obesity reviews

The biomechanics of adiposity structural and

functional limitations of obesity and implications
for movement
A. P. Hills1, E. M. Hennig2, N. M. Byrne3 and J. R. Steele4

Summary

Queensland University of Technology,

Obesity is a significant health problem and the incidence of the condition is

increasing at an alarming rate worldwide. Despite significant advances in the
knowledge and understanding of the multifactorial nature of the condition, many
questions regarding the specific consequences of the disease remain unanswered.
For example, there is a dearth of information pertaining to the structural and
functional limitations imposed by overweight and obesity. A limited number of
studies to date have considered plantar pressures under the feet of obese vs. nonobese, the influence of foot structure on performance, gait characteristics of obese
children and adults, and relationships between obesity and osteoarthritis. A better
appreciation of the implications of increased levels of body weight and/or body
fat on movement capabilities of the obese would provide an enhanced opportunity to offer more meaningful support in the prevention, treatment and management of the condition.

School of Human Movement Studies,

Queensland, Australia. 2Biomechanik Labor,

Universitaet Essen, Essen, Germany.
3

Department of Nutrition Sciences, University

of Alabama at Birmingham, Alabama, USA.

4

Department of Biomedical Science,

University of Wollongong, New South Wales,

Australia
Received 2 July 2001; revised 25 September
2001; accepted 26 September 2001
Address reprint requests to: AP Hills, PhD,
School of Human Movement Studies,
Queensland University of Technology, Victoria

Keywords: Biomechanics, gait, obesity.

Park Road, Kelvin Grove, Queensland 4059,

Australia.

obesity reviews (2002) 3, 3543

E-mail: a.hills@qut.edu.au

Introduction
Prevalence of overweight and obesity and related
musculoskeletal problems
Obesity is recognized as a major health problem in many
parts of the world and the incidence of the condition is
escalating at an alarming rate (1,2). This global trend of
increasing obesity prevalence indicates that current measures in the prevention, treatment and management of the
condition are ineffective (3). Obesity significantly increases
the risk of developing numerous medical conditions,
including hypertension, stroke, respiratory disease, type 2
diabetes, gout, osteoarthritis, certain cancers and various
musculoskeletal disorders, particularly of the lower limbs
and feet (4,5). Despite significant advances in the knowledge and understanding of the multifactorial nature of
the condition, many questions regarding the specific consequences of the disease remain unanswered.

Relative to the extensive literature now available on

many aspects of the obese condition there is a dearth of
information pertaining to the structural and functional
limitations imposed by overweight and obesity. Subjective
references have been made to the difficulties encountered
by the overweight and obese when executing simple activities of daily living (6,7). However, the implications of persistent obesity on the musculoskeletal and locomotor
systems, particularly during weight-bearing tasks such
as walking and stair-climbing, are poorly understood
(811). To date, the study of locomotor tasks has focused
predominantly on normal-weight individuals and particularly those without physical disabilities associated
with obesity. The limited number of studies focusing on
obese individuals published to date encompass the locomotor characteristics of obese children (6,811) and
adults (12), studies of plantar pressures under the feet of
the obese (13,14), the influence of obesity on foot structure and functional performance of children (7,1416), and

2002 The International Association for the Study of Obesity. obesity reviews 3, 3543

35

36 Movement characteristics of the obese

obesity reviews

A. P. Hills et al.

potential relationships between obesity and osteoarthritis

(12,17).
The primary aim of this article is to review the current
literature pertaining to the effects of overweight or obesity
on structure and function. Some of the key issues that may
challenge the overweight and obese when completing activities of daily living are considered, including the most fundamental of voluntary movement patterns, walking. Owing
to the enormity of the problem of obesity, and the relative
paucity of information available, there is an urgent need
to focus greater attention on the physical consequences of
repetitive loading of major structures, particularly in the
lower extremity. Throughout this article key questions are
posed as areas of importance for future research.

The effects of obesity on musculoskeletal

structure and function
Foot structure and function
The feet, as the base of support of the body, are continually exposed to high ground reaction forces generated
during activities of daily living. Various authors have
suggested that excessive increases in weight-bearing forces
caused by obesity may be detrimental to the lower limbs
and feet. Despite the potential negative consequences of
obesity on lower limb structure, only limited research has
considered the effects of obesity on foot structure in obese
individuals (14,15). These studies have indicated that obese
pre-pubescent children have significantly flatter feet than
their non-obese counterparts. It is unknown whether the
greater prevalence of flatfootedness in obese children is a
result of the presence of a fat pad that remains or develops
in their instep, thereby causing a form of flatfeet that
may have no negative consequences. However, it is also
unknown whether excessive weight bearing has caused
some structural dysfunction, such as a collapse of the longitudinal arch, thereby resulting in an increased midfoot
contact area that could have pathological consequences
(15). Dowling & Steele (18) recorded 26 anthropometric
measurements for the right and left leg/foot of 10 obese
[age = 8.8 2.0 years; body mass index (BMI) = 25.8
3.8 kg m-2] and 10 non-obese children (age = 8.9 2.1
years; BMI = 16.8 2.0 kg m-2), who were matched to the
obese children for age, height and gender, to characterize
the external shape of these childrens feet. Significant effects
of obesity were noted on 16 of the 26 anthropometric
variables, whereby the parameters measured for the obese
subjects legs/feet were significantly larger than those calculated for their non-obese counterparts. Whether these
changes in foot structure may develop into symptoms if
excessive weight gain were to continue and, in turn, hinder
participation in physical activity in either childhood or
adulthood, is speculative and requires further investigation.

Furthermore, as the foot structure of obese children has

only been indirectly assessed to date, further research to
directly measure the effects of obesity on foot structure in
both children and adults is also recommended.
The plantar fat pad
The plantar fat pad is specially organized adipose tissue
that provides cushioning to the underlying foot structures.
It is believed to be important for protection of the foot
during ambulation and in the prevention of heel pain
(19,20). Comparing 70 patients with plantar heel pain with
200 normal subjects, Prichasuk (21) reported that the BMI
was greater in the subjects with heel pain. Jorgensen &
Bojsen-Moller (22) reported that thinner heel fat pads
display a reduced ability to absorb shock. Nass et al. (23)
investigated the heel pad properties in overweight subjects.
From 35 normal and 16 overweight persons (BMI > 27),
ultrasound heel pad thickness scans were performed at five
static loading conditions (10, 25, 50, 75 and 100% of body
weight). Heel pad thickness increased as a function of BMI
while the compressibility index of the heel pad did not
differ between the groups. Based on these findings it would
appear that, if thickness and the compressibility index are
indicators of protective properties of the heel pad, overweight subjects are not disadvantaged by their heel pad
structures in terms of protecting their feet during ambulation. An analysis of plantar peak pressures, however,
showed significantly increased values at the heel for the
overweight group. Mechanical and polymodal nociceptors
are widely distributed in the skin to provide information
on pain perception. Greeenspan et al. (24) reported that
through spatial summation of applied pressures a decrease
in pain threshold with an increased field of stimulation is
caused. Comparing pain perception with averaged plantar
pressures, Hodge et al. (25) reported significant positive
correlations between pressure magnitude and the pain
ratings. From these findings and the results of their study,
Nass et al. (23) hypothesized that an increase of foot pressures (and not a change in heel pad properties) leads to a
higher likelihood of the development of plantar heel pain.

Plantar pressures and obesity

It would seem obvious that increased body weight would
result in higher plantar foot pressures. However, in a study
of standing and walking in 111 non-obese adults (26),
surprisingly few relationships between pressures under the
foot and body weight were found. The authors concluded
that an increase in foot dimensions, as well as a redistribution of plantar loads from areas of high pressures towards
areas of lower pressures, was the cause of this surprising
result. Only during walking did the 49 female subjects
show a moderate relationship between body weight and

2002 The International Association for the Study of Obesity. obesity reviews 3, 3543

obesity reviews

Figure 1 Peak pressures in each of the 10 masked areas (mean values

+ standard errors) for the non-obese and obese children. *Denotes a
significant difference (P < 0.05; ref. 29).

peak pressures under the midfoot (r = +0.68, p < 0.01). As

the male subjects did not demonstrate this effect it was
postulated that weaker ligaments in the feet of the women
contributed to the increased collapse of the longitudinal
arch when subjected to the dynamic loads in walking. Measurements with toddlers between 14 and 32 months of age
(27), and a study with 125 school children between 6 and
10 years of age (28), provided data on plantar pressures in
various developmental stages in non-obese children.
Dowling et al. (14) investigated the effects of obesity on
the plantar pressures generated by 13 obese (BMI: 25.5
2.9 kg m-2) and 13 non-obese (BMI: 16.9 1.2 kg m-2)
pre-pubescent children, matched to the obese children for
gender, age and height. The obese pre-pubescent children
generated significantly higher pressures under the forefoot
during walking compared to their non-obese counterparts.
These results were confirmed again by Dowling (29) who
identified that obese children (BMI: 25.8 3.8 kg m-2) generated significantly higher dynamic mean peak pressures and
pressure-time integrals, particularly under their midfoot and
under metatarsal heads II to V, compared to their lean counterparts (BMI: 16.8 2.0 kg m-2; see Fig. 1). The author postulated that these obese children might be at an increased
risk of developing pathologies in this area of the foot, such as
stress fractures of the forefoot or skin ulceration as a result
of increased pressures being borne by the small bones of the
forefoot. Furthermore, foot discomfort associated with this
increased forefoot plantar pressure in obese children may
hinder their participation in physical activity as weightbearing activities can be uncomfortable if not appropriately designed to account for these structural characteristics.
A recent study (13) investigated the effect of obesity in
35 women (BMI = 17.148.4 kg m-2) and 35 men (BMI =
20.055.8 kg m-2) on plantar pressures during standing and
walking. Using a BMI value of 28 as the cut-off, 19 women

Movement characteristics of the obese

A. P. Hills et al. 37

and 19 men were categorized as being overweight. In both

gender groups, foot width during standing was significantly
greater in the overweight subjects. However, no significant
differences in foot length were detected. Both overweight
gender groups had increased pressure values under all
anatomical locations of the foot during standing. For
walking, the two overweight groups also showed higher
pressures under the heel, midfoot and the metatarsal heads
II to IV (see Fig. 2). Comparisons of the standing and
walking data showed stronger relationships between BMI
and plantar pressures during dynamic loading of the foot.
A subset of the 38 overweight subjects (six women and
three men) succeeded in losing a substantial amount of
body weight (19.4 kg or 19.6% of their original body
weight) during a subsequent weight-reduction programme.
As a function of weight loss, reductions in the peak plantar
pressures were observed under the midfoot and especially
under the metatarsal heads (30).

Muscular strength and power

Inadequate muscular strength and/or power, particularly of
the lower limbs, can also impair motor function, limiting
individuals from successfully performing everyday tasks
and predisposing them to a greater risk of musculoskeletal
fatigue and/or injury. Riddiford et al. (16) investigated
the effects of obesity on the strength and power of 43
obese (BMI: 24.1 2.3 kg m-2) and 43 non-obese (BMI:
16.9 0.4 kg m-2) healthy, pre-pubescent children (8.4 0.5
years). Age-appropriate field tests of a basketball throw for
distance, arm push/pull ability, and vertical and standing
long jump performance, were used. Although obesity did
not negatively impact upon upper limb strength or power
in these activities, it impeded the childrens ability to
perform tasks involving lower limb strength and power in
which the obese children were required to move their
larger mass against gravity. That is, the obese children were
disadvantaged in both standing long jump and vertical
jumping tests by the need to apply a greater force to accelerate their larger mass against gravity a given distance. As
decreased muscular strength and power may affect the
ability of children to learn and successfully perform activities of daily living, particularly during their developmental years, this finding was of concern. Similar findings have
been reported by Hills & Parker (31). Further research is
warranted to identify a wider range of activities in which
obesity has a negative impact. This work would be of particular relevance in the design of appropriate intervention
strategies.

Walking gait and other activities of daily living

Walking is a fundamental movement pattern, the most
common mode of physical activity. However, walking is an

2002 The International Association for the Study of Obesity. obesity reviews 3, 3543

38 Movement characteristics of the obese

A. P. Hills et al.

obesity reviews

Figure 2 Peak plantar pressures (kPa)

during walking for obese (O) vs. non-obese
(N) men and women (13). *P < 0.05, **P < 0.01.
This figure is reproduced from Int J Obes
2001; 25: 16741679 with permission from
Nature Publishing Group.

extremely complex biomechanical process, involving an

interplay between muscular and inertial forces (3234). The
quality of gait is associated with the structural and functional constraints imposed by the locomotor system, the
ability to implement an effective motion strategy, and the
individuals metabolic efficiency (35). One of the potential
challenges to the normal pattern of walking in the overweight and obese is the need to carry excess body weight (or

body fat) over the long term. There is a general paucity

of detail in the research literature specifically regarding
the interplay between metabolic and mechanical costs of
walking. Furthermore, no attention has been paid to locomotor characteristics across various levels of body weight
and body fat. A leading question that arises then is whether
excess body weight or excess adiposity is a major limiting
factor in movement. In tasks such as walking, the structural

2002 The International Association for the Study of Obesity. obesity reviews 3, 3543

obesity reviews

(mechanical) and functional (physiological) cost of the

activity are important determinants of a persons movement
capacity (and therefore limitation) and physical fitness. The
interplay of these characteristics also contributes to the rate
of fatigue in physical activity, including activities of daily
living. Furthermore, the intensity and energy equivalence of
physical activities are important elements within an exercise
prescription for the obese (36). Differentials in energy cost
and exercise intensity among people whose body composition (specifically, fat mass and fat-free mass ratio) varies
have consequences for subsequent individualized prescriptions (A. P. Hills & N. M. Byrne, unpublished).
The sustained repetition of load cycles in walking make
significant demands on the musculoskeletal apparatus in
normal-weight individuals (37). How then does the carriage of excess body weight (or body fat) accentuate such
demands in the obese? What additional loading forces may
be experienced by the obese as a function of excess body
weight (or body fat)? In addition to increased loading on
major joints as a function of excess weight (body fat), does
efficient mechanics also contribute to increased energy
expenditure in the obese when they are engaged in the same
movement task as lighter counterparts? Is there an individual threshold of size and shape (or body composition
status) above which potential disruption to the musculoskeletal system is greater?
Detailed analyses of the gait characteristics of obese children (811) and, to a lesser extent, adults (12), has helped
provide a clearer understanding of movement-related
difficulties experienced by the obese. An evaluation of gait
over time may also provide an indication of the potential
problems with the persistence of obesity. During normal
walking the major joints of the lower extremity are exposed
to considerable loads (38,39) with joint reaction forces of
approximately three to fives times body weight (40). Participating in movement tasks such as stair climbing, jogging
and running involves joint reaction forces at the higher
end of this range and beyond. Based on Newtonian Laws
of Motion it would appear reasonable to hypothesize that
obese individuals will experience greater loads on their
joints than normal-weight individuals. However, to date
the joint forces generated by obese individuals during
walking have not been documented. Will the loads experienced at major joints increase when the obese individual
attempts to move at speeds that are different from the
normal, preferred pace of walking?
For all individuals, irrespective of size and shape, a comfortable self-selected free speed of walking is commonly less
variable than any imposed walking speed. That is, the gait
of a mature, normal-weight individual is characterized by
the ability to display consistency across various speeds of
walking. Many growing children, but more commonly
obese children, display considerable disruption to normal
temporal characteristics when walking more slowly or

Movement characteristics of the obese

A. P. Hills et al. 39

faster than their normal, invariant base pattern. Hills &

Parker (9) noted that obese pre-pubertal children showed
greater asymmetry in gait than non-obese children, consistently favouring the right limb. Ease of walking at a selfselected speed and the difficulty of overriding a natural
cadence is a well-documented phenomenon in normal
adults. More research is needed to determine the variability in temporal patterning and the ability of children and
adults at different levels of adiposity to adjust to changes
in walking speed. The additional adiposity of the obese and
duration in the obese state may be important factors
governing such individuals ability to adjust to changes in
walking speed.
In addition to a compromised ability to adjust to changes
in walking speed, several temporal characteristics differ
between obese and normal-weight pre-pubertal children
(8). For example, obese children have a longer stance
phase and slower speed of walking, as reflected by a longer
cycle duration, lower cadence and lower relative velocity
(statures/s). These findings confirm the common qualitative
view of a slower, safer and more tentative walking gait in
obese children relative to normal-weight children.
More unstable individuals, including the obese, display
a longer double- and a shorter single-limb support period
(8,9). Parker et al. (41), in a study of Downs syndrome
children who were overweight, reported a higherthan-normal percentage of the gait cycle spent in support.
As for the obese children in the studies by Hills & Parker
(8,9), the greater support time of these children reinforces
the safer and more tentative ambulation that reduces the
non-support period and potential for instability.
Walking is a central component of gross motor development and the quality of walking is related to the level of
maturity of the individual (33,42,43). There is an urgent
need to conduct further research in this area, to develop
a normative database on obese children and enable
additional comparisons with non-obese children of similar
stature and age. Determining the influence of speed of
walking on children during the growing years to physical
maturity is also warranted. Such normative data could
form the basis for more effective intervention strategies to
combat obesity in children. In summary, the obese typify
an unreliability of gait patterning that is related to body
composition and is affected by speed of walking.
In addition to walking, another activity of daily living
that is performed repeatedly is rising to stand after sitting
in a chair. Adults (aged 2341 years) rise an average of 90
times daily (44). In young healthy persons, rising from a
chair should be achieved with ease. However, recent
research has indicated that when 89-year-old-children
were required to move their larger body mass against
gravity to perform this basic daily task, obesity impeded
their functional capacity. In fact, 69% of the obese children
required assistance from the researchers to successfully

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40 Movement characteristics of the obese

A. P. Hills et al.

stand (45). The authors postulated that difficulty experienced by the obese children in rising was a result of insufficient lower limb strength to move their excess body mass
upright against gravity. This movement difficulty may
perpetuate the cycle of obesity by encouraging sedentary
behaviour (remaining seated) for prolonged periods.
However, the effects of obesity on the frequency and difficulty associated with the performance of activities of daily
living are not documented. Are obese children and adults
likely to have difficulty performing other activities of daily
living in which they are required to raise their larger body
mass against gravity, such as getting out of bed or rising
from the toilet? If performing these activities of daily living
is more difficult, do obese individuals avoid attempting
them as frequently, in turn resulting in reduced energy
expenditure and an increased likelihood of a positive
energy balance?

Obesity and osteoarthritis

The epidemiology of osteoarthritis
Osteoarthritis is a degenerative disease and a comorbid
condition of obesity affecting an increasing proportion of
the population (46,47). It is a complex disease, the aetiology of which bridges biomechanics and biochemistry.
Evidence is growing for the role of systemic factors, such
as genetics, diet, oestrogen use and bone density, and local
biomechanical factors (such as muscle weakness, obesity
and joint laxity). These risk factors are particularly important in the weight-bearing joints, and modifying them may
help to prevent osteoarthritis-related pain and disability
(47).
Unfortunately, as is the case for movement characteristics of the obese, we have a relatively poor understanding
of the inter-relationships between osteoarthritis and excess
body weight (or body fat). However, obesity has consistently been identified as a risk factor for osteoarthritis of
weight-bearing joints (48) and the progression of the condition is reported as being more rapid in the overweight
and obese. For example, persistent loading of the musculoskeletal system in locomotor tasks such as walking has
been implicated in the predisposition of the obese to knee
osteoarthritis. The condition has also been recognized as a
cause of significant disability (49,50). Furthermore, it has
been suggested that the risk of osteoarthritis may be related
to excess total body weight (and/or body fatness) rather
than to the distribution of body fat and predisposition to
metabolic conditions such as type 2 diabetes, characterized
by a central concentration of adiposity.
The effectiveness of exercise in the treatment of
osteoarthritis (51) is also poorly understood, although a
number of studies have illustrated that disability is reduced
in osteoarthritic patients who engage in regular physical

obesity reviews

activity (52,53). No studies have considered doseresponse

relationships between aerobic or resistance exercise (51).
Therefore, it is not surprising that studies considering
the potential improvement of osteoarthritic characteristics
in obese subjects exposed to a controlled weight-loss
intervention have been extremely limited. Felson et al. (54)
reported that weight loss in middle-aged and older women
significantly reduced the incidence of symptomatic
osteoarthritis of the knee, but this study did not consider
the efficacy of weight loss in subjects with existing
osteoarthritis.
Messier et al. (17) have completed one of the few studies
to determine if a combined dietary and exercise intervention would result in significant weight loss in older obese
adults with knee osteoarthritis. The group also compared
the effects of exercise plus dietary therapy with exercise
alone on gait, strength, knee pain, biomarkers of cartilage
degradation and physical function. Significant improvements were noted in both groups in self-reported disability
and knee pain intensity and frequency, as well as in physical performance measures. However, no statistical differences were found between the two groups at six months in
knee pain scores or self-reported performance measures of
physical function and knee strength. In summary, weight
loss was achieved and sustained over a six-month period
in a cohort of older obese persons with osteoarthritis of the
knee through a dietary and exercise intervention. Both
exercise and combined weight loss and exercise regimens
led to improvements in pain, disability and performance.
Moreover, the trends in the biomechanical data suggest that
exercise combined with diet may have an additional benefit
in improved gait compared with exercise alone. A larger
study is indicated to determine whether weight loss
provides additional benefits over exercise alone in this
population of patients.
It is interesting to speculate on the impact of sustained
overweight and obesity on the predisposition to, and progression of, deterioration of articular cartilage and subchondral bone in adults. Similarly, what is the relationship
between age of onset of obesity and predisposition to
osteoarthritis? Is the period of time one has been obese a
significant factor in the development of osteoarthritis?
Does the persistence of overweight and obesity from
childhood and adolescence into adulthood and body composition factors result in a presentation of osteoarthritic
symptoms in progressively obese individuals?
Body composition changes as a function of ageing, in
particular fat mass increases and lean body mass (LBM)
decreases (5559). Reductions in LBM will probably be
paralleled with decreases in muscle mass, muscle strength
and functional capacity (12). Syed & Davis (60) have
suggested that ageing may be a primary risk factor
for osteoarthritis because of age-related reductions in the
muscle strength of key leg muscles and increases in body

2002 The International Association for the Study of Obesity. obesity reviews 3, 3543

obesity reviews

weight. Repeated impulse loading leads to stiffening of

the bone, and a reduced period of eccentric quadriceps
tension at heel strike in gait results in less effective shock
absorbency (12). Weakness of the quadriceps may therefore be considered an aetiological factor in the pathogenesis of knee osteoarthritis (61). A mechanism through which
this may occur could involve the combination of muscle
fatigue and changes in ground reaction forces that result in
detrimental increases in the rate of loading on the knee
joint (60). Support for this notion comes from data which
shows that muscle strengthening, as a part of treatment,
reduces disability (62).
While older females are consistently noted to be more
likely than their male counterparts to suffer from knee
osteoarthritis (6365), no relationship exists between
osteoarthritis and oestrogen use in women (66). The gender
difference in the prevalence of knee osteoarthritis may be
attributed to differences in body composition, with a higher
proportion of body fat in women. Males commonly display
a greater proportion of body weight as lean mass, and more
importantly more muscle mass, and may benefit from
greater musculoskeletal support and increased shock
absorption potential during walking. While Syed & Davis
(60) extend this argument further to suggest that knee
osteoarthritis may be linked to quadriceps fatigue with
long-duration (20 min) walking, there is no empirical
evidence to support this proposal.

What is the long-term influence of obesity on

musculoskeletal structure and function?
Obese adults who have been obese from childhood may
face a compendium of medical problems (67). Many of the
orthopaedic conditions that are manifested in obese adults
may be the consequence of an excessive and prolonged
loading of tissues. Owing to the progressive nature of such
developments, it may be reasonable to hypothesize that
younger individuals who have been obese for a relatively
shorter period of time would be less likely to display
orthopaedic anomalies related to the locomotor apparatus
that are more commonly seen in older counterparts.
However, this review has confirmed that even young,
pre-pubertal children display evidence of alterations to
both their musculoskeletal structure and function as a consequence of excessive weight bearing. Therefore, to minimize joint deterioration from excessive joint loading, any
malalignment or malfunctioning of the lower limbs evident
in obese children should be treated at the earliest possible
opportunity (68).

Conclusions
The maintenance of functional mobility should be one of
the highest priorities in the management of an obese indi-

Movement characteristics of the obese

A. P. Hills et al. 41

vidual, with or without comorbid conditions. High levels

of body fat plus increased loads on the major joints has the
potential to lead to pain and discomfort, inefficient body
mechanics and further reductions in mobility. Efficiency of
movement may be improved with an appropriate prescription of aerobic activity and resistance weight training, and
interventions to improve gait, posture and balance. An
understanding of locomotor characteristics and biomechanical efficiency concurrent with metabolic efficiency
during the performance of daily living tasks would greatly
assist the clearer understanding of movement-related
difficulties of the obese.

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