. Predictors of attrition and weight
loss in patients treated by moderate and severe caloric restric-
tion. In: Wadden TA and VanItallie TB, eds. Treatment of the
Seriously Obese Patient. New York: The Guilford Press;
1992, pp. 383– 410.
OBESITY Vol. 14 No. 10 October 2006 1787
Weight Loss: Personalized Management vs. Standard Care, Byrne et al.
5. Jakicic J, Wing R, Winters-Hart C. Relationship of physical
activity to eating behaviors and weight loss in women. Med
Sci Sports Exerc. 2002;34:1653–9.
6. Deforche B, De Bourdeaudhuij I, Tanghe A, Debode P,
Hills A, Bouckaert J. Post-treatment phone contact: a weight
maintenance strategy in obese youngsters. Int J Obes (Lond).
2005;29:543– 6.
7. Klem M, Wing R, McGuire M, Seagle H, Hill J. A descrip-
tive study of individuals successful at long-term maintenance
of substantial weight loss. Am J Clin Nutr. 1997;66:239 – 46.
8. Klem ML, Wing RR, Lang W, McGuire MT, Hill JO. Does
weight loss maintenance become easier over time? Obes Res.
2000;8:438 – 44.
9. Fogelholm M, Kukkonen-Harjula K, Nenonen A, Pasanen
M. Effects of walking training on weight maintenance after a
very-low-energy diet in premenopausal obese women: a ran-
domized controlled trial. Arch Intern Med. 2000;160:2177– 84.
10. Kayman S, Bruvold W, Stern JS. Maintenance and relapse
after weight loss in women: behavioral aspects. Am J Clin
Nutr. 1990;52:800 –7.
11. Latner J. Self-help in the long-term treatment of obesity.
Obes Rev. 2001;2:87–97.
12. DePue J, Clark M, Ruggiero L, Medeiros M, Pera V Jr.
Maintenance of weight loss: a needs assessment. Obes Res.
1995;3:241– 8.
13. Prochaska J, DiClemente C. Self change processes, self
efficacy and decisional balance across five stages of smoking
cessation. Prog Clin Biol Res. 1984;156:131– 40.
14. Australian Government Department of Health and Aging.
Australian National Physical Activity Guidelines. http://
www.health.gov.au/internet/wcms/publishing.nsf/Content/
healthpubhlth-publicat-document-physguide-cnt.htm (Ac-
cessed October 16, 2002).
15. Borushek A. Doctor’s Pocket Calorie, Fat and Carbohydrate
Counter. Nedlands, WA, Australia: Family Health Publica-
tions; 2003.
16. Byrne NM, Weinsier RL, Hunter GR, et al. Influence of
distribution of lean body mass on resting metabolic rate after
weight loss and weight regain: comparison of responses in
white and black women. Am J Clin Nutr. 2003;77:1368 –73.
17. Borg G. An Introduction to Borg’s RPE-Scale. New York:
Movement Publications; 1985.
18. Borg G. Psychophysical bases of perceived exertion. Med Sci
Sports Exerc. 1982;14:377– 81.
19. Fink WJ, Costill DL. Analytical Methods for the Meaurement
of Human Performance: Human Performance Laboratory.
Muncie, IN: Ball State University; 1990.
20. Ross R, Janssen I, Dawson J, et al. Exercise-induced reduc-
tion in obesity and insulin resistance in women: a randomized
controlled trial. Obes Res. 2004;12:789 –98.
21. World Health Organization. The Asia-Pacific Perspective:
Redefining Obesity and Its Treatment. Canberra, Australia:
Health Communications Australia; 2000.
1788 OBESITY Vol. 14 No. 10 October 2006
22. Irwin ML, Yasui Y, Ulrich CM, et al. Effect of exercise on
total and intra-abdominal body fat in postmenopausal women:
a randomized controlled trial. JAMA. 2003;289:323–30.
23. Slentz CA, Aiken LB, Houmard JA, et al. Inactivity, exer-
cise, and visceral fat. STRRIDE: a randomized, controlled
study of exercise intensity and amount. J Appl Physiol. 2005;
99:1613– 8.
24. Heshka S, Anderson JW, Atkinson RL, et al. Weight loss
with self-help compared with a structured commercial pro-
gram: a randomized trial. JAMA. 2003;289:1792– 8.
25. Segal S, Silverman C, Temkin T. Measuring empowerment
in client-run self-help agencies. Community Ment Health J.
1995;31:215–27.
26. Aron DC, Raff H, Findling JW. Effectiveness versus effi-
cacy: the limited value in clinical practice of high dose dexa-
methasone suppression testing in the differential diagnosis of
adrenocorticotropin-dependent Cushing’s syndrome. J Clin
Endocrinol Metab. 1997;82:1780 –5.
27. U.S. Department of Health and Human Services. Physical
Activity and Health: A Report of the Surgeon General. At-
lanta, GA: U.S. Department of Health and Human Services,
Centers for Disease Control and Prevention, National Center
for Chronic Disease Prevention and Health Promotion; 1996.
28. Wing RR. Behavioral weight control. In: Wadden TA,
Stunkard AJ, eds. Handbook of Obesity Treatment. New York:
Guilford Press; 2002, pp. 301–16.
29. Ross R, Dagnone D, Jones PJH, et al. Reduction in obesity
and related comorbid conditions after diet-induced weight loss
or exercise-induced weight loss in men: a randomized, con-
trolled trial. Ann Intern Med. 2000;133:92–103.
30. Doucet E, Imbeault P, Almeras N, Tremblay A. Physical
activity and low-fat diet: is it enough to maintain weight
stability in the reduced-obese individual following weight loss
by drug therapy and energy restriction? Obes Res. 1999;7:
323–33.
31. Tremblay A, Despres JP, Leblanc C, et al. Effect of inten-
sity of physical activity on body fatness and fat distribution.
Am J Clin Nutr. 1990;51:153–7.
32. Tremblay A, Simoneau JA, Bouchard C. Impact of exercise
intensity on body fatness and skeletal muscle metabolism.
Metabolism. 1994;43:814 – 8.
33. American College of Sports Medicine. ACSM’s Guidelines
for Exercise Testing and Prescription. 7th ed. Baltimore, MD:
Lippincott Williams & Wilkins; 2005.
34. Pollock ML, Gaesser GA, Butcher JD. The recommended
quantity and quality of exercise for developing and maintain-
ing cardiorespiratory fitness, and flexibility in healthy adults.
Med Sci Sports Exerc. 1998;30:975–91.
35. Skinner JS, Jaskolski A, Jaskolska A, et al. Age, sex, race,
initial fitness, and response to training: the HERITAGE Fam-
ily Study. J Appl Physiol. 2001;90:1770 – 6.