New Insights in Obesity: Genetics and Beyond

Research Article

Study of body composition, physiological variables in Grade III obese submitted to arm ergometer test

Felipe Monnerat Marino Rosa1,2, Renato Vidal Linhares2,4,6*, José Quaresma2, João Regis Ivar Carneiro2, Valéria Bender Braulio2,5, Roberto Simão1,3, Denise Pires de Carvalho2 and José Fernandes Filho1-3

1Programa de Pós Graduação em Educação Física da Universidade Federal do Rio de Janeiro-RJ, Brasil

2Hospital Universitário Clementino Fraga Filho - Universidade Federal do Rio de Janeiro-RJ, Brasil

3Escola de Educação Física e Desportos, Universidade Federal do Rio de Janeiro-RJ, Brasil

4Laboratório de Biociência do Movimento Humano (LABIMH), Hospital Universitário Clementino Fraga Filho, Universidade Federal do Rio de Janeiro-RJ, Brasil

5Laboratório de Nutrologia (LABONUTRO), Hospital Universitário Clementino Fraga Filho, Universidade Federal do Rio de Janeiro-RJ, Brasil

6Grupo de Pesquisa em Educação Física Escolar do Colégio Pedro II (GEPEFE), Colégio Pedro II do Rio de Janeiro-RJ, Brasil

*Address for Correspondence: Renato Vidal Linhares, Hospital Universitário Clementino Fraga Filho-Universidade Federal do Rio de Janeiro-RJ, Brasil, Email:

Dates: Submitted: 12 July 2017; Approved: 22 August 2017; Published: 23 August 2017

How to cite this article: Rosa FMM, Linhares RV, Quaresma J, Carneiro JRV, Braulio VB, et al. Study of body composition, physiological variables in Grade III obese submitted to arm ergometer test. New Insights Obes Gene Beyond. 2017; 1: 023-029. DOI: 10.29328/journal.hodms.1001005

Copyright: © 2017 Rosa FMM, et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Keywords: Morbid obesity; Women; Arm ergometry test; Cardiovascular


Introduction: Number of obese people is growing on a daily basis in Brazil, including morbid obese ones, but there is still a lack of studies with this subject. Due to this, the main goal of this study was to identify body profile, physiological variables behavior and oxygen consumption in grade III obese women, submitted to an ergospirometric test in arm ergometer.

Method: Take part in this study, thirteen (13) female grade III obese patients between 20 and 40 years. They were submitted to an electric bioimpedance test for body composition measurement and an Ergospirometric test in arm ergometer for oxygen consumption, heart rate, and oxygen saturation, systolic and diastolic arterial pressure, resting and after exercises, analysis.

Results: The patients revealed a BMI of 46.5±3.81 kg/m², 51.9±1.59% of body fat percentage. The patients reached 168.2±4.57bpm of heart rate, didn’t make any hypertensive response to the effort reaching an arterial pressure of 171.1±22.15mmHg x 87.5±4.18mmHg. Oxygen saturation was 98±0.71% and oxygen consumption peak was, also in average, 12.3±

Conclusion: It was verified that there was no oxygen saturation drop nor hypertensive response and all of the patients reached the maximum heart rate.


Overweight occurs in more than a billion people around the world, which 600 million are obese [1]. World Health Organization (OHS) defines obesity as excessive accumulation of adipose tissue with health implications, [2] with multifactorial etiology, [2-4] and can be classified as several grades according to BMI´s values over 40kg/m² [3,5,6]. The importance of this study about obesity relates to its consequences in other diseases development, such as: diabetes mellitus type II; arterial hypertension; dyslipidemia; chronic obstructive pulmonary disease; heart disease and certain cancers [4,6-9].

These diseases above mentioned can induce modifications in physiological variables. Oxygen consumption (VO2) is an important variable to estimate the quantity of captured oxygen (O2), transported and metabolized to energy production in a time unit during an effort test [10]. Oxygen peripheral saturation (SpO2) is a great indicator of abnormal gas exchange [11,12] and grade III obesity usually compromises cardiovascular system.

Blood Pressure (BP) characterized by blood flow force over arteries [13] in obese people, can show changes, since skin excess has a strong correlation to higher blood pressure [14]. Heart Rate (HR), which reflects the number of heart beats in a time gap [13], has a linear rise during effort, reaching a maximum that may vary, inversely with the age [15].

Ergosperimetry has, as indication, disease monitoring, treatment evolution, disability score, among others and the Ergosperimetric Test in upper limbs´ cycle ergometer has been studied since post war period in paraplegic [16] and some authors [16-18] suggest also to patients with walking difficulties, amputees and heart diseases ones.

Due to the lack of literature involving grade III obese patients, the main goal of this study is to identify the body profile, the behave of physiological variables and oxygen consumption in grade III obese women, submitted to a ergosperimetric test in arm ergometer.

Materials and Methods


The sample was composing of thirteen grade III female patients that were recruited from the Bariatric Surgery Program of the Clementino Fraga Filho University Hospital´s in 2015, and they were followed up by a multidisciplinary staff. Only participated in the maximal exercise test in arm ergometer those patients referred by medical staff and met the inclusion criteria: having a BMI between 40 and 60 kg/m2, sedentary and aged between 20 and 40 years (average age of 34.7±5.07).

Patients who used beta-blockers and insulin, chronic obstructive pulmonary disease, pregnant women, who used pace markers, who had osteoarticular problems that would present exercise and who had already undergone bariatric surgery were excluded. All patients were instructed about the test and that participation was voluntary and with this, only those who signed an Informed and Free Consent Term, according to 196/96 resolution of Brazil´s National Council of Health, were allowed to participate. Throughout the test there was a cardiologist accompanying through an electrocardiogram and this research did not receive from companies and government funding.

The research was of descriptive nature and its transversal analysis, where it was analyzed quantitative parameters about people and situations [19], having Grade III obesity as independent variable and body mass index (BMI), body fat percentage (%BF), heart rate (HR),oxygen saturation(SpO2), systolic blood pressure (SBP), diastolic blood pressure (DBP) and oxygen consumption (VO2) as dependent ones.

Instruments and procedures

For body composition measurement, it was used a multipolar bioimpedance balance, from INBODY® model 230. During evaluation, patients were barefoot, wearing the minimum clothing possible, without any metallic objects. Besides, patients were previously instructed to follow a three hours fasting protocol and not drink any alcohol nor caffeine for twelve hours, water for four hours and intense physical exercise for 12 hours before the measurement.

For ergospirometric evaluation, an interdisciplinary flow chart from Obesity and Bariatric Surgery´s Program was followed, through previous medical approach and subsequent release for test, which was attended by a cardiologist that analyzed electrocardiographic records by an electrocardiograph from TEB ECGPC of twelve derivations with positioning proposed by Mason and Likar [20]. The room was prepared to guarantee calorimeter´s recommendations, from CAREFUSION, mode VMax 29N Encore, those are, minimum noise ambient and not more than three evaluators, with temperature ranging from 20 to 24 degrees and humidity between 50 and 60%. In addition, an arm ergometer from TECHNOGYM model EXCITE PRO.

The systolic and diastolic blood pressure were measured with a stethoscope from GLICOMED, model CARDIOLOGY and an aneroid sphygmomanometer from GLICOMED, on the right arm of the patient with an 33-44 cm clamp, specific for obese people. The SpO2 was checked through a pulse oximetry with the aid of a finger oximeter from CONTEC on left index finger at the same time that the arterial pressure is measured on the other arm by other evaluator.


The protocol applied was the ramp, being used the formula to leg ergometer VO2=40.31-(0.41 x age) (21), rectifying for upper limbs (less 35% of maximum VO2 estimated) considering the difference between the two ergometers [21]. The result was inserted in ACSM formula to calculate the maximum power (WMáx) in arm ergometer VO2máx=Wmáxx18.36+ (weight x 3.5) [22]. After it was reduced 50% of maximum power, according to III guideline of the Brazilian Society of Cardiology for Cardiac Stress test [23]. For ramp´s preparation, it was subtracted 30W (minimum accepted by ergometer) from predicted maximum power and the rest was split by 10 (average time expected for the test), reaching to the number of increments by minute.

Patients were oriented to keep a rhythm between 70 and 90 rpm but the number of rotations did not affect the power. The variables HR, SpO2, systolic and diastolic blood pressure were evaluated in 5 moments: during rest, just after the maximum effort, one, there and five minutes after the test. The calculation for expected maximum heart rate was through the formula HRmáx= 198-(0.42 x age) proposed by SHEFFIELD and Cols (1965). The criteria adopted for test classification as maximum was: R≥1, 1; heart rate equal or over 85% from maximum; and/or voluntary exhaustion [23]. The criteria for test interruption followed ACSM´s guideline to stress test, through absolute and relative indications.

This paper was approved by UFRJ´s Ethics Committee, in Rio de Janeiro, protocol number 12520413.6.0000.5257. For statistics, it was used a descriptive analysis, with measures of central tendency (average), minimum values, maximum and standard deviation.


In the table 1 below, it is possible to analyze the patients´ body profile results, proving the relationship with the morbid obesity.

Table 1: Body Profile from grade III obesity patients.
  Average SD Min Max
Age (years) 34,7 5,07 25 40
Body Mass (kg) 118,3 17,76 92,6 151,6
Stature (m) 1,59 0,07 1,50 1,72
BMI (kg/m²) 46,5 3,81 40,3 53,5
% FM 51,9 1,50 50,1 55,5
% FFM 48,1 1,50 44,6 74,6
FM (kg) 61,4 9,55 47,4 77
MM (kg) 32,1 5,08 24,9 42,4
Data: BMI-Body Mass Index, %G-Percentage of the fat mass, %MLG-Percentage of the fat free mass, MG-Fat Mass, MM-Muscle Mass.

After observing that patients fit the study inclusion criteria, an ergospirometric test was made, verifying the heart rate, arterial pressure and SPO2 in rest and in three other moments: 1, 3 and 5 minutes after physical exercise. It is also possible to observe the aerobic maximum power expected and reached in the test, see table 2.

Table 2: Average Results, Standard Deviation, minimum and maximum of arterial pressure, heart rate, oxygen saturation, oxygen consumption and grade III obesity patient´s power at various times.
Variables Average Standard Deviation Minimum Maximum
Systolic Blood Pressure Resting 130,2 6,85 120,0 142,0
Diastolic Blood Pressure Resting 84,8 5,57 76,0 96,0
Systolic Blood Pressure  Effort Max 171,1 22,15 150,0 210,0
Diastolic Blood Pressure Effort Max 87,5 4,18 80,0 94,0
Systolic Blood Pressure Recovery after 3' 139,9 12,28 120,0 160,0
Diastolic Blood Pressure Recovery after 3' 85,6 5,91 76,0 95,0
Systolic Blood Pressure Recovery after 5' 128,8 8,51 114,0 142,0
Diastolic Blood Pressure Recovery after 5' 85,1 4,94 80,0 92,0
Heart Rate Resting 83,7 10,2 65,0 97,0
Heart Rate Max Preview 183,4 2,13 181,2 187,5
Heart Rate Submaximum 155,9 1,81 154,0 159,4
Heart Rate Max Hit 168,2 14,5 145,0 193,0
Heart Rate Recovery 1’ 124,8 16,8 102,0 159,0
Heart Rate Recovery 3’ 108,9 13,2 96,0 144,0
Heart Rate Recovery 5’ 105,9 11,7 93,0 136,0
Oxygen Saturation Resting 97,9 0,9 96,0 99,0
Oxygen Saturation Effort Max 98,0 0,7 96,0 99,0
Oxygen Saturation Recovery 1’ 98,1 0,8 96,0 99,0
Oxygen Saturation Recovery 3’ 98,0 0,7 97,0 99,0
Oxygen Saturation Recovery 5’­ 97,9 1,0 96,0 99,0
Volume of Oxygen Max Preview 17,0 1,3 15,5 19,5
Volume of Oxygen Peak 12,3 2,7 7,7 17,9
Power Rating Max Preview 115,4 22,8 83,5 152,2
Power Rating Expected 57,6 12,1 41,7 76,1
Power Rating Max Atingido 60,3 14,6 39,0 98,0
Data: SBP-Systolic Blood Pressure (mmHg), DBP-Diastolic Blood Pressure (mmHg), HR-Heart Rate (bpm), SPO2-Oxygen Saturation in percentage (%), VO2-Volume of Oxygen (ml/kg.min-1),W-Power Rating (w).

VO2 curve, like heart rate curve, increased with the rise of intensity in the effort. Patients reached an oxygen consumption peak of, in average, 12.3±2.75ml. Kg. min-1. The identification of maximum VO2 is achieved when the increase of load doesn´t results in a change of VO2 or when a plateau appears. If the criterion is not obtained, it is used the term VO2peak [24].


First step to evaluate the patient´s profile is to analyze her body composition, through electric bioimpedance, revealing a fat percentage according to this population, due to physical inactivity characteristics, key factors to adipose tissue´s accumulation and muscle mass´s reduction [2,3]. Besides, grade III obesity introduces several modifications to body composition, in comparison to other grades, such as bigger total water accumulation, intra and extracellular, that may incite modifications in the lean mass percentage.

It was observed similar results in fat percentage in morbid obese women, in other words, a high percentage (55%) and a positive correlation between this parameter, through electric bioimpedance, and BMI, waist circumference and biochemical variables [25].

Several factors influence in VO2peak values like the type of exercise, gender, age, body composition and physical activities level. Predicted VO2 [22] to arm ergometer was, in average, 17±, higher than the one found in the test. This difference may be related to the obesity grade, physical inactivity and peripheral fatigue. The modifications in the end of the curve might have happened because of biomechanical inefficiency close to maximum effort. Evidences suggest that peripheral fatigue and local muscular perfusion might be limiting factors to reach VO2peak value in upper limbs´ exercise, leading to a intramuscular tension and blood flow rise, limiting VO2 [26].

All patients presented a very low VO2, according to the classification proposed by American Heart Associtation through Ergonometry National Consensus (1995), which is understandable because of excessive weight, physical inactivity, low muscle mass and test specificity, besides this, obese people possess relative VO2 is lower than in eutrophic ones [27,28]. Fornitano [6] compared 290 grade III obese patients with 327 eutrophic ones, through an ergospirometric test in a treadmill and also find very low values of VO2 in the obese group ( showing that obesity negatively interfered in effort tolerance. Salvadori et al. [29], studied cardiopulmonary performance in 11 obese young patients and other 10 young eutrophic through a lower limbs´ ergometer cycle and verified a lower power and VO2 in the obese, concluding that lower tolerance to the effort is related to reduce supply of oxygen to the muscles and to a poorer cardiac performance.

Most of the patients did not reached the maximum heart rate predicted on the test, being able to be related to the upper limbs´ fatigue, since there is a smaller amount of muscular mass involved when compared to lower limbs´ ergometric, generating a smaller cardiac debit and heart rate. Related to the observed after effort results, there was a heart rate reduction of more than 20% (43.4±8.06bpm) in all patients, in the first minute of rest, in comparison to the maximum heart rate. This reduction allows to infer cardiac vagal modulation, since reductions smaller than 12 bpm have association to a higher prevalence of mortality [30].

Pulmonary complications are very usual in obese patients, although BMI values and pulmonary function tests are not able to forecast these problems. Grade III obese people use to present restriction in gas exchange, with a low reduction in oxygen pressure and increase in alveolar-arterial oxygen difference. SpO2 monitoring while effort may indicate an existing pulmonary disease and facilitate the diagnosis of dyspnea on exertion [31], since the demand imposed by the physical exercise increases ventilation and perfusion and decreases SpO2 [32].

However in this study, it was not found a decrease in SpO2 between repose and effort (97.9±0.95% e 98.1±0.86%), what can be related to the selection of young patients with not pulmonary commitment. Other authors investigated the pulmonary response to physical exercise in 92 young people, male and female, obese and not obese, through a prospective transversal study, concluding that SpO2 values reduced while exercises in young obese. Leading to a conclusion that young obese presented pulmonary functions variation in rest and these changes were maintained while all exercise [33].

Regard heart rate during the maximum aerobic power test, there was a linear rise in this parameter, and also in VO2, in all patients, due to cardiac debit increase and involved muscle mass [34]. Because when the exercise is initiated, the autonomic nervous system can elevate the venous return, incurring in a larger distension of the right ventricle to receive more blood volume, added to the tachycardia that follows and to the increase of cardiac debit [33].

Arm ergometer test usually causes an expressive increase in arterial pressure, since exercises involving minor muscular groups may favor vasoconstriction of other inactive muscles [35]. There is no established limit to the increase of systolic blood pressure, but values higher than 250 mmHg can be observed [35], in this research there was no patient with systolic blood pressure higher than 180 mmHg and diastolic blood pressure over 15 mmHg).

Compare, through a ergospyrometric test in a treadmill, morbid obese patients with eutrophics ones and verified that systolic arterial pressure increased in both groups, but reached higher values in the obese, and diastolic arterial pressure presented a small increase with no difference between the groups [28]. Described the rise of average diastoliac arterial pressure while physical exercise performed upper limbs’, suggesting a bigger isometric component, since while this effort the peripheral resistance is higher due to an increased catecholamine secretion and on the isometric contraction required to stabilize the trunk [16].


It can be concluded that the maximal stress test in arm cycle ergometer is a reliable and useful method for the cardiac evaluation for morbid obese women. With this, it can be another tool for the risk stratification for bariatric surgery and the reliable prescription of an individualized program of aerobic physical exercises.

It is recommended to do another study, with the same methods, for male patients and adults with BMI over 60kg/m². Besides, it is important to monitor the arterial pressure and oxygen saturation while effort.


  1. Godoy-Matos AF, Oliveira J, Guedes EP, Carraro L, Lopes AC, et al. Diretrizes brasileiras de obesidade. Associação Brasileira para o Estudo da Obesidade e da Síndrome Metabólica. 3 ed. Itapevi-SP: AC Farmacêutica. 2009.
  2. Mechanick JI, Garber AJ, Handelsman Y, Garvey WT. American Association of Clinical Endocrinologists' position statement on obesity and obesity medicine. Endocr Pract. 2012; 18: 642-648. Ref.:
  3. Oliveira IV. Cirurgia bariátrica no âmbito do sistema único de saúde: tendências custos e complicações [Dissertação de Mestrado]: Universidade de Brasília; 2007. Ref.:
  4. Fornitano LD. O teste ergométrico em indivíduos com obesidade mórbida [Tese de Doutorado]: Faculdade de Medicina de São José do Rio Preto. 2008. Ref.:
  5. Fonseca-Junior SJ, Sá CGAB, Rodrigues PAF, Oliveira AJ, Fernandes-Filho J. Exercício físico e obesidade mórbida: uma revisão sistemática. Arq Bras Cir Dig. 2013; 26: 67-73. Ref.:
  6. Marcon ER, Gus I, Neumann CR. Impacto de um programa mínimo de exercícios físicos supervisionados no risco cardiometabólico de pacientes com obesidade mórbida. Arquivos Braileiro de Endocrinologia e Metabolismo. 2011;55:331-8. Ref.:
  7. Carneiro JRI. Análise de um programa de preparo pré operatório para cirurgia bariátrica com enfase na pratica regular de atividades físicas [Tese de Doutorado]: Universidade Federal do Rio de Janeiro; 2009.
  8. Pouwels S, Wit M, Teijink JAW, Nienhuijs SW. Aspects of Exercise before or after Bariatric Surgery: A Systematic Review. Obes Facts. 2015; 8: 132-146. Ref.:
  9. Fogelholm M, Stallknecht B, Baak M. ECSS position statement: Exercise and obesity. European Journal of Sport Science. 2006; 6: 15-24. Ref.:
  10. Sanches RB, Silva SGA, Rossi S, Fidalgo JPN, Moraes AS, et al. Composição corporal e aptidão aeróbia de mulheres obesas: efeitos benéficos da terapia interdisciplinar. Revista Brasileira de Atividade Física & Saúde. 2013; 18: 354-356.
  11. Balady GJ, Arena R, Sietsema K, Myers J, Coke L, et al. Clinician's Guide to cardiopulmonary exercise testing in adults: a scientific statement from the American Heart Association. Circulation. 2010; 122: 191-225. Ref.:
  12. Cardoso MCAF, Silva AMT. Oximetria de Pulso: Alternativa Instrumental na Avaliação Clínica junto ao Leito para a Disfagia. Arq Int Otorrinolaringol. 2010; 14: 231-238. Ref.:
  13. Powers SK, Howley ET. Fisiologia do Exercício. Teoria e Aplicação ao Condicionamento e ao Desempenho. 1ª ed ed. Barueri-SP: Manole; 2000.
  14. Kohlmann Jr O, Guimarães AC, Carvalho MHC, Chaves Jr HC, Machado CA, et al. III Consenso Brasileiro de Hipertensão Arterial. Arq Bras Endocrinol Metab. 1999; 43: 257-286. Ref.:
  15. Polito MD, Farinatti PTV. Respostas de frequência cardíaca, pressão arterial e duplo-produto ao exercício contra-resistência: uma revisão da literatura. Revista Portuguesa de Ciências do Desporto. 2003; 3: 79-91. Ref.:
  16. Haddad S. Upper limbs ergometry. An important method in the assessment of cardiocirculatory response to exercise. Arq Bras Cardiol. 1997; 69: 189-193. Ref.:
  17. Balady GJ, Weiner DA, Rose L, Ryan TJ. Physiologic response to arm ergometry exercise relative to age and gender. J Am Coll Cardiol. 1990; 16: 130-135. Ref.:
  18. Castro RR, Pedrosa S, Chabalgoity F, Sousa EB, Nobrega AC. The influence of a fast ramp rate on peak cardiopulmonary parameters during arm crank ergometry. Clin Physiol Funct Imaging. 2010; 30: 420-425. Ref.:
  19. Thomas JR, Jack KN, Silverman SJ. Research Methods in Physical Activity. Champaingn, IL: Human Kinetics; 3rd ed. 1996.
  20. Ushida A, Moffa P, Hueb W, Cesar L, Ferreira B, et al. Escore Eletrocardiográfico: Aplicação em Ergometria para Avaliação do Precondicionamento Isquêmico. Arq Bras Cardiol. 2010; 95: 486-492. Ref.:
  21. Shvartz E, Reibold RC. Aerobic fitness norms for males and females aged 6 to 75 years: a review. Aviat Space Environ Med. 1990; 61: 3-11. Ref.:
  22. Cooper CB, Storer TW. Teste ergometrico. Aplicações Práticas e Interpretação. 1ª Ed. Rio de Janeiro: Revinter; 2005.
  23. Meneghelo RS, Araújo CGS, Stein R, Mastrocolla LE, Albuquerque PF, et al./Sociedade Brasileira de Cardiologia. III Diretrizes da Sociedade Brasileira de Cardiologia sobre Teste Ergométrico. Arq Bras Cardiol 2010; 95: 1-26. Ref.:
  24. Stein R. Teste cardiopulmonar de exercício: noções básicas sobre o tema. Revista da Sociedade de Cardiologia do Rio Grande do Sul. 2006; 15: 1-4.
  25. Leal AA, Faintuch J, Morais AA, Noe JA, Bertollo DM, et al. Bioimpedance analysis: should it be used in morbid obesity? Am J Hum Biol. 2011; 23: 420-422. Ref.:
  26. Walker R, Powers S, Stuart MK. Peak oxygen uptake in arm ergometry: effects of testing protocol. Br J Sports Med. 1986; 20: 25-26. Ref.:
  27. Mancini MC. Obstáculos e diagnósticos e desafios terapeuticos no paciente obeso. Arq Bras Endocrinol Metab. 2001; 45. Ref.:
  28. Serés L, López-Ayerbe J, Coll R, Rodriguez O, Manresa JM, et al. Cardiopulmonary Function and Exercise Capacity in Patients With Morbid Obesity. Rev Esp Cardiol. 2003; 56: 594-600. Ref.:
  29. Salvadori A, Farani P, Fontana M, Buontempi L, Saezza A, et al. Oxygen uptake and cardiac performance in obese and normal subjects during exercise. Respiration. 1999; 66: 25-33. Ref.:
  30. Ghorayeb N, Castro I, Daher DJ, Oliveira Filho JA, Oliveira MAB. Diretriz em Cardiologia do Esporte e do Exercício da Sociedade Brasileira de Cardiologia e da Sociedade Brasileira de Medicina do Esporte. Arq Bras Cardiol. 2013; 100: 1-41. Ref.:
  31. Serra S. Considerações sobre ergoespirometria. Arq Bras Cardiol. 1997; 68: 301-304. Ref.:
  32. Klefbeck B, Mattsson E, Weinberg J, Svanborg E. Oxygen Desaturations During Exercise and Sleep in Fit Tetraplegic Patients. Arch Phys Med Rehabil. 1998; 79: 800-804. Ref.:
  33. Faria AG, Ribeiro MAGO, Marson FAL, Schivinski SIS, Severino SD, et al. Effect of exercise test on pulmonary function of obese adolescents. J Pediatr (Rio J). 2014; 90: 242-249. Ref.:
  34. Godoy M, Mantovanini JA, Santana RFT. Teste de Esforço na Mulher. Rev Soc Cardiol Estado de São Paulo. 2001; 3: 621-633. Ref.:
  35. Passaro LC. Resposta cardiovascular na prova de esforço: pressão arterial sistólica. Rev Bras Med Esporte. 1997; 3. Ref.: