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Exercise, energy expenditure and energy balance, as measured with doubly labelled water

  • Klaas R. Westerterp (a1)


The doubly labelled water method for the measurement of total daily energy expenditure (TDEE) over 1–3 weeks under daily living conditions is the indicated method to study effects of exercise and extreme environments on energy balance. Subjects consume a measured amount of doubly labelled water (2H2 18O) to increase background enrichment of body water for 18O and 2H, and the subsequent difference in elimination rate between 18O and 2H, as measured in urine, saliva or blood samples, is a measure for carbon dioxide production and thus allows calculation of TDEE. The present review describes research showing that physical activity level (PAL), calculated as TDEE (assessed with doubly labelled water) divided by resting energy expenditure (REE, PAL = TDEE/REE), reaches a maximum value of 2·00–2·40 in subjects with a vigorously active lifestyle. Higher PAL values, while maintaining energy balance, are observed in professional athletes consuming additional energy dense foods to compete at top level. Exercise training can increase TDEE/REE in young adults to a value of 2·00–2·40, when energy intake is unrestricted. Furthermore, the review shows an exercise induced increase in activity energy expenditure can be compensated by a reduction in REE and by a reduction in non-exercise physical activity, especially at a negative energy balance. Additionally, in untrained subjects, an exercise-induced increase in activity energy expenditure is compensated by a training-induced increase in exercise efficiency.

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Corresponding author

Corresponding author: K. R. Westerterp, fax 31 43 3670976, email


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1. Westerterp, KR (2015) Energy expenditure and energy intake methods. In Nutrition Research Methodologies, pp. 186197 [Lovegrove, JA, Hodson, L, Sharma, S et al. , editors]. Chichester: Wiley-Blackwell.
2. Westerterp, KR, Kayser, B, Brouns, F et al. (1992) Energy expenditure climbing Mt. Everest. J Appl Physiol 73, 18151819.
3. Westerterp, KR, Saris, WH, Van Es, M et al. (1986) Use of the doubly labeled water technique in humans during heavy sustained exercise. J Appl Physiol 61, 21622167.
4. FAO/WHO/UNU (1985) Energy and Protein Requirements. WHO Technical Report Series 724. Geneva, Switzerland.
5. FAO/WHO/UNU (2004) Human Energy Requirements. Joint FAO/WHO/UNU Expert Consultation. FAO Food and Nutrition Technical Report Series no. 1. Rome.
6. Edholm, OG, Fletcher, JG, Widdwson, EM et al. (1955) The energy expenditure and food intake of individual men. Br J Nutr 9, 286300.
7. Westerterp, KR (1999) Body composition, water turnover and energy turnover assessment with labelled water. Proc Nutr Soc 58, 945951.
8. Lifson, N & McClintock, R (1955) Measurement of total carbon dioxide production by means of D2 18O. J Appl Physiol 7, 704710.
9. Speakman, JR (1997) Doubly Labelled Water: Theory and Practice. London: Chapman & Hall.
10. Westerterp, KR, Wouters, L & Van Marken Lichtenbelt, WD (1995) The Maastricht protocol for the measurement of body composition and energy expenditure with labeled water. Obes Res 3, Suppl. 1, 4957.
11. Bhutani, S, Racine, N, Shriver, T et al. (2015) Special considerations for measuring energy expenditure with doubly labeled water under atypical conditions. J Obes Weight Loss Ther 5, Suppl. 5, 002.
12. Westerterp, KR, Kayser, B, Wouters, L et al. (1994) Energy balance at high altitude of 6542 m. J Appl Physiol 77, 862866.
13. Berman, ES, Melanson, EL, Swibas, T et al. (2015) Inter- and intraindividual correlations of background abundances of 2H, 18O and 17O in human urine and implications for DLW measurements. Eur J Clin Nutr 69, 10911098.
14. Lifson, N & McClintock, R (1966) Theory and use of turnover rates of body water for measuring energy and material balance. J Theor Biol 12, 4674.
15. Schoeller, DA (1983) Energy expenditure from doubly labeled water: some fundamental considerations in humans. Am J Clin Nutr 38, 9991005.
16. Trabulsi, J, Troiano, RP & Subar, AF (2003) Precision ofv the doubly labeled water method in a large-scale application: evaluation of a streamlined-dosing protocol in the Observing Protein and Energy Nutrition (OPEN) study. Eur J Clin Nutr 57, 13701377.
17. Rosenkilde, M, Morville, T, Andersen, PR et al. (2015) Inability to match energy intake with energy expenditure at sustained near-maximal rates of energy expenditure in older men during a 14-d cycling expedition. Am J Clin Nutr 102, 13981405.
18. Westerterp, KR, Meijer, EP, Rubbens, M et al. (2000) Operation Everest III: energy and water balance. Eur J Physiol 439, 483488.
19. Brouwer, E (1957) On simple formulae for calculating the heat expenditure and the quantities of carbohydrate and fat oxidized in metabolism of men and animals from gaseous exchange) oxygen intake and carbonic acid output) and urine-N. Acta Physiol Neerl 6, 795802.
20. Black, AE, Prentice, AM & Coward, WA (1986) Use of food quotients to predict respiratory quotients for the doubly-labelled water method of measuring energy expenditure. Hum Nutr: Clin Nutr 40C, 381391.
21. Sjödin, A, Andersson, A, Högberg, J et al. (1994) Energy balance in cross-country skiers: a study using doubly labeled water. Med Sci Sports Exerc 26, 720724.
22. Black, AE, Coward, WA, Cole, JJ et al. (1996) Human energy expenditure in affluent societies: an analysis of 574 doubly-labelled water measurements. Eur J Clin Nutr 50, 7292.
23. Butte, NF, Ekelund, U & Westerterp, KR (2012) Assessing physical activity using wearable monitors: measures of physical activity. Med Sci Sports Exerc 44, Suppl. 1, S5S12.
24. Speakman, JR & Westerterp, KR (2010) Associations between energy demands, physical activity and body composition in adult humans between 18 and 96 y of age. Am J Clin Nutr 92, 826834.
25. Heitmann, BL, Westerterp, KR, Loos, RJ et al. (2012) Obesity: lessons from evolution and the environment. Obes Rev 13, 910922.
26. Blaak, EE, Westerterp, KR, Bar-Or, O et al. (1992) Total energy expenditure and spontaneous activity in relation to training in obese boys. Am J Clin Nutr 55, 777782.
27. Bingham, SA, Goldberg, GR, Coward, WA et al. (1989) The effect of exercise and improved physical fitness on basal metabolic rate. Br J Nutr 61, 155173.
28. Van Etten, LM, Westerterp, KR, Verstappen, FT et al. (1997) Effect of an 18-wk weight-training program on energy expenditure and physical activity. J Appl Physiol 82, 298304.
29. Hunter, GR, Fisher, G, Neumeier, WH et al. (2015) Exercise training and energy expenditure following weight loss. Med Sci Sports Exerc 47, 19501957.
30. Westerterp, KR, Meijer, GA, Janssen, EM et al. (1992) Long-term effect of physical activity on energy balance and body composition. Br J Nutr 68, 2130.
31. Kempen, KP, Saris, WH & Westerterp, KR (1995) Energy balance during an 8-wk energy-restricted diet with and without exercise in obese women. Am J Clin Nutr 62, 722729.
32. Meijer, EP, Goris, AH, Wouters, L et al. (2001) Physical inactivity as a determinant of the physical activity level in the elderly. Int J Obes 25, 935939.
33. Goran, MI & Poehlman, ET (1992) Endurance training does not enhance total energy expenditure in healthy elderly persons. Am J Physiol 263, E950E957.
34. Hunter, GR, Wetzstein, CJ, Fields, DA et al. (2000) Resistance training increases total energy expenditure and free-living physical activity in older adults. J Appl Physiol 89, 977984.
35. Westerterp, KR, Donkers, JH, Fredrix, EW et al. (1995) Energy intake, physical activity and body weight: a simulation model. Br J Nutr 73, 337347.
36. Thomas, DM, Bouchard, C, Church, T et al. (2012) Why do individuals not lose more weight from an exercise intervention at a defined dose? An energy balance analysis. Obes Rev 13, 835847.
37. Piersma, T (2011) Why marathon migrants get away with high metabolic ceilings: towards an ecology of physiological restraint. J Exp Biol 214, 295302.
38. Cooper, JA, Nguyen, DD, Ruby, BC et al. (2011) Maximal sustained levels of energy expenditure in humans during exercise. Med Sci Sports Exerc 43, 23592367.
39. Stroud, MA, Coward, WA & Sawyer, MB (1993) Measurements of energy expenditure using isotope-labelled water (2H2 18O) during an Arctic expedition. Eur J Appl Physiol 67, 375379.
40. Westerterp, KR (1998) Alterations in energy balance with exercise. Am J Clin Nutr 68, Suppl., 970S974S.
41. Ainsli, PN, Campbell, IT, Frayn, KN et al. (2002) Energy balance, metabolism, hydration, and performance during strenuous hill walking: the effect of age. J Appl Physiol 93, 714723.
42. Speakman, JR & Selman, C (2003) Physical activity and resting metabolic rate. Proc Nutr Soc 62, 621634.
43. Westerterp, KR, Meijer, GA, Schoffelen, P et al. (1994) Body mass, body composition and sleeping metabolic rate before, during and after endurance training. Eur J Appl Physiol 69, 203208.
44. Johannsen, DL, Knuth, ND, Huizinga, R et al. (2012) Metabolic slowing with massive weight loss despite preservation of fat-free mass. J Clin Endocrinol Metab 97, 24892496.
45. Sjödin, AM, Forslund, AH, Westerterp, KR et al. (1996) The influence of physical activity on BMR. Med Sci Sports Exerc 28, 8591.
46. Washburn, RA, Lambourne, K, Szabo, AN et al. (2014) Does increased prescribed exercise alter non-exercise physical activity/energy expenditure in healthy adults? A systematic review. Clin Obes 4, 120.
47. Fedewa, MV, Hathaway, ED, Williams, TD et al. (2017) Effect of exercise training on non-exercise physical activity: a systematic review and meta-analysis of randomized controlled trials. Sports Med 47, 11711182.
48. Meijer, GA, Janssen, GM, Westerterp, KR et al. (1991) The effect of a 5-month endurance-training programme on physical activity: evidence for a sex-difference in the metabolic response to exercise. Eur J Appl Physiol 62, 1117.
49. Melanson, EL, Keadle, SK, Donnelly, JE et al. (2013) Resistance to exercise-induced weight loss: compensatory behavioral changes. Med Sci Sports Exerc 45, 16001609.
50. Melanson, EL (2017) The effect of exercise on non-exercise physical activity and sedentary behavior in adults. Obes Rev 18, Suppl. 1, 4049.
51. Meijer, EP, Westerterp, KR & Verstappen, FT (1999) The effect of exercise training on total daily physical activity in elderly humans. Eur J Appl Physiol 80, 1621.
52. Pontzer, H, Durazo-Arvizu, R, Dugas, LR et al. (2016) Constrained total energy expenditure and metabolic adaptation to physical activity in adult humans. Curr Biol 26, 410417.
53. Valenti, G, Bonomi, AG & Westerterp, KR (2016) Multicomponent fitness training improves walking economy in older adults. Med Sci Sports Exerc 48, 13651370.



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