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PubMedDate not supplied

Effects of Pseudomonas colonization on body composition and resting energy expenditure in children with cystic fibrosis.

BACKGROUND: To determine the extent and effects of increased metabolic demand represented by Pseudomonas colonization on body composition and resting energy expenditure in children with cystic fibrosis (CF). METHODS: The study comprised 18 stable children with CF, of whom 10 (6 male/4 female) were colonized with Pseudomonas species and 8 (4 male/4 female) were not. The groups were of similar age range and genotype. Measured resting energy expenditure (REE) was performed by open circuit indirect calorimetry and compared with predicted REE calculated from standard equations. Body composition was determined by dual-energy x-ray absorptiometry, including lean body mass (LBM), fat mass (FM), bone mineral density (BMD), and anterior-posterior spine density (APS); these were compared using z-scores. Routine pulmonary function testing assessed forced vital capacity, forced expiratory volume in 1 second (FEV1), and forced expiratory flow over middle half of vital capacity (FEF25% to 75%); these were compared as percent predicted. RESULTS: As expected, results of pulmonary function testing showed significant deterioration among the children colonized with Pseudomonas species when compared with the children who were not, while standard anthropometry showed no differences in weight, height, or weight-for-height percentile and respective z-scores. Although a trend of lower LBM was noted among the children colonized with Pseudomonas species, no significant differences were found between these children and children who were not colonized with Pseudomonas species when z-scores for LBM, FM, BMD, or APS were compared during body composition analysis. In addition, neither REE as kilocalories per day (kcal/d) nor REE expressed as a percent predicted by standard equations discriminated between subgroups of children colonized with Pseudomonas species and children who were not. However, metabolic demand, expressed as resting energy expenditure in kilocalories per kilogram (kcal/kg) of LBM (REE/LBM), revealed significant differences between children colonized with Pseudomonas species and children who were not (75.4+/-4.4 vs 58.6+/-2.9 kcal/kg, p < .05). CONCLUSIONS: The effect of Pseudomonas colonization on metabolic demand in children with CF can be accurately assessed by expressing resting energy expenditure as kilocalorie per kilogram of LBM, the active metabolic component of the body. The 50% increase in REE/LBM seen in the children colonized with Pseudomonas species represents the metabolic demand from the inflammatory burden and work of breathing resulting from the effects of the Pseudomonas colonization. The trend of a lower LBM in the children colonized with Pseudomonas species makes this finding even more dramatic.

Absorptiometry, Photon↗
PubMed2003

Toward estimating the impact of changes in immigrants' insurance eligibility on hospital expenditures for uncompensated care.

BACKGROUND: The Personal Responsibility and Work Opportunity Reconciliation Act (PRWORA) of 1996 gave states the option to withdraw Medicaid coverage of nonemergency care from most legal immigrants. Our goal was to assess the effect of PRWORA on hospital uncompensated care in the United States. METHODS: We collected the following state-level data for the period from 1994 through 1999: foreign-born, noncitizen population and health uninsurance rates (US Census Current Population Survey); percentage of teaching hospitals (American Hospital Association Annual Survey of Hospitals); and each state's decision whether to implement the PRWORA Medicaid bar for legal permanent residents or to continue offering nonemergency Medicaid coverage using state-only funds (Urban Institute). We modeled uncompensated care expenditures by state (also from the Annual Survey of Hospitals) in both univariate and multivariable regression analyses. RESULTS: When measured at the state level, there was no significant relationship between uncompensated care expenditures and states' percentage of noncitizen immigrants. Uninsurance rates were the only significant factor in predicting uncompensated hospital care expenditures by state. CONCLUSIONS: Reducing the number of uninsured patients would most surely reduce hospital expenditures for uncompensated care. However, data limitations hampered our efforts to obtain a monetary estimate of hospitals' financial losses due specifically to the immigrant eligibility changes in PRWORA. Quantifying the impact of these provisions on hospitals will require better data sources.

Eligibility Determination↗
PubMed2005

Resting energy expenditure is not influenced by classical music.

Obesity shows an increasing prevalence worldwide and a decrease in energy expenditure has been suggested to be one of the risk factors for developing obesity. An increase in resting energy expenditure would have a great impact on total energy expenditure. This study shows that classical music do not influence resting energy expenditure compared to complete silence. Further studies should be performed including other genres of music and other types of stress-inductors than music.

Energy Metabolism↗
PubMed2005

Contribution of anaerobic energy expenditure to whole body thermogenesis.

Heat production serves as the standard measurement for the determination of energy expenditure and efficiency in animals. Estimations of metabolic heat production have traditionally focused on gas exchange (oxygen uptake and carbon dioxide production) although direct heat measurements may include an anaerobic component particularly when carbohydrate is oxidized. Stoichiometric interpretations of the ratio of carbon dioxide production to oxygen uptake suggest that both anaerobic and aerobic heat production and, by inference, all energy expenditure--can be accounted for with a measurement of oxygen uptake as 21.1 kJ per liter of oxygen. This manuscript incorporates contemporary bioenergetic interpretations of anaerobic and aerobic ATP turnover to promote the independence of these disparate types of metabolic energy transfer: each has different reactants and products, uses dissimilar enzymes, involves different types of biochemical reactions, takes place in separate cellular compartments, exploits different types of gradients and ultimately each operates with distinct efficiency. The 21.1 kJ per liter of oxygen for carbohydrate oxidation includes a small anaerobic heat component as part of anaerobic energy transfer. Faster rates of ATP turnover that exceed mitochondrial respiration and that are supported by rapid glycolytic phosphorylation with lactate production result in heat production that is independent of oxygen uptake. Simultaneous direct and indirect calorimetry has revealed that this anaerobic heat does not disappear when lactate is later oxidized and so oxygen uptake does not adequately measure anaerobic efficiency or energy expenditure (as was suggested by the "oxygen debt" hypothesis). An estimate of anaerobic energy transfer supplements the measurement of oxygen uptake and may improve the interpretation of whole-body energy expenditure.

Journal Article↗
PubMed2004

Influence of insulin on glucose metabolism and energy expenditure in septic patients.

INTRODUCTION: It is recognized that administration of insulin with glucose decreases catabolic response in sepsis. The aim of the present study was to compare the effects of two levels of insulinaemia on glucose metabolism and energy expenditure in septic patients and volunteers. METHODS: Glucose uptake, oxidation and storage, and energy expenditure were measured, using indirect calorimetry, in 20 stable septic patients and 10 volunteers in a two-step hyperinsulinaemic (serum insulin levels 250 and 1250 mIU/l), euglycaemic (blood glucose concentration 5 mmol/l) clamp. Differences between steps of the clamp (from serum insulin 1250 to 250 mIU/l) for all parameters were calculated for each individual, and compared between septic patients and volunteers using the Wilcoxon nonpaired test. RESULTS: Differences in glucose uptake and storage were significantly less in septic patients. The differences in glucose oxidation between the groups were not statistically significant. Baseline energy expenditure was significantly higher in septic patients, and there was no significant increase in either step of the clamp in this group; when comparing the two groups, the differences between steps were significantly greater in volunteers. CONCLUSION: A hyperdynamic state of sepsis leads to a decrease in glucose uptake and storage in comparison with healthy volunteers. An increase in insulinaemia leads to an increase in all parameters of glucose metabolism, but the increases in glucose uptake and storage are significantly lower in septic patients. A high level of insulinaemia in sepsis increases glucose uptake and oxidation significantly, but not energy expenditure, in comparison with volunteers.

APACHE↗
PubMed1990

Energy expenditure in obese and nonobese adolescents.

We measured body composition, basal metabolic rate (BMR), and total energy expenditure in 28 nonobese and 35 obese adolescents aged 12-18 y using indirect calorimetry and the doubly labeled water method. BMR was highly correlated with fat-free mass in both the nonobese and obese groups (r = 0.77 and 0.84, respectively). BMR adjusted for fat-free mass was significantly greater in males than females and in the obese subjects. Total energy expenditure was significantly greater in the obese than nonobese cohort but ratios of total energy expenditure/BMR were not significantly different in the two groups (1.79 +/- 0.2 versus 1.68 +/- 0.19, nonobese and obese males and 1.69 +/- 0.28 versus 1.74 +/- 0.19 nonobese and obese females, respectively). These data indicate that BMR and total energy expenditure are not reduced in the already obese adolescent. Therefore, reduced energy expenditure cannot be responsible for the maintenance of obesity in adolescents.

Adolescent↗
PubMed1990

Energy expenditure and deposition of breast-fed and formula-fed infants during early infancy.

The energy intake, expenditure, and deposition of 40 breast-fed and formula-fed infants were investigated at 1 and 4 mo of age to explore possible differences in energy utilization between feeding groups. Energy intake was calculated from 5-d test-weighing records or pre- and postweighing of formula bottles, in combination with bomb calorimetry of the milks. Total daily energy expenditure (TDEE) was determined by the doubly labeled water method. Sleeping metabolic rate (SMR) and minimal observable energy expenditure were measured by indirect calorimetry. Activity was estimated as the difference between TDEE and SMR. Energy deposition was estimated from dietary intake and TDEE. Energy intakes were significantly higher for the formula-fed than breast-fed infants at 1 mo (118 +/- 17 versus 101 +/- 16 kcal/kg/d) and 4 mo (87 +/- 11 versus 72 +/- 9 kcal/kg/d) (p less than 0.001). TDEE averaged 67 +/- 8 and 64 +/- 7 kcal/kg/d at 1 mo and 73 +/- 9 and 64 +/- 8 kcal/kg/d at 4 mo for the formula-fed and breast-fed infants, respectively, and differed between feeding groups (p less than 0.04). SMR and minimal observable energy expenditure (kcal/min) were higher among the formula-fed infants at 1 and 4 mo (p less than 0.005). The energy available for activity and the thermic effect of feeding did not differ between feeding groups. Rates of weight gain (g/d) and energy deposition (kcal/kg/d) tended to be greater among the formula-fed infants at 1 and 4 mo (p less than 0.006).(ABSTRACT TRUNCATED AT 250 WORDS)

Basal Metabolism↗
PubMed1992

Sleep organization and energy expenditure of breast-fed and formula-fed infants.

Sleep organization of infants may be influenced by differences in nutrient intakes from human milk and formula. Because sleep/awake and sleep stage patterns affect energy expenditure, we hypothesized that differences in sleep organization between breast-fed and formula-fed infants might account in part for differences in energy expenditure between feeding groups. Sleep stages and cycling of 4-mo-old breast-fed (n = 10) formula-fed (n = 10) infants were studied with simultaneous measurements of energy expenditure. EEG, electrooculogram, body movement by triaxial accelerometry, heart rate, and oxygen saturation were monitored during an overnight sleep session. Sleep stages, nonrapid eye movement (NREM), and rapid eye movement (REM) were determined. Behavioral observations were recorded by video tape and by a technologist. Oxygen consumption and carbon dioxide production were measured with an indirect calorimeter. Total number and duration of sleep cycles, REM latency, number of NREM and REM epochs, and duration of NREM epochs did not differ between feeding groups. Sleep latency was shorter (p < 0.05) and duration of REM epochs longer (p < 0.01) in the formula-fed group. Formula-fed infants spent a higher percentage of sleep time in REM compared with the breast-fed infants (42 versus 34%) (p < 0.003). Conversely, breast-fed infants spent a higher percentage of sleep time in NREM sleep and their heart rates during sleep were lower (114 versus 126 bpm; p < 0.01). Energy expenditure during REM sleep was 13.0 +/- 4.4% higher than during NREM sleep (p < 0.001).(ABSTRACT TRUNCATED AT 250 WORDS)

Breast Feeding↗
PubMed2003

Total energy expenditure and physical activity in children treated with home parenteral nutrition.

Determining total energy expenditure (TEE) and its components in children treated with home parenteral nutrition (CHPN) under free-living conditions is an important consideration in the assessment of energy requirements and the maintenance of health. The aim of this study was to assess TEE and physical activity in CHPN. Eleven CHPN (three girls and eight boys; median age, 6.0 y; range, 4.5-15.0 y) were compared with 11 healthy children (three girls and eight boys; median age, 6.0 y, range, 4.5-14.0 y) after pairing for sex, age, and weight. Underlying diseases included chronic intractable diarrhea (n = 5), short bowel syndrome (n = 3), and intestinal dysmotility (n = 3). None of these children had inflammatory disease or recent infection when studied. Fat-free mass (FFM), measured by body impedance analysis, fat mass (FM), measured by skinfold thickness, and energy intake were similar between the two groups, suggesting that CHPN had normal body composition and energy intake. Resting energy expenditure (REE), measured by indirect calorimetry, and TEE, assessed by a technique using 24-h heart-rate monitoring calibrated against indirect calorimetry and physical activity using a triaxial accelerometer, were simultaneously recorded and were also similar in the two groups. Sleeping energy expenditure (SEE), expressed per kilogram of FFM, was significantly greater in the CHPN group (median, 0.15; range, 0.10-0.23 kJ/min/kg FFM versus median, 0.12; range, 0.09-0.21 kJ/min/kg FFM for controls; p < 0.05, Wilcoxon rank test). These findings were explained by the high correlation between the energy flow infused by parenteral nutrition and sleeping energy expenditure (p < 0.05, Spearman test) and also-diet induced thermogenesis (p < 0.05 Spearman test). These results suggest that the energy requirements of children on long-term home parenteral nutrition programs do not differ from controls and that cyclic parenteral nutrition does not interfere with physical activity.

Adolescent↗
PubMed2002

Evidence for the existence of distinct central appetite, energy expenditure, and ghrelin stimulation pathways as revealed by hypothalamic site-specific leptin gene therapy.

To identify the specific hypothalamic sites in which leptin acts to decrease energy intake and/or increase energy expenditure, recombinant adeno-associated virus vector-encoding leptin was microinjected bilaterally into one of four hypothalamic sites in female rats. Leptin transgene expression in the ventromedial nucleus and paraventricular nucleus induced comparable decreases in daily food intake (FI; 18-20%) and body weight (BW; 26-29%), accompanied by drastic reductions in serum leptin (81-97%), insulin (92-93%), free fatty acids (35-36%), and normoglycemia. Leptin transgene expression in the arcuate nucleus (ARC) decreased BW gain (21%) and FI (11%) to a lesser range, but the metabolic hormones were suppressed to the same extent. Leptin transgene expression in the medial preoptic area (MPOA) decreased BW and metabolic hormones without decreasing FI. Finally, leptin transgene expression in all four sites augmented serum ghrelin and thermogenic energy expenditure, as shown by uncoupling protein-1 mRNA expression in brown adipose tissue. Proopiomelanocortin gene expression in the ARC was up-regulated by leptin expression in all four sites, but neuropeptide Y gene expression in the ARC was suppressed by leptin transgene expression in the ARC but not in the MPOA. Thus, whereas leptin expression in the paraventricular nucleus, ventromedial nucleus, or ARC suppresses adiposity and insulin by decreasing energy intake and increasing energy expenditure, in the MPOA it suppresses these variables by increasing energy expenditure alone.

Adipose Tissue, Brown↗
PubMed2002

Low dose leptin administration reverses effects of sustained weight-reduction on energy expenditure and circulating concentrations of thyroid hormones.

Maintenance of a reduced body weight is associated with decreased 24-hour energy expenditure, and decreased circulating concentrations of leptin and thyroid hormones. To determine whether these adaptive metabolic and endocrine changes are partly leptin-mediated, we measured body composition, aspects of energy expenditure, and circulating concentrations of leptin and thyroid hormones in 4 subjects at 3 time points: 1.) Usual body weight; 2.) While stable at 10% reduced body weight; and 3.) During a 5-week period at 10% reduced body weight while receiving twice per day leptin injections that restored 8 AM circulating leptin concentrations to those seen at usual body weight. During maintenance of a 10% reduced body weight, circulating T3, T4, and leptin concentrations were decreased. All of these endocrine changes were reversed by administration of "replacement" doses of leptin (r-metHuLeptin). Indirect calorimetry, and subtle changes in body composition associated with leptin administration, were used to calculate the net change in stored calories and in 24-hour energy expenditure. Total energy expenditure increased in all subjects during r-metHuLeptin administration. These data indicate that decrease leptin concentrations resulting from loss of fat mass account for some aspects of the endocrine/metabolic phenotype associated with the weight-reduced state.

Adult↗
PubMed1988

Effects of extremity loading upon energy expenditure and running mechanics.

Physiological and mechanical consequences of running with commercially available hand and/or ankle weights were examined. Five males and three females (age 30 to 56 yr) ran for 30 min on a treadmill (0% grade) at a self-selected pace (8.9 to 13.7 km.h-1), under randomized conditions of: (i) unloaded weights; (ii) hand weights; (iii) ankle weights; and (iv) hand + ankle weights. Respiratory gas exchange determinations, heart rates, and sagittal view film clips were obtained at selected time intervals. Highest energy expenditures and heart values were obtained for the fully loaded condition, with intermediate values measured for independent hand- and ankle-weighted trials. Increased energy expenditure due to loading ranged from 5 to 8%. Lower extremity kinematics were unaffected by loading. Angular velocity and excursion of the arm segments was significantly (P less than 0.05) reduced when hand weights alone were carried. The results indicate that commercial claims of marked increases in energy expenditure during running with hand/ankle weights are exaggerated. It appears that the small actual increases in energy expenditure, the potential for increased impact forces, and the relative discomfort of carrying weights discredit running with hand and/or ankle weights as a desirable exercise alternative.

Adult↗
PubMed1990

Accuracy and reliability of the Caltrac accelerometer for estimating energy expenditure.

The Caltrac accelerometer is designed to assess energy expenditure during normal activity. The aims of the present study were (a) to determine the interinstrument and intersession reliability of the Caltrac and (b) to validate these instruments with measures of oxygen uptake (VO2) and determine whether Caltracs accurately reflect differences in energy expenditure due to sex, body weight, and speed. Caltracs were found to have very good interinstrument and intersession reliability and to accurately reflect differences in expenditure due to sex, weight, and speed. However, Caltracs consistently over-estimated energy expenditure by an average of 9-13%. The absolute percent error (percent error without consideration of the sign) of the Caltrac was greater, averaging 23%. The correlations between Caltrac and VO2 averaged 0.68-0.74. Thus, the Caltracs seem well suited for studies of activity level of groups, but may be less useful in estimating an individual's activity.

Adult↗
PubMed2002

A peroxisome proliferator-activated receptor gamma agonist influenced daily profile of energy expenditure in genetically obese diabetic rats.

Otsuka Long Evans Tokushima Fatty (OLETF) rats were developed as a model of non-insulin-dependent diabetes mellitus (NIDDM) with mild obesity. We reported that the daily profiles of energy expenditure associated with two peaks (one between 05:00 and 08:00 and the other between 20:00 and 22:00) were observed at 8 weeks of age (without NIDDM), while these two peaks disappeared at 24 weeks of age with NIDDM. As a new anti-diabetic drug, a peroxisome proliferator-activated receptor y agonist pioglitazone hydrochloride has been developed, we examined whether pioglitazone normalized daily profiles of energy expenditure at 24 weeks of age. A control diet and pioglitazone (0.1%)-containing diet were fed from 6 weeks of age. The two peaks of daily profiles of energy expenditure, which disappeared in OLETF rats with the control diet at 24 weeks of age, were reproduced by administration of pioglitazone. The respiratory quotient was lower and fat derived energy used for combustion was increased by pioglitazone at both ages. The body weight, daily food intake, plasma levels of fat, insulin, leptin and the wet weight of visceral fat were not influenced, but the levels of blood hemoglobin Alc and plasma tumor necrosis factor a were decreased by pioglitazone. Administration of pioglitazone improved daily profiles of energy expenditure via affecting glucose and fat metabolisms.

Animals↗
PubMed2005

Effect of randomly interesterified triacylglycerols containing medium- and long-chain fatty acids on energy expenditure and hepatic fatty acid metabolism in rats.

In our previous studies, medium- and long-chain triacylglycerols (MLCT), randomly interesterified triacylglycerols containing medium-chain and long-chain fatty acids in the same glycerol molecule, significantly reduced body fat accumulation in humans and rats. To clarify mechanism(s) for this effect of MLCT, we measured energy expenditure and hepatic fatty acid metabolism in rats by comparison with long-chain triacylglycerols (LCT) or medium-chain triacylglycerols (MCT). MLCT, compared with LCT, showed significantly lower body fat accumulation, higher 24-h energy expenditure and acyl-CoA dehydrogenase activity measured using octanoyl-CoA as a substrate, and similar lipogenic activity. MCT, compared with LCT, showed significantly higher energy expenditure, but fat accumulation was comparable. Additionally, MCT exhibited significantly higher lipogenic activity than the other oils. These data suggest that enhancement of energy expenditure and medium-chain fatty acids (MCFA) oxidation without activating de novo lipogenesis are responsible at least for the lower body fat accumulation in rats fed MLCT. The activation of hepatic lipogenesis by excessive intake of MCFA might counteract their preventive effects on body fat accumulation.

Acyl-CoA Dehydrogenase↗
PubMed2002

Resting energy expenditure in pregnant Japanese women.

The subjects were 160 pregnant women with no complications who were examined with indirect calorimetry by a single observer; 20 healthy age-matched non-pregnant women were used as controls. Assessment was performed 12 hours after oral intake of food. Each measurement of resting energy expenditure divided by the body surface area was analyzed and compared with that of the controls. In pregnant women, the mean resting energy expenditure divided by the body surface area did not significantly increase until 32 weeks' gestation. Energy expenditure increased significantly by about 300 approximately 600 kJ/m(2) between before 31 weeks' gestation and the end of pregnancy. Significant changes occurred in the 32 approximately 35 and 36 approximately 40 weeks' gestational stages (3,790+/-370,4,110+/-385 kJ/m(2)) (p<0.05). Resting energy expenditure increases at conception, and does not increase until 32 weeks' gestation, but increases gradually from 32 weeks' gestation to term in normal pregnant women as assessed by indirect calorimetry.

Adult↗
PubMed1994

A predictive equation for determination of resting energy expenditure in mechanically ventilated patients.

STUDY OBJECTIVE: To evaluate an equation that estimates resting energy expenditure from two easily obtained measurements--expired carbon dioxide and minute ventilation, and compare the results of this equation with standard methods of estimating and measuring caloric expenditure in mechanically ventilated patients. DESIGN: Prospective evaluation in a consecutive, unselected cohort. SETTING: Medical, surgical, and coronary intensive care units in a university hospital. PATIENTS: Twenty-five patients (16 to 79 years of age) receiving mechanical ventilation. INTERVENTION: Indirect calorimetry (IC), minute ventilation (VE), and partial pressure of expired carbon dioxide (PECO2) were obtained on all patients. Harris-Benedict equations were calculated and corrected for known stress factors (HBc). Calculated energy expenditure (CEE) was determined using the following equation: CEE = 9.27 x VE x PECO2 CEE was then compared with IC and HBc. MEASUREMENTS AND RESULTS: The IC was interpretable in 22 of 25 patients, and CEE was significantly better at estimating caloric requirements than HBc. The mean absolute difference between CEE and IC was significantly less than between HBc and IC (118 +/- 96 vs 302 +/- 269, p < .003). CEE estimated caloric requirements to within 200 kcal of IC in 16 of 22 (72 percent); HBc estimated within 200 kcal of IC in 9 of 22 (41 percent). CONCLUSIONS: Minute ventilation and expired carbon dioxide measurements are easily and inexpensively obtainable. Energy expenditures calculated from these measurements (CEE) compare favorably with values obtained from a metabolic cart and are significantly more accurate than HBc.

Adolescent↗
PubMed2006

Analysis of the assessment of caloric expenditure in four modes of aerobic dance.

Aerobic dance has been purported to help with weight management; however, it is not known if various forms of dance are as effective as traditional modalities. This study estimated energy expenditure by heart rate for 28 women participating in 4 modes of aerobic dance (Bodycombat [i.e., TAEBO]; Pump; Step; and RPM [i.e., spinning]) compared to 2 running speeds. Pump had significantly (p < 0.01) lower energy expenditure (8.0 +/- 1.6 kcal.min(-1)) compared to the other classes (RPM: 9.9 +/- 1.9 kcal.min(-1); Step: 9.6 +/- 1.8 kcal.min(-1); and Bodycombat: 9.7 +/- 2.0 kcal.min(-1)) and running at 8.05 km.h(-1) (9.16 +/- 1.53 kcal.min(-1)). Also, Step (p < 0.01), Bodycombat (p < 0.01), and RPM (p < 0.01) had significantly higher caloric expenditures than running at 8.05 km.h(-1) but significantly lower than running at 8.37 km.h(-1) (10.30 +/- 1.72 kcal.min(-1)). In conclusion, RPM, Bodycombat, and Step aerobics were equally as effective as jogging between 8.05 and 8.37 km.h(-1), and they met American College of Sports Medicine guidelines for weight modification and maintenance. Additionally, heart rate assessment provided a quantitative method for estimating energy expenditure and the effectiveness of different aerobic programs.

Adult↗