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Energy Expenditure with Exercise in Paralympic 

Athletes with Visual Impairment: a Case Study

Gasto energético con ejercicio en atletas paralímpicos 

con discapacidad visual: un estudio de caso

Gasto energético com exercício em atletas paralímpicos 

com deficiência visual: um estudo de caso


Gabriela Rocha Pegorin*


Daniel Paduan Joaquim**


Ciro Winckler***


Claudia Ridel Juzwiak****



*Registered Dietitian. Student in the Post Graduate Program Interdisciplinary

in Health Sciences from the Universidade Federal de São Paulo

**Registered Dietitian. Specialist in Exercise Physiology

and Master in Health Science from the Universidade Federal de São Paulo

Researcher at the Brazilian Paralympic Academy

***Master and PhD in Physical Education

from Universidade Estadual de Campinas

Associative Professor at the Department of Human Movement Sciences

at the Universidade Federal de São Paulo

Researcher at the Brazilian Paralympic Academy

****Registered Dietitian. Specialist in Nutrition and Sport

by the Brazilian Nutrition Association

Master and PhD in Sciences from the Universidade Federal de São Paulo

Associate Professor at the Department of Human Movement Sciences

at the Universidade Federal de São Paulo

Post-doctorate in the area of Food Anthropology at the Universitat de Barcelona

Researcher at the Brazilian Paralympic Academy



Reception: 02/27/2020 - Acceptance: 07/31/2020

1st Review: 06/24/2020 - 2nd Review: 06/26/2020


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Suggested reference: Pegorin, G.R., Joaquim, D.P., Winckler, C., & Juzwiak, C.R. (2020). Energy Expenditure with Exercise in Paralympic Athletes with Visual Impairment: a Case Study. Lecturas: Educación Física y Deportes, 25(267), 95-107. Retrieved from: https://doi.org/10.46642/efd.v25i267.2022



    Energy expenditure with exercise (EEEx) is an essential factor to estimate daily energy requirement. However, few studies explore this subject in para-athletes. This study aimed to assess the EEEx of Brazilian Paralympic track & field sprinters during a preparatory training phase. Five sprinters athletes with visual impairment (2 males and 3 females) were assessed through direct observation to obtain information on duration and characteristics of the training. Athletes wore a motion sensor (Actical®) to assess EEex. Results were expressed in metabolic equivalents (MET) and ranged between 1.3 and 21.5 METs. Training sessions lasted in average two hours/session and the EEEx of each session assessed ranged between 190 and 380 kcal. It was concluded that the athletes with visual impairment presented EEEx ranging from light intensity to vigorous intensity. More studies will be needed focusing on this theme, covering more athletes, modalities and functional classifications to contribute to the work of the technical team working in the sport.

    Keywords: Energy expenditure. Athletes. Person with disability. Visual impairment.



    El gasto energético en el ejercicio (GEEx) es un factor esencial para estimar el requerimiento diario de energía. Sin embargo, pocos estudios han explorado este tema en atletas con discapacidad. Este estudio tuvo como objetivo evaluar el GEEx de los velocistas del equipo paralímpico brasileño durante el período preparatorio del entrenamiento. Se evaluaron cinco atletas velocistas con discapacidad visual (2 hombres y 3 mujeres) mediante observación directa para obtener información sobre la duración y las características del entrenamiento. Los atletas usaban un sensor de movimiento (Actical®) para evaluar GEEx. Los resultados se expresaron en equivalentes metabólicos (MET) que variaron entre 1.3 a 21.5 METs. Las sesiones de entrenamiento duraron aproximadamente dos horas/sesión y el GEEx de cada sesión varió entre 190 y 380 kcal. Se concluyó que los atletas con discapacidad visual tenían un GEEx que variaba de intensidad muy ligera a muy vigorosa. Se necesitarán más estudios centrados en este tema, que abarquen más atletas, modalidades y clasificaciones funcionales para contribuir al trabajo del equipo técnico que trabaja en el deporte.

    Palabras clave: Gasto energético. Atletas. Persona con discapacidad. Discapacidad visual.



    O Gasto Energético com Exercício (GEEx) é um fator essencial para estimar a necessidade de energia diária. Porém, poucos estudos exploraram esse tema em paratletas. Esse estudo teve como objetivo avaliar o GEEx de velocistas da seleção Paralímpica Brasileira durante o período preparatório de treino. Cinco atletas velocistas com deficiência visual (2 homens e 3 mulheres) foram avaliados através de observação direta para obter informação sobre duração e características do treino. Os atletas usavam um sensor de movimento (Actical®) para avaliar o GEex.Os resultados foram expressos em equivalentes metabólicos (MET) que variaram entre 1.3 a 21.5 METs. As sessões de treino duraram cerca de duas horas/sessão e o GEEx de cada sessão variou entre 190 e 380 kcal. Concluiu-se que os atletas com deficiência visual apresentaram GEEx variando entre intensidade muito leve a muito vigorosa. Serão necessários mais estudos focando nesse tema, abrangendo mais atletas, modalidades e classificações funcionais para contribuir com o trabalho da equipe técnica que atua no para esporte.

    Unitermos: Gasto energético. Atletas. Pessoa com deficiência. Deficiência visual.


Lecturas: Educación Física y Deportes, Vol. 25, Núm. 267, Ago. (2020)




    To estimate the energy requirements is important to adequate the supply of energy to the demand of the sport (Thomas et al., 2016; Broad & Juzwiak, 2019), thus guaranteeing athlete’s optimal body function, body mass and composition, performance and reducing injury risks caused by energy and nutrients deficiency (Thomas et al., 2016). However, to estimate para-athletes’ energy needs become a challenge, due to scarcity of information for this population and the high cost of most available accurate methods. (Broad & Juzwiak, 2019)


    The Total Energy Expenditure (TEE) refers to the energy produced by the demand of the metabolic processes and consists of the sum of three components: Basal Metabolic Rate (BMR) [or Resting Metabolic Rate (RMR)], Energy Expenditure with Exercise (EEEx) and Thermic Effect of Feeding (TEF). (Volp et al., 2011; Thomas et al., 2016; Broad & Juzwiak, 2019)


    The gold standard method to measure TEE is Double Labelled Water (DLW), direct and indirect calorimetry, but both have as disadvantage the high cost (Anastasopoulou et al., 2014; Aparicio-Ugarriza et al., 2015). In the impossibility of using the more accurate methods, a common practice is to estimate the BMR (RMR) using predictive equations and then applying an activity factor (AF) or adding the energy expended during exercise (EEEx) according to values published on different activities/exercises, to finally obtain the TEE. (Broad & Burke, 2014; Thomas et al., 2016)


    In para-athletes this can be challenging, since the predictive equations are based on sedentary or moderately active athletes without impairments and their accuracy for use this group of athletes is little known (Aparicio-Ugarriza et al., 2015). Juzwiak et al. (2016)compared BMR measured by indirect calorimetry with BMR predicted from equations in athletes with different impairments. Owen's equation was found to be the option that least overestimated BMR in athletes with cerebral palsy (104 kcal/day) and limb deficiency (125 kcal/day), while Mifflin's equation had the best performance to estimate BMR in visually impaired athletes (146 kcal/day). Pelly et al. (2017) compared measured BMR with BMR predicted from equations in athletes with spinal cord injury and showed no difference between BMR absolute values predicted and measured. However, when BMR was adjusted by lean tissue mass, BMR was higher in athletes with spinal cord injury in comparison about group control.


    EEEx refers to energy expenditure with daily physical activities, also known as Non-Exercise Activity Thermogenesis (NEAT), and energy expenditure with spontaneous and planned physical activities (Thomas et al., 2016). Its assessment can be conducted through subjective (such as physical activities diaries and retrospective questionnaires) or objective methods (such as direct and indirect calorimetry, DLW, heart rate monitoring, accelerometry and pedometry) (Anastasopoulou et al., 2014; Ainsworth et al., 2015). The least expensive and more easily available methods such as physical activity questionnaires or diaries, which information can be converted to EEEx values available in kilocalories or metabolic equivalent (MET), are most common in field studies and for athletes’ routine assessment (Aparicio-Ugarriza et al., 2015; Broad & Juzwiak, 2019).


    Few studies report EEEx in para-athletes, and the existing information covers mainly spinal cord injury (SCI) athletes. Price (2010) indicates that EEEx in SCI is 30 to 75% lower than in the general population. Collins et al. (2010) measured the EEEx of daily life activities obtained from a telemetry system and established that MET values should be adjusted to 2.7 mL/kg/min (instead of 3,5 mL/kg/min) for SCI athletes. Conger & Basset (2011) after a systematic review published a compendium of EEEx of wheelchair physical activities.


    EEEx information on other impairments is also scarce. However, athletes with limb deficiency may require more energy, in special, more proximal amputations or disarticulations. (Broad & Burke, 2014; Blauwet et al., 2017)


    Athletes with cerebral palsy may have EEEx variable according the presence of athetosis, spasticity or ataxia and the degree of neurological damage (Crosland & Boyd, 2014). EEEx data on other kinds of impairments are not available. (Blauwet et al., 2017)


    Wearable devices such accelerometers and pedometers measure physical activity through the acceleration of the body in motion, identifying gait pattern, number of steps, and from there it estimates EEEx (Anastasopoulou et al., 2014). Accelerometers are also interesting because they provide reasonably reliable estimate and valid measures of EEEx under laboratorial and free-living conditions. (Chowdhury et al., 2017)


    The use the specific devices, as accelerometers may be valid in athletes with visual impairment, intellectual impairments and minimal limb deficiency since they are physiologically similar to athletes without impairment. However, in a more impaired population (for example, dwarfs, unilateral cerebral palsy and neurological disorders) may not be valid, since its software programming is based on a population without impairment. (Juzwiak & Joaquim, 2019)


    Due to the lack of information of EEEx in para-athletes and the importance of this variable to assess and estimate energy needs, this study aims to assess EEEx of Brazilian Paralympic track & field sprinters with visual impairment in the specific preparatory training.




    This is a cross-sectional study approved by the Ethics Committee under appraisal #921.384/2014, and an informed and written consent was obtained from all participants.




    Data were collected during 20 days of training, resulting in 4 consecutive days of preparatory training for each athlete.




    Seven Brazilian Paralympic track & field athletes, from a universe of 12 athletes, all sprinters with visual impairment, were invited, but only 5 accepted to participate in the study. As inclusion criteria athletes had to participate in every training session proposed in the specific phase of the periodization. Athletes who missed a session or did not perform all proposed exercises were excluded from the study. Athletes whose training was altered from the programmed training due to climate changes or injuries were also excluded.


    The study was thus conducted with five athletes, all sprinters with visual impairment (VI), three (one male and two female) with total vision loss and two (one male and one female) with partial vision loss.


Anthropometric measurements 


    Athletes were characterized according to anthropometric measurements: body mass (kg) was assessed using an electronic scale Micheletti® (São Paulo, SP, Brazil) with 0.1 kg accuracy, height (m) using a stadiometer Sanny® (São Bernardo do Campo, SP, Brazil) with 0.1 cm accuracy and body skinfolds using a Lange® skinfold caliper (Santa Cruz, CA, EUA), on the right side of the body. Skinfolds (triceps, subscapular, biceps, iliac crest, abdominal, thigh and calf) were measured according to the procedures proposed by the International Society for the Advancement of Kinanthropometry (Stewart, Marfell-Jones & Ridder, 2011). Skinfolds measurements were presented as skinfolds sum (mm).


Exercise assessment 


    Data were collected through direct observation of each training session and recorded for each athlete. The record contained detailed characteristics of the training session and the duration of each exercise and total training time. The characteristics observed of each exercise were later analyzed concomitantly with the exercise energy expenditure monitored in MET.


    Acceleration motion of exercise was monitored using the accelerometer Actical® activity monitor 3.10 series, (Mini-Mitter Co., Bend, OR, USA). The device measures acceleration from 0.005 to 2.0G, and has a frequency range between 0.5 to 3.0Hz, memory capacity of 32MB, dimensions of 29mmX37mmX11mm and weighs 22g. The standardization employed in this study was of 15 seconds intervals that were converted in one minute of epoch (user-specified time interval) by software. Data in kilocalories (kcal) were obtained from the software and afterwards converted to metabolic equivalents (MET) considering the ratio 1 MET=1kcal/kg/hour.


    The night before each data collection the device was configured according to manufacturer’s information with input of name, weight, height, age, sex, start date. All athletes wore the Actical® activity monitor fixed by an elastic band around their bodies on the iliac crest for better accuracy, as proposed by Heil (2006).


Statistical analysis 


    Descriptive data are presented in mean, standard-deviation (SD) and minimum and maximum values.




    The anthropometric characteristics of the athletes are summarized in Table 1.


Table 1. Characterization of the participants




Age (years)

Height (m)

Body mass (kg)

Skinfolds sum (mm)

Athlete 1







Athlete 2







Athlete 3







Athlete 4







Athlete 5







FC = Functional Class; T = track; M = male; F = female; Skinfold sum = (triceps, subscapular, biceps, iliac crest, abdominal, thigh and calf).


    In general, male athletes had higher values for body mass, height and age, while female athletes had higher skinfolds sum.


    The training phase comprised exercises such as leg quadrant, arm quadrant, foot quadrant, ramp sprints, track sprints, abdominals, weight trains, jumps and medicine ball pitches (see Table 2). Track training sessions began at 8:45 am and ended at 11 am; longer exercises such as 300 m track sprints had a 15 minutes interval between sprints and short exercises such as 100m track sprints had a 6 minutes interval between sprints.


Table 2. Training sessions description


Type of Training


Duration (min)

Warming up

Mobility and flexibility

Mobility exercises


Specific warming up

free sprints, free running, light trot or control turns around track


Specific training

Training: different exercises in the morning train were observed in 4 days collecting data

ramp sprints, medicine ball pitches, abdominals, educational race, track sprints, jumps over plinth, track control turns or foot, arm and leg quadrant.



    The exercises description and METs are summarized in Table 3.


Table 3. Exercises description and Metabolic Equivalents (METs) according to sex


Exercise description






10 jumps over plinth

Plinth is a sports training equipment for jumps. In this exercise athletes had to jump over the plinth with both feet, went down the plinth with both feet and repeat it for 10 times.

2.7 (0.1)

[2.5 - 2.8]

1.3 (0.0)

[1.3 - 1.4]

20 unilateral jumps over plinth

Athletes were instructed to jump over the plinth 10 times once with right leg and after with the left leg for the same 10 times.

2.3 (0.4)

[1.8 – 2.7]

2.0 (0.3)

[1.7 – 2.3]

20 unilateral jumps over plinth with reaction

Athletes had to jump over the plinth with just one leg, and once over the plinth, they were instructed to take another leap, and after this, went down the plint to repeat these instructions for 10 times with right leg and 10 times with left leg.

2.4 (0.1)

[2.3 – 2.5]

2.0 (0.7)

[1.4 – 2.8]

300 m Track Sprint (100% power capacity)

Athletes had to sprint in the outdoor track for 300 m employing 100% of power capacity of the high-performance level.

20.3 (1.2)

[19 – 21.5]

13.9 (3.9)

[9.6 – 17.4]

10 Track Control turns – 300 m running (70%) and 100m walking (30%)

Athletes were instructed to do 10 turns around the outdoor track, employing 30% of the power capacity of the high-performance level in 100m of walking and 70% in 300 m of running.

6.1 (0.8)

[5.3 – 6.9]

6.3 (0.5)

[5.9 – 6.8]

5 Track Control turns – inserting 100 m jogging and 100 m walking.

In this exercise athletes had to do 5 turns around the outdoor track. They had to do 100m jogging and 100m walking for 5 times.

5.6 (0.7)

[4.9 – 6.3]

4.5 (0.0)

[4.4 – 4.5]

Data presented as mean (standard deviation)[minimum – maximum]; M = male; F = female; *The percent apply to the high-performance level.


    Table 4 show the EEEx (kcal/session) during four days of training, including all the exercises performed by the athletes.


Table 4. Athletes’ Energy Expenditure in 4 days training (kcal)






minimum – maximum

Athlete 1





207 - 550

Athlete 2





255 – 382

Athlete 3





194 – 351

Athlete 4





90 – 264

Athlete 5





109 – 315

FC = Functional Class; T = track; M = male; F = female; SD: standard deviation; kcal = kilocalories; Includes the exercises: 10 jumps over plinth, 20 unilateral jumps over plinth, 20 unilateral jumps over plinth with reaction, 300m track sprint (100% power capacity), 10 Track control turns – 300m running (70%) and 100m walking (30%), 5 Track control turns – inserting 100m jogging and 100m walking, leg quadrant, arm quadrant, foot quadrant, ramp sprints, track sprints, abdominals, jumps and medicine ball pitches.


    Mean EEEx during four training sessions ranged between 190 and 380kcal/session. The lowest EEEx session equaled 90kcal/session and the highest 550kcal/session.




    This study investigated EEEx of Brazilian Paralympic track & field sprinters with VI, in a preparatory training phase. In general, male athletes presented EEEx value between 238 at 380kcal and female athletes 190 at 340kcal per session.


    Data were gathered through direct observation during each training session when exercise detailed description and duration was recorded for each athlete. Although it is a subjective method, it is efficient in describing physical activity when employed in a delimited space and contributes with important details (Sylvia, 2014).


    To assess EEEx in real conditions as done in this study brings as limitation the difficult to gather data, since injuries culminate in training adjustments and therefore, fewer athletes participated than expected. As advantage, the results reflect a real training situation and can be used to guide professionals who work with this population, mostly dietitians, to estimate and adjust athletes’ energy requirements.


    When the use of calorimetry or DLW to measure EEEx in para-athletes is not possible, Broad & Burke (2014) suggest the use of accelerometers or heart rate monitors, which results are validated through oxygen uptake information. However, data of EEEx in para-athletes using accelerometers are scarce. (Blauwet et al., 2017; Broad & Juzwiak, 2019)


    Studies suggest (Heil, 2006; Anastasopoulou et al., 2014; Chowdhury et al., 2017) that accelerometers provide most accurate and validated results for full body motion exercises such as running and jogging, being an alternative for EEEx assessment. Furthermore, they are less sensitive to assess energy expenditure in activities such as weight training and isometric exercises, due to this, data regarding abdominal exercises, foot quadrant, leg quadrant, arm quadrant and were not considered in our results.


    Esliger & Tremblay (2006) sought to determine the validity and reliability of three accelerometer models, including Actical®, which presented the best inter and intra-instrument reliability. Klippel & Heil (2003) demonstrated a high correlation (r=0.94, p <0.001) between the counts/minute, used on the iliac crest, and MET measurements, determined by indirect calorimetry, during treadmill running of the healthy adults.


    The accelerometer Actical® is an omnidirectional device, this means the accelerometer can detect motion in several plans, but it is most sensitive in a single plan (Heil, 2006). Thus, due to the accelerometer limitation in capturing motion in the diagonal plane (Heil, 2006), results regarding exercises such as “ramp sprint” and free weights were excluded.


    EEEx was presented separately for male and female athletes because energy requirements differ according to sex due mainly to FFM differences between sexes (Armbruster et al., 2018). It is worth pointing out that in para-athletes the assessment of body composition also poses challenges, because there is no gold-standard method validated for this population. (Blauwet et al., 2017; Broad & Juzwiak, 2019)


    Exercises such as jumps over plinth provided values varying from 1.3 MET, as the minimum (in female athlete) to 2.8 MET as the maximum value (in male athlete). According to Ainsworth et al. (2011) MET values smaller than 3.0 are classified as light intensity activities. The low values obtained may be because the Actical® is less sensitive to assess energy expenditure in jumps and then, does not provides the accurate measurements for jumping exercises. However, Brown et al. (2010) in a study with male and female college athletes performing plyometric jumping found increased oxygen consumption and heart rate.


    Although the scarce information on para-athletes EEEx, Joaquim et al. (2018) evaluated Paralympic track & field athletes using accelerometer all day long, for four days. The VI sprinters showed an EEEx of 314 kcal/hour during an atypical training situation in which they performed tests of speed, power and jump in the morning and in the afternoon training sessions (jumps, sprints, weight train, educational race and mobility).


    Although, athletes with VI can be considered physiologically similar to athletes without impairments (Broad, 2014; Blauwet et al., 2017), it is known that circadian rhythm of individuals with VI are longer than individuals without impairment in a condition called free running (Squarcini et al., 2013) and this has potential to result in reduced peak performance, simple reaction time and body temperature regulation throughout the day (Winckler & Miranda, 2019). Those athletes may have a lower reaction time due to a longer processing time needed to establish their position in the environment; for example, where they are placed in the track, where the track will have a curve, where is their start point and final point (Klippel & Heil, 2003). Loturco et al. (2017) compared the muscle power and maximal isometric strength in Olympic and in Paralympic judo athletes with visual impairment and showed similar levels of maximal isometric strength, but higher muscle power in Olympic athletes. Schaffert & Mattes (2014) examined the effects of auditory feedback on boat speed in para-rowing athletes with VI and showed higher boat speed with auditory feedback independent of vision.


    In the present study, the “300m track sprint” exercise produced the highest increase in energy expenditure (MET value) in all athletes. This value ranged from 17.4 to 21.5 METs for female and male athletes, respectively (about 4.5min/mile), and it is close to the values of running (12mph, 13mph and 14mph, respectively, 5min/mile, 4.6min/mile and 4.3min/mile) as described in the Compendium of Physical Activities (Ainsworth et al., 2011) for individuals without impairments, for whom these activities range from 19.0 to 23.0 MET, respectively.

Although this research presents limitations, the data gathered may have applicability for professionals that work with para-athletes, mainly dietitians, bearing in mind this data are from real training conditions. This research contributes to sports nutrition in para sports knowledge, considering the lack of data about them.




    The results of this study showed that VI athletes have EEex ranging from very light intensity to very intense exercises within their preparatory phase.


    The EEex values found for the different exercises that comprise a track & field training session may support the development of a better estimate of EEex as part of the total energy expenditure (TEE), and therefore, the estimation of the daily energy requirements.




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Lecturas: Educación Física y Deportes, Vol. 25, Núm. 267, Ago. (2020)