International Journal of Obesity (2014), 15

2014 Macmillan Publishers Limited All rights reserved 0307-0565/14

www.nature.com/ijo

ORIGINAL ARTICLE

Correction factors for the calculation of metabolic equivalents

(MET) in overweight to extremely obese subjects
B Wilms1,2, B Ernst3, M Thurnheer3, B Weisser4 and B Schultes3
BACKGROUND/OBJECTIVES: The metabolic equivalent (MET) is a construct that is commonly used to quantify physical activity as
well as exercise performance. One MET is equal to a resting oxygen uptake of 3.5 ml O2 kg 1 min 1. However, this assumption is
unlikely valid in obese subjects. The aim of our study was to quantify the difference between calculated and measured METs in
overweight to severely obese subjects and to provide body mass index (BMI)-specic MET correction factors.
SUBJECTS/METHODS: Resting oxygen uptake (VO2-REE) was measured in 1331 patients with a BMI >25 kg m 2 (72.0% women;
age: 42.5 13.0 years; BMI: 42.5 7.0 kg m 2) by indirect calorimetry and MET-REE, that is, VO2-REE related to body weight was
calculated. Six hundred and fty-two subjects (70.9% women) additionally underwent a bicycle cardiopulmonary exercise test for
measurement of maximal MET (MET peak).
RESULTS: Mean MET-REE was 2.47 0.33 ml O2 kg 1 min 1 in women and 2.62 0.34 ml O2 kg 1 min 1 in men, that is, markedly
lower than the expected 3.5 ml O2 kg 1 min 1. MET-REE decreased with increasing BMI (P o 0.001 for both sexes). On this dataset,
gender-specic MET correction factors were developed for distinct BMI groups. During the exercise test, women performed 4.4 1.3
MET peak and men 4.7 1.3. After applying our correction factors, MET peak increased to 6.2 1.7 and 6.1 1.6, respectively.
CONCLUSIONS: Data indicate that the commonly used 1-MET value of 3.5 ml O2 kg 1 min1 largely overestimates values in
overweight to severely obese subjects. Our correction factors can help to reduce this systematic error and thus appear to be
valuable for clinical practice as well as research studies.
International Journal of Obesity advance online publication, 25 February 2014; doi:10.1038/ijo.2014.22
Keywords: metabolic equivalent; correction factor; resting energy expenditure; exercise capacity

INTRODUCTION
Physical activity is a cornerstone of human health. For instance,
a drop in physical activity during puberty in adolescents has been
shown to predict subsequent weight gain and thus the development of obesity.1 Obesity in turn is associated with reduced
physical activity24 and reduced exercise performance,5 both of
which are predictors for increased morbidity and mortality.68
The metabolic equivalent (MET) is a construct that is commonly
used to quantify physical activity according to its intensity and
energy costs as well as exercise performance.911 MET reects the
energy costs of physical activity as a multiple of resting energy
expenditure (REE). Since REE is often not known in individual
subjects and is largely reected by oxygen (O2) uptake, a constant
of 3.5 ml O2 kg 1 min 1 is commonly used to calculate an
individuals REE, that is, one MET. Although this constant might
be valid for a 70-kg and 40-year-old man, it can be assumed not to
be accurate in heavier men and women.12
Despite this obvious shortcoming, the MET construct is widely
used in clinical practice and may even lead decision-making
processes. For instance, a performance below a cutoff or threshold
level of four METs, which translates to climbing of two ights of
stairs, indicates a poor functional capacity that is associated with
an increased incidence of cardiac events after major surgical
interventions.13
The world is currently facing a global epidemic of obesity and
thus more and more people are obese. Obesity is associated with

an increased fat mass and fat tissue is known to display a lower

metabolic rate than most other tissues such as the skeletal
muscle.14 Thus, with increasing obesity and fat mass, REE (or one
MET) will not increase in a linear fashion. On this background, we
hypothesized that the MET construct is systematically biased
toward lower values with increasing degree of obesity and thus
needs to be computed by using body mass-dependent correction
factors. To test this hypothesis, we exploited our clinical database
that includes a large number of overweight to severely obese
subjects who underwent resting indirect calorimetry as well as
cardiopulmonary exercise test. Furthermore, on this dataset
we established METs' correction factors for different classes of
obesity.
SUBJECTS AND METHODS
Subjects
For this retrospective cross-sectional analysis, a total of 1331 patients with
a body mass index (BMI) of at least 25 kg m 2 and an age between 18 and
77 years were selected from the database of the Interdisciplinary Obesity
Center, St Gallen, Switzerland. All patients had undergone a measurement
of REE (REE group) by indirect calorimetry. In addition, data from 652
patients, who had undergone a symptom-limited bicycle cardiopulmonary
exercise test (CPET) for measurement of maximal achievable METs during a
second visit, were extracted from the database (CPET group). REE as well as
CPET measurements were performed between May 2006 and May 2012.
In most cases, both tests were part of a standardized assessment protocol

1
Department of Surgery, Cantonal Hospital, St Gallen, Switzerland; 2Exercise Physiology Lab, Institute of Human Movement Sciences, ETH Zurich, Zurich, Switzerland; 3eSwiss
Medical and Surgical Center, St Gallen, Switzerland and 4Institute of Sport Science, University of Kiel, Kiel, Germany. Correspondence: Professor B Schultes, eSwiss Medical and
Surgical Center, Brauerstrasse 97, 9016 St Gallen, Switzerland.
E-mail: bernd.schultes@stephanshorn.ch
Received 6 August 2013; revised 26 November 2013; accepted 14 January 2014; accepted article preview online 7 February 2014

Calculation of metabolic equivalents

B Wilms et al

2
before starting a weight loss program including bariatric surgery. All
patients gave written informed consent for a scientic use of their clinical
data and data analysis was performed in accordance to the Swiss Federal
Expert Commission for Physical Condentiality recommendations.

Assessment and analyzed variables

Body weight (BW) was measured to the nearest 0.1 kg with subjects
wearing light clothes. Height was measured without shoes to the nearest
0.5 cm and BMI was calculated from BW and height.
Resting oxygen uptake (VO2-REE) was measured by indirect calorimetry
using ventilated hood systems (from May 2006 to January 2011: Deltatrac
II, TM MBM 200, Hoyer, Bremen, Germany; since February 2011: Quark
CPET, Cosmed, Rome, Italy) for 20 min (Deltatrac II) and 30 min (Quark
CPET), respectively, under standardized conditions in the morning after an
overnight fast. During measurement, patients were laying in a supine
position awake, quiet and motionless. Measured VO2-REE and carbon
dioxide (VCO2-REE) were converted to REE by using the abbreviated Weirs
equation.15 Resting MET values (MET-REE) were calculated as ratio of
resting VO2-REE and BW (VO2-REE/BW).
Maximal achievable METs (MET peak) were assessed by bicycle
ergospirometry (CARDIO-VIT CS-200, Schiller AG, Baar, Switzerland). The
test protocol was characterized by starting at 2575 W depending on the
presumed patients' tness and increased by 25 W every 2 min until
volitional exhaustion ( = peak exercise). O2 uptake (VO2 peak), heart rate
(HR peak), work load (W peak) and respiratory exchange ratio peak (RER;
VCO2/VO2 ratio) were measured at the end of the exercise and MET peak
was calculated as VO2 peak/BW ratio divided by 3.5. Respiratory exchange
ratio peak as well as percentage of predicted maximal HR (HR max) were
used to characterize the degree of exhaustion at the end of the exercise.
All exercise tests were performed in the afternoon between 14:00 and
17:00h. All subjects were instructed not to performe any type of intense
physical activity on the day of the exercise testing and not to eat at least
1h before the test.
Before each indirect calorimetry and ergospirometry measurements,
systems were calibrated using standard gases of known oxygen and
carbon dioxide concentration and a 3-l syringe according to manufacturers' instructions.

Statistics
All statistical analyses were performed by using SPSS for Windows (Version
12, SPSS, Chicago, IL, USA). With subjects classied by BMI groups
(25.029.9, 30.034.9, 35.039.9, 40.044.9, 45.049.9, 50.054.9, 55.059.9,
60), between-group differences were obtained by using analysis of
variance. Student's t-tests for unpaired samples were used to test for
differences between men and women as well as between METs based on
the 1-MET concept of 3.5 ml O2 kg 1 min 1 and corrected METs. MET
correction factors were calculated as difference between 3.5 ml O2 kg 1
min 1 and mean of resting oxygen uptake for the respective BMI groups.
Stepwise multiple regression analysis was performed to explain variance of
deviation between measured and assumed METs (delta MET-REE).
Respective models included age, weight and height (or BMI instead of
weight and height) as independent variables. P-values of o0.05 were
considered to indicate statistical signicance.

RESULTS
Patients characteristics
The clinical characteristics of the study population are summarized
in Table 1. The age of the 1331 patients (72% women) included in
the REE group ranged from 18 to 77 years, BW from 69 to 234 kg
and the BMI from 26.1 to 73.2 kg m 2. The 652 patients
(71% women) included in the CPET group, who had undergone
the cardiopulmonary exercise test, displayed age range from 18 to
75 years, BW range from 69 to 197 kg and a BMI range from 25.3 to
71.3 kg m2. In both of the two groups, men were on average older,
heavier and displayed a higher BMI than women (all Po0.05).
METs under resting conditions
Results on the resting indirect calorimetry are summarized in
Table 2. As expected, men showed a higher O2 uptake (VO2-REE)
and a higher REE than women (both Po 0.001), as well a slightly
International Journal of Obesity (2014), 1 5

Table 1.

Characteristics of the REE and the CPET groups

Women
REE group

Men

CPET group

REE group

CPET group

n
960
462
371
190
Age (Years)
41.7 13.0 40.2 11.3 44.5 12.7a 44.9 11.6b
a
Body weight (kg) 112.0 20.0 117.0 19.7 133.7 23.5 140.3 21.8c
BMI (kg m 2)
42.2 7.1
43.9 6.5
43.1 6.6d
45.3 6.3b
Abbreviations: BMI, body mass index; CPET, cardiopulmonary exercise test;
REE, resting energy expenditure. Data are given as mean s.d. or n.
P-values derived by students t-test. aPo0.001 for differences between
women and men of the REE group. bPo0.05 for differences between women
and men of the CPET group. cPo0.001 for differences between women and
men of the CPET group. dPo 0.05 for differences between women and
men of the REE group.

Table 2. Data of resting energy expenditure measurement and

cardiopulmonary exercise test
Women
REE measurement
n
RQ
REE (kcal d 1)
VO2-REE (ml min 1)
MET-REE (ml kg 1 min 1)
Delta MET-REE (ml kg 1 min 1)
Delta MET-REE (%)

Men

960
371
0.84 0.07 0.85 0.06*
1902 323 2414 408**
274 47
347 60**
2.47 0.33 2.62 0.34**
1.03 0.33 0.88 0.34**
29.4 9.3
25.2 9.6**

Cardiopulmonary exercise testing

n
Percentage of predicted HR max (%)a
RER peak
VO2 peak (l min 1)
VO2 peak/BW (ml kg 1 min 1)
MET peak
Corrected MET peak

462
82.2 10.6
1.08 0.11
1.76 0.49
15.2 4.4
4.4 1.3
6.2 1.7

190
81.8 11.1
1.09 0.09
2.28 0.60**
16.4 4.5*
4.7 1.3*
6.1 1.6

Abbreviations: BW, bodyweight; corrected MET peak, metabolic equivalent

based on 1-MET concept of 3.5 ml O2 kg 1 min 1 using corrections
factors (provided in Table 3); delta MET-REE, deviation between measured
METs and METs of the traditional concept of 3.5 ml kg 1 min 1; HR,
heart rate; MET peak, metabolic equivalent based on 1-MET concept of
3.5 ml O2 kg 1 min 1; MET-REE, resting oxygen uptake related to BW
(VO2/BW); REE, resting energy expenditure; RER, respiratory exchange ratio;
VO2 peak, oxygen uptake at peak exercise; VO2 peak/BW, oxygen uptake at
peak exercise related to BW; VO2-REE, resting oxygen uptake. Data are
given as mean s.d. or n. P-values derived by students t-test. *Po 0.05.
**Po0.001. aSubjects taking beta blockers were excluded for analysis
(women: n = 39; men: n = 27).

higher RQ (P o0.05). Mean MET-REE values, which were overall

markedly lower than the expected 3.5 ml kg 1 min 1, were also
higher in men than in women (Po 0.05). The absolute as
well as relative deviation of MET-REE values from the expected
3.5 ml kg 1 min 1 were signicantly greater in women than in
men (both Po 0.001).
When women and men were classied in distinct BMI groups it
became clear that MET-REE progressively decreased with increasing BMI (Po 0.001 for both sexes; Figure 1). Accordingly, the
deviation of MET-REE values from the predicted 1-MET value of
3.5 ml O2 kg 1 min 1 progressively increased, that is, a progressive overestimation. Thus, the calculated correction factors
became progressively higher with increasing BMI (P o 0.001 for
both sexes, Table 3).
2014 Macmillan Publishers Limited

Calculation of metabolic equivalents

B Wilms et al

Figure 1. Measured resting oxygen uptake (METs; ml O2 kg 1 min 1) stratied by BMI for women (left) and men (right). P-values derived by
one-way ANOVA.
Table 3.

CF for the calculation of METs in overweight to severely obese subjects

BMI range

25.029.9
30.034.9
35.039.9
40.044.9
45.049.9
50.054.9
55.059.9
>60.0

Women of the REE group

Men of the REE group

CF (ml kg 1min 1)

Delta (%)

CF (ml kg 1 min 1)

Delta (%)

27
108
244
285
173
75
36
12

0.66 0.32
0.82 0.30
0.96 0.30
1.04 0.29
1.14 0.29
1.21 0.34
1.27 0.31
1.36 0.24

18.7 9.0
23.5 8.6
27.5 8.5
29.6 8.2
32.6 8.13
34.5 9.6
36.2 8.7
38.8 6.9

26
101
118
75
32
12
8

0.54 0.28
0.79 0.36
0.91 0.31
0.97 0.28
1.01 0.26
1.14 0.34
1.14 0.28

15.3 8.0
22.5 10.3
26.0 8.9
27.6 7.8
28.7 7.6
32.4 9.8
32.7 7.9

Abbreviations: BMI, body mass index; CF, correction factors; METs, metabolic equivalents; REE, resting energy expenditure. All values are mean s.d. or n.

In women, multiple stepwise regression analysis revealed that

weight alone explained 17.2% of the variance in the deviation of
MET-REE from the expected 3.5 ml O2 kg 1 min 1 (beta: 0.46;
P o0.001). Age and height explained further 1.7% (beta: 0.15;
P o0.01) and 0.6% (beta: 0.08; P = 0.013), respectively (total
explained variance, R2 = 20.8%). When BMI instead of weight and
height was included as an independent variable in the regression
model, it turned out that BMI was the strongest independent
predictor of the deviation explaining 17.3% of its variance (beta:
0.42; Po 0.001), whereas age explained further 1.5% (beta: 0.12;
P o0.001; R2 = 18.8). In men, weight turned out to be the strongest
independent predictor of the MET-REE 3.5 ml O2 kg 1 min 1
deviation explaining 14.5% of its variance (beta = 0.49;
P o0.001), whereas age and height independently explained a
further 3.3% (beta: 0.18; P o0.001) and 1.1% (beta: 0.12;
P = 0.029), respectively (R2 = 18.9%). When BMI was included in
the regression model, it explained 15.1% of respective variance
(beta: 0.42; P o 0.001). Age further improved the model by
increasing explained variance by 2.4% (beta: 0.16; P = 0.001;
R2 = 17.5).
METs at peak exercise
Data on the cardiopulmonary exercise tests and respective
calculated MET peak are presented in Table 2. The degree of
exhaustion, as indicated by respiratory exchange ratio peak and
percentage of predicted HR max values, was similar in women and
men (both P 0.16). In both sexes, the average respiratory
exchange ratio peak value was about 1.08, which indicates that
the patients reached a relatively high degree of exercise intensity
during the test. In line, mean percentage of predicted HR max of
about 82% was relatively high. Men, as expected, showed higher
relative, that is, related to BW, as well as absolute VO2 peak values
2014 Macmillan Publishers Limited

than women (both Po 0.05). The same was true when respective
data were transformed to MET peak values (both Po 0.003).
Table 3 provides an overview on the percentage deviation of
the MET peak values calculated on the classical 3.5 ml O2 kg 1
min 1 from those calculated on our new correction factors for
distinct BMI classes. On average, women showed a 41% higher
MET peak performance and men a 30% higher MET peak
performance when our correction factors were used (both
P o0.001). Interestingly, sex differences in peak performance did
not exist longer when corrected MET peak were considered
(P = 0.46). The VO2 peak and calculated MET values as well as the
MET values corrected by the BMI-specic correction factors for
different BMI classes are shown in Table 4.
According to previously reported age-adjusted reference values
for maximal METs,16 women performed on average only 46.9% of
the predicted maximal MET values and men achieved on average
only 43.6%. Using our newly calculated MET correction factors,
respective values increased to 67.3% in women and to 57.0%
in men.
When considering the commonly accepted threshold of four
METs at peak performance13 for an increased risk for perioperative
cardiac events, 192 (41.6%) women and 62 (32.6%) men displayed
MET peak values below this threshold. When our correction factors
were used, respective numbers decrease to 9.1 and 6.8%.
DISCUSSION
Present data indicate that the calculation of resting oxygen uptake
on the widely accepted 1-MET value of 3.5 ml O2 kg 1 min 1
overestimates actual values by 16.638.8% in overweight to
severely obese subjects. As a consequence, MET values calculated
from this equation markedly underestimate the O2 taken up and
hence the expended energy during physical activities as well as
International Journal of Obesity (2014), 1 5

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B Wilms et al

4
Table 4. VO2 peak, MET peak and corrected MET peak assessed by bicycle cardiopulmonary exercise testing in overweight to severely obese subjects
of the CPET group
BMI range

o35.0
35.039.9
40.044.9
45.049.9
50.054.9
55.0

Women of the CPET group

Men of the CPET group

VO2 peak
(ml kg 1 min 1)

MET peak

Corrected MET peak

25
98
161
109
39
30

1.68 0.47
1.74 0.54
1.73 0.47
1.78 0.49
1.80 0.48
1.91 0.45

5.4 1.5
4.9 1.4
4.4 1.1
4.1 1.0
3.7 0.9
3.5 0.8

7.0 1.8
6.7 1.9
6.2 1.6
6.1 1.5
5.7 1.4
5.5 1.3

38
59
51
29
13

VO2 peak
(ml kg 1 min 1)

MET peak

Corrected MET peak

2.33 0.55
2.17 0.63
2.27 0.64
2.40 0.58
2.37 0.57

5.6 1.3
4.8 1.3
4.4 1.1
4.2 1.0
3.8 1.0

6.7 1.5
6.2 1.6
6.0 1.6
5.8 1.3
5.5 1.4

Abbreviations: BMI, body mass index; corrected MET peak, metabolic equivalent based on 1-MET concept of 3.5 ml O2 kg 1 min 1 using corrections factors
(provided in Table 3); CPET, cardiopulmonary exercise testing; MET peak, metabolic equivalent based on 1-MET concept of 3.5 ml O2 kg 1 min 1; VO2 peak,
oxygen uptake at peak exercise. All values are mean s.d. or n.

performance on exercise tests. Here, we for the rst time provide

BMI-specic correction factors that will allow for a more reliable
judgement on physical activity and exercise performance in
overweight and, in particular, obese subjects.
Uncorrected MET tables17 or calculation formulas are often used
in software programs of exercise-testing machines and devices for
the assessment of physical activity, for example, accelerometers.
Our data indicate that respective software tools need to be
adapted to an individuals BMI (or height and weight) by using
validated correction factors such as established in our present
study. Otherwise, physical activity intensities as well as cardiopulmonary tness will systematically be underestimated with
increasing BMI. Therefore, we would like to encourage providers of
respective medical and lifestyle devices to integrate our, or other
yet to be established, correction factors in their software
programs. The same pertains to physical activity questionnaires
that often also report results on physical activity estimations as
METs.911 Here, we recommend to adapt respective questionnaires accordingly for obese subjects.
With increasing degree of obesity there is a disproportional rise
in body fat mass, which is metabolically less active than other
tissues such as skeletal muscle.14 Accordingly, we found that the
deviation of MET values measured by indirect calorimetry from the
predicted one MET value of 3.5 ml O2 kg 1 min 1 progressively
increases with increasing BMI. It can be assumed that an even
more appropriate correction of MET values than by using BMIrelated correction factors can be achieved if actual body
composition is considered. However, reliable technologies to
accurately measure body composition are rarely available in the
clinical stetting. Furthermore, body composition values usually
vary when different technologies, for example, bioelectrical
impedance analyses, dual-energy X-ray absorptiometry, air displacement plethysmography, are applied.18,19 On this background,
we believe that BMI-related correction MET factors provide a
valuable way to trait off accuracy and applicability in the clinical
setting.
Overall, exercise performance was rather weak in our tested
subjects even when the MET correction factors were applied.
In the context it should be noted that the subjects were not
systematically familiarized to the testing procedures so that it
might be possible that better results would have been obtained
when subjects were tested on a second occasion. The lack of a
second testing procedure clearly represents a limitation of study,
as respective test-re-test data would have provided important
information on the internal validity and reliability of the obtained
results.
Several other limitations of the present study need to be
mentioned. First, our MET correction factors are not adjusted for
age. In adults, REE is known to decrease with increasing age
International Journal of Obesity (2014), 1 5

independently of body composition changes.20 Putting this

forward, one can assume that our correction factors lead to MET
values that are systematically biased by age. In fact, multivariate
regression analyses in our study indicated an independent
inuence of age on REE. However, results also indicated that this
biasing inuence of age is rather small (1.5% explained variance in
women and 2.4% in men of the difference between measured and
assumed MET values) and thus, of minor importance in the clinical
context. Second, it is well known that peak VO2 and MET values
assessed by treadmill are commonly higher than those assessed
by bicycle ergospirometry. Thus, it would also be interesting to
apply our corrections factors on measurements assessed by
treadmill and compare this with those obtained by bicycle
ergometer. Finally, data were obtained in a Caucasian population.
Therefore, our correction factors might not be applicable in other
ethnic groups.
In conclusion, our data may help to develop more accurate
questionnaires and devices for the assessment of physical activity
in overweight to severely obese subjects. The novel correction
factors provided here will allow for an improved judgment on
exercise capacity, for example, during a preoperative risk
assessment, in this growing part of the population.
CONFLICT OF INTEREST
The authors declare no conict of interest.

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