Review Article

Obesity, diet, exercise and weight control

—a current review
M. K. Chin, Archie Y. S. Lo, X. H. Li, Mimi Y. M. Sham and Yvonne W. Y. Yuan

Abstract
Obesity can be attributed to complex physiological, genetic, cultural and psychological factors. It
should not be regarded merely as a result of weak will power or other character deficits. This
paper attempts to provide background information on energy balance which is important vis-a-
vis weight control. Weight reduction as a desirable end-point of negative energy balance is best
achieved through a combination of dietary restriction and exercise. Two alternative methods of
weight reduction are proposed and discussed. Nutritional, behavioural changes and careful
monitoring of exercise and diet should be implemented holistically to ensure a successful weight
reduction programme. Individuals also need to be aware of the many myths and misconceptions
surrounding weight control.

Keywords: Obesity; Diet; Exercise; Weight control

Introduction 3%-5% of the children had body weight in excess of

Despite a growing awareness of the detrimental ef-
fects of excessive body fat on health, obesity remains
a major public health problem among many Western
societies, and more recently, in Asian countries as
well. It has been estimated that at least 20% of the
adult population in the United States are overweight,
with this figure increasing to 35%-40% in adults over
40 years old.1 In a National Heart Foundation study
on Australian men and women over the age of 45,
60% and 50%, respectively, were considered over-
weight.2 In a recent survey of school children in Beijing,
Sports Science Department, Hong Kong Sports Institute, Sha Tin, Hong
Kong
M. K. Chin, PhD,
Mimi Y. M. Sham, BSc, Dipl Dietetics
Hong Kong Heart Centre, 40 Stubbs Road, Hong Kong
Archie Y. S. Lo, MD (Chicago), FRCPC
Department of Physiology, University of Cambridge, Downing Street,
Cambridge, CB2 3EG, United Kingdom
X. H. Li, MD
Hong Kong Centre of Sports Medicine and Sports Science, The Chinese
University of Hong Kong, Sha Tin, Hong Kong
Yvonne W.Y. Yuan, MSc
Correspondence to: Dr M. K. Chin
20% over the recommended range.3 Comprehensive
data are not available on obesity in the Hong Kong
population, but the frequency and variety of com-
mercial advertisements pertaining to weight reduction
programmes indicate that there is strong interest in
this issue. The objective of this paper is to present the
scientifically verifiable facts on diet, exercise and
weight control in relation to obesity, as opposed to
sundry popular myths and misconceptions.
Definition of obesity
Obesity can be broadly defined as an excessive en-
largement of the body's fat stores. Total body fat
exists in one of two forms: essential or storage fat.
Essential fat is necessary for normal physiological
functions, and can be found in varying degrees in all
organs including the central nervous system. Storage
fat is deposited in the adipose tissue throughout the
body mainly under the skin. Adipose tissue serves as
an efficient means of insulation and fuel storage.
The amount of essential fat in a person remains
fairly constant; it is primarily storage fat that is affected
by diet or exercise.

181
 182 J Hong Kong Med Assoc Vol. 44, No. 3, September 1992
While no universally accepted definition for obes-
ity exists, there is a general consensus that total body
fat levels above 20% and 30% for men and women,
respectively, would constitute obesity.4 The health
consequences associated with obesity are numerous,
including hypertension, hypercholesterolaemia,
hypertriglyceridaemia, non-insulin-dependent dia-
betes mellitus, gallstone disease (cholelithiasis), and
several forms of cancer.5 Men and women should
strive to maintain total body fat levels at about 15%
and 25%, respectively.
Obesity can also be understood in terms of the
'body mass index' (BMI). This index is derived by
dividing body weight (W) in kilograms by height
squared (H2) in metres (BMI = W/H 2 ). The health risk.s
associated with obesity progressively increase as the
BMI exceeds 30.6 Being above average weight does
not necessarily imply that a person is too fat. Elite
athletes and body builders have increased muscle
mass which, produces a raised BMI in the 'overweight'
range, but such persons do not have any abnormal
increase in body fat. Therefore, the interpretation of
the BMI must be carried out judiciously.
Types of obesity
There are two major categories of obesity: hyperplastic
and hypertrophic obesity, Hyperplastic obesity re-
sults from excess caloric intake during critical periods
(the last trimester of pregnancy, adolescence and in-
fancy) resulting in the formation of additional fat
cells. Hypertrophic obesity is caused, by the formation
of excessively large fat cells as a result of excess caloric
intake. This latter form is characteristic of adult-onset
obesity. It appears that once adulthood is attained,
the number of fat cells (adipocytes) is constant, The
adipocytes do not increase or decrease in number
under normal conditions; they merely expand or con-
tract.7 Obese individuals who lose weight tend to
gain it back quickly because the abundant adipocytes
are available as vacant storage sites.
Childhood obesity
Animal and human studies have demonstrated that
genetic factors can contribute to obesity. The inci-
dence of obesity in children is about 7% in those with
two lean, parents, 40% in those with one obese parent
and 80% in those with two obese parents.8 Further,
childhood obesity is a significant risk factor for adult
obesity.9 Infants are often overfed, partly because
parents misinterprets the signals. A baby may cry
because he is wet, restless, hot, cold or lonely. It is a
common response, however, lor parents to assume
that the baby is hungry and hasten to feed him.
Childhood eating
permanent. If poo
that obesity will de
motivated person
habits of a lifetime
Body fat
People come in all shapes and sizes. Body composi-
tion and fat distribution are strongly influenced by-
genetics, age and gender. Abdominal obesity, typical
in men, tends to result in persons with 'apple' shapes.
A peripheral fat pattern with extra fat on the hips and
thighs, more commonly seen in women, results in
'pear' shapes. People are most commonly classified
as 'apples' or 'pears' using the waist-to-hip ratio
(WHR). WHR is a ratio of the circumferences at these
two locations, and compares favourably with com-
puted tomography of the abdominal area. l 0 The WHR
reveals not only the relative distribution of abdomi-
nal to gluteal-femoral fat, but also the quantity of
intra-abdominal or visceral fat. Men are considered
upper-body obese when the WHR is greater than 0.95
and in women, when it exceeds 0.85." There is in-
creasing evidence to indicate that abdominal obesity
is, more so than total body obesity, a serious risk
factor for coronary artery disease,11 Excess abdominal
fat accelerates the rate of coronary artery disease in
three ways, it increases blood cholesterol levels, raises
blood pressure and decreases the body's ability to
use insulin effectively, leading to insulin resistance.12
Abdominal fat is, however, hyperactive, and re-
sponds well to weight reduction. This means that
abdominal fat levels may be reduced with even a
modest reduction in body weight On the other hand,
fat in the cells on the hips and thighs of females are
difficult to lose. In fact, research suggests that gluteal-
femoral fat cells cling to their fat except during
lactation.13
Energy balance- -intake versus
expenditure
Energy balance is the relationship between energy
intake and energy expenditure. When this balance is
positive, the extra calories are stored as fat, When this
balance is negative, storage fat is metabolized to pro-
vide for energy needs. If the number of calories
ingested corresponds to that consumed in metabo-
lism, body weight does not change except for a small
intra-day variation (± 1 kg), which is mainly due to
fluctuations in the body's water content. Many com-
plex factors affect the rates of energy ingestion, and
caloric expenditure through exercise and metabolic
needs.
 Chin et al.: Obesity, exercise and weight control 183

Energy intake Table 1. Typical one day Chinese menu and isocaloric
modified low-fat, high carbohydrate diet.

Quantity
Low-fat,
Obesity has classically been regarded as a problem of Regular diet high carbohydrate diet
disordered eating habits. Most surveys of energy in- (44% of energy as fat) (20% of energy as fat)
take, however, show that in general, obese individuals
Breakfast Breakfast
do not consume more calories than lean individu- Bread: 1 slice Bread: 2 slices
als.14 A recent study15 of 107 males and 109 females Margarine: 1 tbsp Jam: 1 tbsp
ranging in age from 18 to 71 years, showed that the Whole milk: 1/2 cup Skim milk: 1 cup
daily energy intakes of lean and obese adults were
identical when expressed as kJ-kg-1 lean body weight. Lunch Lunch
Stir fried chicken noodle Chicken noodle in soup
Lean individuals actually consumed more energy than Chicken with skin: 3.5 oz Chicken breast: 3.5 oz
obese individuals when daily caloric intake was ex- Cooking oil: 1.5 tsp Cooking oil: 1 tsp
pressed as kJ-kg-1 total body weight. Bamboo shoot: 1/2 cup Corn: 1/2 cup
Egg noodles: 1 cup Egg noodles: 1 cup
Chinese tea Chinese tea
Diet composition
Snack Snack
Nutritionists previously thought that a calorie was a Peanuts: 1/2 oz Crackers: 4 pieces
calorie, but we know now that not all calories are the
same. A forced feeding study showed that prisoners on Dinner Dinner
a high fat diet gained weight more easily than those on Stir fried marbled pork Stir fried lean pork
with pineapple with pineapple
a low fat, high carbohydrate diet.16 Researchers in this Pork chop Pork chop (lean): 3 oz
study cited two probable mechanisms for this observa- (lean and fat): 3 oz Cooking oil: 1.5 tsp
tion. Firstly, extra fat calories contribute more to body Cooking oil: 1.5 tsp Pineapple: 1/2 cup
fat because dietary fat is converted to stored fat with Pineapple: 1/2 cup Rice: 2 cups
97% efficiency. Carbohydrates from a meal, in contrast, Rice: 1 cup Orange: 1
Orange: 1
are converted to body fat with only 77% efficiency.
There is, therefore, an eightfold difference in the amount
of energy wasted. Secondly, the metabolic rate following
a meal (thermic effect of a meal) is much higher when age.18, 19 Since BMR accounts for 70% of total daily
the meal is high in carbohydrates than when it is high in expenditure, this reduction in BMR is a significant
fat. Calories expended in this way contribute to daily difference. This BMR reduction may account in part
energy expenditure, rather than to increasing fat stores. for the 'plateau' reached by most dieters when weight
The relationships linking diet composition, energy intake loss slows and stops even when caloric intake re-
and body fat are illustrated by another study of 216 mains stable. Secondly, as much as 25% of the weight
adult men and women.15 The obese derived a greater lost by dieting alone can have come from lean body
portion of their daily energy intake from fat when com- mass (LBM).20 This loss of LBM is potentially danger-
pared with the lean. Therefore, one should aim for energy ous if the body depletes protein reserves in essential
intake from a high carbohydrate, low fat diet, as diet areas of the body. The percentage of LBM lost de-
composition may be as important as diet energy content creases when exercise is combined with diet. Thirdly,
in the reduction of obesity. A comparison of a typical the energy conservation process resulting from severe
Chinese menu with a low fat, high carbohydrate sample dieting can persist even after the dieting period is
menu is illustrated in Table 1. over. This causes body weight to be regained rapidly
until it reaches the pre-dieting level.21 Studies in ani-
mals and humans have shown that when these
Caloric restriction repeated cycles of weight gain and loss occur, subse-
For a long time, caloric restriction has been regarded quent weight loss can be made more difficult. 22
as the cornerstone of weight-loss regimens. Numer- Research has also shown that when weight is regained
ous low and very low calorie diets have been after dieting, muscle tissue tends to be replaced by
introduced for the treatment of obesity.17 However, fat. This has also been confirmed in a current study
energy-reduced dieting may not be the best weight- on diet manipulation in rats.23
loss therapy because of the many problems associated
with reduced energy consumption. Firstly, severe re- Energy expenditure
striction in energy intake reduces the basal metabolic
rate (BMR) by as much as 30%. This may shift the In the past, the focus of both health professionals and
energy balance back in the direction of energy stor- obese individuals has been on energy intake. Research
184 J Hong Kong Med Assoc Vol. 44. No,

has, however, increasingly demonstrated that the key

50
to effective therapy is to work on the expenditure
side of the equation. The average daily energy ex-
penditure in individuals between the ages of 23 and 48
50 is 2,700 kcal for men and 2,100 kcal for women.24
Total energy expenditure is determined by three ma- 46 -i
jor components, viz. the BMR (70%), thermic effects
of food (10%) and exercise (20%). In the previous two CO .
sections, we addressed the issues of diet composition
in relation to the thermic effect of food, and diet re-
striction in relation to BMR in the energy expenditure
equation. In the following section, we will focus on
the thermic effect of exercise.

Exercise and weight control

Hours After Exercise
In human beings of all ages, inactivity has been asso-
ciated with obesity.25, 26 The addition of an exercise
component in a weight loss regimen appeared to im-
prove the outcome, both initially and in the long
term, by increasing the total energy output and af-
fecting substrate utilization.2

(i) Energy output

Exercise affects energy output in several ways.

The most obvious way is via the thermic response
to acute exercise, the magnitude of which is de-
termined by the mode, intensity and duration of
the exercise.27 The guidelines suggested by the
American College of Sports Medicine28 state that
the 'minimal threshold' of exercise training for
weight and fat reduction includes continuous ex-
ercise of at least 20 to 30 minutes duration, at Hours A f t e r Exercise
moderate exercise intensity (60%~70% of maximal
heart rate) sufficient to spend 300 or more kcal
per session, with an exercise frequency of at least Fig. 1, Top, BMR after a vigourous exercise session
three days per week. Significant elevations in compared with non-exercise control day; bottom,
resting energy expenditure have also been ob- BMR ranged from 6% to 17% higher after a vigorous
exercise session than if was at the same time of the
served in the post-exercise recovery period.29 A day on non-exercise control days. The higher BMR
systematic study30 on the metabolic after-effects lasted six hours after exercise. Modified from de
of exercise indicated that the resting metabolic Vries and Gray.30
rate ranged from 7.5% to 28% higher four hours
after exercise compared with a control day in
which no exercise was taken. The higher metabolic
rate persisted for six hours and returned to base- (ii) Substrate utilization
line levels after eight hours as shown in Figure 1.
The investigators calculated that this elevated Mild to moderate intensify exercise is effective
post-exercise metabolism (about 40 to 50 kcal), for weight reduction because of the increased
over and above the energy cost of the exercise utilization of free fatty acids. 31 Energy for short
bout itself, would result in a reduced caloric periods of high intensity exercise is derived almost
equivalent of about 2 kg a year if individuals entirely from stored carbohydrates in the liver
exercised daily. It appears that exercise is benefi- and muscles. Mild to moderate intensity activities
cial in the control of body weight, not only for the of longer duration use both carbohydrate and fat
energy loss incurred during exercise, but also be- (Fig. 2).32 These data highlight the importance of
cause a considerable additional caloric the 'long slow distance' concept when targeting
expenditure may occur post-exercise. body fat as the energy substrate during exercise.
 Chin et al.: Obesity, exercise and weight control 185

•o 100- _OM Fats ^o Table 2. Compariso n of different approaches of losing

3
01
a> \<^ weight.
a
""""O n Carbohydrate y^
3 •fj

„ 80-
Losing weight Losing weight
2 /
•?. only by severe by exercise and
£f t __
^ limitation of slight limitation
Ji 60 - c^^ m
BOlimuiii« ""^ Variable energy intake of energy intake
(O
O
TJ ..a*"'"^^""^ Cardiovascular
S 40- O*** ^i and pulmonary Decrease Increase
^W function
£
"5 ^^ Nutritional Occurs easily Generally
e 20- \^ deficiency does not occur
O Tv.
o ^^w^ Lean body weight Decrease Increase or
a ^\j unchanged
° 0•
a
Rest 20 40 60 80 100 Level of HDL-C Decrease Increase
% of maximum oxygen uptake Sensitivity of insulin ? Increase
Thermic effect Decrease Increase or
Fig. 2. Relative contribution of fat and carbohydrate as a unchanged
function of exercise intensity, expressed as a Physiological and Under great Improved
percentage of the maximal oxygen uptake (VO2 max). psychological state pressure
Modified from Astrand and Rodahl.32
Physical strength Decrease Increase
Side-effect Metabolic Generally
Exercise and diet disorder none
, .. , . . , . ,. , ., , Plan of losing Difficult to Easy to
A negative energy balance is best achieved through a weight maintain maintain
combination of dietary restriction and exercise. A
convenient means to partition a 500 kcal/day (3,500
kcal/week) energy deficit is to reduce energy intake
by 250 kcal/day and increase energy expenditure by resulting increased caloric intake negates the caloric
250 kcal/day. It is relatively easy to identify food expenditure of the exercise itself. Although it is true
items that can be eliminated or reduced to provide a that increased food intake generally parallels increased
250 kcal/day reduction in intake. A caloric deficit of physical activity, this relationship appears to hold
3,500 kcal/week is equivalent to 0.5 kg weight loss. only with respect to normal activity.
A comparison of two alternative methods of weight In a classical study,34 rats which were exercised daily
reduction is illustrated in Table 2.3 By combining diet for up to one hour showed a decrease in food intake and
and exercise, it is possible to achieve a deficit of 1,000 body weight when compared to sedentary control ani-
calories/day, which is equivalent to approximately 1 mals. When the exercise duration was increased beyond
kg of fat loss per week. While this may appear to be one hour, food intake was increased but only to the
the slow approach to weight loss, it is the most sensi- extent that body weight was maintained. In contrast, at
ble approach. Losses of lean body mass are minimal, exhaustive levels of exercise (i.e. six hours), both body
and fat loss so attained is more likely to be of a per- weight and food intake decreased. The results of this
manent nature.33 classical experiment are shown in Figure 3. Longitudinal
physical conditioning studies in humans also show no
change in calorie intake with mild to moderate intensity
Myths and misconceptions of diet, exercise training.35
exercise and weight control
Rapid weight loss
With the increased popularity of exercise, obese indi-
viduals are often confronted with exercise myths and Most rapid weight loss diets have one feature in com-
misconceptions, along with gimmicks that are pro- mon—they allow only a modest intake of
moted as 'miracle agents' to assist in weight reduction. carbohydrates. Carbohydrates constitute approxi-
mately 60% of a normal mixed diet. When
carbohydrates make up 10% or less of the diet, in
Exercise and appetite addition to an overall reduction in food intake, the
A common misconception of exercise in weight control body starts to utilize its own carbohydrate stores in
is that physical activity stimulates appetite, and the the liver and muscles. Since 3 g of water are stored
188 J Hong Kong Med Assoc Vol.
2 4 6 8 10
Duration of exercise (hours)
Fig. 3. Relationship between food intake, energy
expenditure and body weight in laboratory rats. A,
sedentary zone; B, range of proportional response
(normal activity); C, exhaustion zone.
34
Modified from
Mayer et al.
along with 1 g of carbohydrate from the body stores,
there is a substantial loss of body water along with
the depletion in the stores of carbohydrates. Thus,
weight loss in. the first few weeks of dieting is essen-
tially loss of body fluid, not body fat Rapid weight
loss diets so often fail because once a desired weight
is achieved, the individual typically returns to a nor-
mal diet which is high in carbohydrates. The water
lost during the diet period is rapidly regained, often
in a matter of days. Thus, the individual's weight
literally jumps back to its previous level, and the diet
is considered a failure.
Spot reduction
Spot reduction is the attempt to reduce fat in a local-
ized area of the body through exercise. It is true that
vigorous exercise and. caloric restriction will cause a
general reduction in body fat stores. There is, how-
ever, no conclusive scientific evidence that exercise,
massage, sauna, special skin creams, body wrappings
or pseudo-electric devices will break up or reduce fat
deposits located in specific regions, in a study com-
paring the subcutaneous tat of the active (playing)
and inactive arms of elite tennis players, skinfold
Conclusion
recently, among A:
as well. The associated health risks and diseases present
a tremendous drain to the economy and affect the quality
of life. Obesity can be attributed to complex physiologi-
cal, genetic, cultural and psychological factors. It should
y as a result of weak will power
ts. The most effective programmes for
losing and maintaining a desirable body weight incor-
porate restrictions in caloric intake, and increases in
caloric expenditure through exercise. Nutrition, behav-
ioural changes, and careful monitoring of exercise and
diet should be implemented holistically to ensure a
successful weight reduction, programme. Individuals
need to be aware of the many myths and misconceptions
surrounding weight control Most 'miracle agents' for
" . , ', , *T,' •' Jr •
weight loss do not have a scientific basis.
Acknowledgements
The authors would like to thank Mr Dennis Whitby
for his valuable suggestions to the manuscript and
Miss Queenie Tam for her clerical support.
References
1. Miller WJ, Stephens T, The prevalence of overweight
and obesity in Britain, Canada and United States. Am J
Public Health 1987; 77: 38-41,
2. National Heart Foundation of Australia Risk Factor
Prevalence Study, Survey no. 3. 1989, Canberra: NHF
of Australia and Australian Institute of Health, 1990:
47-103,
3. Chen JD, Chao GH Exercise and weight control. Chin 1
Sports Med, 1989; 8: 167-72.
4. Leon AS, The role of physical activity in the prevention
and management of obesity. In: Ryan AJ, Allman FL Jr,
eds. Sports medicine. 2nd ed. San Diego: Academic
Press, 1989: 593-617,
5. Bray GA. Effects of obesity on health and happiness.
In: Brownell KD, Foreyt JP, eds. Handbook of eating
disorders: physiology, psychology, and treatment of
obesity, anorexia, and bulimia. New York: Basic Books
Inc., 1986: 3-44.
6. Miles DS. Weight control and exercise. Clin Sports Med
1991; 10: 157-69,
 Chin et al.: Obesity, exercise and weight control
7. Hager A, Sjostrom L, Arvidsson B, et al. Body fat and
adipose tissue cellularity in infants: a longitudinal
study. Metabolism 1977; 26: 607-14.
8. Mirkin G. Getting thin. Boston: Little, Brown & Com-
pany, 1983: 79-80.
9. National Institutes of Health Consensus Development
Panel on the Health Implications of Obesity. Health
implications of obesity. Ann Intern Med 1985; 103:147-
51.
10. Peiris AN, Hennes MI, Evans DJ, et al. Relationship of
anthropometric measurements of body fat distribution
to metabolic profile in premenopausal women. Acta
Med Scand Suppl 1987; 723: 179-88.
11. Kaplan NM. The deadly quartet: upper-body obesity,
glucose intolerance, hypertriglyceridemia, and hyper-
tension. Arch Intern Med 1989; 149: 1514-20.
12. Stamford B. Apples and Pears—where you 'wear' your
fat can affect your health. Phys Sportsmed 1991; 19:
123-4.
13. Rebuffe-Scrive M, Enk L, Crona N, et al. Fat cell me-
tabolism in different regions in women—effect of
menstrual cycle, pregnancy, and lactation. J Clin Invest
1985; 75: 1973-6.
14. Dreon DM, Frey-Hewitt B, Ellsworth N, Williams PT,
Terry RB, Wood PD. Dietary fat: carbohydrate ratio
and obesity in middle-aged men. Am J Clin Nutr 1988;
47: 995-1000.
15. Miller WC, Linderman AK, Wallace J, Niederpruem
M. Diet composition, energy intake, and exercise in
relation to body fatness in men and women. Am J Clin
Nutr 1990; 52: 426-30.
16. Danforth E. Diet and obesity. Am J Clin Nutr 1985; 41:
11-32.
17. Atkinson RL. Low and very low calorie diets. Med Clin
North Am 1989; 73: 203-15.
18. Bray GA. Effect of caloric restriction on energy ex-
penditure in obese patients. Lancet 1969; ii: 397-8.
19. Elliot DL, Goldberg L, Kuehl KS, Bennett WM. Sus-
tained depression of the resting metabolic ratio after
massive weight loss. Am J Clin Nutr 1989; 49: 93-6.
20. Zuti NB, Golding IA. Comparing diet and exercise as
weight reduction tools. Phys Sportsmed 1976; 4: 49-55.
21. Jen KL. Effects of diet composition of food intake and
carcass composition in rats. Physiol Behav 1988; 42:
551-6.
22. Brownell KD, Greenwood MRC, Stellar E, et al. The
187
effects of repeated cycles of weight loss and regain in
rats. Physiol Behav 1986; 38: 459-64.
23. Dulloo AG, Girardier L. Adaptive changes in energy
expenditure during refeeding following a low-calorie
intake: evidence for a specific metabolic component
favoring fat storage. Am J Clin Nutr 1990; 52: 415-20.
24. Katch FI, McArdle WD. Nutrition, weight control and
exercise. 3rd ed. Philadelphia: Lea & Febiger, 1988:
108-9.
25. Rose HE, Mayer J. Activity, calorie intake, fat storage
and the energy balance of infants. Pediatrics 1969; 41:
18-29.
26. Curtis DE, Bradfield RB. Long-term energy intake and
expenditure of obese housewives. Am J Clin Nutr 1971;
24: 1410-7.
27. Epstein LA, Wing RR. Aerobic exercise and weight.
Addict Behav 1980; 5: 371-88.
28. American College of Sports Medicine. Resource manual
for guidelines for exercise testing and prescription.
Philadelphia: Lea & Febiger, 1988: 355-61.
29. Lawson S, Webster JD, Pacy PJ, Garrow JS. Effect of a
10 week aerobic exercise programme on metabolic rate,
body composition and fitness in lean sedentary fe-
males. Br J Clin Pract 1987; 41: 684-8.
30. de Vries HA, Gray DE. After effects of exercise upon
resting metabolic rate. Res Q Exerc Sport 1963; 34: 314-21.
31. Girandola RN. Body composition change in women:
effects of high and low exercise intensity. Arch Phys
Med Rehabil 1976; 57: 297-300.
32. Astrand PO, Rodahl K. Textbook of work physiology.
3rd ed. New York: McGraw-Hill Book Company, 1986:
543-9.
33. Wilmore J. Sensible fitness. Champaign: Human Ki-
netics Publishers, 1986: 44-50.
34. Mayer J, Marshall NB, Vitale JJ, et al. Exercise, food
intake and body weight in normal rats and genetically
obese adult mice. Am J Physiol 1954; 177: 544-8.
35. Woo R, Garrow JS, Pi-Sunyer FX. Effect of exercise on
spontaneous calorie intake in obesity. Am J Clin Nutr
1982; 36: 470-7.
36. Gwinup G, Chelvam R, Steinberg T. Thickness of sub-
cutaneous fat and activity of underlying muscles. Ann
Intern Med 1971; 74: 408-11.
37. Katch FI, Clarkson PM, McBride T, et al. Preferential
effects of abdominal exercise training on regional adipose
cell size [Abstract]. Med Sci Sports Exerc 1980; 12: 96.