Physical Activity Interventions to Alleviate Depressive Symptoms in Children and Adolescents: A Systematic Review and Meta-analysis.

Importance: Depression is the second most prevalent mental disorder among children and adolescents, yet only a small proportion seek or receive disorder-specific treatment. Physical activity interventions hold promise as an alternative or adjunctive approach to clinical treatment for depression. Objective: To determine the association of physical activity interventions with depressive symptoms in children and adolescents. Data Sources: PubMed, CINAHL, PsycINFO, EMBASE, and SPORTDiscus were searched from inception to February 2022 for relevant studies written in English, Chinese, or Italian. Study Selection: Two independent researchers selected studies that assessed the effects of physical activity interventions on depressive symptoms in children and adolescents compared with a control condition. Data Extraction and Synthesis: A random-effects meta-analysis using Hedges g was performed. Heterogeneity, risk of bias, and publication bias were assessed independently by multiple reviewers. Meta-regressions and sensitivity analyses were conducted to substantiate the overall results. The study followed the PRISMA reporting guideline. Main Outcomes and Measures: The main outcome was depressive symptoms as measured by validated depression scales at postintervention and follow-up. Results: Twenty-one studies involving 2441 participants (1148 [47.0%] boys; 1293 [53.0%] girls; mean [SD] age, 14 [3] years) were included. Meta-analysis of the postintervention differences revealed that physical activity interventions were associated with a reduction in depressive symptoms compared with the control condition (g = -0.29; 95% CI, -0.47 to -0.10; P = .004). Analysis of the follow-up outcomes in 4 studies revealed no differences between the physical activity and control groups (g = -0.39; 95% CI, -1.01 to 0.24; P = .14). Moderate study heterogeneity was detected (Q = 53.92; df = 20; P < .001; I2 = 62.9% [95% CI, 40.7%-76.8%]). The primary moderator analysis accounting for total physical activity volume, study design, participant health status, and allocation and/or assessment concealment did not moderate the main treatment effect. Secondary analyses demonstrated that intervention (ie, <12 weeks in duration, 3 times per week, unsupervised) and participant characteristics (ie, aged ≥13 years, with a mental illness and/or depression diagnosis) may influence the overall treatment effect. Conclusions and Relevance: Physical activity interventions may be used to reduce depressive symptoms in children and adolescents. Greater reductions in depressive symptoms were derived from participants older than 13 years and with a mental illness and/or depression diagnosis. The association with physical activity parameters such as frequency, duration, and supervision of the sessions remains unclear and needs further investigation.

Physical activity and exercise for cancer-related cognitive impairment among individuals affected by childhood cancer: a systematic review and meta-analysis.

BACKGROUND: Individuals affected by childhood cancer can have cognitive dysfunction that persists into adulthood and negatively affects quality of life. In this study, we aimed to evaluate the effects of physical activity and exercise on cognitive function among individuals affected by childhood cancer. METHODS: In this systematic review and meta-analysis, we searched seven databases (CINAHL Plus, Cochrane Library, Embase, MEDLINE, PsycINFO, SPORTDiscus, and Web of Science) and two clinical trial registries (ClinicalTrials.gov and the International Clinical Trials Registry Platform) for randomised controlled trials (RCTs) and non-randomised studies of interventions (NRSIs) published (or registered) from database inception to Jan 30, 2022, with no language restrictions. We included studies that compared the effects of physical activity or exercise interventions with controls (no intervention or usual care) on cognitive function among individuals diagnosed with any type of cancer at age 0-19 years. Two reviewers (JDKB and FR) independently screened records for eligibility and searched references of the selected studies; extracted study-level data from published reports; and assessed study risk of bias of RCTs and NRSIs using the Cochrane risk of bias tool for randomised trials (RoB 2) and Risk Of Bias In Non-randomised Studies-of Interventions (ROBINS-I) tools, certainty of the evidence using the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) approach, and any adverse events. We used intention-to-treat data and unpublished data if available. Cognitive function was assessed by standardised cognitive performance measures (primary outcome) and by validated patient-reported measures (secondary outcome). A random-effects meta-analysis model using the inverse-variance and Hartung-Knapp methods was used to calculate pooled estimates (Hedges' g) and 95% CI values. We estimated the heterogeneity variance by the restricted maximum likelihood method and calculated I2 values to measure heterogeneity. We examined funnel plots and used Egger's regression test to assess for publication bias. This study is registered with PROSPERO, CRD42021261061. FINDINGS: We screened 12 425 titles and abstracts, which resulted in full-text assessment of 131 potentially relevant reports. We evaluated 22 unique studies (16 RCTs and six NRSIs) with data on 1277 individuals affected by childhood cancer and low-to-moderate risk of bias. Of the 1277 individuals, 674 [52·8%] were male and 603 [47·2%] were female; median age at study start was 12 (IQR 11-14) years, median time since the end of cancer treatment was 2·5 (IQR -1·1 to 3·0) years, and median intervention period was 12 [IQR 10-24] weeks. There was moderate-quality evidence that, compared with control, physical activity and exercise improved cognitive performance measures (five RCTs; Hedges' g 0·40 [95% CI 0·07-0·73], p=0·027; I2=18%) and patient-reported measures of cognitive function (13 RCTs; Hedges' g 0·26 [0·09-0·43], p=0·0070; I2=40%). No evidence of publication bias was found. Nine mild adverse events were reported. INTERPRETATION: There is moderate-certainty evidence that physical activity and exercise improves cognitive function among individuals affected by childhood cancer, which supports the use of physical activity for managing cancer-related cognitive impairment. FUNDING: Research Impact Fund of Research Grants Council of the Hong Kong University Grants Committee (R7024-20) and Seed Fund for Basic Research of the University of Hong Kong. COPYRIGHT: © 2022 Published by Elsevier Ltd. All rights reserved.

A new strategy for the implementation of an aerobic training session.

The objectives were to propose a new strategy for adjusting aerobic training variables based on the eighth American College of Sports Medicine (ACSM) guidelines and maximal aerobic power (&OV0312;O2max) and to establish energy expenditure (EE) recommendations for training, which depend on a subject's body mass (BM). Exclusively based on aerobic training recommendations that are available in the ACSM guidelines, 16 equally partitioned subcategories were created from the slope of a linear regression between the lower (16.4 ml·kg(-1)·min(-1)) and upper (61.2 ml·kg(-1)·min(-1)) limits of VO(2max) percentile tables and all aerobic variables (intensity: 30-85%Reserve, duration: 60-300 min·wk(-1), frequency: 3-5 d·wk(-1), and EE: 1,000-4,000 kcal·wk). ACSM's EE (EE(ACSM)) recommendation was compared to EE based on VO(2max) (EE(Actual)), BM, exercise intensity and duration combined, for five BM categories (60 to 100 kg). The following equations were generated to adjust aerobic training: Intensity (%(Reserve)) = VO(2max) (ml·kg(-1)·min(-1)) × 1.23 + 9.85, Duration (min·wk(-1)) = VO(2max) × 5.36-27.91, Frequency (d·wk(-1) = VO(2max) × 0.044 + 2.27, EE(ACSM) (kcal·wk(-1)) =VO(2max) × 82.61-1,055.29, and EE(Actual) (kcal·wk(-1)) = ([V(O2max) - 3.5] × Intensity + 3.5) × BM (kg)/200 × Frequency. A comparison of EE(ACSM) and EE(Actual) for 5 BM and 3 aerobic fitness categories demonstrated an effect size classification that is equal or superior to "large" in 9 of 15 comparisons, suggesting that EE(ACSM) adjustment is inadequate at least 60% of the time. Despite the need to verify the adequacy of the linear model and perform future cross-sectional and longitudinal studies, the present proposal first provides criteria to adjust aerobic training variables consistent with subject capacity, thus diminishing the risk of the imprecise aerobic prescription.

Comparison of two proposed guidelines for aerobic training sessions.

The purpose was to compare 24 participants' acute physiological and affective responses to two aerobic prescriptions in three sessions. Anthropometry, International Physical Activity Questionnaire, and VO2max were recorded. In subsequent visits two aerobic prescriptions were randomly applied: one based on VO2max (PBVO2max) and another based on physical activity level (PBPA). Physiological and affective variables were measured in each session. The PBVO2max showed lower risk for dropout than the PBPA. An effect size analysis showed higher ratings on the Feeling Scale in the PBVO2max session at the end of exercise. After categorizing participants by fitness (High, Medium, and Low) according to VO2max, significant differences were observed for the training impulse between Low and High fitness categories, indicating PBVO2Max were sensitive in distinguishing levels of fitness. The PBVO2max, compared to PBPA, seems to provide better physiological and affective responses. VO2max (even if estimated) is recommended as the basis for aerobic prescriptions.

The Effects of Exclusive Walking on Lipids and Lipoproteins in Women with Overweight and Obesity: A Systematic Review and Meta-Analysis.

OBJECTIVE: To evaluate the effects of walking, independent of diet and weight-loss, on lipids and lipoproteins in women with overweight and obesity. DATA SOURCE: Academic Search Complete, Alternative Health Watch, Global Health, Health Source, CINAHL, MEDLINE, EMBASE, SportDiscus, and ProQuest. STUDY INCLUSION AND EXCLUSION CRITERIA: (1) experiment-control design; (2) women with overweight or obesity; (3) walking as the experiment's independent variable; (4) four or more weeks; and (5) pre- to post-assessment of lipids and/or lipoproteins. Excluded studies reported use of lipid-lowering medication, diet or other modes of physical activity, and alternative interventions as the control. DATA EXTRACTION: Data extraction and study quality were completed by the first 2 authors using the Cochrane review protocol and risk of bias assessment. DATA SYNTHESIS: Raw mean difference between the experiment and control groups using a random effects model. RESULTS: Meta-analyses of 21 interventions (N = 1129) demonstrated exclusive walking improves total cholesterol (raw mean difference = 6.67 mg/dL, P = .04) and low-density lipoproteins (raw mean difference = 7.38 mg/dL, P = .04). Greater improvement in total cholesterol, triglycerides, high-density lipoproteins, and low-density lipoproteins existed in women with obesity. CONCLUSIONS: Exclusive walking aids in normalizing total cholesterol and LDLs in women with overweight and obesity. Exclusive walking can be used as a non-pharmacologic therapy, which may have positive clinical outcomes for individuals who especially struggle with diet and weight-reduction.

Comparative Efficacy of 5 Exercise Types on Cardiometabolic Health in Overweight and Obese Adults: A Systematic Review and Network Meta-Analysis of 81 Randomized Controlled Trials.

BACKGROUND: Although regular exercise is recommended for preventing and treating overweight/obesity, the most effective exercise type for improving cardiometabolic health in individuals with overweight/obesity remains largely undecided. This network meta-analysis aimed to evaluate and rank the comparative efficacy of 5 exercise modalities on cardiometabolic health measures in individuals with overweight/obesity. METHODS: A database search was conducted in MEDLINE, Embase, Scopus, and Web of Science from inception up to September 2020. The review focused on randomized controlled trials involving exercise interventions consisting of continuous endurance training, interval training, resistance training, combined aerobic and resistance training (combined training), and hybrid-type training. Exercise interventions aimed to improve somatometric variables, body composition, lipid metabolism, glucose control, blood pressure, cardiorespiratory fitness, and muscular strength. The Cochrane risk of bias tool was used to evaluate eligible studies. A random-effects network meta-analysis was performed within a frequentist framework. The intervention ranking was carried out using a Bayesian model where mean and SD were equal to the respective frequentist estimates. RESULTS: A total of 4331 participants (59% female; mean age: 38.7±12.3 years) from 81 studies were included. Combined training was the most effective modality and hybrid-type training the second most effective in improving cardiometabolic health-related outcomes in these populations suggesting a higher efficacy for multicomponent exercise interventions compared to single-component modalities, that is, continuous endurance training, interval training, and resistance training. A subgroup analysis revealed that the effects from different exercise types were mediated by gender. CONCLUSIONS: These findings corroborate the latest guidelines on exercise for individuals with overweight/obesity highlighting the importance of a multicomponent exercise approach to improve cardiometabolic health. Physicians and healthcare professionals should consider prescribing multicomponent exercise interventions to adults with overweight/obesity to maximize clinical outcomes. REGISTRATION: URL: https://www.crd.york.ac.uk/PROSPERO/; Unique identifier: CRD42020202647.

Consortium for Health and Military Performance and American College of Sports Medicine consensus paper on extreme conditioning programs in military personnel.

A potential emerging problem associated with increasingly popularized extreme conditioning programs (ECPs) has been identified by the military and civilian communities. That is, there is an apparent disproportionate musculoskeletal injury risk from these demanding programs, particularly for novice participants, resulting in lost duty time, medical treatment, and extensive rehabilitation. This is a significant and costly concern for the military with regard to effectively maintaining operational readiness of the Force. While there are certain recognized positive aspects of ECPs that address a perceived and/or actual unfulfilled conditioning need for many individuals and military units, these programs have limitations and should be considered carefully. Moreover, certain distinctive characteristics of ECPs appear to violate recognized accepted standards for safely and appropriately developing muscular fitness and are not uniformly aligned with established and accepted training doctrine. Accordingly, practical solutions to improve ECP prescription and implementation and reduce injury risk are of paramount importance.

Perspectives on research conducted at the Paralympic Games.

BACKGROUND AND PURPOSE: In 1994, the International Paralympic Committee (IPC) established the IPC Sport Science Committee in an effort to bring Paralympic Movement relevant research questions to the academic world. In 1996, the IPC Sport Science Committee put an application system in place, allowing scholars to conduct research at the Paralympic Games. The aim of this perspective paper is to overview the main outcomes of the fifty-six research projects conducted from Atlanta 1996 until PyeongChang 2018 during Paralympic Games' time; and to discuss the state-of-the-art of the IPC Research Strategic Goals. METHODS: Research projects conducted at the Paralympic Games from Atlanta 1996 to PyeongChang 2018 were clustered according to the IPC Research Strategic Goals (publications retrieved through the following procedure: analyzing the IPC Medical & Scientific Department project file; systematic search of Pubmed and SportDiscus with "Name Principal Investigator" and "Paralympic" as search terms; email to principal investigator if no outcome retrieved). RESULTS: Games-time projects targeted Paralympic research strategic goals, such as athletes' health, athletes' performance, evidence-based classification, participation, Paralympic legacy, and education. CONCLUSION: Some of the projects proved high relevance and became standard Games' operations; however, generally, projects operate in isolation and could benefit from collaboration with expert-stakeholders (e.g., athletes, coaches, governing International Sport Federations, relevant IPC departments, network of academic scholars). Sport science research in the Paralympic Movement should move fast and collaborative to catch up on evolution.IMPLICATIONS FOR REHABILITATIONFrom a health perspective, fine-tuning of the patient/athlete-equipment interface to optimize function/performance is a challenge for the rehabilitation specialist/coach.The musculoskeletal balance of the shoulder joints is a lifelong concern for permanent wheelchair users, especially those involved in dynamic wheelchair sports.Education about autonomic dysreflexia and boosting in patients/athletes with spinal cord injury is an integral part of the rehabilitation process.Rehabilitation experts have an ideal educational profile to contribute to evidence-based classification, as a para-sports classifier, or as a researcher.

Exercise Is Medicine.

There is overwhelming evidence in the scientific and medical literature that physical inactivity is a major public health problem with a wide array of harmful effects. Over 50% of health status can be attributed to unhealthy behaviors with smoking, diet, and physical inactivity as the main contributors. Exercise has been used in both the treatment and prevention of a variety of chronic conditions such as heart disease, pulmonary disease, diabetes, and obesity. While the negative effects of physical inactivity are widely known, there is a gap between what physicians tell their patients and exercise compliance. Exercise is Medicine was established in 2007 by the American College of Sports Medicine to inform and educate physicians and other health care providers about exercise as well as bridge the widening gap between health care and health fitness. Physicians have many competing demands at the point of care, which often translates into limited time spent counseling patients. The consistent message from all health care providers to their patients should be to start or to continue a regular exercise program. Exercise is Medicine is a solution that enables physicians to support their patients in implementing exercise as part of their disease prevention and treatment strategies.

Effects of yoga on inflammation and exercise capacity in patients with chronic heart failure.

BACKGROUND: Despite recent advances in pharmacologic and device therapy, morbidity and mortality from heart failure (HF) remain high. Yoga combines physical and breathing exercises that may benefit patients with HF. We hypothesized that an 8-week regimen of yoga in addition to standard medical therapy would improve exercise capacity, inflammatory markers, and quality of life (QoL) in patients with HF. METHODS AND RESULTS: New York Heart Association Class I-III HF patients were randomized to yoga treatment (YT) or standard medical therapy (MT). Measurements included a graded exercise test (GXT) to V O(2Peak) and the following serum biomarkers: interleukin-6 (IL-6), high-sensitivity C-reactive protein (hsCRP), and extracellular superoxide dismutase (EC-SOD). The Minnesota Living with Heart Failure Questionnaire (MLHFQ) was administered to assess changes in QoL. A total of 19 patients were enrolled after the initial screening. Of the 19 patients, 9 were randomized to YT and 10 to MT. Patients had a mean EF of 25%. GXT time and V O(2Peak) were significantly improved in the YT versus MT groups (+18% in the YT and -7.5% in MT; P = .03 vs. control and +17 in YT and -7.1 in MT; P = .02, respectively). There were statistically significant reductions in serum levels of IL-6 and hsCRP and an increase in EC-SOD in the YT group (all P < .005 vs. MT). MLHFQ scores improved by 25.7% in the YT group and by 2.9% in the MT group. CONCLUSIONS: Yoga improved exercise tolerance and positively affected levels of inflammatory markers in patients with HF, and there was also a trend toward improvements in QoL.

Comparison of creatine monohydrate and carbohydrate supplementation on repeated jump height performance.

Creatine monohydrate (CrMH) supplementation aids the ability to maintain performance during repeated bouts of high-intensity exercise, including jump performance. However, carbohydrate supplementation may also provide similar benefits and is less expensive. This study compared the effects of an energy-free placebo, 2 different caloric concentrations of carbohydrate drinks, and a CrMH supplement on repeated jump heights. Sixty active males (mean age, 22 +/- 3.2 years) performed 2 sets of countermovement static jump height tests (10 jumps over 60 seconds) separated by 5 days to determine the differential effects of the placebo, carbohydrate, and CrMH on jump height sustainability over 10 jumps. Subjects were randomly assigned to groups (15 subjects per group) to receive daily doses (x5 days) of carbohydrate drinks containing 100 or 250 kilocalories (kcal), a 25-g CrMH supplement, or an energy-free placebo. After 5 days, the CrMH group experienced a significant weight gain (+1.52; +/-0.89 kg, p < 0.01), while the other groups did not. The 2 levels of carbohydrate and CrMH supplements were all significantly better at sustaining jump height than the energy-free placebo over the final 3-4 jumps. The 250-kcal carbohydrate-supplemented group experienced a level of benefit (p < 0.01) that was at least equal to that of the CrMH group (p < 0.05), suggesting that the higher dose of carbohydrate was as effective as CrMH in maintaining repeated bouts of high-intensity activity as measured by repeated static jumps. Given the equivalent performance improvement and the absence of weight gain, the carbohydrate supplementation could be considered the preferred option for weight-conscious power athletes involved in activities that require repeated- motion high-intensity activities.

Yoga for Heart Failure: A Review and Future Research.

BACKGROUND: Complementary and alternative medicine is a rapidly growing area of biomedical inquiry. Yoga has emerged in the forefront of holistic medical care due to its long history of linking physical, mental, and spiritual well-being. Research in yoga therapy (YT) has associated improved cardiovascular and quality of life (QoL) outcomes for the special needs of heart failure (HF) patients. AIM: The aim of this study is to review yoga intervention studies on HF patients, discuss proposed mechanisms, and examine yoga's effect on physiological systems that have potential benefits for HF patients. Second, to recommend future research directions to find the most effective delivery methods of yoga to medically stable HF patients. METHODS: The authors conducted a systematic review of the medical literature for RCTs involving HF patients as participants in yoga interventions and for studies utilizing mechanistic theories of stretch and new technologies. We examined physical intensity, mechanistic theories, and the use of the latest technologies. CONCLUSIONS: Based on the review, there is a need to further explore yoga mechanisms and research options for the delivery of YT. Software apps as exergames developed for use at home and community activity centers may minimize health disparities and increase QoL for HF patients.

Anaesthesia underpins acute patient care in hospitals.

The Australian and New Zealand College of Anaesthetists (ANZCA) carried out a review of the roles of anaesthetists in providing acute care services in both public and private hospitals in Europe, North America and South-East Asia. As a result, ANZCA revised its education and training program and its processes relating to overseas-trained specialists. The new training program, introduced in 2004, formed the basis for submissions to the Australian Medical Council, and the Australian Competition and Consumer Commission/Australian Health Workforce Officials' Committee review of medical colleges. A revised continuing professional development program will be in place in 2007. Anaesthetists in Australia and New Zealand play a pivotal role in providing services in both public and private hospitals, as well as supporting intensive care medicine, pain medicine and hyperbaric medicine. Anaesthesia allows surgery, obstetrics, procedural medicine and interventional medical imaging to function optimally, by ensuring that the patient journey is safe and has high quality care. Specialist anaesthetists in Australia now exceed Australian Medical Workforce Advisory Committee recommendations.

Benefits of yoga for African American heart failure patients.

BACKGROUND: The number of African American (AA) patients living with heart failure (HF) has been increasing, especially among the economically disadvantaged. Yoga therapy has been found to improve physical and psychological parameters among healthy individuals, but its effect in patients with HF remains unknown. The purpose of this study was to examine the effects of yoga therapy on cardiovascular endurance (VO2peak), flexibility, quality of life (QoL), and inflammatory markers on medically stable HF patients. METHODS: Forty patients (38 AA, 1 Asian, and 1 Caucasian) with systolic or diastolic HF were randomized to the yoga group (YG, n = 21) or the control group (CG, n = 19). All patients were asked to follow a home walk program. Premeasurement and postmeasurement included a treadmill stress test to peak exertion, flexibility, interleukin-6 (IL-6), C-reactive protein (CRP), and extracellular superoxide dismutase (EC-SOD). QoL was assessed by the Minnesota Living with Heart Failure Questionnaire (MLwHFQ). RESULTS: The statistical analyses (assessed by ANOVA and t-tests) were significant for favorable changes in the YG, compared with those in the CG, for flexibility (P = 0.012), treadmill time (P = 0.002), VO2peak (P = 0.003), and the biomarkers (IL-6, P = 0.004; CRP, P = 0.016; and EC-SOD, P = 0.012). Within the YG, pretest to posttest scores for the total (P = 0.02) and physical subscales (P < 0.001) of the MLwHFQ were improved. CONCLUSIONS: Yoga therapy offered additional benefits to the standard medical care of predominantly AA HF patients by improving cardiovascular endurance, QoL, inflammatory markers, and flexibility.

Boosting in athletes with high-level spinal cord injury: knowledge, incidence and attitudes of athletes in paralympic sport.

UNLABELLED: Autonomic dysreflexia (AD) is unique to individuals with spinal injuries (SCI) at T6 or above and can be voluntarily induced. Although AD improves wheelchair racing performance in some athletes, it also elicits exaggerated blood pressure, which could be dangerous. The International Paralympic Committee considers AD doping and banned its use. PURPOSE: The purpose of this study is to evaluate AD knowledge, incidence and attitudes (KIA) of Paralympians with SCI. METHODS: An existing questionnaire was modified to include questions of AD KIA, validated by three experts and piloted with a small sample. It was administered on-line, mailed to members of a scientific network and distributed during the Beijing Paralympic Games. Fisher Exact test was used to evaluate differences across gender, injury and education. RESULTS: Of 99 participants, 54.5% had previously heard of AD while 39.4% were unaware; 16.7%, all males, had used AD to enhance performance. Participants reported that AD was (1) useful for middle (78.6%) and long distance (71.4%), marathon (64.3%) and wheelchair rugby (64.3%); (2) somewhat dangerous (48.9%), dangerous (21.3%) or very dangerous (25.5%) to health. Results were not influenced by age, injury level or injury duration. CONCLUSIONS: Findings indicate the need for educational programmes directed towards enhancing the AD knowledge of rehabilitation professionals, coaches and trainers working with SCI individuals.

Physiological and Training Profiles of Ultramarathoners.

In brief This study describes the physiological profile and training pattern of ultramarathoners and their performance variables during an ultramarathon. The authors studied 17 experienced male ultramarathoners who had completed a 50-mile race. They were arbitrarily divided into two groups for comparison: those who finished in less than six hours (elite) and those who finished in more than six hours (nonelite). The elite ultramarathoners averaged 96 miles per week in training runs with a long single run of 35 miles before a race. They averaged 84% of Vo2 max throughout the 50-mile race. The nonelite runners averaged 60 miles per week with a long run of 27 miles before a race. They averaged 72% of Vo2 max. All subjects expended approximately 6,000 kcal during the race and had low levels of blood lipids.