Clinical Investigation

Effects of Self-selected or Predetermined

Intensity Aerobic Exercise on the Quality of Life of
Adolescents with Obesity
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Tércio Araújo do Rêgo Barros,1 Wagner Luiz do Prado,2 Thiago Ricardo dos Santos Tenório,3,4 and Ricardo Freitas-Dias5

related to obesity are estimated to be U.S.

ABSTRACT $2.1 billion annually (2). Obesity often leads
This study aimed to compare the effects of aerobic training at self-selected in- to impairments on one’s health-related qual-
tensity (SIE) and predetermined intensity (PIE) on the health-related quality of ity of life (HRQOL), for both children and
life (HRQOL) in adolescents with obesity. Randomized clinical trial conducted adolescents (3). In Brazil, the prevalence of
with 37 adolescents (boys and girls), 13–18 yr old, at Tanner stages 3–4, and childhood obesity is around 20% (4), with
body mass index ≥95th. Eighteen adolescents were randomly assigned to SIE a great increase over the last 40 yr (5).
and 19 to PIE. Aerobic training sessions consisted of 35 min of training on a tread- HRQOL is a multidimensional concept
mill, three times per week, for 12 wk. SIE group chose the speed/intensity at the involving self-perceptions about physical,
beginning of each training session and was able to change it every 5 min. PIE psychological, and social functioning as
group trained at a PIE of 60%–70% of heart rate reserve. The Pediatric Quality well as overall life satisfaction (6). Adoles-
of Life Inventory was used in to measure HRQOL. Twenty-five adolescents com- cents with obesity report lower HRQOL
pleted the experimental protocol (SIE = 13 and PIE = 12). Heart rate during ses- in both physical (7) and social domains
sions was higher for PIE than SIE. Both groups decreased body mass (SIE from (8,9) than normal weight peers. Adolescents
100.7 ± 21.85 to 92.1 ± 25.20 kg; PIE from 98.9 ± 24.93 to 88.1 ± 12.91 kg;
−2 with severe obesity showed HRQOL similar
P = 0.01), body mass index (SIE from 37.4 ± 7.24 to 33.7 ± 8.55 kg·m ; PIE from
−2 to those diagnosed with cancer (8). HRQOL
37.3 ± 7.15 to 33.4 ± 5.48 kg·m ; P < 0.01), and sum of skinfold thickness (SIE
is also negatively correlated with body mass
from 180.4 ± 26.33 to 163.5 ± 25.04 mm; PIE from 174.00 ± 28.55 to
149.00 ± 32.10 mm; P = 0.01) without group differences. PIE improved HRQOL index (BMI) (10) and depression (9).
at social functioning (PIE from 70.0 ± 15.9 vs to 80.9 ± 13.75; P = 0.02). Compared Aerobic training is one of the key com-
with PIE exercise, SIE did not induce additional improvements in HRQOL in ado- ponents in childhood obesity treatment
lescents with obesity. (11) because of its positive effects on body
composition (12,13), health-related out-
comes (14), and HRQOL (15). It has been found that 12 wk
of aerobic training may be able to improve HRQOL domains
INTRODUCTION such as physical (16), mental (17), and emotional functioning,
Obesity is a major public health issue and is associated with as well as social and psychosocial domains (18). Noteworthy,
various chronic health conditions (1). The financial costs those studies used exercise programs with predetermined in-
tensity (PIE) exercise, and the exercise intensity was controlled
based on speed, percentage of heart rate (HR), or maximum
oxygen uptake (V̇O2max) (16–18).
1
Graduation in Hebiatrics University of Pernambuco, Recife, Pernambuco, PIE has shown significant effects, mainly on the physical,
BRAZIL; 2Kinesiology Department — California State University San Bernadino,
3
San Bernardino, CA; Associate Graduation Program in Physical Education, Uni-
social, and psychosocial domains of HRQOL in adolescents
versity of Pernambuco, Recife, Pernambuco, BRAZIL; 4Federal Institute from with obesity (16–18). However, dropout rates in such pro-
Sertão Pernambucano (IF SERTÃO-PE), Petrolina, Pernambuco, BRAZIL; and grams can reach 60% (11). Therefore, aiming to improve ad-
5
Hebiatrics Program, Health Determinants in Adolescence and Department of herence to exercise programs, self-selected intensity (SIE)
Physioterapy, University of Pernambuco, Petrolina, Pernambuco, BRAZIL
exercise has been indicated as a promising approach (19).
Address for correspondence: Ricardo Freitas-Dias, Ph.D., Department of SIE is characterized by the controlling of intensity by the par-
Physiotherapy, University of Pernambuco, BR 203, Km 2, s/n, Petrolina, ticipant, being he/she is free to choose and adjust the exercise
Pernambuco, Brazil (E-mail: ricardo.freitas@upe.br). intensity during the training sessions (19).
2379-2868/0424/0266–0271
In recent years, SIE has gained greater recognition and is be-
Translational Journal of the ACSM ing applied in the treatment of obesity (19,20). SIE could be an
Copyright © 2019 by the American College of Sports Medicine alternative approach to PIE, with data documenting high levels

266 Volume 4 • Number 24 • December 15 2019 Self-selected Exercise and QoL in Obese Youth

Copyright © 2019 by the American College of Sports Medicine. Unauthorized reproduction of this article is prohibited.
of pleasure among adolescents (21), more minutes per week of
physical activity (20), and for improving adherence to physical
activity–based interventions in obese populations (22) com-
pared with PIE. Related to the HRQOL of adolescents with
obesity, studies have only investigated programs based on
PIE activities, with intensities ranging from 50% to 60%
V̇O2max (16,18) or from 65% to 85% of HRmax (17,23).
Thus, despite evidence for the effects of PIE on HRQOL,
there is a lack of scientific data on SIE. The aim of this study
was to compare the effects of SIE and PIE on HRQOL in ado-
lescents with obesity, after 12 wk of aerobic training. Our hy-
pothesis was that both programs have similar effects on
HRQOL, and both modes would be viable for improving
HRQOL within this population.
MATERIALS AND METHODS
Subjects
Participants were recruited through local and social media ad-
vertisements. Inclusion criteria were as follows: ages 13–18 yr old,
Tanner stage of 3 or 4 (24), BMI ≥95th for age and gender (25),
physical activity readiness assessed through the Physical Activity
Readiness Questionnaire, and an agreement to participate in a
regular exercise program. Exclusion criteria included pregnancy,
self-reported chronic or metabolic disease, genetic syndromes,
and the use of drugs that may modulate the study’s outcomes
(e.g., antihypertensive, hypoinsulinemics, or psychotropics). The
Ethics Committee of the Federal Institute of Education, Science,
and Technology approved this study (no. 2.341.136). Written in-
formed consent was gained from legal guardians, and assent from
the adolescents. This study is registered on the Brazilian Clinical
Trials Registry (RBR 2Y8F8R/UTN: U1111-1199-1132).
Trial Design and PROTOCOL
This is a randomized clinical trial with a parallel design. A total
of 51 adolescents volunteered for this study; however, 14 of them
did not meet the inclusion criteria (2 because of age, 5 had BMI
<95th, and 7 had Tanner stage <3). Thus, after baseline assess-
ments, 37 adolescents were randomly assigned into the SIE exer-
cise group (SIE; n = 18; 6 girls) or the PIE exercise group (PIE;
n = 19; 6 girls). During the first visit to the laboratory, anthropom-
etry, body composition, Tanner stage, and Physical Activity Read-
iness Questionnaire were assessed.
Aerobic Exercise Training
Exercise training was conducted in a gym, with exclusive ac-
cess granted for the adolescents from the same allocation group
and the research team. The training program lasted 12 wk. The
adolescents exercised three times per week (Monday, Wednesday,
and Friday), for 35 min, at the same time each day. Every session
started with a 5-min warm-up at 4.0 km·h−1, followed by 25 min
of training (PIE or SIE), and 5 min of cooldown at 4.0 km·h−1. The
adolescents were allowed to use cell phones, electronic devices,
and to talk with one another during the training sessions.
For the SIE group, a standard oral instruction was given before
each session as follows: “Select the intensity/speed that you think
you will be able to finish in 35 minutes of exercise; however, you
can modify the intensity/speed every 5 minutes.” Thus, adolescents
had 5 min of warm-up, and at the fifth minute, they then chose their
intensity/speed and maintained it for the following 5 min. This was
repeated until they reached a total of 30 min of exercise. This is sim-
ilar to the protocols applied in previous studies (21,26).
The PIE group exercised at a PIE of 60%–70% of their HR re-
serve. To ensure that participants remained at the target intensity,
the treadmill’s speed was strictly controlled by the research team.
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HRmax was predicted using the following formula: 208 − (0.7  age)
(27). To determine resting HR (HRrest), participants were placed in a
quiet room, with a fixed temperature of 23°C, in a supine position
for 5 min. HR was monitored during the period with an HR monitor
(Polar Ft4; Polar®, Kempele, Finland). The lowest HR value was re-
corded. The exercise training zone for PIE was determined as follows:
HR = percent of target intensity (HRmax – HRrest) + HRrest.
HR was continuously monitored throughout the exercise ses-
sions and recorded every 5 min for both groups. If needed, the ve-
locity was adjusted to return HR to the target-training zone for the
PIE. The mean HR for each 5-min interval across sessions was
then calculated, as well as the percentage of HRmax.
Outcomes
All participants underwent the same assessment protocol, both
at baseline and after the 12-wk period, conducted by the same
trained staff. Assessments were performed during a similar time
each day to reduce the circadian influence.
Anthropometry
Body weight was measured by a Welmy scale (Welmy® model
160/300, Brazil) to the nearest 0.1 kg. All participants were bare-
foot and were instructed to wear light clothing. Height was mea-
sured to nearest 0.1 cm, using a wall-mounted stadiometer
(Welmy scale, Welmy® model 160/300, Brazil). BMI was calcu-
lated in terms of kilograms per square meter. Body composition
was assessed through the use of an adipometer caliper (Lange, CA),
with a resolution of 1 mm. Triceps, biceps, subscapular, abdominal,
and medial calf muscles were measured in triplicate, through consid-
eration of the mean value in the right hemisphere of the body. Body
fat was estimated by gender-specific equations (28).
HRQOL
HRQOL was assessed by the generic version of the Pediatric
Quality of Life Inventory (PedsQL™) (29) specified for adoles-
cents from 13 to 18 yr old, which has been documented as a reli-
able and valid instrument for the Brazilian population (30).
PedsQL™ is an adolescent, self-report scale consisting of 23 items
separated into four domains—physical, emotional, social, and
school—and provides global and psychosocial scores as well. The
instructions ask, “In the past month, how much of a problem has
this been for you?” The items are then reverse-scored, ranging from
0 to 4 (0 = never a problem; 1 = almost never; 2 = sometimes; 3 = of-
ten; 4 = almost always), and, finally, are linearly transformed onto a
0–100 scale. There is no cutoff point for clinical significance; there-
fore, higher scores indicate a better HRQOL. Participants were
instructed by the main investigator on how to complete the ques-
tionnaire and to do so independently. All participants were pro-
vided free time and privacy to complete the questionnaire.
Sample Size
Power analysis was calculated a posteriori. Considering al-
pha = 0.05 and power = 0.80, the sample size in this study was suf-
ficiently large to detect a significant difference for effect size
between groups greater than 0.84.
Randomization
For the allocation to either group, a sequential number was
given according to enrollment within the study. Boys and girls
were randomized separately, generating the same ratio girls/boys
per group. Randomization process was completed using the
website randomizer.org.
Translational Journal of the ACSM 267
Statistical Analyses
All analyses were performed using the software SPSS® 17.0
(Statistical Package for the Social Sciences). The Shapiro–Wilk test
and the Levene test were used to evaluate both the normality and
heterogeneity of variances, respectively. Data presented here had a
normal and homogeneous distribution for all except for the age
variable. Continuous variables were summarized according to
their mean, SD, and 95% confidence interval values. The baseline
characteristics were compared through use of an independent
t-test, except the baseline age (Mann–Whitney U test). The drop-
out rates were compared using a chi-square test.
To compare the effects of the intervention on HRQOL indicators
and body composition parameters, generalized estimating equations
(GEE) were conducted, which were followed by a post hoc pairwise
comparison with a Bonferroni adjustment. The model was specified
for a between-group factor (PIE vs SIE), a within-group factor of time
(baseline vs 12 wk), and a group–time interaction.
To analyze the mean HR and percentage of HRmax during the
sessions, a repeated-measures general linear model (GLM) for
group  time  group–time interaction was conducted, followed
by a Bonferroni post hoc analysis when significance was found.
The Greenhouse–Geisser correction was applied to the F-ratio, Figure 1: Flow chart.
as the assumption of sphericity was violated. The significance level
was set at P < 0.05.
SIE and 0.77 PIE) in the PIE group, with a 15% improvement in
In addition, the ES was used to estimate the magnitude of the
the PedsQL score, as well as a large Cohen’s d ES.
differences between pre- and postinterventions. Cohen’s d was ap-
plied with the classifications ≤0.2, 0.2–0.5, 0.5–1.0, and >1.0, Repeated-measures GLM analyzed the mean and percent-
which were defined as small, moderate, large, and very large ES, age of HRmax across all training sessions (Table 3). Significant group
respectively (31). After GLM analysis, partial eta-square (η2p) ES (F1,34 = 6.59, P = 0.015, ES = 0.16), time (F2.676,90.988 = 248.244,
was used with the classifications ≤0.05, 0.05–0.25, 0.25–0.50, P < 0.001, ES = 0.88), and group–time (F2.676,90.988 = 5.983,
and >0.5, which represented small, moderate, large, and very P = 0.001, ES = 0.87 SIE and 0.94 PIE) differences were found.
large ES, respectively (31). A Bonferroni post hoc analysis exhibited differences in the
mean and percentage of HRmax at 10 min (P = 0.003),
RESULTS 15 min (P < 0.001), 20 min (P = 0.022), and 25 min
Of the 37 participants enrolled within this study, 12 ado- (P = 0.012), showing that PIE had a higher mean HR and per-
lescents (63%) from the PIE group and 13 adolescents (72%) centage of HRmax than SIE.
from the SIE group completed the study protocol, with no dif-
ferences in the dropout rates between groups (χ2 = 2.3,
P = 0.12). The participant dropouts occurred before the first DISCUSSION
week of training (n = 1), as well as during the first (n = 1), To the best of our knowledge, this is the first study to an-
fourth (n = 1), fifth (n = 1), seventh (n = 2), eighth (n = 2), alyze the effects of SIE on HRQOL in adolescents with obesity.
and ninth (n = 4) weeks of the intervention. The reasons given The main findings demonstrate that only the PIE group exhib-
for dropouts included symptoms of depression (n = 2), living ited a positive change in the social functioning of HRQOL,
too far from the location of the training sessions (n = 5), lack with a large ES. Our findings for the PIE group corroborate
of motivation (n = 3), and lack of time (n = 2) (Fig. 1). those of other investigations, which concluded that PIE led to
We have reported all of our data together, as there were no improvements within social parameters of HRQOL, along
gender differences found for the outcomes assessed. No differ- with reductions in BMI and body mass (15,17,32). Notewor-
ences between the groups were verified for the variables of an- thy, regardless of group assignment, there were improvements
thropometry, body composition, or the HRQOL at baseline. in body mass, BMI, and skinfold thickness.
Although all participants had Tanner stages 3–4, significant The PedsQL questionnaire has been validated (30), widely
differences were found in the baseline chronological age applied, and used in varying study designs focusing on obese
(SIE = 15.27 ± 1.48 yr, PIE = 14.15 ± 1.64 yr, P = 0.02). children and adolescents (33,34). PedsQL is a self-report scale
GEE analysis with a Gamma distribution showed, in Table 1, (29) and involves an easy and fast application, with questions
significant time effects on total body mass (ES = 0.34 SIE and relating to problems around walking, running, practices of
0.48 PIE), BMI (ES = 0.53 SIE and 0.64 PIE), and the sum of physical activity, difficulties with peers, emotions, and the pres-
skinfold thickness (ES = 0.67 SIE and 0.83 PIE) for both SIE ence of related diseases associated with obesity (35).
and PIE with a moderate–large Cohen’s d ES. However, no Our self-report PedsQL scores are in accordance with those
group effects, or group–time effects, were found. of other researchers (15,17,32). The PIE and the SIE groups
According to the GEE with a Gamma distribution, presented showed social scores at a baseline of 70.0 and 71.1, respec-
in Table 2, no effects (group, time, or group–time) were found tively. These are proximal to the mean values of 67.3 found
for the physical, emotional, school, psychosocial, or total score by Quinlan et al. (32), and the 67.5 reported by Schwimmer
of HRQOL for either group. However, the social functioning et al. (8), which investigated adolescents with obesity having
parameter demonstrated significant interaction effects (ES = 0.12 a BMI greater than that of 30 kg·m−2.

268 Volume 4 • Number 24 • December 15 2019 Self-selected Exercise and QoL in Obese Youth

Copyright © 2019 by the American College of Sports Medicine. Unauthorized reproduction of this article is prohibited.
TABLE 1.
Effects of SIE and PIE on Body Composition and Anthropometric Characteristics in Adolescents with Obesity.

Baseline, 12 wk, SIE vs PIE, 12 wk, Group Time

Outcomes Mean (SD) Mean (SD) Relative Change (95% CI) Effect Effect Group–Time

Total body mass (kg)

SIE 100.7 (21.85) 92.1 (25.20)a −4 (−20.79 to 12.79)

a
PIE 98.9 (24.93) 88.1 (12.91) 0.675 0.012 0.736

Height (m)

SIE 1.64 (0.08) 1.65 (0.07) −0.03 (−0.09 to 0.03)

PIE 1.62 (0.09) 1.62 (0.07) 0.463 0.631 0.737

BMI (kg·m−2)

SIE 37.4 (7.24) 33.7 (8.55)a −0.3 (−6.30 to 5.70)

PIE 37.3 (7.15) 33.4 (5.48)a 0.928 <0.001 0.950

Σ Skinfold thickness

SIE 180.4 (26.33) 163.5 (25.04)a −14.3 (−38.01 to 9.41)

a
PIE 174.0 (28.55) 149.2 (32.10) 0.254 0.001 0.464

Body fat (%)

SIE 52.5 (5.99) 48.8 (8.05) −2.4 (−11.07 to 6.27)

PIE 50.7 (8.21) 46.4 (12.59) 0.486 0.083 0.847

Data are presented as mean (SD) and effects of intervention (mean between-group differences, adjusted for baseline values, with 95% CI). Group, time
effects, and group–time are presented as P values. Σ: sum of triceps, biceps, subscapular, abdominal, and medial calf skinfold thickness.
a
Difference between 12 wk versus baseline (P < 0.05).

Although most studies reporting HRQOL improvements
used a multidisciplinary approach (e.g., exercise, nutrition,
and psychological counseling), only few studies have ad-
dressed the isolated effect of exercise (16–18). Yackobovitch-
Gavan et al. (15) demonstrated that the effects of exercise set
at a PIE (75% HRmax) for 12 wk induce improvements on
HRQOL similar to diet alone or diet and exercise combined
groups (15). In the present study, only the social functioning
domain has been improved, and previous research has indi-
cated that adolescents with obesity perceive lower levels of so-
cial support when compared with their healthy weight peers (36).
Therefore, increases on social functioning may influence one’s so-
cial network, which could decrease distress levels and increase the
probability of them engaging in healthier behaviors (36).
Recently, SIE has gained greater attention and is being pro-
moted to the public because of its potential benefits for obese
populations (e.g., greater adherence levels, lower dropout rates,
positive affective responses, and more minutes per week of exer-
cise performance) (21,22). These benefits have emphasized the
potential of SIE for the treatment of obesity (22). PIE has been
described as unpleasant for adults with obesity, as well as for ad-
olescents (21,22). Unpleasant experiences may lead adolescents
to avoid engagement in physical activity programs, collaborat-
ing for a vicious cycle of physical inactivity and obesity (19,22).
Our results are clinically relevant because obesity has a neg-
ative effect on the HRQOL of adolescents, comparable, at
some degrees, to adolescents undergoing cancer treatment (8).
Past research that explored the effects of exercise interventions
has found positive changes in the HRQOL of obese adolescents
after PIE protocols, varying from 50% to 60% of maximum ox-
ygen uptake (18) and from 65% to 85% of HRmax (predicted
by formula) (15,17). Those investigations, along with ours,
demonstrate that the relative intensity of an exercise is a key fac-
tor that could affect the HRQOL of obese adolescents.
As secondary outcomes, we found a reduction in the param-
eters related to mass and adiposity (skinfolds and BMI) within
both groups. Under normal metabolic conditions, a chronic
negative energy balance, induced by a reduction in dietary in-
take or an increase in energy expenditure, leads to an overall re-
duction in body mass (37). The higher the energy deficit, the
greater the reduction in body adiposity (38); thus, in situations
where the caloric deficit is similar, body composition changes
are supposed to be similar, regardless of the exercise intensity.
This study has some limitations that should be considered in
the interpretation and application of its results. Individual
changes in physical activity outside the supervised training,
as well as energy intake, may have influenced the study’s re-
sults. In addition, self-report questionnaires were used for
assessing the main outcome. Individual choices for music
(tempo, volume, and rhythms) may also have influenced the
perception of effort during the exercise sessions, mainly for
the SIE group. Because of these limitations, our data must be
interpreted with caution, and further research is therefore
needed to corroborate or refute these findings.

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TABLE 2.
Effects of SIE and PIE on the HRQOL of Adolescents with Obesity.

Baseline, 12 wk, SIE vs PIE, 12 wk, Group Time

Outcomes Mean (SD) Mean (SD) Relative Change (95% CI) Effect Effect Group–Time

Physical functioning

SIE 66.5 (22.3) 72.8 (14.56) 1.1 (−11.34 to 13.54) 0.535 0.239 0.619

PIE 71.2 (14.9) 73.9 (15.51)

Emotional functioning

SIE 60.8 (27.7) 60.4 (22.40) 1.4 (−19.16 to 21.96) 0.757 0.479 0.421

PIE 55.1 (17.5) 61.8 (27.22)

Social functioning

SIE 71.1 (17.1) 67.3 (16.40) 13.6 (1.02 to 26.18) 0.200 0.301 0.021

PIE 70.0 (15.9) 80.9 (13.75)a

School functioning

SIE 60.55 (24.1) 60.0 (30.61) 5.4 (−16.44 to 27.24) 0.419 0.548 0.679

PIE 68.8 (21.3) 65.4 (20.79)

Psychosocial functioning

SIE 64.4 (19.3) 62.5 (19.93) 6.9 (−9.08 to 22.88) 0.575 0.609 0.246

PIE 64.3 (14.1) 69.4 (18.57)

Total score

SIE 64.4 (18.6) 66.5 (16.85) 4.4 (−9.56 to 18.36) 0.509 0.310 0.743

PIE 66.7 (13.2) 70.9 (16.87)

Data are presented as mean (SD) and effects of intervention (mean between-group differences, adjusted for baseline values, with 95% CI). Group, time
effects, and group–time are presented as P values.
a
Differences between 12 wk versus baseline are significantly different between groups (P < 0.05).

TABLE 3.
Percentage of HRmax Across 5-min Interval.

Time HRmax (%) SIE (mean ± SD) HRmax (%) PIE (mean ± SD) SIE vs PIE, 12 wk, Relative Change (95% CI)

0 min 54.7 ± 4.2 53.6 ± 5.4 1.1 (−2.14 to 4.34)

5 min 64.6 ± 4.9 67.4 ± 6.4 −2.5 (−6.32 to 1.32)

a
10 min 71.3 ± 6.1 77.0 ± 4.9 −5.7 (−9.38 to −2.02)a

15 min 71.5 ± 6.2 78.3 ± 4.6a −6.8 (−10.43 to −3.17)a

20 min 73.7 ± 7.2 78.4 ± 4.9a −4.7 (−8.79 to −0.61)a

25 min 72.9 ± 7.7 78.3 ± 5.1a −5.4 (−9.74 to −1.06)a

30 min 76.9 ± 7.7 79.4 ± 4.3 −2.5 (−6.63 to 1.63)

35 min 68.3 ± 7.8 69.3 ± 6.8 −1 (−5.91 to 3.91)

Data are presented as mean ± SD and effects of intervention (mean between-group differences, adjusted for baseline values, with 95% CI).
a
Difference between groups (P < 0.05).

270 Volume 4 • Number 24 • December 15 2019 Self-selected Exercise and QoL in Obese Youth

Copyright © 2019 by the American College of Sports Medicine. Unauthorized reproduction of this article is prohibited.
 For practical applications, this research points out the impor-
tance of PIE and of monitoring of exercise intensity by exercise
professionals to help adolescents with obesity in reaching an exer-
cise intensity sufficient for improving overall social functioning.
CONCLUSION
Compared with PIE, SIE did not improve any aspect of
HRQOL. Our research demonstrates that a PIE of exercise
(60%–70% HRreserve) improved the social functioning param-
eter of HRQOL in the studied population.
This research has been granted by the Federal Institute of Sertão
Pernambucano (IF-Sertão-PE) and the Programa de Fortalecimento
Acadêmico from the University of Pernambuco.
The authors declare no conflicts of interest. The results of this
study do not constitute an endorsement by the American College of
Sports Medicine.
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