VO2max in Overweight and Obese Adults: Do

They Meet the Threshold Criteria?

RACHEL E. WOOD1, ANDREW P. HILLS1, GARY R. HUNTER2, NEIL A. KING1, and NUALA M. BYRNE1
1
School of Human Movement Studies and Institute of Health and Biomedical Innovation, Queensland University
of Technology, Brisbane, AUSTRALIA; and 2School of Human Studies, University of Alabama at Birmingham,
Birmingham, AL

ABSTRACT
WOOD, R. E., A. P. HILLS, G. R. HUNTER, N. A. KING, and N. M. BYRNE. V O2max in Overweight and Obese Adults: Do They
Meet the Threshold Criteria? Med. Sci. Sports Exerc., Vol. 42, No. 3, pp. 470477, 2010. Purpose: The purpose of this study was to
determine whether adiposity affects the attainment of V O2max. Methods: Sixty-seven male and 68 female overweight (body mass index
(BMI) = 2529.9 kgImj2) and obese (BMI Q 30 kgImj2) participants undertook a graded treadmill test to volitional exhaustion (phase
BASIC SCIENCES

1) followed by a verification test (phase 2) to determine the proportion who could achieve a plateau in V O2 and other maximal
markers (RER, lactate, HR, RPE). Results: At the end of phase 1, 46% of the participants reached a plateau in V O2, 83% increased HR
to within 11 beats of age-predicted maximum, 89% reached an RER of Q1.15, 70% reached a blood lactate concentration of
Q8 mmolILj1, and 74% reached an RPE of Q18. No significant differences between genders and between BMI groups were found with
the exception of blood lactate concentration (males = 84% vs females = 56%, P G 0.05). Neither gender nor fatness predicted the
number of other markers attained, and attainment of other markers did not differentiate whether a V O2 plateau was achieved. The
verification test (phase 2) revealed that an additional 52 individuals (39%) who did not exhibit a plateau in V O2 in phase 1 had no
further increase in V O2 in phase 2 despite an increase in workload. Conclusions: These findings indicate that the absence of a plateau in
V O2 alone is not indicative of a failure to reach a true maximal V O2 and that individuals with excessive body fat are no less likely than
normal-weight individuals to exhibit a plateau in V O2 provided that the protocol is appropriate and encouragement to exercise
to maximal exertion is provided. Key Words: MAXIMAL AEROBIC POWER, OBESITY, CARDIORESPIRATORY FITNESS,
EXERCISE TESTING

M
aximal oxygen consumption or maximal aerobic
power (V O2max) represents the highest rate at
which oxygen can be used by an individual to
perform muscular work. The measure reflects the optimal
integration of oxygen uptake, transport, and delivery by the
pulmonary and cardiovascular systems and the uptake and
utilization of oxygen at the muscle level. Measurement of
V O2max was originally used to determine the aerobic power
of athletes, and although this remains a common applica-
tion, it is increasingly used to quantify impairment in
cardiorespiratory fitness in clinical populations and to
monitor changes in response to interventions (pharmaco-
logical or lifestyle modifications).
The notion that there is an upper limit to the rate of
oxygen consumption originates from the work of Hill and
Address for correspondence: Rachel E. Wood, Ph.D., Institute of Health
and Biomedical Innovation, Queensland University of Technology, 60
Musk Ave, Kelvin Grove, Brisbane, Queensland 4059, Australia;
E-mail: re.wood@qut.edu.au.
Submitted for publication January 2009.
Accepteid for publication July 2009.
0195-9131/10/4203-0470/0
MEDICINE & SCIENCE IN SPORTS & EXERCISE
Copyright 2010 by the American College of Sports Medicine
DOI: 10.1249/MSS.0b013e3181b666ad
Lupton (18). Although this seminal work was conducted
using a discontinuous exercise test, continuous incremen-
tal or graded exercise test (ramp) protocols in which work
rate is increased continuously until an individual termi-
nates the test at volitional exhaustion have been favored
since the late 1960s/early 1970s (9,2123). Such protocols
have the potential to provide additional information (e.g.,
ventilatory threshold) and require less time than traditional
discontinuous tests; tests may last between 5 and 26 min
(24) and are commonly completed within 812 min (1).
The response to a graded exercise test is characterized by
an initial linear increase in oxygen consumption as a
function of work rate followed by a plateau or a point
beyond which the increase in V O2 is considerably less
than expected for a given increase in workload. Although
the definition of a plateau is highly contentious
(2,3,10,13,16), it remains the primary physiological marker
to indicate that a true maximal has been achieved.
However, as few as 17% (but up to 95%) of individuals
may attain a V O2 plateau on completion of a graded
exercise test despite a good effort (3,10,27). This
suggests that a plateau in oxygen consumption is not
obligatory to demonstrate a true V O2max and has led to
the use of other markers to verify a maximal effort in the
absence of a plateau in V O2. As with the definition of a
plateau, the inclusion and application of these criteria vary

470

Copyright @ 2010 by the American College of Sports Medicine. Unauthorized reproduction of this article is prohibited.
widely between studies (19) but typically include the
attainment of a percentage of age-predicted maximum
HR (90%), an RER Q 1.15, a blood lactate concentration
Q 8.0 mmolILj1, and an RPE Q 18 (13,19).
Despite the widespread use of V O2max testing in clinical
populations, few reports have detailed whether individuals
from these populations are capable of attaining a true
V O2max. As such, there is an obvious need to ensure that
the test is valid in individuals who may be older, less fit,
more sedentary, and have a different body composition (i.e.,
a greater fat mass) than leaner, healthier, and more active
individuals. There is some evidence to suggest that the
elderly, children, and low-fit individuals are less likely to
reach a plateau in V O2 (19), although it has also been
shown that neither age nor cardiorespiratory fitness was
predictive of the tendency to exhibit a plateau in V O2 at the
point of volitional fatigue (10). Whether adiposity affects
O2 has not been
the ability to attain a plateau in V
specifically investigated.
Excess body fat increases the oxygen cost and, therefore,
cardiorespiratory load at a given submaximal workload,
particularly in weight-bearing exercise. However, excess
body fat does not seem to impair the capacity of the
cardiorespiratory system to deliver oxygen to active muscle
during maximal exercise, at least in individuals with up to
34% body fat (8). Furthermore, in formerly overweight
women who lost an average 16% of their initial body
weight, V O2peak per kilogram of body weight was higher
after weight loss, but V O2peak expressed per kilogram of
fat-free mass (FFM) was similar in the overweight and
weight-reduced states (15). Thus, although excess body fat
may limit exercise tolerance (performance), there seems to
be no physiological reason why individuals with higher
levels of body fat would not be capable of exhibiting a
plateau in V O2, given adequate motivation.
As such, the main aims of this study were 1) to determine
whether overweight and obese individuals could achieve a
plateau in oxygen consumption in response to a graded
exercise test; 2) to determine whether these individuals
could also attain other criteria (RER, lactate, HR, RPE);
and 3) to identify and characterize individuals who attain, or
fail to attain, a plateau.
METHODS
Subjects
Sixty-seven male and 68 female participants were
recruited from the university staff and student population.
For both genders, there were two groups: overweight (body
mass index (BMI) = 25.029.9 kgImj2) and obese (BMI
Q 30.0 kgImj2; Table 1). The obese group included 53 class
I obese (BMI between 30.0 and 34.9 kgImj2), 13 class II
obese (BMI between 35.0 and 39.9 kgImj2), and 3 class III
obese (BMI Q 40.0 kgImj2). All participants were sedentary
and otherwise considered healthy. Ethical approval was
VO2max IN OVERWEIGHT AND OBESE ADULTS
Copyright @ 2010 by the American College of Sports Medicine. Unauthorized reproduction of this article is prohibited.
obtained from Queensland University of Technology
Human Research Ethics Committee, and participants gave
their written informed consent to take part in the study.
Materials and Methods
Testing to assess maximal oxygen consumption (V O2max)
consisted of two phases. Phase 1 was a graded exercise test
performed to volitional exhaustion on a treadmill (Quinton
Instrument, Co., Seattle, WA). Participants were fitted with
a Hans-Rudolf headset (with two-way breathing valve and
pneumotach), nose clip, and Polar Coded Transmitter and
receiver (Polar Electro Oy, Kempele, Finland) before
testing. Treadmill speed was set at 5.6 kmIhj1 for the first
4 min at 0% grade, and thereafter, the velocity was
increased to a speed consistent with a fast-paced walk/slow
jog according to each individuals ability. This individual-
BASIC SCIENCES
ized speed was kept constant throughout the remainder
of the test while the grade of the treadmill increased
2.5%Iminj1 until volitional exhaustion. During a short rest
(510 min), finger-prick blood samples were taken for
blood lactate analysis, and the participant was given a small
drink of water. Participants then resumed their position
on the treadmill and began walking or running at, or within
0.5 kmIhj1 of, the maximum workload achieved during
the preceding continuous incremental test. As for phase 1,
workload was increased each minute until volitional
exhaustion. However, an individualized approach was taken
with the protocol for phase 2 (the booster test) where
increases in workload were achieved by increasing speed,
grade, or a combination of speed and grade, depending on
the tolerance and motor control of the individual participant.
Throughout both phases of the testing session, HR was
recorded every 5 s, and HRmax was defined as the highest
HR recorded for 30 s. Ventilation (VE), oxygen consump-
tion (V O2), carbon dioxide production (V CO2), and RER
were calculated from respiratory gases sampled every 15 s
throughout phases 1 and 2 using a Q-PLEX Gas Analysis
System (Quinton Instrument, Co.). The O2 and CO2 ana-
lyzers were calibrated before each test against known gas
concentrations, and the flow meter was calibrated against a
3.0-L syringe. All data are reported as 30-s averages taken
during the final 30 s of the last completed stage. Data are
not reported for stages that were attempted but not com-
pleted. Before treadmill testing, participants were 1famil-
iarized with the Borg 620 scale for the RPE (5,6), and RPE
was assessed at the end of each stage of the treadmill test.
Participants were instructed to walk or run to volitional
exhaustion, at which point the test was terminated.
Duplicate 0.5-mL samples of capillary blood obtained via
the finger-prick method were collected immediately at the
end of each phase of the testing. Blood samples were
immediately deproteinized in chilled perchloric acid, then
refrigerated. Blood lactate concentrations were subsequent-
ly analyzed via an ultraviolet end point method using the
spectrophotometric assay procedure (7,14). Forty milliliters
Medicine & Science in Sports & Exercised 471
 TABLE 1. Anthropometric characteristics for all participants.
Overweight Males Obese Males Overweight Females Obese Females
(BMI G 30 kgImj2; n = 32) (BMI Q 30 kgImj2; n = 35)a (BMI G 30 kgImj2; n = 36) (BMI Q 30 kgImj2; n = 32)
Age (yr) 36.7 T 5.4 37.7 T 5.0 36.9 T 5.5 37.1 T 4.7
Height (cm) 180.6 T 6.4 180.6 T 6.9 164.2 T 6.2 166.3 T 5.8
Weight (kg)* 92.5 T 6.9 109.7 T 14.0 75.7 T 6.6 91.0 T 10.5
BMI (kgImj2)* 28.3 T 0.9 33.6 T 0.9 28.1 T 1.3 32.9 T 2.9
FFM (kg)* 62.3 T 5.9 65.9 T 4.7 42.4 T 4.5 47.1 T 5.5
FM (kg)* 26.8 T 3.7 37.2 T 8.1 30.5 T 4.3 40.4 T 7.3
%BF* 29.0 T 3.5 34.5 T 4.8 40.3 T 3.8 44.6 T 4.3
a
Except n = 32 for BMI, FFM (kg), FM (kg), and %BF.
* P G 0.05 for overweight versus obese.
P G 0.05 for male versus female.

of clear supernatant was added to 2 mL of reagent (14),
vortexed, and incubated for 45 min at 37-C. The absorbance
of reduced nicotinamide adenine dinucleotide (NADH) for
the sample was read off a spectrophotometer using a UV
lamp set at a wavelength of 340 nm. The coefficient of vari-
ation for the repeated measures was 4.3%.
BASIC SCIENCES
ular lean body mass and fat mass (FM) was made according
to the approach described by Heymsfield et al. (17). Percent
body fat (%BF) was determined as FM expressed relative to
body weight.
Statistics/Analysis

The continuous incremental exercise test (phase 1) was

deemed to be a valid maximal test on the basis of achieve-
ment of at least three of the following criteria during the
final 30 s of the last completed stage:
O2 G 50% of that expected for the change
i. Increase in V
in mechanical work;
ii. HR within T11 bpm of age-predicted maximum (13,19),
calculated as 220 j age;
iii. RER Q 1.15;
iv. Peak blood lactate concentration Q8 mmolILj1; and
v. RPE Q 18.
In the week before exercise testing, measurements of
body height (stretch stature) to the nearest 0.1 cm using a
wall-mounted Harpenden stadiometer and body weight to
the nearest 5 g using a digital scale were recorded when
subjects were in a fasted and voided state. Whole-body and
regional (trunk, arm, and leg) lean and fat tissues were
determined with the use of dual x-ray absorptiometry (DXA)
(DPX-L; Lunar Radiation Corp., Madison, WI). All scans
were analyzed with the use of ADULT software, version
3.6 (Lunar Radiation Corp.). The calculation of appendic-
Analyses were performed with SPSS 16 (SPSS, Chicago,
IL). All data are expressed as mean (TSD) unless otherwise
specified.
O2peak and HR, blood lactate concentration,
Phase 1. V
RER, and RPE at the termination of the maximal exercise
test were compared between males and females and
between overweight and obese participants using indepen-
dent t-tests. Chi-square analysis was used to determine
whether the proportion of participants who attained each of
O2 plateau, RER Q 1.15, blood lactate
the criteria (V
Q8 mmolILj1, HR within 11 beats of age-predicted
maximum (13,19), and RPE Q 18) differed between males
and females and between overweight and obese par-
ticipants. An independent t-test was used to determine
whether the mean number of criteria attained differed
between each group. Independent t-tests were used to
compare age, body weight, BMI, maximal exercise
responses, and attainment of the other criteria between
those who did and did not exhibit a plateau in V O2.
Phase 2. Paired t-tests were used to compare workload,
and peak values for V O2, RER, blood lactate concentration,
HR, and RPE between phases 1 and 2 of the testing. For

TABLE 2. Peak exercise responses to the incremental treadmill test (phase 1) in overweight and obese males and females.
Overweight Males Obese Males Overweight Females Obese Females
(BMI G 30 kgImj2; na = 32) (BMI Q 30 kgImj2; nb = 35)c (BMI G 30 kgImj2; nd = 36) (BMI Q 30 kgImj2; n = 31)
HRmax (bpm) 183 T 9 178 T 10 180 T 9 178 T 13
HR as %APMHR 99.7 T 4.7 97.7 T 5.2 98.3 T 4.7 97.3 T 8.2
Max RER* 1.35 T 0.09 1.28 T 0.08 1.27 T 0.10 1.27 T 0.10
Lactate (mmolILj1)* 11.3 T 2.4 9.1 T 2.1 8.5 T 2.4 7.9 T 2.3
RPE 18.5 T 1.1 18.4 T 1.5 18.4 T 1.4 18.0 T 1.8
VO2peak (LIminj1)* 3.9 T 0.7 4.1 T 0.7 2.4 T 0.4 2.5 T 0.4
Adjusted VO2peak (LIminj1)e 3.3 T 0.6 3.1 T 0.7 3.3 T 0.7 3.0 T 0.5
VO2peak (mLIminIkgj1)* 42.4 T 6.1 37.7 T 5.3 32.2 T 5.1 27.2 T 3.9
VO2peak (mLIminIkgj1 FFM)* 62.8 T 7.6 61.1 T 8.09 57.4 T 7.5 52.4 T 6.8
a
Except n = 31 for lactate (mmolILj1 ).
b
Except n = 32 for VO2peak (mLIminIkgj1 FFM).
c
Except n = 33 for RER.
d
Except n = 35 for RER.
e
Adjusted for FFM.
* P G 0.05 for males versus females.
P G 0.05 for overweight versus obese.
APMHR, age-predicted maximum HR (220 j age).

472 Official Journal of the American College of Sports Medicine http://www.acsm-msse.org

Copyright @ 2010 by the American College of Sports Medicine. Unauthorized reproduction of this article is prohibited.
each individual, the expected change in V O2 was calculated
from the American College of Sports Medicine (ACSM)
metabolic equations for either walking or running (1). A
plateau in V O2 between the penultimate and last completed
stage is phase 1, and that between the last completed stages
in phases 1 and 2 was defined as a measured change in V O2
of less than 50% of that expected on the basis of the change
in workload. Repeated-measures ANOVA was used to
determine whether the increase in V O2 between phases 1
and 2 was different between those who did and those who
did not attain a plateau in phase 1.
RESULTS
Participant characteristics and peak response in
phases 1 and 2. The characteristics of the participants
are shown in Table 1, and the peak exercise responses
for phases 1 and 2 are shown in Tables 2 and 3. Peak
HR and RPE at termination of the test in phase 1 were
similar among all groups and maximum RER, and blood
lactate concentrations were higher in males than in fe-
males (Table 2). Although V O2peak (LIminj1) was higher in
males compared with that in females (4.03 vs 2.45 LIminj1,
P G 0.001), this difference between genders was no longer
evident after adjusting for FFM via covariance (3.30 vs
3.10 LIminj1, P = 0.22). Compared with overweight
participants, the obese had lower blood lactate concentra-
O2peak when
tion at the termination of the test and a lower V
expressed relative to body weight and body composition
(mLIminIkgj1 and mLIminIkgj1 FFM) but not when ex-
pressed in absolute terms (LIminj1; Table 2).
Attainment of VO2 plateau. Figures 1 and 2 show the
percentage of males and females and overweight and obese
participants who attained each of the five criteria for
O2max in phase 1. At the end of phase 1, 46% of the
V
participants reached a plateau in V O2, 83% increased HR to
within 11 beats of age-predicted maximum, 89% reached an
RER of Q1.15, 70% reached a blood lactate concentration
of Q8 mmolILj1, and 74% reached an RPE of Q18. No
significant differences between genders or between BMI
groups were found with the exception of blood lactate,
where males met the criterion for blood lactate concentra-
tion with a higher frequency than females (84% vs 56%,
TABLE 3. Comparison of the peak exercise responses for participants who completed
phases 1 and 2 of testing (n = 114).
Phase 1
Treadmill workload (METs)* 11.3 T 2.4
VO2peak (mLIminIkgj1) 34.5 T 7.4
Peak HR (bpm) 180 T 10
Peak HR (%APMHR) 98 T 6
Peak RER* 1.28 T 0.09
Peak lactate (mmolILj1)* 9.03 T 2.52
Peak RPE* 18 T 1
MET values are calculated from the appropriate ACSM equations for walking or running.
* P G 0.0001 for phase 1 versus phase 2.
APMHR, age-predicted maximum HR (220 j age).
VO2max IN OVERWEIGHT AND OBESE ADULTS
Copyright @ 2010 by the American College of Sports Medicine. Unauthorized reproduction of this article is prohibited.
FIGURE 1Proportion of overweight (OW) and obese (OB) partic-
O2max.
ipants attaining each of the five criteria for V
P G 0.05; Fig. 2). When considered as a group, partici-
pants achieved a mean T SD criteria of 3.6 T 1.2. Although
the number of criteria met was lower in obese versus
overweight individuals (P G 0.05), and tended to be lower
BASIC SCIENCES
in females compared with males (P = 0.07), on average, all
groups met at least three of the criteria. There was a
significant negative correlation between %BF and V O2peak
(mLIminIkgj1) for the whole group (r = j0.53, P G 0.01;
n = 131), and when males (r = j0.47, P G 0.01; n = 67) and
females (r = j0.45, P G 0.01; n = 64) were considered
separately.
V O2 did not change between phases 1 and 2 despite a
significant increase in workload (METs, calculated from the
ACSM equations for walking or running; Table 3). RER
was higher during phase 1, and lactate concentration was
higher in phase 2 (Table 3). On the basis of the verification
test (phase 2), 52 individuals who did not attain a plateau in
V O2 in phase 1 could be classified as having reached a
plateau in phase 2 on the basis of an increase of G50% of
that expected on the basis of the change in workload from
phase 1 to phase 2. When both phases 1 and 2 are con-
sidered, 85% of participants attained a plateau in V O 2.
Plateau versus no plateau. As shown in Table 4,
neither were there differences in the age, BMI, and body
weight of participants who did or did not attain a plateau in
phase 1 nor were there differences in maximum HR, RER,
blood lactate concentration, RPE, and V O2peak expressed in
both absolute and relative terms. The number of other
Phase 2
11.8 T 2.2
34.6 T 6.9
180 T 10
98 T 6
1.06 T 0.11
12.01 T 3.08
19 T 1
FIGURE 2Proportion of male (M) and female (F) participants
O2max.
attaining each of the five criteria for V
Medicine & Science in Sports & Exercised 473
 TABLE 4. Anthropometric and peak exercise responses of participants who did and did less likely than lean individuals to cease a maximal test
not attain a plateau in VO2 at the completion of the incremental treadmill test (phase 1).
because of an oxygen limitation and therefore exhibit a
Plateau (n = 60) No Plateau (n = 72) O2. Astorino et al. (2) reported that body
plateau in V
M/F 26:34 39:33 O2 .
Age (yr) 37.0 T 5.0 37.1 T 5.2
composition was not predictive of a plateau in V
Weight (kg) 90.4 T 14.5 93.1 T 16.8 However, all participants were very lean, and their %BF
BMI (kgImj2) 30.5 T 3.2 30.8 T 3.7 fell within a very narrow range (11%18%). Although it is
VO2peak (LIminj1) 3.2 T 1.0 3.3 T 1.1
VO2peak (mLIminIkgj1) 34.7 T 7.5 35.0 T 7.8 not surprising that body composition was unrelated to the
VO2peak (mLIminIkgj1 FFM) 58.1 T 7.6 58.7 T 9.1 likelihood of attaining a plateau in this group, similar
Peak HR (bpm) 180 T 10 180 T 11
Peak RER 1.31 T 0.09a 1.27 T 0.10b findings have previously been reported in individuals with a
Peak lactate (mmolILj1) 9.57 T 2.70 8.77 T 2.53c wider range of %BF (up to 34% [8]). In this early work,
Peak RPE 19 T 1 18 T 2 O2max
Buskirk and Taylor (8) reported no differences in V
a
n = 59. expressed per kilogram of FFM between individuals
b
n = 70.
c
n = 71. grouped on the basis of their %BF (0%10%, 10%25%,
and 925%), indicating that the presence of body fat, at least
in this range, did not hinder the capacity of the cardiore-
criteria attained was not different between those who did spiratory system to deliver oxygen during maximal exer-
and did not attain a plateau (3.0 T 1.2 vs 3.2 T 0.9 criteria, cise. However, many obese individuals have levels of body
BASIC SCIENCES

P = 0.10). Furthermore, those individuals who did not attain
a plateau in phase 1 of the testing had no greater increase
in V O2peak in phase 2 than those who did plateau (0.10 vs
0.34 mLIminIkgj1, P = 0.57). The peak data for phases 1
and 2 (booster test) are shown in Table 3.
DISCUSSION
The primary aim of this study was to determine the
frequency of a plateau in V O2 at the termination of a
continuous incremental exercise test in overweight and
obese individuals and to investigate whether attainment of
other criteria was contingent on achieving a plateau in V O 2.
The main findings of this study were that: 1) 46% of par-
ticipants achieved a plateau in V O2 at the point of termi-
nating a continuous incremental exercise test (phase 1); 2)
a large proportion of participants met the criteria for each of
the other markers; 3) there were no differences in age, body
weight, BMI, the maximal exercise responses, or attainment
of the other criteria between those who did and did not
achieve a plateau; and 4) the verification test (phase 2)
revealed that 52 individuals (39%) who did not exhibit a
plateau in V O2 in phase 1 had no further increase in V O2 in
phase 2 despite an increase in workload. Therefore, when
both phases 1 and 2 are considered, 85% of participants
attained a plateau in V O 2.
Attainment of a plateau in VO2 in overweight and
obese individuals. Of interest in the present study is the
question of whether excessive body fat impedes the ability
of an individual to attain a plateau in V O2; that is, are
overweight and obese individuals less likely to attain a
plateau in V O2 than leaner individuals? This question is of
clinical interest in evaluating the effect of a weight loss
intervention on cardiorespiratory function and functional
capacity, where it is important that the comparison before
and after weight loss is made on the basis of the same
termination criteria. There seems to be no physiological
reason why individuals with excessive body fat should be
fat far greater than the maximum of 34% reported by
Buskirk and Taylor (8); in the present study, %BF ranged
from 22% to 47% in males and from 26% to 57% in
females.
The authors are aware of only two studies conducted with
the specific purpose of evaluating the attainment of V O2max
in overweight and obese individuals. These studies, from
Donnelly et al. (12) and Misquita et al. (25), reported that as
few as 15% and 18% of obese individuals attained a plateau
in V O2, respectively; this is considerably lower than the
49% of overweight and obese individuals who attained a
plateau in the present study. There are several postulates for
the markedly higher occurrence of a plateau in the present
study. Donnelly et al. (12) and Misquita et al. (25) studied
only obese females, and it is therefore possible that the
larger proportion of individuals attaining a plateau in the
present study may be attributable to the greater heteroge-
neity of our sample, specifically the inclusion of both males
and females, and those classified as overweight in addition
to only obese individuals. However, similar proportions of
overweight and obese males and females achieved a plateau
in oxygen consumption. Furthermore, although not signif-
icant, the plateau criterion was attained with a greater
frequency in obese females (63%) than in the other
subgroups (overweight and obese males and overweight
females). It therefore seems unlikely that the attainment of a
plateau can be explained by the inclusion of a more
heterogeneous population.
It seems more likely that the low incidence of a plateau in
the studies of Donnelly et al. (12) and Misquita et al. (25) is
attributable to the premature termination of the exercise test
and thus failure to reach a true physiological maximum,
rather than being indicative of the fact that individuals in
this population were less able to attain a plateau. If we
consider only the obese females in the present study for
ease of comparison, although the women in our study were
younger than those in the studies by Donnelly et al. (12)
and Misquita et al. (25), they were similar in BMI and
%BF. Unfortunately, Donnelly et al. (12) did not report the

474 Official Journal of the American College of Sports Medicine http://www.acsm-msse.org

Copyright @ 2010 by the American College of Sports Medicine. Unauthorized reproduction of this article is prohibited.
actual V O2peak values, but the obese females in the present
study achieved higher V O2peak values (expressed in
absolute terms as well as relative to body weight) than
the women in the Misquita et al. study (25) (27 vs 19
mLIminIkgj1). Although the postmenopausal women in the
cohort of Misquita et al. (25) were older than the women in
the present study, this factor alone does not account for the
lower V O2peak, given that it remains lower when adjusted
for age (10th vs 30th percentile for gender-specific, age-
adjusted maximal aerobic power) (1). That the low
incidence of a plateau may be attributed to the premature
termination of the exercise test seems even more plausible
given that only 57% of the women in the study by Misquita
et al. (25) reached an RER of Q 1.10 and only 60% of those
in the study by Donnelly et al. (12) met the criterion for
RER that was only set at 90.95. In contrast, 74% of the
obese females in the present study achieved an RER Q 1.15.
Furthermore, only 54% of the participants in the study by
Donnelly et al. (12) attained a peak HR within 10 bpm of
age-predicted maximum HR compared with 83% of par-
ticipants in the present study, and only 44% of partici-
pants in the study by Donnelly et al. (12) had an RPE of
at least 19, whereas 74% of those in the present study met
this criterion.
It is also important to consider the results of the present
study in the context of previously reported data in nonobese
individuals. It has been suggested that motivation, high pain
tolerance, muscle strength, high anaerobic capacity, and
greater ability to buffer hydrogen ions during maximal work
could collectively, or independently, differentiate between
those individuals who do, and those who do not, exhibit a
plateau in V O2 (2,20,29). According to Wagner (29), only
those able or willing to tolerate the pain associated with a
maximal effort may exhibit a plateau in oxygen consump-
tion, which implies that attaining a plateau is dependent
largely on motivation. This opinion is supported more
recently by Shephard (28), who noted regarding the testing
of athletes that, the power of the observer is important to
the reaching of an oxygen Fplateau,_ and laboratories that
have difficulty in demonstrating this phenomenon probably
need to upgrade their motivational skills.
Whereas certain populations, for example, children, the
elderly, and low-fit individuals (19), may have greater
difficulty achieving a plateau, the frequency with which
even young, healthy, active, individuals exhibit a plateau
has been reported to be as low as 17% (26). This is the case
even among the most highly motivated individuals and
those presumably well accustomed to the pain and
discomfort associated with producing and sustaining a
maximal effort. Indeed, it has been reported that only
25%39% of elite male and female middle- and long-
distance runners (11) and 47% of elite male road cyclists
(20) exhibited a plateau in oxygen consumption at the
completion of continuous incremental tests. When consid-
ered in this context, the occurrence of a plateau is unlikely
to be explained by motivation alone because the individuals
VO2max IN OVERWEIGHT AND OBESE ADULTS
Copyright @ 2010 by the American College of Sports Medicine. Unauthorized reproduction of this article is prohibited.
in the present study, possibly one of the least motivated
groups (on the basis of long-term sedentary lifestyles), were
no less likely, and in fact were more likely, to attain a
plateau in V O2 than arguably some of the most highly
motivated individuals (i.e., athletes). This is not to
undervalue the importance of creating a highly motivating
testing environment but rather to note that motivation is
unlikely to be the primary determinant of a plateau in V O 2.
If motivation was the main factor in determining whether
an individual attained a plateau in V O2, we would have
expected to find differences in the maximal responses and a
higher incidence of the other criteria in those who exhibited
a plateau compared with those who did not. However, in the
present study, there were no differences in age, body
weight, BMI, V O2peak, and maximal exercise responses
between those individuals who did and did not exhibit a
plateau (Table 4). As noted by Bassett and Howley (4), if a
O2max is reached, there may be too
BASIC SCIENCES
subject fatigues just as V
few data points for a plateau to be evident. To have enough
data points to provide evidence of a plateau, a participant
must be able or be prepared to continue exercising for a
sufficient duration at an increasing level of anaerobic
energy metabolism (i.e., once V O2max has been achieved).
The blood lactate responses in the present study, and those
reported by Lucia et al. (20) in elite cyclists, support this
notion. In the present study, the peak blood lactate tended to
be lower (not statistically significant) in the group that did
not attain a plateau (Table 4). This is consistent with the
findings in elite cyclists (20) where, although peak blood
lactate concentration was lower and pH was higher in
cyclists who did not plateau compared with those who did,
there were no differences in maximal HR, V O2peak,
ventilation, and RER. Thus, although the absence of a
plateau makes it difficult to determine whether a maximal
oxygen consumption has been achieved, it is not necessarily
indicative of a failure to attain a true maximal oxygen
consumption.
Attainment of other criteria in overweight and
obese individuals. In the absence of a plateau, other
criteria may be used to provide evidence that a maximal
oxygen consumption has been achieved. In phase 1, the
frequency with which individuals met each of the other
criteria was greater than the frequency with which they
attained a plateau in V O2 (Figs. 1 and 2). The number of
other criteria attained was not different between those who
did and did not attain a plateau in phase 1, and there were
no differences in V O2peak or the number of the other criteria
attained in phase 1 of testing in the 85% who attained a
plateau in V O2 (phases 1 and 2) versus those who did not
plateau (data not shown). Furthermore, neither gender nor
fatness predicted the number of V O2 markers attained, and
attainment of the other criteria did not differentiate whether
aV O2 plateau was achieved (Figs. 1 and 2).
Verification test. Given the questionable usefulness of
the other criteria, it has been suggested that a verification or
booster test may be used to determine whether a V O2peak
Medicine & Science in Sports & Exercised 475
 is indicative of a true maximal V O2 (27). Although
protocols vary between studies, the verification test typi-
cally involves participants undertaking a standard incre-
mental exercise test, having a short rest, and then
undertaking an additional verification test at a workload
higher than that achieved at the end of the incremental
exercise test (27). This two-phase test can be conducted
within a single session and thus may provide a time-
efficient means of verifying whether a V O2peak reflects a
true V O2max without relying on other ill-defined and
controversial criteria.
All participants in the present study undertook a
verification test after the standard incremental exercise test.
When analyzed as a group, there was a small, but
significant, increase in work rate between phases 1 and 2
of the testing (0.48 METs, P G 0.0001; Table 3). Despite
the higher workload, there were no differences in the peak
BASIC SCIENCES
HR attained during each phase of testing, and although
peak RER, lactate concentration, and RPE differed bet-
ween phases 1 and 2 (Table 3), these differences were
likely related to the duration of the exercise and were
unlikely to be clinically meaningful. In addition, the mea-
sured change in V O2 between phases 1 and 2 for the
whole group (0.13 mLIminIkgj1, P = 0.55) was far less
than the 1.68 mLIminIkgj1 that would be predicted for a
0.48-MET increase in mechanical work. Importantly, the
change in V O2 between phases 1 and 2 was not different
between those who did and did not attain a plateau in
phase 1.
For each individual who completed both phases of
testing, we also compared the measured change in V O2
with the expected change in VO2 on the basis of the change
in workload. This individualized approach provides further
evidence that a large number of participants had reached a
true maximal oxygen consumption at the end of the
incremental exercise test. Of the 132 participants who have
complete V O2 data for both tests, 60 (46%) attained a
plateau in V O2 at the end of the incremental treadmill test.
The phase 2 test provided verification that an additional 52
participants (39%) had indeed attained maximum on the
basis of an increase in V O2 of less than 50% of that
expected on the basis of the change in workload between
the final stage of the incremental exercise test (phase 1) and
the final stage of the verification test (phase 2). This is
consistent with previous research using a verification test in
lean males where all participants failed to attain a plateau in
V O2 at the end of a continuous incremental exercise test but
had no further increase in V O2 at the end of a verification
test performed 5 min later at either 95% or 105% of the
previously attained maximal workload (27).
LIMITATIONS
For both phases of testing, a plateau was defined as an
increase in of less than 50% of that expected on the basis of
the increase in mechanical work. In phase 1 (incremental
476 Official Journal of the American College of Sports Medicine
Copyright @ 2010 by the American College of Sports Medicine. Unauthorized reproduction of this article is prohibited.
treadmill test), the change in workload was a uniform
increase in grade of 2.5% between the penultimate and
ultimate stages of the test. For phase 2 (the verification test),
the increase in workload was individualized for each
participant and was achieved via increases in either speed
or grade or a combination of speed and grade. For both
phases, the expected change in V O2 was predicted from the
appropriate ACSM walking or running equation (1),
depending on speed. It is possible that this method may
overestimate the incidence of a plateau, given that the
equations are valid only for steady-state conditions and the
workload in this study was increased each minute during
exercise. A preferable way of determining the expected
increase in V O 2 would have been to establish the
relationship between V O2 and workload from individual
regression equations for submaximal workloads completed
during the incremental test. However, because the test
protocol was designed to avoid participants undertaking
unduly long tests, there were too few data points to
establish regression equations with any predictive power.
Practical implications. V O2max is commonly used to
measure changes in cardiorespiratory capacity in over-
weight and obese individuals during exercise (or other) in-
terventions. If successful, these interventions may result in
considerable weight loss such that individuals who entered
the intervention as obese may be classified as overweight or
even normal weight by the end of the intervention period.
Implicit in the use of a V O2max test to measure changes in
cardiorespiratory capacity is that the test is limited by the
same variable, cardiorespiratory power, at each time point. If
the ability to reach V O2max (as defined by a plateau in V O2)
is affected by excess body fat, then apparent changes in
V O2max in response to an exercise intervention (with accom-
panying weight loss) may be attributable, at least in part, to a
reduced fat mass. The findings of the present study, in com-
bination with the limited existing evidence (15), suggest that
this is not the case.
In the present study, 85% of participants attained a
plateau in despite having %BF levels ranging from 22%
to 47% in males and from 26% to 57% in females.
Furthermore, although there was a moderate negative
correlation between %BF and V O2peak (mLIminIkgj1) in
both males and females in the present study, neither BMI
nor %BF was different between those who did and did not
achieve a plateau in V O2 (Table 4). This suggests that even
a very high level of body fat does not prevent an individual
from attaining a plateau in V O2. This is in agreement with
the only longitudinal study addressing this question in
which Goran et al. (15) reported no differences in V O2max
when expressed relative to FFM in formerly obese women
who had lost an average of 13 kg (16%) of their body
weight and reduced their fat mass by 31%. Although this
warrants further investigation, the available evidence sug-
gests that a high level of body fat does not impede the
maximum capacity of the cardiorespiratory system and does
not preclude the use of V O2max testing in longitudinal
http://www.acsm-msse.org
studies in which individuals experience large changes in
body composition.
CONCLUSIONS/SUMMARY
There are two important findings from the present
research. Firstly, 46% of overweight and obese individuals
attained a plateau in V O2 at the end of a continuous
incremental exercise test, and there were no differences in
any of the measured variables between those who did and
did not attain a plateau. Secondly, in an additional 39% of
individuals who did not attain a plateau in V O2 in the
continuous incremental test, the verification test failed to
induce further increases in V O2 despite a significant
REFERENCES
1. American College of Sports Medicine. ACSMs Guidelines for
Exercise Testing and Prescription. 7th ed. Philadelphia (PA):
Lippincott Williams & Wilkins; 2006. 368 p.
2. Astorino TA, Willey J, Kinnahan J, et al. Elucidating determinants
of the plateau in oxygen consumption at V O2max [commentary].
Br J Sports Med. 2005;39(9):65560.
3. Bassett DR, Howley ET. Maximal oxygen uptake: classical 18. Hill A, Lupton H. Muscular exercise, lactic acid, and the supply
versus contemporary viewpoints. Med Sci Sports Exerc. 1997;
29(5):591603.
4. Bassett DR, Howley ET. Limiting factors for maximum oxygen
uptake and determinants of endurance performance. Med Sci
Sports Exerc. 2000;32(1):7084.
5. Borg G. Psychophysical bases of perceived exertion. Med Sci
Sports Exerc. 1982;14(5):37781.
6. Borg G. An Introduction to Borgs RPE-scale. Ithaca (NY):
Mouvement Publications; 1985. 26 p.
7. Burtis CA, Ashwood ER. Tietz Textbook of Clinical Chemistry.
2nd ed. Philadelphia (PA): WB Saunders Company; 1994. 2326 p.
8. Buskirk E, Taylor HL. Maximal oxygen intake and its relation to
body composition, with special reference to chronic physical
activity and obesity. J Appl Physiol. 1957;11(1):728.
9. Davies CT, Tuxworth W, Young JM. Physiological effects of
repeated exercise. Clin Sci. 1970;39(2):24758.
10. Day JR, Rossiter HB, Coats EM, Skasick A, Whipp BJ. The
maximally attainable V O2 during exercise in humans: the peak vs.
maximum issue. J Appl Physiol. 2003;95(5):19017.
11. Doherty M, Nobbs L, Noakes TD. Low frequency of the plateau
phenomenon during maximal exercise in elite British athletes.
Eur J Appl Physiol. 2003;89(6):61923.
12. Donnelly JE, Jakicic J, Roscoe M, Jacobsen DJ, Israel RG.
Criteria to verify attainment of maximal exercise tolerance test with
obese females. Diabetes Res Clin Pract. 1990;10(1 suppl):S2836.
13. Duncan GE, Howley ET, Johnson BN. Applicability of V O2max
criteria: discontinuous versus continuous protocols. Med Sci
Sports Exerc. 1997;29(2):2738.
14. Fink WJ, Costill DL. Analytical Methods for the Measurement of
Human Performance. Muncie (IN): Human Performance Labora-
tory, Ball State University; 1990. p. 3843.
15. Goran M, Fields DA, Hunter GR, Herd SL, Weinsier RL. Total
body fat does not influence maximal aerobic capacity. Int J Obes
Relat Metab Disord. 2000;24(7):8418.
VO2max IN OVERWEIGHT AND OBESE ADULTS
Copyright @ 2010 by the American College of Sports Medicine. Unauthorized reproduction of this article is prohibited.
increase in workload. Together, these findings suggest that
O2 alone is not indicative of a
the absence of a plateau in V
failure to reach a true maximal oxygen consumption and
that individuals with excessive body fat are no less likely
than normal-weight individuals to exhibit a plateau in
V O2 at the end of a continuous incremental exercise test,
provided that the protocol is appropriate to the population
and encouragement to exercise to maximal exertion is
provided.
This research received financial support from Polar Electro Oy
and HUR Oy. The results of this study do not constitute endorse-
ment by ACSM.
16. Hale T. History of developments in sport and exercise physiology:
BASIC SCIENCES
A. V. Hill, maximal oxygen uptake, and oxygen debt. J Sports
Sci. 2008;26(4):365400.
17. Heymsfield SB, Smith R, Aulet M, et al. Appendicular skeletal
muscle mass: measurement by dual-photon absorptiometry. Am J
Clin Nutr. 1990;52(2):2148.
and utilization of oxygen. Q J Med. 1923;16:13571.
19. Howley ET, Bassett DR, Welch HG. Criteria for maximal oxygen
uptake: review and commentary. Med Sci Sports Exerc.
1995;27(9):1292301.
20. Lucia A, Rabadan M, Hoyos J, et al. Frequency of the V O2max
plateau phenomenon in world-class cyclists. Int J Sports Med.
2006;27(12):98492.
21. Maksud MG. Coutts Comparison of a continuous and discontin-
uous graded treadmill test for maximal oxygen uptake. Med Sci
Sports. 1971;3(2):635.
22. McArdle WD, Magel JR. Physical work capacity and maximum
oxygen uptake in treadmill and bicycle exercise. Med Sci Sports.
1970;2(3):11823.
23. Michael ED Jr, Horvath SM. Physical work capacity of college
women. J Appl Physiol. 1965;20(2):2636.
24. Midgley AW, Bentley DJ, Luttikholt H, McNaughton LR,
Millet GP. Challenging a dogma of exercise physiology: does an
incremental exercise test for valid V O2max determination really
need to last between 8 and 12 minutes? Sports Med. 2008;
38(6):4417.
25. Misquita NA, Davis DC, Dobrovolny CL, Ryan AS, Dennis KE,
Nicklas BJ. Applicability of maximal oxygen consumption criteria
in obese, postmenopausal women. J Womens Health Gend Based
Med. 2001;10(9):87985.
26. Niemela K, Palatsi I, Linnaluoto M, Takkunen J. Criteria for
maximum oxygen uptake in progressive bicycle tests. Eur J Appl
Physiol Occup Physiol. 1980;44(1):519.
27. Rossiter HB, Kowalchuk JM, Whipp BJ. A test to establish max-
imum O2 uptake despite no plateau in the O2 uptake response to
ramp incremental exercise. J Appl Physiol. 2006;100(3):76470.
28. Shephard RJ. Is the measurement of maximal oxygen intake
passe? Br J Sports Med. 2009;43(2):835.
29. Wagner PD. New ideas on limitations to V O2max. Exerc Sport Sci
Rev. 2000;28(1):104.
Medicine & Science in Sports & Exercised 477