Energy Balance, Body Composition and Weight

Management

Energy Balance

Definition:Definition: Calories IN = Calories OUTCalories IN = Calories OUT

Positive energy balancePositive energy balance Energy intake > energy expendedEnergy intake > energy expended Results in weight gainResults in weight gain

Negative energy balanceNegative energy balance Energy intake < energy expendedEnergy intake < energy expended Results in weight lossResults in weight loss

Energy In:

Food Intake: Physiological/Cognitive Food Intake: Physiological/Cognitive InfluencesInfluences

Physiological: Empty stomach, gastric Physiological: Empty stomach, gastric contractions, GI hormones, absence of contractions, GI hormones, absence of nutrients in small intestinenutrients in small intestine hunger hunger

Satiation, satiety – gastric distention, GI Satiation, satiety – gastric distention, GI hormones, feeling of satisfaction hormones, feeling of satisfaction during/after eatingduring/after eating stop eating stop eating

Hunger, Satiation, and Satiety

Physiological influences

Satiety

Cognitive influences

Sensoryinfluences

Postabsorptiveinfluences

Postingestiveinfluences

Hunger

Satiation

Satiety

Satiety

1

2

3

4

5

Liver Pancreas FatGastrointestinal tract

Hypothalamus

Glucose InsulinFFA

LeptinGut hormone

Modulators of feeding behavior

Name Site of production Effect

-melanocyte stimulating hormone (-MSH) Hypothalamus InhibitionAgouti-related peptide (AGRP) Hypothalamus StimulationCocaine-amphetamine-

regulated transcript (CART) Hypothalamus InhibitionNeuropeptide Y (NPY) Hypothalamus Stimulation

Peptide YY (PYY) G-I tract InhibitionGhrelin G-I tract Stimulation

Insulin Pancreas Inhibition

Leptin Adipose Inhibition

Energy Out

The kcals the body expends:The kcals the body expends: Basal metabolismBasal metabolism

Physical ActivityPhysical Activity

Digestion, absorption, and processing of Digestion, absorption, and processing of ingested nutrients (thermic effect of food)ingested nutrients (thermic effect of food)

Components of Energy Expenditure

Physicalactivities

Thermic effectof food

Basal metabolism

Basal Metabolism

Supports the basic processes of lifeSupports the basic processes of life

60 – 70% of the total energy needs60 – 70% of the total energy needs

Amount of energy needed varies between Amount of energy needed varies between individualsindividuals

Factors affecting Basal Metabolism AgeAge HeightHeight GrowthGrowth Body CompositionBody Composition Fever/StressFever/Stress Environmental temperatureEnvironmental temperature Fasting/Starvation/MalnutritionFasting/Starvation/Malnutrition HormonesHormones

Energy for Physical Activity

Most variable and changeableMost variable and changeable Significant in weight loss and weight gainSignificant in weight loss and weight gain VoluntaryVoluntary Increases energy expenditure beyond BMR Increases energy expenditure beyond BMR

by 25 – 40%by 25 – 40%

Thermic Effect of Food (TEF)

Energy used to digest, absorb, and Energy used to digest, absorb, and metabolize nutrientsmetabolize nutrients

6 – 10% above the total energy consumed6 – 10% above the total energy consumed Protein 20-30%Protein 20-30% Carbohydrate 5-10%Carbohydrate 5-10% Fat 0-5%Fat 0-5%

Estimating Energy Requirements

Gender – men generally have a higher BMRGender – men generally have a higher BMR Growth – BMR is high in people who are Growth – BMR is high in people who are

growinggrowing Age – BMR declines as lean body mass Age – BMR declines as lean body mass

decreasesdecreases Physical Activity – Vary considerablyPhysical Activity – Vary considerably Body size and compositionBody size and composition

Defining Healthy Body Weight

Weight within suggested range for htWeight within suggested range for ht Fat distribution pattern assoc with low risk Fat distribution pattern assoc with low risk

of illnessof illness Medical history with absence of risk factorsMedical history with absence of risk factors Good health supercedes appearanceGood health supercedes appearance Healthy lifestyle means more than absolute Healthy lifestyle means more than absolute

body weightbody weight

Weight Classification by BMI

Underweight: BMI < 18.5Underweight: BMI < 18.5 Healthy Weight: BMI 18.5 – 24.9Healthy Weight: BMI 18.5 – 24.9 Overweight: BMI 25.0 – 29.9Overweight: BMI 25.0 – 29.9 Obesity: BMI >30.0Obesity: BMI >30.0

Defining Obesity

Overweight = 10-20% above ideal body Overweight = 10-20% above ideal body weightweight

Mild Obesity = >20% Mild Obesity = >20% Moderate Obesity > 40%Moderate Obesity > 40% Super Obesity > 80%Super Obesity > 80% Morbid Obesity > 100%Morbid Obesity > 100%

Distribution of Body Fat

Central Obesity – Abdominal fat (apple Central Obesity – Abdominal fat (apple shape) with higher risk of Diabetes Type 2, shape) with higher risk of Diabetes Type 2, HTN, CVDHTN, CVD

Hip and thigh body fat (pear shape) – less Hip and thigh body fat (pear shape) – less harmfulharmful

Waist circumference: Women > 80-88 cm; Waist circumference: Women > 80-88 cm; Men > 94-102 cm; high riskMen > 94-102 cm; high risk

Energy Balance and Body Composition- FON 241; L. Zienkewicz

Body Types:

Apple shape:•Intra-abdominal fat.

•Common in men.

Pear shape:•Lower-body fat

•Common in women.

Estimating Body Fat Content

Measure % body fatMeasure % body fat Hydrodensitometry: Underwater weighing Hydrodensitometry: Underwater weighing

(most accurate)(most accurate) Fatfold measures/calipers (Triceps, abdomen, Fatfold measures/calipers (Triceps, abdomen,

thigh, etc)thigh, etc)

Desirable amount of body fatDesirable amount of body fat

21 – 35% for women21 – 35% for women

8 – 24% for men8 – 24% for men

Methods Used to Assess Body Fat

Bioelectrical impedanceFatfold measures

Air displacementplethysmography

Dual energy X-rayabsorptiometry (DEXA)

Hydrodensitometry

Energy Balance,Body Composition and Weight

Management

Chapters 8 and 9Chapters 8 and 9

Skinfolds Common field method Relationships among

selected skinfold sites and body density

Caliper exerts constant tension of 10 g/mm2

Sum of skinfolds indicates relative fatness of individual

Anatomical Landmarks for Skinfold Measurements

Chest

Abdomen

TricepsSuprailium

Thigh

Girth Measurements

Uses 3 sites: see Appendix F Men: right forearm, abdomen, right

upper arm or buttocks Women: abdomen, right thigh, right

forearm or right calf

Pattern of fat distribution Predicting Body Fat

Waist-to-Hip Ratio

Predicts disease risk according to “apple” or “pear” shape

Disease Risk according to Waist-to-Hip Ratio

Essential andStorage Fat

Techniques to Assess Body Composition

Determining Recommended Body Weight

Bioelectrical Impedance

Hydrated, fat-free body tissues and extracellular water facilitate electrical flow compared to fat tissue because of greater electrolyte content of fat-free component.

Health Risks of Obesity

Cardiovascular diseaseCardiovascular disease Type 2 DiabetesType 2 Diabetes HypertensionHypertension Some cancersSome cancers Gallbladder diseaseGallbladder disease OsteoarthritisOsteoarthritis Costly for healthcare systemCostly for healthcare system

Fat Cell Development

Fat cells increase in numbers (hyperplastic Fat cells increase in numbers (hyperplastic obesity) and in size (hypertrophic obesity)obesity) and in size (hypertrophic obesity)

Fat cell numbers increase most rapidly in Fat cell numbers increase most rapidly in later childhood and early puberty; in times later childhood and early puberty; in times of positive energy balanceof positive energy balance

Fat cell size increases when energy intake Fat cell size increases when energy intake exceeds expenditure (feasting)exceeds expenditure (feasting)

Fat Cell Development

When fat cells have enlargedand energy intake continues toexceed energy expenditure, fatcells increase in number again.

During growth,fat cells increasein number.

When energy intakeexceeds expenditure,fat cells increase in size.

With fat loss, the size ofthe fat cells shrinks, butnot the number.

Fat cells are capable of increasing their size by20-fold and their number by several thousandfold.

Causes of Obesity

Psychological/EnvironmentalPsychological/Environmental Learned response/habitLearned response/habit Food satisfies emotional needsFood satisfies emotional needs

stress, boredom, depression, feeling unlovedstress, boredom, depression, feeling unloved

Food as rewardFood as reward External cuesExternal cues

time, sight, smelltime, sight, smell

AvailabilityAvailability

Environment

OvereatingOvereating Present & past eating influences current body wtPresent & past eating influences current body wt Increase availability of convenient food, large portions, energy-Increase availability of convenient food, large portions, energy-

dense foodsdense foods

Physical InactivityPhysical Inactivity Modern technology replaces physical activitiesModern technology replaces physical activities Physical activity allows people to eat enough food to get needed Physical activity allows people to eat enough food to get needed

nutrientsnutrients

Environmental Causes (cont)

High kcal, high fat foods available; High kcal, high fat foods available; inexpensive, advertised (ex. Fast foods)inexpensive, advertised (ex. Fast foods)

Physical inactivity: change in modern Physical inactivity: change in modern technology, TV watchingtechnology, TV watching

Est. that < 1/3 people exercise 30 min./day; Est. that < 1/3 people exercise 30 min./day; 40% do not exercise at all40% do not exercise at all

Causes of Obesity - Genetics

Heredity (twin research, adoptive children Heredity (twin research, adoptive children research)research)

Set-Point Theory Set-Point Theory Body’s natural regulatory centers maintain Body’s natural regulatory centers maintain

homeostasis at set pointhomeostasis at set point Human body tends to maintain a certain weightHuman body tends to maintain a certain weight Obesity is the state of very high set pointObesity is the state of very high set point

Genetic Causes

Leptin (ob protein)Leptin (ob protein) Hormone produced by adipose tissueHormone produced by adipose tissue Decreases appetiteDecreases appetite Increases energy expenditureIncreases energy expenditure Central fat pattern produces less leptin than Central fat pattern produces less leptin than

peripheral fatperipheral fat More research neededMore research needed

Genetic Causes - Ghrelin

Protein produced by stomach cellsProtein produced by stomach cells Acts as a hormone to decrease energy Acts as a hormone to decrease energy

expenditure, increase appetiteexpenditure, increase appetite

• Even though the risk for premature illness and death is greater for those who are overweight, the risk also increases for individuals who are underweight

4.6Disease and Mortality Risk Based on BMI

Because of the typical reduction in physical activity, each year the average person gains 0.68 kg of body fat and loses 0.23 kg of lean tissue

15.8Body Composition Changes for Adults in the U.S

OBESITA’Dati IstatOBESITA’Dati Istat

Dimensioni dell’Obesità negli adulti in Italia

Validità delle informazioni disponibili Dati riferiti: gli intervistati tendono a sottostimare l’eccesso di peso -

buona rappresentatività, ma probabile sottostima dell’obesità Dati misurati: aree selezionate in modo opportunistico – buona

accuratezza, ma il campione potrebbe rappresentare in modo distorto la realtà nazionale

Dati riferiti: ♂ 1 su 2 sovrappeso (BMI ≥ 25) ♀ 1 su 3 sovrappeso (BMI ≥ 25)

Dati misurati: ♂ 3 su 4 sovrappeso (BMI ≥ 25) ♀ 1 su 2 sovrappeso (BMI ≥ 25)

Fonte: Progetto del Ministero della Salute ”Sorveglianza ed educazione nutrizionale basata su dati locali per la prevenzione di malattie cronico-degenerative” anni 2000-2002.

16%23%

26% 24%

31%28%

24%

7%

9%

10% 13%

20% 27%

11%

0%

10%

20%

30%

40%

50%

60%

Lombardia

(Lodi)

Toscana Emilia

Romagna

(Bologna)

Puglia

(Brindisi)

Campania

(Pomigliano

d'arco)

Calabria

(Lamezia

Terme)

Totale

Sovrappeso Obesi

Dimensioni dell’Obesità infantile in 6 diverse aree Italiane

Confronti internazionali, indagini con misurazioni dirette usando le soglie dell’IOTF, 2008

Difficile fare paragoni validi a causa di gruppi di età diversi e mancanza di studi recenti che utilizzino le soglie IOTF* Bambini 7-9 anni

Ma il cambiamento c’è dagli anni ‘70

Distribuzione IMC anni 70 dati INRAN e 2008 OKkio, pool ASL (Abruzzo meno Sulmona, Salerno, Cosenza)

0%

5%

10%

15%

20%

25%

11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27

Anni 70 2008

mediana anni 70 = 16,3

mediana 2008 = 17,9 (n=1784)

Distribuzione percentuale dei bambini per consumo di frutta e verdura. Italia, 2008

Distribuzione percentuale dei bambini per consumo di bevande zuccherate e/o gassate. Italia, 2008

Attività fisica il giorno prima dell’indagine

Il 26% dei bambini non ha svolto attività fisica il giorno precedente l’indagine

≤ 22%

> 22% e ≤ 24%

> 24% e ≤ 27%

> 27%

Attività fisica settimanale extrascolastica

Il 25% dei bambini svolge attività fisica per non più di un’ora a settimana

I maschi tendono a essere più costanti

Nei piccoli centri più che nelle grandi città

21%

60%

20%30%

56%

14%

0-1 2-3 4-7

numero di giorni con almeno un'ora di attività fisica

Modalità utilizzata dai bambiniper recarsi a scuola

modalità utilizzata per raggiungere la scuola

13%

59%

25%

1% 2%

scuolabus macchina a piedi bicicletta altro modo

Numero di ore giornaliere dedicatealla TV e ai videogiochi

Solo il 3% dei bambini dedica a TV e videogiochi meno di 1 ora al giorno

L’11% dedica a queste attività più di 4 ore al giorno

310

31 30

15 11

< 1 1 1 – 2 2 – 3 3 – 4 > 4

numero di ore/die dedicate a comportamenti sedentari

Prevention

Eat regular meals and limit snackingEat regular meals and limit snacking Drink water in place of high-kcal beveragesDrink water in place of high-kcal beverages Select sensible portion sizesSelect sensible portion sizes Limit daily energy intake to energy Limit daily energy intake to energy

expendedexpended Limit sedentary activities; be physically Limit sedentary activities; be physically

activeactive

Role of Metabolism in Nutrition

Metabolism Metabolism – process by which living systems Metabolism – process by which living systems

acquire and use free energy to carry out vital acquire and use free energy to carry out vital processesprocesses

Catabolism (degradation)Catabolism (degradation) Nutrients and cell constituents are broken down for Nutrients and cell constituents are broken down for

salvage and/or generation of energysalvage and/or generation of energy Exergonic oxidationExergonic oxidation

Anabolism (biosynthesis)Anabolism (biosynthesis) Endergonic synthesis of biological molecules from Endergonic synthesis of biological molecules from

simpler precursorssimpler precursors Coupled to exergonic processes through Coupled to exergonic processes through ““high-energyhigh-energy””

compoundscompounds

Role of Metabolism in Nutrition

Definition: the sum of all biochemical changes that takeplace in a living organism.

Group these reactions into two types:

anabolic catabolic

Reactions: require energy release energy

Produce: more complex more simple compoundscompounds

ModusOperandi: Occurs in small steps, each of which is controlled by specific enzymes.

Relationship Between Catabolic and Anabolic Pathways

Catabolic pathwaysCatabolic pathways Complex metabolites are transformed into Complex metabolites are transformed into

simpler products simpler products Energy released is conserved by the synthesis Energy released is conserved by the synthesis

of ATP or NADPHof ATP or NADPH Anabolic pathwaysAnabolic pathways

Complex metabolites are made from simple Complex metabolites are made from simple precursors precursors

Energy-rich molecules are used to promote Energy-rich molecules are used to promote these reactions these reactions

Examples of each type of metabolism:

Anabolic Pathways Catabolic Pathways

Protein Biosynthesis GlycolysisGlycogenesis TCA (Krebs cycle)Gluconeogenesis ß-oxidationFatty Acid Synthesis Respiratory Chain

Other useful generalizations:

Some of the steps in the anabolic path (going “uphill”) may not beidentical to the catabolic path--but some are shared.

ATPGeneratedProvidesEnergy

FOR

56

Il metabolismo dei carboidrati

Tortora, Derrickson Conosciamo il corpo umano © Zanichelli editore 2009

57

Il metabolismo dei carboidrati

Tortora, Derrickson Conosciamo il corpo umano © Zanichelli editore 2009

Carbohydrate metabolism

Glucose

55% Oxidation

20% Glycolysis

25% Re-uptake

10% Muscle

45% Brain

59

Il metabolismo dei lipidi

Tortora, Derrickson Conosciamo il corpo umano © Zanichelli editore 2009

1. Triglycerides-----consists of fatty acids

major energy component of fat

2. Essential dietary fatty acids-----linoleic, linolenic, arachidonic

precursors for membrane phospholipids

3. Cholesterolprecursors for steroid hormones and bile acid

Fat metabolism

Lipoprotein

Fat metabolism

Hydrophilic surfacePhospholipidCholesterolProtein

Hydrophobic coreTriglyceride (TG)

Lipoprotein Density TG Cholesterol Phospholipid Protein

ChylomicronsVLDLIDLLDLHDL

High

Low

1. Protein synthesis2. Oxidation3. Gluconeogenesis-----Krebs cycle, a reversal of glycolysis 4. Ketogenesis-----ketone body (acetoacetate)5. Ureagenesis-----urea (into urine) through the Krebs-Henseleit cycle

Protein metabolism

Amino acids Amino acids

Protein (Diet) Protein

E N E N

Glucose

Amino acids

N

Pyruvate

Dei 20 aminoacidi contenuti nelle proteine, 9 sono essenziali.

Fabbisogno (mg/kg) Lattante (4-6 mesi) Bambino (10-12 anni) Adulto

Istidina (29) - -

Isoleucina 88 28 10

Laucina 150 44 14

Lisina 99 49 12

Metionina e cistina 72 24 13

Fenilalanina e tirosina 120 24 14

Treonina 74 30 7

Triptofano 19 4 3

Valina 93 28 13

TOTALE (esclusa istidina)

715 231 86

64

Protein Metabolism

65

Alcohol Metabolism Effects

How do we employ energy?

• MECHANICAL- muscle contraction

• ELECTRICAL- maintaining ionic gradients (e.g., Na-K ATPase; 70% of ATP used by kidney & brain used to maintain gradient)

• CHEMICAL- biotransformation of molecules (e.g., synthesis degradation, metabolism)

International Unit of Energy: Joule

: energy used when 1 Kg is moved 1 meter by a force of 1 Newton

: kJ = 103 J; MJ = 106 J

: 1 kcal = 4.184 kJ

: Protein: 17 kJ or 4 kcal/g CHO: 17 kJ or 4 kcal/g

Fat: 37 kJ or 9 kcal/g

Measurement of Energy Intake

Energy needs

Metabolic Energy Yields

Conversion Efficiency: Food to Usable Energy

40% used to makehigh energy phosphatebonds

60% “lost” (?) as60% “lost” (?) asheatheat

Energy Balance

Sources of fuel for energySources of fuel for energy Input from diet: carbs, fat, prot, alcoholInput from diet: carbs, fat, prot, alcohol Stored energy: glycogen, fat, muscleStored energy: glycogen, fat, muscle

Energy outgo from:Energy outgo from: Basal metabolismBasal metabolism Physical activityPhysical activity ““Dietary thermogenesisDietary thermogenesis””

Energy Out Energy of food = Body Energy = ATPEnergy of food = Body Energy = ATP

Overall efficiency 25%, 75% released heatOverall efficiency 25%, 75% released heat Energy out:Energy out: 3 main components: 3 main components:

Basal Metabolic RateBasal Metabolic Rate Thermic Effect FoodThermic Effect Food Physical activityPhysical activity

BMR > Activity > Dietary Thermogenesis

Basal Metabolic Rate

BMR = number of calories would need daily simply to stay BMR = number of calories would need daily simply to stay alive if were totally inactive, in bed, awake for 16 hours & alive if were totally inactive, in bed, awake for 16 hours & slept for 8 hoursslept for 8 hours

Harris-Benedict Equation:Harris-Benedict Equation: Women: 655+(9.56 x weight in kg)+(1.85 x height in cm)-Women: 655+(9.56 x weight in kg)+(1.85 x height in cm)-

(4.7 x age)=BMR(4.7 x age)=BMR Men: 67+(13.75 x weight in kg)+(5.0 x height in cm)- (6.9 Men: 67+(13.75 x weight in kg)+(5.0 x height in cm)- (6.9

x age)=BMRx age)=BMR

1) Basal Metabolic Rate 50-70% Energy Expenditure50-70% Energy Expenditure Maintain basic metabolic processesMaintain basic metabolic processes

CellsCells MusclesMuscles Temperature regulationTemperature regulation

GrowthGrowth Osmotic pumpsOsmotic pumps Protein synthesisProtein synthesis HeartHeart Respiratory systemRespiratory system Digestive tractDigestive tract Individual variationIndividual variation Within individual variationWithin individual variation

10%

Factors affecting BMR

1) Body Size & Composition1) Body Size & Composition Lean tissue Lean tissue BMRBMR Body weight Body weight wt wt lean tissue (but also lean tissue (but also fat)fat)

2) Age:2) Age: age age Lean tissueLean tissue

3) Sex: Men 3) Sex: Men leanlean 4) Activity: Exercise 4) Activity: Exercise lean tissuelean tissue

Factors affecting BMR

5) Growth 5) Growth BMRBMR Children, pregnancyChildren, pregnancy

6) Fasting/starvation: 6) Fasting/starvation: BMRBMR 7) Fever/stress 7) Fever/stress BMRBMR 8) Smoking/caffeine: 8) Smoking/caffeine: BMRBMR

2) Energy Out: Dietary Thermogenesis

Dietary thermogenesisDietary thermogenesis Energy to digest, absorb, metabolize foodEnergy to digest, absorb, metabolize food About 10% of calories eatenAbout 10% of calories eaten

2) Thermic Effect of Food

3-6 hours following ingestion3-6 hours following ingestion ~10% energy intake~10% energy intake

2000 kcal diet = 200 kcal TEF2000 kcal diet = 200 kcal TEF Affected by:Affected by:

Meal size/frequencyMeal size/frequency Composition: Protein > Carbs/fatComposition: Protein > Carbs/fat GeneticsGenetics

3) Energy Out: Physical Activity

Physical Activity affected by:Physical Activity affected by: Intensity -- how vigorousIntensity -- how vigorous Time spentTime spent Body weightBody weight

3) Physical Activity

Variable: 20-40%Variable: 20-40% Working muscles require energyWorking muscles require energy

Heart/lung extra energyHeart/lung extra energy Amt energy used depends on:Amt energy used depends on:

Muscle massMuscle mass Body weightBody weight Activity nature & durationActivity nature & duration

Activity Level and Metabolism

Activity can account for 20-30% of metabolismActivity can account for 20-30% of metabolism1.1. Sedentary = Multiplier 1.15 x BMRSedentary = Multiplier 1.15 x BMR

2.2. Light activity (Normal Every day activities) = Light activity (Normal Every day activities) = Multiplier 1.3 x BMRMultiplier 1.3 x BMR

3.3. Moderately Active(exercise 3-4 xModerately Active(exercise 3-4 x’’s week) = Multiplier s week) = Multiplier 1.4 x BMR1.4 x BMR

4.4. Very Active (exercise more than 4 xVery Active (exercise more than 4 x’’s week) = s week) = Multiplier 1.5 x BMRMultiplier 1.5 x BMR

5.5. Extremely Active (exercise 6-7 xExtremely Active (exercise 6-7 x’’s week) = Multiplier s week) = Multiplier 1.6 x BMR1.6 x BMR

Activity Level and Metabolism If you change Light activity (Normal Every day If you change Light activity (Normal Every day

activities) to Moderately Active (exercise 3-4 xactivities) to Moderately Active (exercise 3-4 x’’s week) s week) daily caloric burning goes up 7.7%daily caloric burning goes up 7.7%

If you change Light activity (Normal Every day If you change Light activity (Normal Every day activities) to Very Active (exercise more than 4 xactivities) to Very Active (exercise more than 4 x’’s s week) daily caloric burning goes up 23%week) daily caloric burning goes up 23%

If you change Light activity (Normal Every day If you change Light activity (Normal Every day activities) to Extremely Active (exercise 6-7 xactivities) to Extremely Active (exercise 6-7 x’’s week) s week) daily caloric burning goes up 38.5%daily caloric burning goes up 38.5%

Energy Requirements

Difficult to estimateDifficult to estimate Direct measurementDirect measurement

ResearchResearch Estimates from averagesEstimates from averages

Based on age/sexBased on age/sex Assume light/moderate activityAssume light/moderate activity Estimate TEFEstimate TEF