Total daily energy expenditure (TEE) (Continued)

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Table 6 Total daily energy expenditure of well-nourished and of stunted or marginally malnourished children, measured with heart-rate monitoring techniques and expressed as multiples of basal metabolic rate

*Age*	n	*Energy expenditure or PAL*	*Condition*	*Reference*
Boys
6.9 ± 0.5	41	1.60 ± 0.35	Normal	Spurr & Reina (1989)
7.1 ± 0.6	42	1.46 ± 0.29	Underweight
11.1 ± 0.6	54	1.74 ± 0.45	Normal	Spurr & Reina (1989)
11.0 ± 0.6	82	1.77 ± 0.47	Underweight
11.1 ± 0.5	34	1.75 ± 0.35	Normal	Ramirez & Torun (1994)
10.8 ± 0.5	34	1.83 ± 0.31	Stunted
14.8 ± 0.5	34	1.84 ± 0.50	Normal	Spurr & Reina (1989)
14.8 ± 0.6	47	1.92 ± 0.43	Underweight
Girls
7.0 ± 0.7	29	1.53 ± 0.38	Normal	Spurr & Reina (1989)
7.3 ± 0.7	20	1.43 ± 0.16	Underweight
10.8 ± 0 7	24	1.45 ± 0.21	Normal	Spurr & Reina (1989)
10.8 ± 0.5	32	1.57 ± 0.38	Underweight
14.9 ± 0.6	19	1.61 ± 0.31	Normal	Spurr & Reina (1989)
15.2 ± 0.5	22	1.61 ± 0.43	Underweight

Figure 3a Total energy expenditure estimated by heart rate monitoring, excluding stunted and underweight boys.

Figure 3b Total energy expenditure estimated by heart rate monitoring, excluding stunted and underweight girls.

Figure 4a Total energy expenditure estimated with doubly labeled water or by heart rate monitoring, excluding stunted and underweight boys. Solid symbols: doubly labeled water.

Figure 4b Total energy expenditure estimated with doubly labeled water or by heart rate monitoring, excluding stunted and underweight girls. Solid symbols: doubly labeled water.

Table 7 Groups of children, classified by sex and age, whose total daily energy expenditure was estimated from time-motion observations or activity diaries^a

*Age (y)*	n	*Weight* *(kg)*	*Total energy expenditure*
*Age (y)*	n	*Weight* *(kg)*	*(kcal/d)*	*(kcal/kg/d)*	*PAL^b*	*Country*	*Condition*	*Method^c*	*Source*
Boys
1.5	12^d	9.3	725^e,f	78.5^e,f	1.39	Gambia	Mild malnutrition	O-Estimated EC	Lawrence et al (1991)
2-6	26	12.7 ± 3.2	1026^f	81^f	1.35	Guatemala	Stunted	O-Estimated EC	Torun (1990b)
4-6	25	17 ± 2	1130	66.5	1.27	Philippines	Normal	O-Estimated EC	Guzman et al (1991)
7-9	26	24 ± 3	1499	62.5	1.43	Philippines	Normal	O-Estimated EC	Guzman et al (1991)
10-12	25	32 ± 4	1971	61.6	1.61	Philippines	Normal	O-Estimated EC	Guzman et al (1991)
12-14	16	31.3 ± 5.6	1810	58.0	1.49	Singapore	Normal	D-Measured EC	Banerjee & Saha (1972)
13-15	24	47 ± 6	2043	43.5	1.37	Philippines	Normal	O-Estimated EC	Guzman et al (1991)
14.5 ± 0.4	102	51 ± 10	2626	51.6	1.68	UK	Normal	D-Adult EC	Durnin (1971)
14.6 ± 2.9	75^d	49.3 ± 12.8	2222 ± 572^f	45.1^f	1.45	Canada	Normal	D-Estimated EC	Bouchard et al (1983)
16-17	65	69.4 ± 9.5	2766 ± 247	39.9	1.47	Australia	Normal, Students	D-Adult EC	McNaughton et al (1970a,b)
16-17	9	65.0 ± 9.6	2886 ± 235	444	1.60	Australia	Normal, Workers	D-Adult EC	McNaughton et al (1970a)
16-19	32	56 ± 5	2726	48.7	1.71	Philippines	Normal	O-Estimated EC	Guzman et al (1991)
18-19	12	72.3 ± 8.1	2714 ± 276	37.4	1.46	Australia	Normal, Students	D-Adult EC	McNaughton et al (1970a)
18-19	9	68.4 ± 8.4	2740 ± 268	40.1	1.52	Australia	Normal, Workers	D-Adult EC	McNaughton et al (1970a)
Girls
1.5	12^d	9.3	725^e,f	78.5^e,f	1.43	Gambia	Mild malnutrition	O-Estimated EC	Lawrence et al (1991)
2-6	22	12.7 ± 3.2	1026^f	81^f	1.41	Guatemala	Stunted	O-Estimated EC	Torun (1990b)
4-6	27	17 ± 2	1058	62.2	1.28	Philippines	Normal	O-Estimated EC	Guzman et al (1991)
7-9	24	24 ± 2	1528	63.7	1.57	Philippines	Normal	O-Estimated EC	Guzman et al (1991)
13-15	24	46 ± 3	1744	37.9	1.33	Philippines	Normal	O-Estimated EC	Guzman et al (1991)
14.5 ± 0.5	90	52 ± 8	2211	42.5	1.59	UK	Normal	D-Adult EC	Durnin (1971)
14.6 ± 2.9	75^d	49.3 ± 12.8	2222 ± 572^f	45.1^f	1.64	Canada	Normal	D-Estimated EC	Bouchard et al (1983)
16-17	6	50.9 ± 5.3	1893 ± 195	37.2	1.38	USA	Normal	D-Estimated EC	Bradfield et al (1971)
16-17	113	58.3 ± 5.4	2025 ± 167	34.7	1.37	Australia	Normal, Students	D-Adult EC	McNaughton et al (1970a)
16-17	32	54.8 ± 7.2	2139 ± 237	39.2	1.50	Australia	Normal, Workers	D-Adult EC	McNaughton et al (1970a)
16-19	32	50 ± 3	1922	38.4	1.49	Philippines	Normal	O-Estimated EC	Guzman et al (1991)
18-19	21	58.7 ± 5.4	1949 ± 195	33.2	1.38	Australia	Normal, Students	D-Adult EC	McNaughton et al (1970a,b)
18-19	24	54.3 ± 5.6	2073 ± 159	38.2	1.53	Australia	Normal, Workers	D-Adult EC	McNaughton et al (1970a,b)

^a Energy expenditure data published by the authors or calculated from their data by B. Torun.
^b Physical Activity Level calculated using BMR estimated with Schofield's equations (1985).
^c O: Observations during daytime and diary or recall interview at night. D: Activity diary. EC: Energy cost of activities.
^d Assume 50% boys and 50% girls.
^e Mean of wet (76 kal/kg) and dry (81 kcal/kg) seasons.
^f Using the same mean values for boys and girls.

Time-motion data and comparison of methods

PALs calculated from heart rate studies coincided within 5% with those calculated from doubly-labeled water studies, except for girls 6-13 years old (Tables 3 and 5). Figure 4 also indicates that the estimates of daily energy expenditure per unit of body weight calculated by heart rate monitoring coincide quite well with those based on doubly-labeled water, at least among non stunted, well nourished boys and girls.

A review of the literature allowed us to identify several studies that estimated total daily energy expenditure of children from time-motion observations or activity diaries recorded for several days, combined with indirect calorimetry measurements or estimates of the energy cost of the recorded activities. The results of those studies, listed in Table 7, were published as such by the authors or calculated by us from their data.

Figure 5a Selected values of total energy expenditure estimated with time-motion/diary methods, compared with doubly labeled water (DLW) and heart rate monitoring (HR)*: boys. *B; Bouchard et al 1983; b: Banerjee & Saha 1972; D: Durnin 1971; G: Guzman et al 1991; L Lawrence et al 1988; M: MaNaughton et al 1970a,b; T: Torun 1990

Figure 5b Selected values of total energy expenditure estimated with time-motion/diary methods, compared with doubly labeled water (DEW) and heart rate monitoring (HR)*: girls. *B; Bouchard et al 1983; b: Banerjee & Saha 1972; D: Durnin 1971; G: Guzman et al 1991; L Lawrence et al 1988; M: MaNaughton et al 1970a,b; T: Torun 1990

Figure 5 shows all the experimental data from the studies described in Tables 2, 4 and 7. Most time-motion/diary results agree reasonably well with the results from doubly-labeled water and heart rate studies, but there is a tendency to underestimate the energy expenditure of older adolescents, especially boys, with the diary method.

Conclusions

Total daily energy expenditure of free-living children has been measured by a limited number of investigators using doubly-labeled water or adequate heart rate monitoring techniques. Most of those studies have been done in industrialized countries, and none in school aged children or adolescents in rural areas of developing countries.

The experimental results suggest that current FAO/ WHO/UNU recommendations for dietary energy are too high for children under 5, and possibly under 7, years of age. By contrast, current dietary recommendations for adolescent boys and for girls around puberty seem somewhat low.

Energy expenditure per unit of body weight of stunted or mildly underweight, but otherwise healthy, school-children and adolescents in developing countries tends to be higher than among those with adequate height and weight. The causes for this must be explored further. In the meantime it seems convenient to make dietary recommendations based on the ideal weights or PALs of the general population.

The validity of these conclusions must be confirmed by other studies, as they are based on research carried out within a very narrow range of geographic and social environments, and most investigations with doubly labeled water or heart rate monitoring in industrialized countries involved small numbers of children in each age and sex group. Studies with heart-rate monitoring in developing countries included larger series of children, but they were done mainly among low income urban groups.

Studies are especially needed in rural areas of the developing world and among middle and upper socioeconomic groups of children in developing and industrialized cities. The minute-by-minute heart rate monitoring technique seems promising for this purpose, provided that the samples of children studied are of appropriate size. If finances allow it, they should be validated in the field with the doubly-labeled water method.

Time-motion/diary techniques can be useful to confirm the accuracy of the recommendations if the values used for the energy cost of activities are appropriate for children and adolescents (Town, 1983, 1990a). They also provide important information on activity patterns that will allow better estimates of the 24-h PAL, and an understanding of the behavioral determinants of physical activity in children and adolescents.

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