Using Metabolic Equivalents in Clinical Practice

Barry A. Franklin, PhDa,b,*, Jenna Brinks, MSc, Kathy Berra, MSN, NPd, Carl J. Lavie, MDe,
Neil F. Gordon, MD, PhD, MPHf, and Laurence S. Sperling, MDg

Metabolic equivalents, or METs, are routinely employed as a guide to exercise training

and activity prescription and to categorize cardiorespiratory fitness (CRF). There are, however,
inherent limitations to the concept, as well as common misapplications. CRF and the pa-
tient’s capacity for physical activity are often overestimated and underestimated, respectively.
Moreover, frequently cited fitness thresholds associated with the highest and lowest mor-
tality rates may be misleading, as these are influenced by several factors, including age
and gender. The conventional assumption that 1 MET = 3.5 mL O2/kg/min has been chal-
lenged in numerous studies that indicate a significant overestimation of actual resting energy
expenditure in some populations, including coronary patients, the morbidly obese, and
individuals taking β-blockers. These data have implications for classifying relative energy
expenditure at submaximal and peak exercise. Heart rate may be used to approximate
activity METs, resulting in a promising new fitness metric termed the “personal activity
intelligence” or PAI score. Despite some limitations, the MET concept provides a useful
method to quantitate CRF and define a repertoire of physical activities that are likely to
be safe and therapeutic. In conclusion, for previously inactive adults, moderate-to-
vigorous physical activity, which corresponds to ≥3 METs, may increase MET capacity
and decrease the risk of future cardiac events. © 2017 Elsevier Inc. All rights reserved.
(Am J Cardiol 2018;121:382–387)

The term metabolic equivalents, or METs, indicates the several inherent limitations, inaccurate assumptions, and
oxygen requirements of varied activities. One MET equals common misapplications.
the amount of oxygen the body uses at rest sitting, which ap-
proximates 3.5 mL O2/kg/min. This expression of resting Energy Expenditure of Physical Activity
energy expenditure, originating from the work of Balke,1 is
traditionally considered to be independent of body weight and The energy cost of many household, recreational, and oc-
thus relatively constant for all persons. Thus, multiples of this cupational activities has been previously defined in terms of
value provide a simple, practical, and easily understood clas- oxygen requirements, expressed as METs. In fact, to facili-
sification scheme to quantify relative levels of energy tate exercise and activity prescription, a compendium of
expenditure. For example, it is easier, and more meaning- physical activities has been developed to quantify energy ex-
ful, to explain to a patient that he has exercised at 3 times penditures based on the ratio of estimated or measured work
his resting metabolic rate than to indicate he has consumed metabolic rate to a standard resting metabolic rate.2 Conse-
10.5 mL/kg/min. METs are also routinely used to describe quently, this resource is often used to identify and prescribe
an individual’s aerobic capacity or level of cardiorespira- appropriate physical activities for varied populations. This in-
tory fitness (CRF) and to prescribe activities that a patient volves recommending activities that are sufficiently below the
can safely perform. The concept is easy to understand, and highest MET level achieved during exercise testing. Walking
is often employed as an exercise training and activity pre- at a leisurely pace uses about 2 to 3 METs, whereas faster
scription guide, and to categorize CRF. However, there are walking speeds (e.g., 3.5 to 4.5 miles per hour [mph]) may
approximate 4 to 5 METs. Singles tennis requires about 6 to
7 METs. In contrast, jogging and running typically require
8 to 10 or more METs, respectively.
a
Preventive Cardiology and Cardiac Rehabilitation, William Beaumont
Hospital, Royal Oak, Michigan; bOakland University William Beaumont Using METs to Quantitate Fitness
School of Medicine, Rochester, Michigan; cCardiovascular Medicine, William
Beaumont Hospital, Royal Oak, Michigan; dCardiovascular Medicine and Peak or symptom-limited CRF can be directly measured
Coronary Interventions, Stanford Prevention Research Center, Stanford or estimated during an exercise test, using either a treadmill
University School of Medicine (Emeritus), Redwood City, or cycle ergometer. Direct assessment of CRF using venti-
California; eDepartment of Cardiovascular Diseases, John Ochsner Heart and latory gas exchange responses may be particularly useful in
Vascular Institute, Ochsner Clinical School-The University of Queensland
risk-stratifying patients with heart failure who may be con-
School of Medicine, New Orleans, Louisiana; fINTERVENT International,
Savannah, Georgia; and gEmory Heart Disease Prevention Center, Emory
sidered for heart transplantation, clarifying the functional
University School of Medicine, Atlanta, Georgia. Manuscript received Sep- impact and severity of valvular heart disease, differentiating
tember 6, 2017; revised manuscript received and accepted October 23, 2017. cardiac versus pulmonary limitations as a cause of exertional
See page 386 for disclosure information. dyspnea or impaired exercise tolerance, and in evaluating
*Corresponding author: Tel: (248) 665-5766; fax: (248) 655-5751. aerobic capacity more precisely because of the inaccuracies
E-mail address: [email protected] (B.A. Franklin). associated with estimating peak or maximal oxygen

0002-9149/© 2017 Elsevier Inc. All rights reserved. www.ajconline.org

https://doi.org/10.1016/j.amjcard.2017.10.033
 Review/METs in Exercise Testing and Prescription 383

Table 1
The conventional Bruce treadmill protocol with MET values* for each minute
interval completed
MET Requirement*
Stage MPH Grade Minutes Men Women Cardiac
I 1.7 10% 1 3.2 3.1 3.6
2 4.0 3.9 4.3
3 4.9 4.7 4.9
II 2.5 12% 4 5.7 5.4 5.6
5 6.6 6.2 6.2
6 7.4 7.0 7.0
III 3.4 14% 7 8.3 8.0 7.6
8 9.1 8.6 8.3
9 10.0 9.4 9.0
IV 4.2 16% 10 10.7 10.1 9.7
11 11.6 10.9 10.4
12 12.5 11.7 11.0
V 5.0 18% 13 13.3 12.5 11.7
14 14.1 13.2 12.3
15 15.0 14.1 13.0 Figure 1. The risks of coronary heart disease and cardiovascular disease de-
crease in association with increasing quintiles of CRF or aerobic capacity.
* MET values are for each minute completed. Note that women and cardiac There is a precipitous drop in risk when comparing the lowest (poor) with
patients achieve lower VO2 for equivalent workload. Holding on to front rail the next-lowest quintile (below average) for aerobic capacity, with a 64%
will increase the apparent MET expenditure or capacity.Adapted from decline in the overall risk of heart disease from the least to the most fit. In-
Reference 6. terestingly, little or no additional benefit occurs when moving from quintile
4 to 5, that is, “good” to “excellent” aerobic capacity, suggesting a plateau
in reduced relative risk. Adapted from Reference 17.
consumption.3,4 Average healthy, young- to middle-aged adults
generally have fitness levels ranging from 8 to 12 METs, in-
dicating that they can increase their oxygen consumption (or time (minutes) from the start of stage I of this standardized
energy expenditure) by 8- to 12-fold above their resting level. test, which involves simultaneous speed/grade increments every
Patients with heart failure and those who are elderly or mor- 3 minutes, was the single most important determinant of the
bidly obese may have exercise capacities as low as 2 to 4 VO2 max (r2 = 0.822).5
METs. Conversely, some elite endurance athletes can achieve
20 to 25 METs during maximal treadmill testing.
Fitness Thresholds and Mortality
Our experience indicates that when CRF is estimated from
the widely used Bruce treadmill protocol,5 characterized by As a guideline, persons with fitness levels <5 to 6 METs
large aerobic increments per stage (≥2 METs), it is com- generally have a poorer prognosis.7,8 In contrast, fitness levels
monly overestimated, which may be minimized by ramping of 9 to 12 METs or higher are associated with a marked sur-
protocols that increase treadmill speed and incline continu- vival advantage,9–13 even in men and women with and without
ously but in smaller increments. Aside from the fact that tight abnormal risk factor profiles14 or patients with known heart
handrail holding is often permitted, reducing the aerobic re- disease.15 A moderate-to-high level of fitness, expressed as
quirement of treadmill walking while spuriously increasing METs, confers a reduced risk of initial and recurrent cardiac
the apparent MET expenditure, methodological misapplica- events. For both primary and secondary prevention, each
tions can also contribute to estimation error. A common mistake 1-MET increase in CRF is associated with a 15% decrease
is to credit the patient for attaining a given stage of the Bruce in mortality.12,16 This reduction compares favorably with the
protocol, even though they may have only partially com- survival benefit provided by commonly prescribed
pleted their last attempted stage. For example, an apparently cardioprotective medications after myocardial infarction (e.g.,
healthy woman stops exercising because of volitional fatigue aspirin, β-blockers, angiotensin-converting enzyme inhibi-
after she has performed 30 seconds of stage 3 of the Bruce tors, and statins). Thus, a previously inactive, deconditioned
protocol (3.4 mph, 14% grade). The estimated MET capac- patient who increases his or her MET capacity from 5 to 7
ity for this example is frequently listed as 9 to 10 METs, could reduce their mortality risk by ~30%.
although the interpolated level of CRF is 7.5 METs. To provide In a seminal meta-analysis, Williams17 reported a 64%
more accurate estimates of the patient’s functional capacity, decline in the risk of heart disease when moving from “poor”
we recommend minute-by-minute estimates of the MET ca- (bottom 20%) to “good” to “excellent” levels of CRF or
pacity using the conventional Bruce treadmill protocol. aerobic capacity. In addition, a precipitous drop in risk is found
Maximal oxygen consumption (VO2 max) values were ob- when comparing the lowest quintile (#1) to the next lowest
tained in healthy men, women, and cardiac men using quintile (#2) (Figure 1). These data strongly support that poor
ventilatory expired gas analysis, expressed as mL/kg/min, and fitness warrants consideration as an independent risk factor,
subsequently converted to METs (Table 1).5,6 Stepwise mul- and that the primary beneficiaries of an exercise regimen are
tiple regression analysis, using the directly measured VO2 max those in the least fit, least active quintile. However, the above-
as the dependent variable, demonstrated that the duration of referenced fitness thresholds may be misleading, as they are
384 The American Journal of Cardiology (www.ajconline.org)

Table 2
(Top) Fitness and mortality in men, Aerobics Center Longitudinal Study, fitness categories*. (Bottom) Fitness and mortality in women, Aerobics Center Longitu-
dinal Study, fitness categories*

Table values are maximal METs attained during the exercise test.
* Adapted from Reference 18.

influenced by several factors, including age and gender. Ac- Although traditional recommendations suggest that accumu-
cordingly, CRF levels decrease with age, commonly because lated MVPA bouts should last 10 or more minutes to achieve
of reductions in physical activity, peak heart rate, myocar- the 30-minute daily minimum, recent studies suggest that even
dial contractility, and the consequences of associated weight shorter periods of MVPA, accrued over time, can produce car-
gain and chronic diseases. Healthy CRF cut points are also diovascular and metabolic health benefits.25,26
lower for women than for men, because of their lesser muscle Regular endurance exercise or MVPA generally raises the
mass, hemoglobin levels, and stroke volume. level of CRF when performed for an appropriate duration or
To further clarify age- and gender-specific exercise ca- frequency. When initiating an exercise program, level walking
pacity thresholds to guide assessment of mortality risk in at a 2- to 3-mph pace is strongly recommended, then gradu-
individuals undergoing exercise testing for diagnostic and/ ally increasing walking speed over time. This is referred to
or functional capacity assessment, Table 2 was developed using as the “progressive transitional phase.”27 Patients should be
previously published data from the Aerobics Center Longi- advised to stop exercise for symptoms of lightheadedness, per-
tudinal Study,18 the principal research asset of the Cooper sistent arrhythmias, angina, unusual shortness of breath,
Institute, Dallas, Texas, with specific reference to “good” (top moderate-to-severe claudication, or musculoskeletal discom-
40%), fair, and poor (bottom 20%) fitness levels. For both fort. They should also be instructed to report new or worsening
age and gender, the difference in achieving the cut point for symptoms with exercise to their physician and should seek
“good” versus “poor” fitness approximates only 2 METs. Col- immediate medical attention for symptoms that do not resolve
lectively, these data suggest that moving either from “poor” with rest. As a general guideline, the exercise intensity should
to “below average” fitness, or from “poor” (bottom 20%) to feel “fairly light” to “somewhat hard”—rather than “hard”
“good” fitness (top 40%), is likely to be achieved by moderate- or “very hard.” For young or middle-aged adults, about 4 to
intensity physical activity for a minimum of 30 minutes on 5 METs correspond to moderate-intensity activity, and 6 to
5 days each week or vigorous-intensity physical activity for 8 METs for vigorous activity. In healthy adults aged 65 and
a minimum of 20 minutes on 3 days each week. Other epi- older, moderate-intensity activity approximates 3 to 4 METs,
demiologic studies now support a cause-and-effect relation and vigorous exercise about 5 METs or higher.
between improved CRF and reduced mortality,19,20 rather than There are, however, limitations that influence the use of
merely an association between these variables, especially when METs when characterizing exercise intensity and estimat-
combined with relevant experimental and clinical data pro- ing the energy expenditure of physical activities.28–30 One
viding biologic plausibility.21,22 Thus, it appears that even limitation is the assumption that 1 MET = 3.5 mL/kg/min. Con-
modest increases in CRF can have a favorable impact on popu- temporary studies in some populations demonstrate that this
lation health. value significantly overestimates directly measured resting
oxygen consumption (VO2) and caloric expenditure by, on
average, 30% to 35%.29,31 In our experience32 and in the ex-
Employing METs in Exercise Programming or
perience of others,33 coronary patients and those on β-blocker
Prescription
therapy demonstrate a significantly lower resting metabolic
Moderate-intensity physical activity is typically defined rate as compared with the commonly accepted MET value.
as 3 to 5.9 METs, whereas vigorous-intensity physical ac- Similarly, our data34 and previous reports29,30 suggest a sig-
tivity involves aerobic requirements ≥6 METs. Accordingly, nificantly lower resting VO2, expressed as mL/kg/min, in
moderate-to-vigorous intensity physical activity (MVPA), coronary patients and the morbidly obese. Our obese study
which corresponds to any activity ≥3 METs, has been con- population (n = 64; 78% female) averaged 2.4 ± 0.5 mL/kg/
sistently shown to reduce the health risks associated with min at rest, and most subjects fell between 2.0 and 2.6 mL/
numerous chronic diseases and the risk of developing them.23 kg/min, corresponding to 57% to 74% of the standard
Other recent reports suggest that interventions that replace “normative” value. These data have implications for classi-
sedentary time with even brief periods of light-intensity physi- fying energy expenditure at submaximal and peak exercise.
cal activity (~2 min/h) may confer a survival benefit.24 For example, the morbidly obese patient with a resting VO2
 Review/METs in Exercise Testing and Prescription 385

Table 3
Variables influencing resting metabolic rate*
• Age
• Body composition
– Fat mass
– Fat-free mass
• Cardiorespiratory fitness
• Resistance training
• Clinical status
– Coronary artery disease
– Congestive heart failure
• Prescribed medications
– Beta-blockers
• Gender

* Adapted from References 29, 35.

Figure 2. Oxygen uptake during intermittent activity that requires 17.5 mL/
kg/min (5 METs) during continuous effort is shown by the solid line. Oxygen
of 2.4 mL/kg/min and a peak VO2 of 16.6 mL/kg/min who consumption for the same activity performed intermittently (2 minutes of
is consuming 14.0 mL/kg/min would be classified as working work [W] followed by 1 minute of rest [R]) is shown by the broken line.
at 5.8 METs (14.0/2.4) rather than the conventional esti- Oxygen consumption is lower during intermittent exercise than for continu-
mate, that is, 4 METs (14/3.5). Moreover, her CRF would ous exercise because of partial repayment of oxygen debt during interspersed
actually be 6.9 METs (16.6/2.4) as opposed to 4.7 METs (16.6/ rest periods.
3.5). Depending on the ordering indication, underestimating
CRF during peak or symptom-limited exercise testing may
have significant implications for a patient’s plan of care, in- seled to refrain from gardening (a requirement of 5 to 6 METs),
cluding incorrectly risk stratifying patients for presurgical because presumably it represents maximal or supramaximal
clearance. Common variables that may potentially influ- effort. However, if the activity is performed intermittently (i.e.,
ence the resting metabolic rate are shown in Table 3.29,35 2 minutes work, 1 minute rest), it can be accomplished at
The above-referenced findings also have relevance to ex- oxygen consumption levels well below those estimated for
ercise prescription and activity interventions in selected patient the task (Figure 2). Thus, by using the MET concept, one may
subsets (e.g., deconditioned, coronary, morbidly obese), in- considerably underestimate the patient’s capacity for physi-
cluding those with reduced levels of CRF, resting metabolic cal work.37 This is particularly important when counseling
rate, or both. The threshold intensity for improving CRF in patients about activities they enjoy and that will encourage
unfit individuals approximates only 30% of the VO2 reserve, them to be active such as gardening, swimming, dancing, or
as follows: training VO2 = 0.3 (peak VO2 − VO2 at rest) + VO2 walking the dog.
at rest.36 A patient with congestive heart failure taking a
β-blocker, whose peak and resting VO2 values are 15.4 and Estimating METs During Level and Graded Walking
2.5 mL O2/kg/min, respectively, would suggest a minimum Oftentimes, the MET values provided by contemporary ex-
aerobic requirement of 6.4 mL/kg/min (i.e., 0.3 [15.4–2.5] + ercise equipment may differ considerably from the actual
2.5), corresponding to walking speeds ~1.0 to 2.0 mph. Thus, energy expenditure. The treadmill, however, is a notable ex-
even “light” activity in this cohort, if maintained, may augment ception. Because the mechanical efficiency of treadmill
CRF and ultimately reduce mortality. walking is relatively constant, the oxygen cost of treadmill
Another limitation is that MET values of selected physi- walking is weight-dependent and at a given workload (speed
cal activities represent average energy expenditure levels, and and grade) requires approximately the same relative oxygen
these levels may vary considerably in individuals, depend- cost, expressed as METs, for all persons, regardless of age,
ing on age, body habitus, fitness, musculoskeletal integrity, fitness, or body weight.
and whether the activity is performed in a competitive The “Rule of 2 and 3 mph” has been suggested as an assist
environment.2 Metabolic demands are also highly depen- in estimating “steady-state” energy expenditure (at ~3 minutes
dent on speed and mechanical efficiency (skill). Activities that or longer) during treadmill walking.38 At a 2 mph walking
are less affected by skill include walking, jogging, and cycling. speed at 0% grade, which approximates 2 METs, each 3.5%
On the other hand, swimming, cross-country skiing, and tennis increase in treadmill grade adds 1 additional MET to the gross
are associated with a wide range of energy expenditures. En- energy cost (e.g., 2.0 mph, 3.5% grade approximates 3 METs).
vironmental conditions, clothing, and equipment can also For persons who can negotiate a 3-mph walking speed on level
influence the metabolic cost of activities. ground, which approximates 3 METs, each 2.5% increase in
Finally, the oxygen costs or MET requirements listed in treadmill grade adds an additional MET to the gross energy
the compendium of physical activities were derived from con- expenditure (e.g., 3.0 mph, 5% grade approximates 5 METs).
tinuous steady-state work (≥3 minute bouts), whereas activities
of daily living are often performed intermittently, rather than
Estimating Activity METs from Heart Rate
continuously. Accordingly, a patient who completed only stage
I of the conventional Bruce treadmill protocol (1.7 mph, 10% Heart rate may be used to estimate METs during struc-
grade), corresponding to a 5-MET capacity, might be coun- tured exercise or physical activity. Naughton and Haider39
386 The American Journal of Cardiology (www.ajconline.org)

Table 4
Changes in heart rate to estimate energy expenditure (METs) during daily activities*
The energy cost of any activity, expressed as METs, can be estimated from the resting and exercise heart rates using the equation:
METs = (6 x Heart Rate Index) – 5
where the Heart Rate Index equals the activity heart rate divided by the resting heart rate.
Example #1 A tennis player’s resting heart rate of 60 beats per minute (bpm) is increased to 120 bpm during a tennis match. His MET level is estimated as
follows: 120 bpm/60 bpm = 2.0 Heart Rate Index which is multiplied by 6, yielding 12, from which we subtract 5, yielding an estimated 7 METs.
(120/60 x 6) – 5 = (2 x 6) – 5 = 7 METs
Example #2 A recreational walker with a resting heart rate of 70 bpm walks at 105 bpm. Her estimated MET level is….
(105/70 x 6) – 5 = (1.5 x 6) – 5 = 4 METs

* Adapted from Reference 40.

suggested that in sedentary subjects, each 10 beat per minute accumulated throughout the day, encourages regular physi-
(bpm) increase in heart rate approximated a 1-MET in- cal activity and decreases sitting time. At all patient encounters,
crease in energy expenditure. Thus, a resting heart rate of 75, asking about minutes of daily MVPA is a strong message to
which increases to ~95 with walking (Δ = 20 bpm ~2 addi- patients.45 How do we explain the practical significance of
tional METs), is the equivalent of exercising at ~3 METs METs to our patients? By counseling them to increasingly
(1 MET [resting] + 2 METs = 3 METs). The larger the in- incorporate “Moderate-to-vigorous Exercise, Tuesday through
crease between the resting heart rate and the heart rate during Sunday,” or METs, into their lives.
exercise, the greater the energy expenditure. Wicks et al40 re-
ported a simple method for the prediction of oxygen uptake
(METs) in patients with and without heart disease, includ- Disclosures
ing those taking β-blockers, using the heart rate index equation The authors have no conflicts interest to disclose.
(Table 4).
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