RESSALVA Atendendo solicitação da autor, o texto completo deste d o c u m e n t o será disponibilizado somente a partir de 21/11/2025. ² THÈSE pour obtenir le grade de DOCTEUR DE L’UNIVERSITÉ GRENOBLE ALPES et de SAO PAULO STATE UNIVERSITY École doctorale : Ingénierie pour la Santé, la Cognition et l'Environnement Spécialité : MCA - Mouvement et Comportement pour la santé et l’Autonomie Unités de recherche : AUTONOMIE, GÉRONTOLOGIE, E-SANTÉ, IMAGERIE & SOCIÉTÉ (AGEIS) École doctorale : Post-Graduate Program in Movement Sciences Spécialité : Movement Sciences Unités de recherche : HUMAN MOVEMENT RESEARCH LABORATORY (MOVI-LAB) Les effets du surpoids et de l'obésité lors du franchissement d'obstacle pendant la marche The effects of overweight and obesity on obstacle crossing while walking Présentée par : Matthias CHARDON Thèse soutenue publiquement le 20/09/2024, devant le jury composé de : Patrice FLORE Président Professeur des Universités, Université Grenoble Alpes, France Anthony FLEURY Rapporteur Professeur des Universités, IMT Nord Europe, France Pascal MADELEINE Rapporteur Full Professor, Aalborg University, Denmark Ricardo Augusto BARBIERI Examinateur Assistant Professor, Università di Bologna, Italy Clint HANSEN Examinateur Researcher, University of Kiel, Germany Julie SOULARD Examinatrice PhD, Université Grenoble Alpes, France Fabio Augusto BARBIERI Directeur de thèse Associate Professor, Sao Paulo State University, Brazil Nicolas VUILLERME Directeur de thèse Professeur des Universités, Université Grenoble Alpes, France Sistema de geração automática de fichas catalográficas da Unesp. Dados fornecidos pelo autor(a). C471e Chardon, Matthias Michel François Les effets du surpoids et de l'obésité lors du franchissement d'obstacle pendant la marche / Matthias Michel François Chardon. -- Bauru, 2024 331 p. : il., tabs. Tese (doutorado) - Universidade Estadual Paulista (UNESP), Faculdade de Ciências, Bauru Orientador: Fabio Augusto Barbieri 1. Obésité. 2. Franchissement d'obstacles. 3. Démarche. 4. Fiabilité. 5. Dégagement. I. Título. UNIVERSIDADE ESTADUAL PAULISTA Câmpus de Bauru ATA DA DEFESA PÚBLICA DA TESE DE DOUTORADO DE MATTHIAS MICHEL FRANÇOIS CHARDON, DISCENTE DO PROGRAMA DE PÓS-GRADUAÇÃO EM CIÊNCIAS DO MOVIMENTO, DA FACULDADE DE CIÊNCIAS - CÂMPUS DE BAURU. Aos 20 dias do mês de setembro do ano de 2024, às 09:00 horas, por meio de Videoconferência, realizou-se a defesa de TESE DE DOUTORADO de MATTHIAS MICHEL FRANÇOIS CHARDON, intitulada Les effets du surpoids et de l'obésité lors du franchissement d'obstacle pendant la marche. A Comissão Examinadora foi constituida pelos seguintes membros: Prof. Dr. PATRICE FLORE (Participação Virtual) do(a) Université Grenoble Alpes, Prof. Dr. ANTHONY FLEURY (Participação Virtual) do(a) IMT Nord Europe, Prof. Dr. PASCAL MADELEINE (Participação Virtual) do(a) Department of Health Science and Technology / Aalborg University, Prof. Dr. RICARDO AUGUSTO BARBIERI (Participação Virtual) do(a) Università di Bologna, Prof. Dr. CLINT HANSEN (Participação Virtual) do(a) University of Kiel, Profa. Dra. JULIE AURORE SOULARD (Participação Virtual) do(a) Université Grenoble Alpes, Prof. Dr. FABIO AUGUSTO BARBIERI (Orientador(a) - Participação Virtual) do(a) Departamento de Educação Física / Faculdade de Ciências - Unesp Bauru, Prof. Dr. Assistente NICOLAS CLAUDE ROLAND VUILLERME (Orientador(a) - Participação Virtual) do(a) Faculty of Medicine / AGEIS, Univ. Grenoble Alpes. Após a exposição pelo doutorando e arguição pelos membros da Comissão Examinadora que participaram do ato, de forma presencial e/ou virtual, o discente recebeu o conceito final:_ _ _ _ _ _ _ _ _ _ _ _ _ . Nada mais havendo, foi lavrada a presente ata, que após lida e aprovada, foi assinada pelo(a) Presidente(a) da Comissão Examinadora. Prof. Dr. PATRICE FLORE Faculdade de Ciências - Câmpus de Bauru - Eng. Luiz Edmundo Carrijo Coube, 14-01, 17033360, Bauru - São Paulo https://www.fc.unesp.br/#!/ensino/pos-graduacao/programas/ciencia-do-movimento/CNPJ: 48.031.918/0028-44. APROVADO Fabinho Barbieri II Abstract Being overweight or obese is a major public health issue. According to a report by the World Obesity Observatory, 38% of the world’s population aged 5 and over were overweight or obese in 2020, a figure that is forecast to rise to 51% by 2035. In addition to its well-documented harmful effects on the cardiovascular system, overweight and obesity also lead to functional deficits related to mobility. Balance and gait disorders are thus frequently observed in overweight and obese people, sometimes leading lead to falls. To date, however, few studies have focused on a locomotor task that is particularly at risk of falling, yet frequently encountered in our daily lives: crossing an obstacle while walking. In this context, the aim of this doctoral work was to assess the effect of overweight on obstacle crossing during walking. To meet this main objective, we first carried out two reviews of the literature on this topic. The main conclusions of these reviews led us to compare a group of overweight and normal-weight individuals during an obstacle-crossing task through spatiotemporal gait parameters and horizontal and vertical clearances relative to the obstacle. They further highlighted the existence of pre-existing data from which a secondary analysis could advantageously address our main objective. We thus felt that re-using these existing data - for a purpose other than that of the initial study - was highly relevant, especially considering the high financial, material, human and time costs involved in producing new data. We therefore set out to re-analyse the experimental data collected in 3 of the studies included in the previous literature reviews. Our dataset consisted of 5 spatiotemporal gait parameters and 3 clearance parameters measured on each foot during 3 trials using a system of 10 infra-red cameras among 43 young adults who were asked to walk at a comfortable speed over an 8.5- metre course and to cross a fixed-height vertical obstacle of 15cm positioned in the middle of this course. Our results showed that: (1) spatiotemporal gait parameters and horizontal and vertical clearances in young adults during an obstacle crossing task were reliable over 3 trials, III (2) compared to individuals with a normal body mass index (BMI), overweight young adults exhibited greater horizontal clearances before and after the obstacle, whereas kinematic parameters and vertical clearances remained unchanged, and (3) age and anthropometric characteristics of individuals were correlated with several spatiotemporal gait parameters and horizontal clearances, which was not the case for vertical clearances. Overall, the results of this doctoral work suggest that being overweight has a minimal impact on obstacle crossing during walking, and does not seem to increase the risk of tripping in young adults and under these particular experimental conditions. In these particular conditions, which were relatively mild and easy in that the task consisted of crossing a vertical obstacle 15 centimeters high at a comfortable speed without any other particular constraint. Hence, several perspectives arise from this doctoral work. On the one hand, it will be about implementing more demanding obstacle-crossing tasks and/or closer to those encountered in daily life. On the other hand, it will involve assessing individuals with a wider range of BMIs corresponding to different categories of overweight and obesity (moderate, severe and morbid), but also of different ages and health conditions. IV Résumé Le surpoids et l’obésité représentent un problème majeur de santé publique. Selon un rapport de l’Observatoire Mondial de l’Obésité, 38% de la population mondiale âgée de 5 ans et plus était en surpoids ou en situation d’obésité en 2020, chiffre qui, selon les prévisions, devrait atteindre 51% en 2035. En plus de ses conséquences délétères largement documentées sur le système cardio-vasculaire, le surpoids et l’obésité induisent également des déficits fonctionnels liés à la mobilité. Troubles de l’équilibre et de la marche sont ainsi fréquemment observés chez les personnes en surpoids ou en situation d’obésité, pouvant parfois conduire à la chute. Or, à ce jour, peu d’études se sont intéressées à une tâche locomotrice particulièrement à risque de chute, et pourtant fréquemment rencontrées dans notre quotidien : le franchissement d’un obstacle pendant la marche. Dans ce contexte, l’objectif de ce travail doctoral était d’évaluer l’effet du surpoids sur le franchissement d’obstacle pendant la marche. Pour répondre à cet objectif, deux revues de littérature ont dans un premier temps été réalisées. Les conclusions de ces deux revues nous d’une part ont amenés à vouloir comparer un groupe d’individus en surpoids et en poids normal lors d’une tâche de franchissement d’obstacle au travers de paramètres spatio-temporels de la marche et de dégagements horizontaux et verticaux par rapport à l’obstacle. Elles nous ont d’autre part encouragé à re-exploiter des données existantes - pour une autre finalité que celle de l’étude initiale - compte tenu notamment des coûts financiers, matériels, humains et temporels élevés de la production de nouvelles données. Nous nous sommes dès lors attachés de ré-analyser des données expérimentales collectées dans 3 des études incluses dans les précédentes revues de la littérature. Notre jeu de données était ainsi constitué de 5 paramètres spatio-temporels de la marche et 3 paramètres de dégagements mesurés sur chaque pied lors de 3 essais au moyen d’un système de 10 caméras infra-rouge auprès de 43 jeunes adultes à qui il avait été demandé de marcher à vitesse confortable sur un parcours de 8,5 mètres et de franchir un obstacle vertical d’une hauteur fixe de 15 cm positionné au milieu de ce parcours. Nos résultats ont montré que : V (1) chez de jeunes adultes, les paramètres spatio-temporels de la marche et des dégagements horizontaux et verticaux sont reproductibles sur 3 essais de franchissement d’obstacle; (2) comparés aux individus avec un indice de masse corporel (IMC) normal, les jeunes adultes en surpoids présentent des dégagements horizontaux supérieurs avant et après l’obstacle, alors que les paramètres cinématiques et les dégagements verticaux restent inchangés, et (3) l’âge et les caractéristiques anthropométriques des individus sont corrélés à plusieurs paramètres spatio-temporels de la marche et de dégagement horizontaux, ce qui n’est pas le cas des dégagements verticaux. Dans leur ensemble, les résultats de ce travail doctoral suggèrent que le surpoids à un impact minimal sur le franchissement d’obstacle pendant la marche, et ne semble pas augmenter le risque de trébuchement, chez de jeunes adultes et dans des conditions expérimentales particulières relativement clémentes dans la mesure où la tâche consistait à franchir un obstacle vertical de 15 centimètres de hauteur à vitesse confortable sans autre contrainte particulière. Dès lors, plusieurs perspectives découlent de ce travail doctoral. Il s’agira, d’une part, de mettre en œuvre des tâches de franchissement d’obstacle plus contraignantes et/ou plus proches de celles rencontrées dans la vie quotidienne. Il s’agira, d’autre part, d’évaluer des individus présentant non seulement un éventail d’IMC plus large correspondant à plusieurs catégories de surpoids et d’obésité (modérée, sévère et morbide), mais aussi d’âges et de conditions de santé différentes. VI Detailed abstract Being overweight or obese is a major public health issue. According to a report by the World Obesity Observatory, 38% of the world’s population aged 5 and over were overweight or obese in 2020, a figure that is forecast to rise to 51% by 2035. In addition to its well-documented harmful effects on the cardiovascular system, overweight and obesity also lead to functional deficits related to mobility. Balance and gait disorders are thus frequently observed in overweight and obese people, sometimes leading lead to falls. To date, however, few studies have focused on a locomotor task that is particularly at risk of falling, yet frequently encountered in our daily lives: crossing an obstacle while walking. In this context, the aim of this doctoral work is to assess the effect of overweight on obstacle crossing during walking. To meet this main objective, we first carried out a systematic review of the literature on this topic. The results show that very few published studies have addressed this research question, and that overweight and obesity modify the kinematic and kinetic parameters of walking over a vertical obstacle in adults. This literature review also opens up some interesting avenues of original research, since none of the included studies compared a group of overweight individuals (body mass index, or BMI, between 25.0 and 29.9 kg/m²) and normal-weight individuals (BMI between 18.5 and 24.9 kg/m²). In addition, certain parameters considered to be the most important for assessing the risk of tripping over obstacles, such as the horizontal and vertical distances of the feet relative to the obstacle, commonly referred to as horizontal and vertical clearances, have not to date been the subject of specific analysis in overweight or obese adults. These two main conclusions led us to compare a group of overweight and normal- weight individuals during an obstacle-crossing task through spatiotemporal gait parameters and clearances relative to the obstacle. The aim of a second study was to identify the anthropometric characteristics of height, weight and BMI of Brazilian adults included in published studies on obstacle crossing. The results showed that no published study had been conducted using BMI, height or weight values as inclusion and/or exclusion criteria for participants. Moreover, BMI was very rarely reported (4 studies out of the 35 included, 11%). Interestingly, of the 7 groups of participants included in VII these 4 studies, 6 had a mean BMI greater than 25 kg/m². The average height and weight of the participant groups were reported in 34 of the 35 included studies (97%), which enabled us to recalculate the BMI of each group. In a very large majority of these studies (29 out of 35, 83%), at least one group of included participants had an average BMI of 25.0 kg/m² or higher. Finally, the individual weight and height characteristics of each participant were reported in 4 studies (11%), enabling us to calculate the BMI of each participant. Of the 63 participants included in these 4 studies, 25 (40%) had a BMI between 25.0 and 29.9 kg/m², and 8 (13%) above 30 kg/m². In other words, our results highlight that a significant proportion of the Brazilian participants included in the published studies on obstacle crossing during walking were overweight or obese. More generally, these results suggest the existence of pre-existing data from which a secondary analysis could advantageously address our main objective. We thus felt that re-using these existing data - for a purpose other than that of the initial study - was highly relevant, especially considering the high financial, material, human and time costs involved in producing new data. We therefore set out to re-analyse the experimental data collected in 3 of the studies included in the previous literature reviews. Our dataset consisted of 5 spatiotemporal gait parameters and 3 clearance parameters measured on each foot during 3 trials using a system of 10 infra-red cameras among 43 young adults who were asked to walk at a comfortable speed over an 8.5- metre course and to cross a fixed-height vertical obstacle of 15cm positioned in the middle of this course. Three sub-objectives were successively addressed: (1) to assess the intra-session reliability of spatiotemporal gait parameters and horizontal and vertical clearances in young adults during an obstacle crossing task (n=43); (2) to compare these parameters obtained in young adults of normal weight (n=28) with those obtained in overweight young adults (n=15); and (3) to assess the correlations between anthropometric characteristics and obstacle crossing performance in these same young adults (n=43). Our results showed that (1) spatiotemporal gait parameters and clearances were reliable over 3 trials, (2) compared to individuals with a normal BMI, overweight young adults exhibited greater horizontal clearances before and after the obstacle, whereas kinematic parameters and vertical clearances remained unchanged, and VIII (3) age and anthropometric characteristics of individuals were correlated with several spatiotemporal gait parameters and horizontal clearances, which was not the case for vertical clearances. Overall, the results of this doctoral work suggest that being overweight has a minimal impact on obstacle crossing during walking, and does not seem to increase the risk of tripping in young adults and under these particular experimental conditions. In these particular conditions, which were relatively mild and easy in that the task consisted of crossing a vertical obstacle 15 centimeters high at a comfortable speed without any other particular constraint. Hence, several perspectives arise from this doctoral work. On the one hand, it will be about implementing more demanding obstacle-crossing tasks and/or closer to those encountered in daily life by testing, for example several obstacle heights, imposing walking speeds, or conducting these protocols under dual-task conditions, or in different fatigue states. On the other hand, it will involve assessing individuals with a wider range of BMIs corresponding to different categories of overweight and obesity (moderate, severe and morbid), but also of different ages and health conditions. IX Résumé détaillé Le surpoids et l’obésité représentent un problème majeur de santé publique. Selon un rapport de l’Observatoire Mondial de l’Obésité, 38% de la population mondiale âgée de 5 ans et plus était en surpoids ou en situation d’obésité en 2020, chiffre qui, selon les prévisions, devrait atteindre 51% en 2035. En plus de ses conséquences délétères largement documentées sur le système cardio-vasculaire, le surpoids et l’obésité induisent également des déficits fonctionnels liés à la mobilité. Troubles de l’équilibre et de la marche sont ainsi fréquemment observés chez les personnes en surpoids ou en situation d’obésité, pouvant parfois conduire à la chute. Or, à ce jour, peu d’études se sont intéressées à une tâche locomotrice particulièrement à risque de chute, et pourtant fréquemment rencontrées dans notre quotidien : le franchissement d’un obstacle pendant la marche. Dans ce contexte, l’objectif de ce travail doctoral est d’évaluer l’effet du surpoids sur le franchissement d’obstacle pendant la marche. Pour répondre à cet objectif principal, nous avons dans un premier temps réalisé une revue systématique de la littérature sur ce sujet. Les résultats montrent d’une part que très peu d’études publiées ont adressé cette question de recherche, et que, d’autre part, le surpoids et l’obésité modifient les paramètres cinématiques et cinétiques de la marche lors du franchissement d’un obstacle vertical chez l’adulte. Cette revue de littérature ouvre également des pistes des recherches originales intéressantes puisqu’aucune des études incluses n’a comparé un groupe d’individus en surpoids (indice de masse corporelle, ou IMC, compris entre 25 et 29,9 kg/m²) et en poids normal (IMC compris entre 18,5 et 24,9 kg/m²). De plus, certains paramètres considérés comme les plus importants pour évaluer le risque de trébuchement lors du franchissement d’obstacles, tels que les distances horizontales et verticales des pieds par rapport à l’obstacle couramment nommés dégagements horizontaux et verticaux, n’ont à ce jour pas fait l’objet d’analyse spécifique chez des adultes en surpoids ou en situation d’obésité. Ces deux principales conclusions nous ont dès lors amenés à vouloir comparer un groupe d’individus en surpoids et en poids normal lors d’une tâche de franchissement d’obstacle au travers de paramètres spatio-temporels de la marche et de dégagements par rapport à l’obstacle. X L’objectif d’un deuxième travail était d’identifier les caractéristiques anthropométriques de taille, de poids et d’IMC des adultes brésiliens inclus dans des études publiées sur le franchissement d'obstacles. Les résultats montrent qu’aucune étude n’a été conduite en considérant des valeurs d’IMC, de taille et de poids comme critères d’inclusion et/ou d’exclusion des participants. De plus, l’IMC n’a que très rarement été rapporté (4 études sur les 35 incluses, 11%). De manière intéressante, parmi les 7 groupes de participants inclus dans ces 4 études, 6 présentaient un IMC moyen supérieur à 25 kg/m². La taille et le poids moyen des groupes de participants ont en revanche été rapportés dans toutes les 35 études incluses (100%), ce qui nous a permis de recalculer l’IMC de chaque groupe. Dans une très large majorité de ces études (29 sur 35, 83%), au moins un groupe de participants inclus présentait un IMC moyen supérieur ou égal à 25 kg/m². Enfin, les caractéristiques individuelles de poids et de taille de chaque participant ont enfin été rapportées dans 4 études (11%), ce qui nous a permis de calculer les IMC de chaque participant. Parmi les 63 participants inclus dans ces 4 études, 25 (40%) présentaient un IMC compris entre 25 et 29,9 kg/m%, et 8 (13%) supérieur à 30 kg/m². Autrement dit, nos résultats soulignent qu’une proportion non négligeable des participants brésiliens inclus dans les études publiées portant sur le franchissement d’obstacle pendant la marche était en surpoids ou moins. Plus largement, ces résultats suggèrent l’existence de données déjà constituées à partir desquelles une analyse secondaire pourrait avantageusement permettre de répondre à notre objectif principal. Aussi, re-exploiter ces données existantes - pour une autre finalité que celle de l’étude initiale - nous a paru très pertinent, compte tenu notamment des coûts financiers, matériels, humains et temporels élevés de la production de nouvelles données. Nous nous sommes dès lors attachés de ré-analyser des données expérimentales collectées dans 3 des études incluses dans les précédentes revues de la littérature. Notre jeu de données était ainsi constitué de 5 paramètres spatio-temporels de la marche et 3 paramètres de dégagements mesurés sur chaque pied lors de 3 essais au moyen d’un système de 10 caméras infra-rouge auprès de 43 jeunes adultes à qui il avait été demandé de marcher à vitesse confortable sur un parcours de 8,5 mètres et de franchir un obstacle vertical d’une hauteur fixe de 15cm positionné au milieu de ce parcours. Trois sous-objectifs ont été adressés successivement : (1) évaluer la reproductibilité intra-session des paramètres spatio-temporels de la marche et des dégagements horizontaux et verticaux chez de jeunes adultes lors d’une tâche de franchissement d’obstacle (n= 43) ; XI (2) comparer ces paramètres obtenus chez de jeunes adultes de poids normal (n=28) à ceux obtenus chez de jeunes adultes en surpoids (n=15); et (3) évaluer les corrélations entre les caractéristiques anthropométriques et la performance en franchissement d’obstacle chez ces mêmes jeunes adultes (n= 43). Nos résultats ont montré que (1) les paramètres spatio-temporels et les dégagements sont reproductibles sur 3 essais de franchissement d’obstacle, (2) comparés aux individus avec un IMC normal, les jeunes adultes en surpoids présentent des dégagements horizontaux supérieurs avant et après l’obstacle alors que les paramètres cinématiques et les dégagements verticaux restent inchangés, et (3) l’âge et les caractéristiques anthropométriques des individus sont corrélés à plusieurs paramètres spatio-temporels de la marche et de dégagement horizontaux, ce qui n’est pas le cas des dégagements verticaux. Dans leur ensemble, les résultats de ce travail doctoral suggèrent que le surpoids à un impact minimal sur le franchissement d’obstacle pendant la marche, et ne semble pas augmenter le risque de trébuchement, chez de jeunes adultes et dans ces conditions expérimentales particulières relativement clémentes dans la mesure où la tâche consistait à franchir un obstacle vertical de 15 centimètres de hauteur à vitesse confortable sans autre contrainte particulière. Dès lors, plusieurs perspectives découlent de ce travail doctoral. Il s’agira, d’une part, de mettre en œuvre des tâches de franchissement d’obstacle plus contraignantes et/ou plus proches de celles rencontrées dans la vie quotidienne en testant par exemple plusieurs hauteurs d’obstacles, en imposant des vitesses de marche, ou encore en réalisant ces protocoles en double tâche et dans différentes conditions de fatigue. Il s’agira, d’autre part, d’évaluer des individus présentant non seulement un éventail d’IMC plus large correspondant à plusieurs catégories de surpoids et d’obésité (modérée, sévère et morbide), mais aussi d’âges et de conditions de santé différentes. XII Resumo detalhado Obesidade é um grande problema de saúde pública. Além dos bem documentados efeitos nocivos no sistema cardiovascular, o sobrepeso e a obesidade também levam a déficits funcionais relacionados à mobilidade. Distúrbios de equilíbrio e marcha são frequentemente observados em pessoas com sobrepeso e obesidade, às vezes levando a quedas. No entanto, poucos estudos focaram em uma tarefa locomotora que representa um risco particular de queda, mas que é frequentemente encontrada em nossas vidas diárias: ultrapassar um obstáculo. Nesse contexto, o objetivo desta tese é avaliar o efeito do sobrepeso na ultrapassagem de obstáculo durante o andar em adultos jovens. Para atingir esse objetivo principal, esta tese é composta por 5 estudos. No primeiro estudo, foi realizada uma revisão sistemática da literatura que apontou que poucos estudos publicados abordaram essa questão de pesquisa e que o sobrepeso e a obesidade modificam os parâmetros cinemáticos e cinéticos da ultrapassagem de obstáculo durante o andar em adultos. Além disso, nenhum dos estudos incluídos comparou um grupo de indivíduos com sobrepeso (índice de massa corporal – IMC - entre 25,0 e 29,9 kg/m²) e indivíduos com peso normal (IMC entre 18,5 e 24,9 kg/m²). Além disso, certos parâmetros considerados os mais importantes para avaliar o risco de tropeçar em obstáculos, como as distâncias horizontais e verticais dos pés em relação ao obstáculo, não foram, até o momento, objeto de análise específica em adultos com sobrepeso ou obesidade. A segunda revisão identificou as características antropométricas de altura, massa corporal e IMC de adultos brasileiros incluídos em estudos publicados sobre ultrapassagem de obstáculos. Os resultados mostraram que nenhum estudo publicado havia sido conduzido usando valores de IMC, altura ou massa corporal como critérios de inclusão e/ou exclusão para os participantes. Além disso, o IMC foi muito raramente relatado (4 estudos dos 35 incluídos, 11%). Interessantemente, dos 7 grupos de participantes incluídos nesses 4 estudos, 6 tinham um IMC médio superior a 25 kg/m². A altura e a massa corporal médios dos grupos de participantes foram relatados em todos os 35 estudos incluídos (97%), o que nos permitiu recalcular o IMC de cada grupo. Na maioria desses estudos (29 de 35, 83%), pelo menos um grupo de participantes incluídos tinha um IMC médio de 25,0 kg/m² ou superior. Finalmente, as características individuais de massa corporal e altura de cada participante foram relatadas em 4 XIII estudos (11%), permitindo-nos calcular o IMC de cada participante. Dos 63 participantes incluídos nesses 4 estudos, 25 (40%) tinham um IMC entre 25,0 e 29,9 kg/m², e 8 (13%) acima de 30 kg/m². Em outras palavras, nossos resultados destacam que uma proporção significativa dos participantes brasileiros incluídos nos estudos publicados sobre ultrapassagem de obstáculos durante o andar estavam com sobrepeso ou obesos. De forma mais geral, esses resultados sugerem a existência de dados pré-existentes dos quais uma análise secundária poderia abordar vantajosamente nosso objetivo principal. Os próximos 3 estudos se propõem a reanalisar os dados experimentais coletados nas revisões de literatura anteriores. O conjunto de dados usado nesta tese consistiu em 5 parâmetros de marcha espaço-temporais e 3 parâmetros de distância dos pés para o obstáculo durante 3 tentativas usando um sistema de 10 câmeras infravermelhas entre 43 jovens adultos que foram solicitados a andar em velocidade preferida por um percurso de 8,5 metros e ultrapassar um obstáculo vertical de 15 cm de altura posicionado no meio deste percurso. Três objetivos específicos foram sucessivamente abordados: (1) avaliar a confiabilidade intra-sessão dos parâmetros espaço-temporais da marcha e das distâncias horizontais e verticais para o obstáculo em jovens adultos durante o andar com ultrapassagem de obstáculo (n=43); (2) comparar esses parâmetros entre jovens adultos com peso normal (n=28) e jovens adultos com sobrepeso (n=15); e (3) avaliar as correlações entre as características antropométricas e o desempenho na ultrapassagem de obstáculos (n=43). Nossos resultados mostraram que: (1) os parâmetros espaço-temporais da marcha e as distâncias para o obstáculo foram confiáveis ao longo de 3 tentativas, (2) em comparação com indivíduos com IMC normal, jovens adultos com sobrepeso exibiram maiores distâncias horizontais antes e depois do obstáculo, enquanto os parâmetros cinemáticos do andar e as distâncias verticais permaneceram inalterados, e (3) a idade e as características antropométricas dos indivíduos foram correlacionadas com vários parâmetros de marcha espaço-temporais e distâncias horizontais para o obstáculo, o que não foi o caso para as distâncias verticais. XIV De forma geral, os resultados desta tese sugerem que estar acima do peso tem um impacto mínimo na ultrapassagem de obstáculo durante o andar, e não parece aumentar o risco de tropeçar em jovens adultos sob essas condições experimentais específicas, que são relativamente fáceis, consistindo na tarefa de ultrapassar um obstáculo vertical de 15 centímetros de altura a uma velocidade confortável, sem qualquer outra restrição particular. Assim, várias perspectivas surgem desta tese. Por um lado, incluir análises em tarefas de ultrapassagem de obstáculos mais exigentes e/ou mais próximas daquelas encontradas na vida diária, por exemplo, várias alturas de obstáculos, aumentando velocidades do andar, ou conduzindo esses protocolos sob condições de dupla tarefa ou em diferentes estados de fadiga. Por outro lado, é importante avaliar indivíduos com uma gama mais ampla de IMCs correspondentes a diferentes categorias de sobrepeso e obesidade (moderada, severa e mórbida), mas também de diferentes idades e condições de saúde. XV Acknowledgments “No one has ever become poor by giving.” Anne Frank, The Diary of a Young Girl, 1947 This PhD thesis, subjected to the PhD Cotutelle Agreement signed between the University Grenoble Alpes (UGA), Grenoble, in France and the São Paulo State University (UNESP) Bauru in Brazil, has been carried out at the AGEIS lab from UGA and at the MOV-LAB from UNESP. This PhD thesis was supported by the French National Research Agency (ANR) in the framework of the Investissements d’avenir program (ANR-10-AIRT-05) and the MIAI @ Grenoble Alpes (ANR-19-P3IA-0003). First of all, I would like to express my gratitude to my two thesis supervisors, Nicolas Vuillerme and Fabio Augusto Barbieri. Nicolas, it has now been 5 years since you welcomed a somewhat lost STAPS student eager to discover the world of academic research. I thank you for the trust you placed in me from the outset by offering me an international collaboration during my first internship. I am also grateful for involving me in projects beyond my PhD thesis. I particularly think of my (failed) attempt to establish shared gardens for students, and the various reviews that opened up previously unknown horizons to me. In addition, you gave me the opportunity to teach my first courses at the faculty, to assist you in the defenses of STAPS master's students and supervise the numerous interns we hosted in the lab during my time there. These experiences significantly contributed significantly to my growth. Beyond the professional aspects and the opportunities you offered, I would like to highlight your human qualities, which were decisive in my choice to pursue a PhD after my two university internships at the laboratory. Your professional guidance, marked by your unquestionable expertise, and your personal support, reflecting values that resonate with mine, have been of great help during challenging times. Fabio, I also want to thank you for all the support you provided throughout this project. You have been guiding me for 5 years now since the first systematic review project. Thank you for accepting my stubbornness (or my "cabeça dura" as you taught me). Your expertise in human movement science was crucial to the success of this project. I am grateful for the time you took to help me develop and refine my scientific thinking. Meeting you in person allowed me to get to know and appreciate you better. I sincerely hope to collaborate with you on various upcoming projects. I would also like to extend my thanks to Patrice Flore, Anthony Fleury, Pascal Madeleine, Riciardo Augusto Barbieri, Clint Hansen, and Julie Soulard for honoring us by being part of the jury for this PhD thesis. The written assessments from Anthony Fleury and Pascal Madeleine significantly helped us to improve the readability of this manuscript. Their insights and suggestions were invaluable, and I greatly appreciated their support. A special thank you goes to all my colleagues. First, my "querido colega", Valkiria Amaya, who shared her office with me and was patient with my inability to sit still for more than 45 minutes. Thank you, also for always bringing me a little something from your trips and for being the best office mate one could hope for. Then, Pascal Petit, your "magic tricks" with R will always impress me, as well as your ability to reason on subjects outside your expertise. Thank you also for mentoring the novice I was in statistical analysis. On the Brazilian side, I extend my gratitude to Tiago Penedo, my Brazilian "alter ego". Thank you for all those Zoom meetings to XVI advance our reviews. I also thank Paulo Cezar Da Rocha Dos Santos for his scientific support in this thesis project and the time he dedicated to my work. I would like to acknowledge the various interns in the laboratory: Tracy, Lea, the two Quentins, Yanis, Antonin, Mathias, Oceane, Dorian, Norman, Mathis, Tamara, Thomas, Majd, Enzo, Vincent, and Reine, to name but a few. Thank you for your enthusiasm and energy, which boosted my morale more than once. From a somewhat selfish perspective, thank you for being reference points to judge my progress during my thesis, something not easily perceived daily. To the joy of my life, my family, my words go beyond gratitude. Mom, thank you for your unique and extroverted personality, for always considering me your little boy and offering unwavering support even in my moments of doubt, for raising me the way you did, and for giving me my brothers and sisters. Thank you also for regularly preparing delicious meals, whose secrets only you know. Elsa, Thomas, Julia, and Swan, my siblings, my clan, as well as your partners, Samuel, Rebecca, and Aziz. I thank you for your distinct personalities, strong opinions, and the convivial moments we regularly share. Thank you for my nephew already here, for the next one expected (or a niece), and for all those to come, I hope. I am a Chardon before I am Matthias. I also extend my gratitude to my extended family, my uncles, aunts, and cousins. Dad, no one can imagine the pain that accompanies me when I think of you and the fact that you will not see your son defend his thesis. You were, you are, and you will forever be my hero. I cannot find better words than those of my cousin Alexandre, which I would like to address to you again: "SIT TIBI TERRA LEVIS" May the ground be light to you, forever. Finally, Grandpa Claude or “Pipa Declau”, this thesis is also for you. I know that if life had offered you different opportunities, you would have pursued a brilliant academic career, but you have nothing to be ashamed of when facing your grandson, for whom you have been a driving force throughout this project. I hope you are proud of your "little rascal". To concluded, I would like to thank all my friends for their unwavering support and for helping me remember the essentials of a balanced life. Therefore, thank you to my "Kikitoss" friends in Grenoble: Nicolas, Marie, Remi, Léon, Bastien, Mélodie, Simon, Hugo, Edouard, Maxime, and your respective partners. Thanks also to my former roommate, Jonas, whose perseverance is beyond question, for regularly accepting to be my “whipping boy” at squash, and to his partner Luna for her everyday kindness. I would also like to mention my friends from Chamonix, even though our lives no longer allow us to maintain the same relationships, you still hold an important place in my life. So, thank you to Pierre, Tanguy, Alexandre, Nelson, Jean, and especially Kevin, my best friend, the smartest and silliest person I have ever had the pleasure of meeting. To all of you, thank you for everything. XVII Scientific contributions This work has been the subject of scientific contributions published in international peer- reviewed journals -Chardon M, Barbieri FA, Penedo T, Santos PCR, Vuillerme N. The Effects of Overweight and Obesity on Obstacle Crossing During Walking: Protocol for a Systematic Review. JMIR Res Protoc. 2022 May 20;11(5):e36234. doi: 10.2196/36234. -Chardon M, Barbieri FA, Penedo T, Santos PCR, Vuillerme N. A Systematic Review of the Influence of Overweight and Obesity across the Lifespan on Obstacle Crossing during Walking. Int J Environ Res Public Health. 2023 May 23;20(11):5931. doi: 10.3390/ijerph20115931. -Chardon, M., Barbieri, F. A., Petit, P., & Vuillerme, N. (2024). Reliability of Obstacle- Crossing Parameters during Overground Walking in Young Adults. Sensors (Basel, Switzerland), 24(11), 3387. https://doi.org/10.3390/s24113387. -Chardon M, Barbieri FA, Penedo T, Santos PCR, Vuillerme N. The effects of experimentally-induced fatigue on gait parameters during obstacle crossing: A systematic review. Neurosci Biobehav Rev. 2022 Nov;142:104854. doi: 10.1016/j.neubiorev.2022.104854. This work has been the subject of scientific contributions submitted, under review in international peer-reviewed journals: -Chardon M., Barbieri FA, Petit P, Vuillerme N. Obstacle avoidance task during walking and body mass index: a scoping review of Brazilian studies. (submitted) -Chardon M., Barbieri FA., Petit P., Hansen C., Vuillerme N. Obstacle avoidance has minimum impact on spatial-temporal parameters in young overweight adults. (submitted) -Chardon M., Barbieri FA., Petit P., Vuillerme N. Determinants of obstacle crossing performance in young male adults: do anthropometrics and age matter? (submitted) Additional work has been the subject of scientific contributions published in international peer-reviewed journals: -Amaya V, Chardon M, Klein H, Moulaert T, Vuillerme N. What Do We Know about the Use of the Walk-along Method to Identify the Perceived Neighborhood Environment Correlates of Walking Activity in Healthy Older Adults: Methodological Considerations Related to Data Collection—A Systematic Review. Sustainability. 2022; 14(18):11792. https://doi.org/10.3390/su141811792. XVIII -Correno MB, Hansen C, Chardon M, Milane T, Bianchini E, Vuillerme N. Association between Backward Walking and Cognition in Parkinson Disease: A Systematic Review. Int J Environ Res Public Health. 2022 Oct 6;19(19):12810. doi: 10.3390/ijerph191912810. -Milane T., Hansen C., Chardon M., Bianchini E., Vuillerme N. Comparing Backward Walking Performance in Parkinson's Disease with and without Freezing of Gait-A Systematic Review. Int J Environ Res Public Health. 2023 Jan 4;20(2):953. doi: https://10.3390/ijerph20020953. -Amaya, V., Chardon, M., Moulaert, T., Vuillerme, N. Systematic Review of the Use of the Walk-Along Interview Method to Assess Factors, Facilitators and Barriers Related to Perceived Neighborhood Environment and Walking Activity in Healthy Older Adults. Sustainability 2024, 16, 882. https://doi.org/10.3390/su16020882. -Suau, Q., Bianchini, E., Bellier, A., Chardon, M., Milane, T., Hansen, C., & Vuillerme, N. (2024). Current Knowledge about ActiGraph GT9X Link Activity Monitor Accuracy and Validity in Measuring Steps and Energy Expenditure: A Systematic Review. Sensors (Basel, Switzerland), 24(3), 825. https://doi.org/10.3390/s24030825. -Milane, T., Hansen, C., Correno, M. B., Chardon, M., Barbieri, F. A., Bianchini, E., & Vuillerme, N. (2024). Comparison of sleep characteristics between Parkinson’s disease with and without freezing of gait: A systematic review. Sleep Medicine, 114, 24–41. https://doi.org/https://doi.org/10.1016/j.sleep.2023.11.021. -Milane, T., Hansen, C., Correno, M. B., Chardon, M., Barbieri, F. A., Bianchini, E., & Vuillerme, N. (2024). Comparison of number of people with freezing of gait in Parkinson’s disease with and without sleep disturbances: A systematic review. Sleep Medicine, 121, 32–41. https://doi.org/https://doi.org/10.1016/j.sleep.2024.06.001. XIX Abbreviations list BMI Body Mass Index CCC Lin’s Concordance Correlation oefficient ICC Intraclass correlation coefficient LOA Limits of Agreement MDC Minimal Detectable Change SEM Systematic Error of Measurement WHO World Health Organization XX List of figures Figure 1. Different weight categories according to BMI. .......................................................... 2 Figure 2. Prevalence of overweight (A) and obesity (B) worldwide [14,15]. ............................ 3 Figure 3. Flowchart of the study selection and analysis of the bibliometric analysis. ............... 7 Figure 4. Number of documents published per year. ................................................................. 8 Figure 5. Schematic representation of an obstacle crossing task (A), a typical obstacle during daily walking (B), and a representation of an individual crossing an obstacle on his travel path (C). .............................................................................................................................................. 9 Figure 6. Horizontal (A) and vertical (B) obstacle clearance parameters. ............................... 10 Figure 7. The 30 most used keywords in the 200 most cited obstacle crossing studies. .......... 11 Figure 8. Research areas in the 200 most cited obstacle crossing studies. .............................. 14 Figure 9. Framework of the PhD thesis. ................................................................................... 17 Figure 10. Synthesis of the characteristics of the studies investigating the influence of overweight and obesity during obstacle crossing. .................................................................. 236 Figure 11. Synthesis of the Brazilian studies included in the review. .................................... 239 Figure 12. Mean ICC(2.1) for the means of trial 1–2, 1–3, 2–3 and 1–2–3 calculated for each obstacle crossing parameter in all participants, normal weight and overweight groups ........ 244 Figure 13. Summary of the findings of the PhD thesis and perspectives. .............................. 252 XXI List of tables Table 1. Population characteristics of previous studies and in our study ............................... 246 XXII Table of contents 1. General introduction ............................................................................................................ 1 1.1. Overweight and obesity: A growing global health crisis ............................................ 1 1.1.1. Overweight and obesity: Assessment and classification ...................................... 1 1.1.2. Overweight and obesity: Prevalence ..................................................................... 2 1.1.3. Overweight and obesity: A complex etiology ....................................................... 3 1.1.4. Overweight and obesity: Impact on health status ................................................ 4 1.1.5. Overweight and obesity: Impact on functional capacities .................................. 5 1.2. Obstacle crossing during walking ................................................................................ 6 1.2.1. A common daily task more challenging than usual level ground walking ........ 8 1.2.2. A task with a risk of falling .................................................................................. 10 1.2.3. Previous works ...................................................................................................... 12 1.2.4. Practical use of obstacle crossing ......................................................................... 13 2. Rationale and Thesis aims ................................................................................................. 15 3. Contribution 1: A Systematic Review of the Influence of Overweight and Obesity across the Lifespan on Obstacle Crossing during Walking ........................................................... 18 4. Contribution 2: Obstacle crossing task during walking and body mass index: a scoping review of Brazilian studies ..................................................................................................... 57 5. Contribution 3: Reliability of Obstacle-Crossing Parameters during Overground Walking in Young Adults .................................................................................................... 149 6. Contribution 4: Impact of overweight on spatial-temporal gait parameters during obstacle crossing in young adults: a cross-sectional study ............................................... 192 7. Contribution 5: Determinants of obstacle crossing performance in young male adults: do anthropometrics and age matter? ................................................................................. 210 8. General discussion ............................................................................................................ 235 8.1. Scientific Contributions of the PhD thesis ............................................................... 235 8.1.1. The literature on the influence of overweight during obstacle crossing is limited ......................................................................................................................................... 235 XXIII 8.1.2. Body mass index and obstacle crossing: a review of Brazilian studies .......... 238 8.1.2. Spatial-temporal and obstacle crossing parameters are reliable during within- session among young adults ......................................................................................... 241 8.1.3. Overweight has a minimal influence on obstacle crossing during walking among young adults ................................................................................................................... 245 8.1.4. Anthropometric parameters and age of individuals are correlated with spatial- temporal parameters of gait and obstacle clearances parameters while crossing an obstacle during walking ................................................................................................ 249 8.2 Clinical implications of the PhD thesis ..................................................................... 253 8.3. Limitations and perspectives .................................................................................... 254 8.3.1. Limitations ........................................................................................................... 254 8.3.2. Research perspectives ......................................................................................... 257 9. Conclusion ......................................................................................................................... 262 10. References ....................................................................................................................... 264 11. Annexes ........................................................................................................................... 282 1 This PhD project specifically examines overweight individuals (Population), focusing on their ability to cross obstacles during walking (Intervention). This capability is compared with that of normal weight individuals (Comparator), highlighting differences in spatial- temporal parameters and obstacle clearance (Outcomes). This introductory chapter provides a comprehensive exploration of the complex nature of overweight and obesity, delving into the assessment, prevalence, root causes, and health impacts of these conditions, as well as their implications for functional capacities. This chapter further elucidates the significance of obstacle crossing in addressing mobility issues among the overweight and obese populations. Finally, the objectives and methodology employed throughout this PhD project are outlined. 1. General introduction 1.1. Overweight and obesity: A growing global health crisis It is recognized that dietary habits [1] and physical activity [2] are two major health- related lifestyle determinants of an individual's health and well-being [3] as they are reported to influence the incidence of non-communicable diseases such as cardiovascular diseases [4,5], cancer [6,7], and diabetes [4,8] to name a few. Poor diet and/or lack of physical activity are also associated with adverse effects such as overweight and obesity [9], which is defined by the World Health Organization (WHO) as “condition/disease of excessive fat deposits” [10]. In fact, obesity and overweight have emerged as challenges to public health worldwide, with their prevalence reaching alarming levels in recent years. Overweight and obesity are even considered the global epidemic of the 21st century [10,11]. According to the WHO, worldwide adult obesity doubled since 1990 [10]. Additionally, over 390 million children and adolescents (5-19 years old) were overweight, including 160 million of obese children in 2022 [10]. 1.1.1. Overweight and obesity: Assessment and classification Various metrics, including body mass index (BMI), waist circumference, and body fat percentage, are used to classify individuals as underweight (BMI < 18.5), normal weight (18.5 ≤ BMI < 25), overweight (25 ≤ BMI < 30), obesity class I (30 ≤ BMI < 35), obesity class II (35≤ BMI < 40), obesity class III (40 ≤ BMI) overweight or obese or not [10,12]. Among them, BMI is the most used tool to define the weight status of an individual [12], due to its straightforward, cost-effective approach that estimates body fat based on weight and height. BMI is calculated using body height and body mass with the following equation: BMI (kg/m²) 2 = (Body weight (kg) / Body height² (m)). Several BMI thresholds are used to define weight status as in clinical practice an increased BMI correlates with a large number of individuals found to be overweight [12]. These BMI categories provide valuable insights into the distribution of overweight across different demographic groups and geographical regions. The different weight categories according to BMI are presented in Figure 1. Figure 1. Different weight categories according to BMI. Source: https ://www.vecteezy.com/vector-art/5905467-bmi-classification-chart-measurement-man- set-male-body-mass-index-infographic-with-weight-status-from-underweight-to-severely-obese- medical-body-mass-control-graph-vector-eps-illustration. 1.1.2. Overweight and obesity: Prevalence Assessing the prevalence of overweight and obesity is crucial for understanding the scope of the problem and informing public health interventions. Figure 2 (A-B) shows the worldwide prevalence percentages of overweight and obesity categories according to the WHO in 2022, respectively. These figures highlight the geographical variation in the prevalence of overweight and obesity. Countries from specific regions, such as North and South America, the Middle East, and Australia, have the highest prevalence rates for both overweight and obesity. In contrast, the regions with the lowest prevalence of overweight and obesity are Asia and Central Africa. Globally, approximately 38% of the population aged 5 years old and older were living overweight in 2020, with projections indicating an increase to 51% by 2035 [13]. These statistics and other reports [10,11,13] hence underscore the urgent need for addressing the overweight and obesity epidemic and its association with health risks linked to functional status. 3 Focusing on Brazil, according to the WHO, in 2022, 34.9% of the adult population was overweight [14] and 28.1% was obese [15]. Regarding France, in 2022, 24.6% of the adult population was overweight [14], and 9.7% was obese [15]. According to the Obesity Atlas report, the projected trends of the prevalence of obesity are 41%, and 34% of adults living with obesity in 2050 for Brazil and France respectively, which is considered “Very High” for both countries [13]. Figure 2. Prevalence of overweight (A) and obesity (B) worldwide [14,15]. Note: country with no data available are represented in gray 1.1.3. Overweight and obesity: A complex etiology The etiology of overweight and obesity is multifactorial [16,17], reflecting the complex interplay of genetic, environmental, lifestyle, and socio-economic factors. Previous studies showed an association between genes and protein and obesity. As an example, a deficiency of the proopiomelanocortin gene (i.e., an appetite inhibitory gene) leads to hyperphagia and a lower resting metabolic rate [18], which can result in severe obesity. Regarding suggested environmental risk factors, there is a suggestion that a lack of access to healthy food is associated with obesity [19]. In addition, sedentary lifestyles and physical inactivity [20], increase the risk of being obese. Socioeconomic factors, including income level, education [21], and access to healthcare [22], play a significant role in shaping individual health behaviors and outcomes. There is a notable inverse relationship between socioeconomic status and obesity across different income-level countries. In lower-income countries, such as Brazil, higher socioeconomic groups are more likely to experience overweight and obesity, while in higher- income countries, it is the lowest socioeconomic groups that are more frequently obese [23]. 4 Therefore, it is crucial to consider these multifactorial risk factors when developing strategies to prevent and manage obesity effectively. 1.1.4. Overweight and obesity: Impact on health status Overweight and obesity are associated with a wide range of adverse health outcomes, including cardiovascular diseases, such as hypertension [24], coronary artery disease [25], and heart failure [24]. Obesity can also affect individual’s quality of life [26,27] and is linked with various mental health problems, especially depression [28]. These conditions are driven by the increased body fat which often leads to elevated blood pressure, cholesterol abnormalities, and impaired glucose tolerance, all of which contribute to the heightened cardiovascular risk type. Additionally, obesity can exacerbate heart disease through the promotion of chronic inflammation and the disruption of metabolic homeostasis, further compounding the cardiovascular burden [29]. Beyond cardiovascular issues, obesity significantly impacts the risk of developing type 2 diabetes by promoting insulin resistance [30]. Adipose tissue, particularly when excessive, serves not only as a fat storage depot but also as an active endocrine organ, secreting various substances that influence insulin sensitivity [31]. The resultant insulin resistance hampers glucose uptake by cells, leading to high blood sugar levels, which over time can lead to the chronic condition of diabetes, characterized by serious complications such as kidney damage, vision impairment, and an increased risk of heart disease. Moreover, recent evidence showed the association between obesity and several types of cancer (including pancreas, uterus stomach among others) [32], but also the association with cancer recurrence and mortality in cancer survivors [33,34]. However, a recent review showed that BMI was poorly reported and considered regarding drug medications in individuals with breast cancer despite the impact of obesity on cancer biology [35]. Therefore, the authors recommended to systematically reporting individuals’ BMI to evaluate its possible negative impact on treatment efficacity [35]. Furthermore, obesity increases the likelihood to have obstructive sleep apnea [36]. The accumulation of fat and adipose tissues induces a narrowing of the upper respiratory muscles causing obstruction in breathing [37]. Apart from the physiological impact of obesity on health, obesity is also associated with psychological/mental conditions. Obesity is also linked to various mental health problem including depression [38,39], anxiety [40], eating disorders such as binge-eating (a large food consumption in a reduced amount of time) or night eating (excessive food intake during evening 5 or nocturnal eating) [41]. Obesity also impacts negatively body image and self-esteem [42]. From a global health perspective, overweight and obesity were responsible for approximately 5 million deaths due to noncommunicable diseases in 2019 (including cardiovascular diseases, diabetes, cancers etc.) [43]. Economically, the cost of the overweight and obesity pandemic is predicted to reach $3 trillion by 2030 and could expand six-fold by 2060 [13,44]. 1.1.5. Overweight and obesity: Impact on functional capacities The excess weight associated with overweight and obesity places additional stress on the musculoskeletal system [45], particularly the joints [46]. This can accelerate the wear and tear that leads to osteoarthritis [46], especially in the knees [47] and hips [48], severely impacting mobility [49] and quality of life [50]. Moreover, overweight and obesity compromise functional capabilities such as balance [51,52], walking [53,54] and overall mobility. These functional impairments associated with overweight, and obesity could be exacerbated in more challenging walking conditions such as crossing an obstacle along the pathway. Excessive body weight impairs the body's ability to perform basic movements and maintain balance. Previous studies have reported the negative impact of increased body weight on balance stability, with individuals with overweight and obesity exhibiting greater postural sway compared to their normal-weight counterparts [55]. Efficient balance control relies on integrating information from the sensorimotor system—including vision, proprioception, and vestibular senses—which may be compromised in individuals with high BMI. For instance, obesity can diminish the quality and amount of mechanoreceptor feedback from the foot due to increased pressure and larger plantar contact areas [56], and there is evidence suggesting that obesity impairs the capacity to utilize proprioceptive information effectively [57]. Furthermore, being overweight or obese leads to modifications in body geometry and adds passive mass to various regions [58] altering body biomechanics and postural stability. As a result, previous studies have shown that the center of pressure displacement is greater in overweight and obese individuals [55,59], and that weight loss in obese individuals leads to increases in postural stability [60]. This information is crucial for activities of daily living, as an impaired balance control can lead to falls [61]. Additionally, studies have shown that obese individuals possess higher absolute muscle strength, but their normalized muscle strength for actions like knee flexion, trunk extension, and handgrip is reduced compared to normal-weight individuals [62]. These observations could be the reflection of the overall impairment of physical fitness in obese 6 individuals, which could lead to difficulties in postural corrections during balance disturbances. Furthermore, overweight and obesity also affects dynamic tasks such as overground walking. Previous studies have reported that, compared to normal weight individuals, obese adults walk slower [63–65] by reducing both step length and walking cadence [63–68]. Obese individuals decrease the swing phase time whereas an increase in stance time is observed [63], likely as a strategy to minimize the duration spent in single-leg dynamic balance (swing time) and maximize the period spent in double-leg stance, possibly due to weaker leg strength. Additionally, step width is greater in overweight individuals [64] and obesity [68]. The authors speculated that this behavior was adaptative to face unstable postural control by increasing their base of support [68]. Regarding joint motion and mechanics, obese individuals have less knee flexion [54]. In addition, increased transversal plane motion of the pelvis and greater knee abduction and adduction moments have been observed in overweight and obese adolescents [69]. These biomechanical deviations are likely to heighten the risk of injuries during activities of daily living [70], contribute to musculoskeletal disorders [52,71], and increase the likelihood of falls among overweight and obese individuals [72]. 1.2. Obstacle crossing during walking Mobility challenges during daily living extend beyond upright standing and level- ground walking. Daily activities inherently involve individuals interacting and coping with their physical environment [73]. Among others, one particular task often encountered during daily living is avoiding/crossing an obstacle in the travel path [74], which can pose a challenge to the center-of-mass control and maintenance of forward progression [73]. To gain a comprehensive understanding of obstacle crossing during walking, a first bibliometric analysis was conducted using Web of Science database. The keywords used were focused on obstacle crossing and its variant terms: (ts= ("obstacle crossing" OR "obstacle negotiation" OR "obstacle avoidance" OR "obstructed walking")). Reports were included if they discussed obstacle crossing tasks during walking in humans, with no restriction criteria based on the study design. The database search was performed on December 11th, 2023. The 200 most cited reports investigating an obstacle crossing task during walking in humans were selected. A total of 2341 abstracts were reviewed. After screening titles, abstracts and keywords, 44 full texts were read to verify and confirm their eligibility, resulting in the inclusion of the 200 most cited records that have investigated obstacle crossing tasks during walking in humans. 7 Examining highly cited papers helps in understanding the historical development and evolution of the research area, providing valuable insights into which topics have garnered the most attention and recognition from the academic community. The choice of 200 records strikes a balance between depth and manageability. Note that this method (i.e., bibliometric analysis of the 200 most cited papers in a research area) has been used in recent research [75–79]. Figure 3 presents the flowchart of the article selection process. Figure 3. Flowchart of the study selection and analysis of the bibliometric analysis. The reports retrieved were published between 1991 and 2020 with varying numbers published each year (from 2 in 1991, 1994, 1995, 1998, and 2020 to 20 in 2012). Of these, 19 reports (9.5%) were published in the 1990-2000 decade, 97 reports (48.5%) in the 2000-2010 decade, and 84 reports (42%) in the 2010-2020 decade. Figure 4 presents the number of documents included per year. 8 Figure 4. Number of documents published per year. 1.2.1. A common daily task more challenging than usual level ground walking Obstacle crossing during walking is a ubiquitous activity encountered in daily life, requiring individuals to navigate environmental barriers such as curbs, stairs, or uneven terrain. Figure 5 presents a schematic representation of an obstacle crossing task (A), depicts a typical obstacle that might be encountered (B) during daily walking and illustrates an individual crossing an obstacle on his travel path (C). 9 Figure 5. Schematic representation of an obstacle crossing task (A), a typical obstacle during daily walking (B), and a representation of an individual crossing an obstacle on his travel path (C). Unlike level ground walking, which involves a straightforward locomotion, obstacle crossing introduces additional complexities that challenge balance, coordination, and spatial awareness. Even simple obstacles, such as a curb or a small step, can significantly alter gait patterns and require adjustments in stride length, foot placement for both leading and trailing limb, and body posture [80]. To adequately avoid collision while crossing an obstacle, individuals need to integrate visual information available [81]. From a neurological point of view, a smoother steering performance during obstacle crossing was associated with a greater activation of the superior parietal lobe [82]. Moreover, Chen and colleagues (2017) showed that the activation of the prefrontal cortex increased while crossing obstacle compared to unobstructed walking, especially in individuals with mobility limitations [83]. Beyond vision and brain activity, the use of other sensorimotor information is a crucial element in the body’s motor control. Proprioception (i.e., the ability to sense body position and movement) is one of the key elements of sensorimotor control and movement [84]. Hosp and colleagues (2018) showed that in individuals with impaired knee proprioception due to experimentally-induced fatigue (i.e., the experimentally-induced fatigue protocol was designed to decrease knee proprioception), participants with kinesiology tape (i.e., used to enhance knee proprioception) had lower impairments in dynamic stability while crossing and obstacle [85]. In addition to the neurological and sensorimotor components, crossing an obstacle places greater muscular demand on the individual. For instance, greater activation of the knee flexor was found while crossing an obstacle compared to unobstructed walking [86] but also with increased obstacle height. As above mentioned, excess body weight can exacerbate the 10 challenges associated with obstacle crossing during walking, potentially compromising balance, coordination, and muscular strength. Moreover, overweight-related comorbidities such as musculoskeletal disorders and reduced proprioceptive acuity may further impede obstacle crossing capabilities. 1.2.2. A task with a risk of falling Despite its frequent occurrence, obstacle crossing carries a heightened risk of falls, especially among older adults or individuals with mobility impairments [87,88]. The consequences of falls can be severe, leading to injuries, hospitalizations, and functional decline [89]. As an example, more than half of falls in older adults are due to trips over an obstacle [87]. Some parameters are considered crucial to assess the risk of falls during an obstacle crossing task. These parameters, often called obstacle clearances parameters, are the horizontal (between the toe and the obstacle before crossing it and between the heel and the obstacle after crossing it) and vertical (distance between the toe and the obstacle while crossing it). Figure 6 describes the different obstacle horizontal (A) and vertical (B) clearance parameters. Previous studies showed that trips were more frequent with reduction in vertical clearance [80,90,91]. Indeed, it seems obvious that when the vertical distance between the foot and the obstacle is reduced, the likelihood to trip over the obstacle increases. Therefore, combined with gait spatial-temporal, the investigation of such parameters could reveal people who at are risk of trips, thus that might fell while crossing an obstacle in a large boarder of population with different health and functional status. Figure 6. Horizontal (A) and vertical (B) obstacle clearance parameters. Note: A: Trailing limb horizontal clearance before the obstacle, B: Leading limb horizontal clearance after the obstacle, C: Leading limb horizontal clearance before the obstacle, D: Trailing limb horizontal clearance after the obstacle. 11 Moreover, the results of our bibliometric analysis showed that “Fall” was the second most used keyword (n = 71 studies out of 200, 35.5%) by the authors from the articles selected, even before keywords related to the task (i.e., “Obstacle avoidance” n = 56, “Obstacle” n = 48, and “Obstacle crossing” n = 20). This emphasize that a large number of studies were conducted in regard to the fall risk associated with the performance of the obstacle crossing task. Figure 7 shows the 30 most used keywords in the included studies. Identifying and mitigating fall risks associated with obstacle crossing during daily living is essential for promoting safe mobility and reducing the burden of fall-related injuries. Additionally, the neighborhood walkability environment is linked to physical activity levels [92], a crucial factor in managing the obesity pandemic [93]. Indeed, neighborhoods with higher walkability are associated with lower obesity rates [94]. The task of obstacle crossing not only highlights individuals at risk of falling but can also shed light on elements of the urban environment that may hinder physical activity. Figure 7. The 30 most used keywords in the 200 most cited obstacle crossing studies. 12 1.2.3. Previous works Previous research on obstacle crossing has provided valuable insights into the biomechanics, fall risk, and rehabilitation potential of this complex task [80,90,91,95,96]. Published studies have extensively examined the kinematic and kinetic adaptations involved in negotiating obstacles, highlighting the factors that contribute to falls during this activity. Notably, much of this research has focused on comparing the obstacle crossing performance of various populations including older adults (see for a review [97]), and individuals with conditions such as stroke [88], Parkinson's disease (see for a recent review [98]), multiple sclerosis [99,100], and knee osteoarthritis [101,102]—to healthy, non-pathological groups. These comparisons have been set to know how these conditions affect mobility and the specific challenges they pose during obstacle crossing. For example, a recent review aimed to compare the spatial-temporal gait parameters of people with and without Parkinson’s disease while stepping over obstacles and including 25 articles, showed that individuals with Parkinson's disease tend to adopt a conservative strategy when crossing obstacles [98]. This strategy is characterized by reduced step length and walking speed during the crossing step [98]. This reduction in step length affects foot horizontal clearance, decreasing both the trailing foot placement distance before the obstacle and the leading foot placement after after the obstacle. However, this review did not identified differences in toe clearance for both legs between Parkinson’s disease and healthy individuals. Similar conservative strategies (i.e., reduced step length and speed) are observed in older adults as shown by a review of 15 articles comparing obstacle crossing performance between younger and older adults [97]. However, compared to young adults, older adults contacted the obstacle more frequently, particularly under time- constrained conditions, suggesting that this conservative approach may not always be sufficient to prevent risky situations during obstacle crossing [97]. People with stroke also exhibit differences during all phases of obstacle crossing (approaching, crossing and after crossing phases) to increase safety while crossing the obstacle [103] compared to healthy individuals. People with stroke exhibit adaptations during all phases of obstacle crossing—approaching, crossing, and post-crossing—to enhance safety, such as not reducing pre-obstacle horizontal clearance to avoid early contact during the swing phase [88], a contrast to the approach seen in Parkinson's disease. This observation indicates that motor adaptations vary significantly among different populations with functional impairments. Regarding obstacle contacts, in a previous systematic review designed to identify and 13 synthesize available evidence on the effects of experimentally-induced fatigue on gait parameters during obstacle crossing by healthy individuals, results showed that the occurrence of obstacle contacts was higher when individuals are in a fatigued state [104]. It is worth noting that this information was poorly reported in the review investigating the effects of experimentally-induced fatigue (2 studies out of 9 studies included) [104] compared to the review investigating obstacle crossing in older adults (10 out of 15 studies) [97]. Perhaps surprisingly, this parameter (i.e., contact with the obstacle while crossing) was not reported on the review investigating the influence of Parkinson disease on obstacle crossing behavior. In addition to the diversity of populations studied, various obstacle crossing protocol modalities have also been investigated, including dual-task conditions [105,106], varying walking speeds [107] and crossing different obstacle heights [108–110] or crossing multiples obstacles [111,112], the use of different footwear [113,114] and light conditions [115] or while using an exoskeleton [116]. These specific conditions aimed to better simulate real-life scenarios and enhance our understanding of how individuals navigate obstacles in everyday environments. Consequently, various internal factors such as health and functional status as well as fatigue levels and external factors have an influence on individuals’ performance during obstacle crossing leading to risky situations. Nevertheless, to date, only a few studies have focused on the influence of anthropometric factors, in particular BMI, on obstacle crossing performance in adult populations [63,68,117]. 1.2.4. Practical use of obstacle crossing Obstacle crossing during walking serves as a valuable exercise in rehabilitation settings [103,118], enhancing gait symmetry, and dynamic stability [119]. Rehabilitation programs that include obstacle negotiation exercises have proven effective in improving functional outcomes [118], and reducing fall risks [119,120]. These interventions typically focus on exercises that enhance lower limb strength and balance, along with cognitive training to improve spatial awareness and executive function. Studies have demonstrated that obstacle crossing training programs are more effective than overground walking training in enhancing functional abilities during gait and balance tests in individuals post-stroke [121], and with spinal cord injuries [118]. Additionally, such programs have been shown to alleviate symptoms of freezing gait in people with mild to moderate Parkinson’s disease [122] and are more effective than conventional training programs in reducing fall risks and improving gait parameters in geriatric 14 populations [120]. The increased complexity and intensity required by these tasks make obstacle crossing training particularly beneficial for populations with poor gait endurance and balance abilities. This demonstrates that the ability to cross obstacles not only reflects an individual's functional capabilities but also appears to enhance them. Therefore, it seems essential that individuals be able to regularly navigate obstacles along their path. Additionally, the results of our bibliometric analysis showed that “Rehabilitation” was the 4th research areas with most occurrence on the obstacle crossing studies selected (n = 28 out of 200, 14%), the 3 research areas with more occurrences were “Neurosciences & Neurology (n = 130), “Sport Sciences” (n = 80), and “Orthopedics” (n = 64). Figure 8 presents the occurrence of the different research areas in the obstacle crossing studies selected. By integrating obstacle crossing into rehabilitation protocols, clinicians can address the specific functional challenges faced by individuals with mobility impairments and promote optimal recovery and autonomy. Figure 8. Research areas in the 200 most cited obstacle crossing studies. 238 these records fulfilled the eligibility criteria and therefore could not be included to update the review. Our findings emphasize the need for the systematic documentation of participants’ body height and leg length in future obstacle crossing studies, as well as the recording of vertical obstacle clearance and instances of obstacle contacts, and the study of different BMI subgroups. To that end, several challenges will have to be overtaken, in particular using standardized equipment to assess gait and clearance parameters and including comparable group of participants from different BMI categories (i.e., same age, sex, body height etc.). 8.1.2. Body mass index and obstacle crossing: a review of Brazilian studies Building upon our initial systematic review, we conducted an analysis of Brazilian research focusing on obstacle crossing tasks. The aim of this second review was to identify the anthropometric characteristics of height, weight and BMI of Brazilian adults included in published studies on obstacle crossing. This review was limited to studies involving adult participants aged 18 and above, without regard to their health status. A total of 35 studies met our inclusion criteria for this analysis. The characteristics of these studies are synthesized in Figure 11, offering a comprehensive overview of how BMI has been integrated into obstacle crossing research in Brazil. 262 9. Conclusion This PhD thesis aimed to evaluate the effect of overweight on obstacle crossing during walking. Despite the well-documented adverse effects of overweight and obesity on cardiovascular health, their impact on functional mobility, such as balance and gait disturbances, has been less explored, especially in the context of obstacle crossing. First two systematic reviews were conducted, on focused on the available research investigating the influence of overweight and obesity on obstacle crossing during walking [202], the second aimed to characterize the BMI of Brazilian participants included in published studies. Our initial systematic review highlighted a critical gap: no existing studies had compared the gait behavior of normal-BMI and overweight individuals during obstacle crossing. Furthermore, while overweight and obesity was found to alter kinematic and kinetic walking parameters in adults facing a vertical obstacle, the research specifically focusing on obstacle clearance parameters remained scarce. Notably, critical parameters for evaluating the risk of tripping, such as horizontal and vertical foot clearances, had not been thoroughly investigated in adults categorized as overweight or obese. In addressing our main objective, a detailed analysis was conducted, which revealed that spatial-temporal and obstacle clearance parameters are reliable across trials, demonstrating the consistency of our measurement methods. Interestingly, our analysis indicated that overweight individuals showed increased horizontal clearances both before and after the obstacle when compared to their normal-BMI peers. This suggests a distinct strategy possibly aimed at navigating obstacles safely. However, no significant differences were found in kinematic parameters and vertical clearances between the two groups. Furthermore, our study identified correlations between age, body height, body mass, and various spatial-temporal and horizontal clearance parameters, yet these factors did not influence vertical clearances. Based on these findings, several research perspectives emerge for future studies. The first relates the pressing need to investigate obstacle crossing under more diverse and challenging conditions that closely mimic everyday scenarios. This includes examining the effects of different obstacle heights and imposing varied walking speeds to uncover how these factors interact with weight status in obstacle negotiation. Additionally, the integration of dual- task protocols, such as manual and cognitive tasks, could offer valuable insights into the cognitive and physical demands of obstacle crossing and their interaction with overweight and 263 obesity. Expanding the participant pool to include a broader range of BMI categories, ages, and health statuses will also be crucial for generalizing findings and understanding the multifaceted impact of overweight and obesity on functional mobility. This PhD thesis provides a foundational understanding of the minimal impact of overweight on obstacle crossing performance within specific experimental setups. However, it underscores the importance of further research into more dynamic and real-world applicable protocols to enhance our comprehension of mobility challenges and inform interventions aimed at improving safety and mobility for individuals across the BMI spectrum. 264 10. References 1. Li B, Tang X, Le G. Dietary Habits and Metabolic Health. Nutrients; 2023 Sep 1;15(18). 2. Warburton DER, Bredin SSD. Health benefits of physical activity: a systematic review of current systematic reviews. Curr Opin Cardiol; 2017 Sep 1;32(5):541–556. 3. Gheonea TC, Oancea CN, Mititelu M, Lupu EC, Ioniță-Mîndrican CB, Rogoveanu I. Nutrition and Mental Well-Being: Exploring Connections and Holistic Approaches. J Clin Med; 2023 Nov 1;12(22). 4. Miller V, Micha R, Choi E, Karageorgou D, Webb P, Mozaffarian D. Evaluation of the Quality of Evidence of the Association of Foods and Nutrients With Cardiovascular Disease and Diabetes: A Systematic Review. JAMA Netw Open; 2022 Feb 4;5(2). 5. Goya Wannamethee S, Gerald Shaper A. Physical activity and cardiovascular disease. Semin Vasc Med; 2002;2(3):257–266. 6. McTiernan A, Ulrich C, Slate S, Potter J. Physical activity and cancer etiology: associations and mechanisms. Cancer Causes Control; 1998;9(5):487–509. 7. Papadimitriou N, Markozannes G, Kanellopoulou A, Critselis E, Alhardan S, Karafousia V, Kasimis JC, Katsaraki C, Papadopoulou A, Zografou M, Lopez DS, Chan DSM, Kyrgiou M, Ntzani E, Cross AJ, Marrone MT, Platz EA, Gunter MJ, Tsilidis KK. An umbrella review of the evidence associating diet and cancer risk at 11 anatomical sites. Nat Commun; 2021 Dec 1;12(1). 8. Hamasaki H. Daily physical activity and type 2 diabetes: A review. World J Diabetes; 2016;7(12):243. 9. Moschonis G, Trakman GL. Overweight and Obesity: The Interplay of Eating Habits and Physical Activity. Nutrients; 2023 Jul 1;15(13). 10. Obesity and overweight. Available from: https://www.who.int/news-room/fact- sheets/detail/obesity-and-overweight 11. Defining Adult Overweight & Obesity | Overweight & Obesity | CDC. Available from: https://www.cdc.gov/obesity/basics/adult-defining.html 12. Weir CB, Jan A. BMI Classification Percentile And Cut Off Points. StatPearls Publishing; 2023 Jun 26; 13. Obesity Atlas 2023 | World Obesity Federation Global Obesity Observatory. Available from: https://data.worldobesity.org/publications/?cat=19. 265 14. Prevalence of overweight among adults, BMI >= 25 (age-standardized estimate) (%). Available from: https://www.who.int/data/gho/data/indicators/indicator- details/GHO/prevalence-of-overweight-among-adults-bmi-=-25-(age-standardized- estimate)-(-) 15. Prevalence of obesity among adults, BMI >= 30 (age-standardized estimate) (%). Available from: https://www.who.int/data/gho/data/indicators/indicator-details/GHO/prevalence-of- obesity-among-adults-bmi--30-(age-standardized-estimate)-(-) 16. Masood B, Moorthy M. Causes of obesity: a review. Clin Med (Lond); 2023 Jul 1;23(4):284–291. 17. Singh A, Hardin BI, Singh D, Keyes D. Epidemiologic and Etiologic Considerations of Obesity. StatPearls Publishing; 2023 Aug 28; 18. Hilado MA, Randhawa RS. A novel mutation in the proopiomelanocortin (POMC) gene of a Hispanic child: metformin treatment shows a beneficial impact on the body mass index. J Pediatr Endocrinol Metab; 2018 Jul 26;31(7):815–819. 19. Cerceo E, Sharma E, Boguslavsky A, Rachoin JS. Impact of Food Environments on Obesity Rates: A State-Level Analysis. J Obes; 2023;2023. 20. Silveira EA, Mendonça CR, Delpino FM, Elias Souza GV, Pereira de Souza Rosa L, de Oliveira C, Noll M. Sedentary behavior, physical inactivity, abdominal obesity and obesity in adults and older adults: A systematic review and meta-analysis. Clin Nutr ESPEN; 2022 Aug 1;50:63–73. 21. Witkam R, Gwinnutt JM, Humphreys J, Gandrup J, Cooper R, Verstappen SMM. Do associations between education and obesity vary depending on the measure of obesity used? A systematic literature review and meta-analysis. SSM Popul Health; 2021 Sep 1;15. 22. Petersen R, Pan L, Blanck HM. Racial and Ethnic Disparities in Adult Obesity in the United States: CDC’s Tracking to Inform State and Local Action. Prev Chronic Dis; 2019 Apr 1;16(4). 23. Dinsa GD, Goryakin Y, Fumagalli E, Suhrcke M. Obesity and socioeconomic status in developing countries: a systematic review. Obes Rev; 2012 Nov;13(11):1067–1079. 24. Chacaroun S, Borowik A, Doutreleau S, Belaidi E, Wuyam B, Tamisier R, Pépin JL, Flore P, Verges S. Cardiovascular and metabolic responses to passive hypoxic conditioning in overweight and mildly obese individuals. Am J Physiol Regul Integr Comp Physiol; 2020 Aug 1;319(2):R211–R222. 266 25. Manoharan MP, Raja R, Jamil A, Csendes D, Gutlapalli SD, Prakash K, Swarnakari KM, Bai M, Desai DM, Desai A, Penumetcha SS. Obesity and Coronary Artery Disease: An Updated Systematic Review 2022. Cureus; 2022 Sep 23;14(9). 26. Stephenson J, Smith CM, Kearns B, Haywood A, Bissell P. The association between obesity and quality of life: a retrospective analysis of a large-scale population-based cohort study. BMC Public Health; 2021 Dec 1;21(1). 27. Ghai S, Ghai I, Effenberg AO. Effects of dual tasks and dual-task training on postural stability: a systematic review and meta-analysis. Clin Interv Aging; 2017 Mar 23;12:557– 577. 28. Luppino FS, De Wit LM, Bouvy PF, Stijnen T, Cuijpers P, Penninx BWJH, Zitman FG. Overweight, obesity, and depression: a systematic review and meta-analysis of longitudinal studies. Arch Gen Psychiatry; 2010 Mar;67(3):220–229. 29. Ren J, Wu NN, Wang S, Sowers JR, Zhang Y. Obesity cardiomyopathy: evidence, mechanisms, and therapeutic implications. Physiol Rev; 2021 Oct 1;101(4):1745–1807. 30. Yashi K, Daley SF. Obesity and Type 2 Diabetes. Handbook of Obesity - Volume 1: Epidemiology, Etiology, and Physiopathology, Fourth Edition StatPearls Publishing; 2023 Jun 19;1:496–502. 31. Santoro A, McGraw TE, Kahn BB. Insulin action in adipocytes, adipose remodeling, and systemic effects. Cell Metab; 2021 Apr 6;33(4):748–757. 32. Pati S, Irfan W, Jameel A, Ahmed S, Shahid RK. Obesity and Cancer: A Current Overview of Epidemiology, Pathogenesis, Outcomes, and Management. Cancers (Basel); 2023 Jan 1;15(2). 33. Petrelli F, Cortellini A, Indini A, Tomasello G, Ghidini M, Nigro O, Salati M, Dottorini L, Iaculli A, Varricchio A, Rampulla V, Barni S, Cabiddu M, Bossi A, Ghidini A, Zaniboni A. Association of Obesity With Survival Outcomes in Patients With Cancer: A Systematic Review and Meta-analysis. JAMA Netw Open; 2021 Mar 29;4(3). 34. Aune D, Sen A, Prasad M, Norat T, Janszky I, Tonstad S, Romundstad P, Vatten LJ. BMI and all cause mortality: systematic review and non-linear dose-response meta-analysis of 230 cohort studies with 3.74 million deaths among 30.3 million participants. BMJ; 2016 May 4;353. 35. Van Cauwenberge J, Van Baelen K, Maetens M, Geukens T, Nguyen HL, Nevelsteen I, Smeets A, Deblander A, Neven P, Koolen S, Wildiers H, Punie K, Desmedt C. Reporting on 267 patient’s body mass index (BMI) in recent clinical trials for patients with breast cancer: a systematic review. Breast Cancer Res BMC; 2024 Dec 1;26(1). 36. Jehan S, Zizi F, Pandi-Perumal SR, Wall S, Auguste E, Myers AK, Jean-Louis G, McFarlane SI. Obstructive Sleep Apnea and Obesity: Implications for Public Health. Sleep Med Disord NIH Public Access; 2017 Dec 12;1(4). 37. Destors M, Tamisier R, Galerneau LM, Lévy P, Pepin JL. [Pathophysiology of obstructive sleep apnea syndrome and its cardiometabolic consequences]. Presse Med; 2017 Apr 1;46(4):395–403. 38. Carpenter KM, Hasin DS, Allison DB, Faith MS. Relationships between obesity and DSM- IV major depressive disorder, suicide ideation, and suicide attempts: results from a general population study. Am J Public Health; 2000;90(2):251–257. 39. Stunkard AJ, Faith MS, Allison KC. Depression and obesity. Biol Psychiatry Elsevier Inc.; 2003 Aug 1;54(3):330–337. 40. Amiri S, Behnezhad S. Obesity and anxiety symptoms: a systematic review and meta- analysis. Neuropsychiatr; 2019 Jun 1;33(2):72–89. 41. McCuen-Wurst C, Ruggieri M, Allison KC. Disordered eating and obesity: associations between binge-eating disorder, night-eating syndrome, and weight-related comorbidities. Ann N Y Acad Sci; 2018;1411(1):96–105. 42. Chu DT, Minh Nguyet NT, Nga VT, Thai Lien NV, Vo DD, Lien N, Nhu Ngoc VT, Son LH, Le DH, Nga VB, Van Tu P, Van To T, Ha LS, Tao Y, Pham VH. An update on obesity: Mental consequences and psychological interventions. Diabetes Metab Syndr; 2019 Jan 1;13(1):155–160. 43. Abbafati C et al. Global burden of 87 risk factors in 204 countries and territories, 1990- 2019: a systematic analysis for the Global Burden of Disease Study 2019. Lancet; 2020 Oct 17;396(10258):1223–1249. 44. Okunogbe A, Nugent R, Spencer G, Powis J, Ralston J, Wilding J. Economic impacts of overweight and obesity: current and future estimates for 161 countries. BMJ Glob Health; 2022 Sep 20;7(9). 45. Messier SP, Gutekunst DJ, Davis C, DeVita P. Weight loss reduces knee-joint loads in overweight and obese older adults with knee osteoarthritis. Arthritis Rheum; 2005 Jul;52(7):2026–2032. 268 46. Nedunchezhiyan U, Varughese I, Sun ARJ, Wu X, Crawford R, Prasadam I. Obesity, Inflammation, and Immune System in Osteoarthritis. Front Immunol Frontiers Media S.A.; 2022 Jul 4;13. 47. Lee R, Kean WF. Obesity and knee osteoarthritis. Inflammopharmacology; 2012 Apr;20(2):53–58. 48. Jiang L, Rong J, Wang Y, Hu F, Bao C, Li X, Zhao Y. The relationship between body mass index and hip osteoarthritis: a systematic review and meta-analysis.Joint Bone Spine; 2011 Mar;78(2):150–155. 49. McDonough CM, Jette AM. The contribution of osteoarthritis to functional limitations and disability. Clin Geriatr Med; 2010 Aug;26(3):387–399. 50. King LK, March L, Anandacoomarasamy A. Obesity & osteoarthritis. Indian J Med Res Wolters Kluwer -- Medknow Publications; 2013 Aug;138(2):185. 51. Porto H Del, Pechak C, Smith D, Reed-Jones R. Biomechanical Effects of Obesity on Balance. Int J Exerc Sci 2012 Oct 22;5(4). 52. Steinberg N, Nemet D, Pantanowitz M, Eliakim A. Gait Pattern, Impact to the Skeleton and Postural Balance in Overweight and Obese Children: A Review. Sports (Basel); 2018 Sep 1;6(3). 53. Pau M, Capodaglio P, Leban B, Porta M, Galli M, Cimolin V. Kinematics Adaptation and Inter-Limb Symmetry during Gait in Obese Adults. Sensors 2021 Sep;21(17). doi: 10.3390/s21175980 54. Capodaglio P, Gobbi M, Donno L, Fumagalli A, Buratto C, Galli M, Cimolin V. Effect of Obesity on Knee and Ankle Biomechanics during Walking. Sensors 2021 Nov;21(21). doi: 10.3390/s21217114 55. Hue O, Simoneau M, Marcotte J, Berrigan F, Doré J, Marceau P, Marceau S, Tremblay A, Teasdale N. Body weight is a strong predictor of postural stability. Gait Posture; 2007 Jun;26(1):32–38. 56. Birtane M, Tuna H. The evaluation of plantar pressure distribution in obese and non-obese adults. Clin Biomech (Bristol, Avon); 2004 Dec;19(10):1055–1059. 57. Dutil M, Handrigan GA, Corbeil P, Cantin V, Simoneau M, Teasdale N, Hue O. The impact of obesity on balance control in community-dwelling older women. Age (Dordr); 2013 Jun;35(3):883–890. 269 58. De Souza SAF, Faintuch J, Valezi AC, Sant Anna AF, Gama-Rodrigues JJ, De Batista Fonseca IC, Souza RB, Senhorini RC. Gait cinematic analysis in morbidly obese patients. Obes Surg; 2005 Oct;15(9):1238–1242. 59. Bernard PL, Geraci M, Hue O, Amato M, Seynnes O, Lantieri D. Effets de l’obésité sur la régulation posturale d’adolescentes. Étude préliminaire. Annales de Readaptation et de Medecine Physique Elsevier Masson SAS; 2003;46(4):184–190. 60. Teasdale N, Hue O, Marcotte J, Berrigan F, Simoneau M, Doré J, Marceau P, Marceau S, Tremblay A. Reducing weight increases postural stability in obese and morbid obese men. Int J Obes (Lond); 2007 Jan 25;31(1):153–160. 61. Maffiuletti NA, Agosti F, Proietti M, Riva D, Resnik M, Lafortuna CL, Sartorio A. Postural instability of extremely obese individuals improves after a body weight reduction program entailing specific balance training. J Endocrinol Invest; 2005;28(1):2–7. 62. Hulens M, Vansant G, Lysens R, Claessens AL, Muls E, Brumagne S. Study of differences in peripheral muscle strength of lean versus obese women: an allometric approach. Int J Obes Relat Metab Disord; 2001;25(5):676–681. 63. Gill S V. Effects of obesity class on flat ground walking and obstacle negotiation. J Musculoskelet Neuronal Interact 2019 Dec;19(4):448–454. 64. Ahsan M. Determine the kinematics and kinetics parameters associated with bilateral gait patterns among healthy, overweight, and obese adults. Acta Biomed; 2022;93(5). 65. Runhaar J, Koes BW, Clockaerts S, Bierma-Zeinstra SMA. A systematic review on changed biomechanics of lower extremities in obese individuals: a possible role in development of osteoarthritis. Obes Rev; 2011 Dec;12(12):1071–1082. 66. DeVita P, Hortobágyi T. Obesity is not associated with increased knee joint torque and power during level walking. J Biomech Elsevier Ltd; 2003 Sep 1;36(9):1355–1362. 67. Spyropoulos P, Pisciotta J, Pavlou K, Cairns M, Simon S. Biomechanical gait analysis in obese men. Arch Phys Med Rehabil 1991; 68. Desrochers PC, Kim D, Keegan L, Gill S V. Association between the functional gait assessment and spatiotemporal gait parameters in individuals with obesity compared to normal weight controls: A proof-of-concept study. Journal of Musculoskeletal and Neuronal Interactions; 2021;21(3):335–342. 69. Molina-Garcia P, Migueles JH, Cadenas-Sanchez C, Esteban-Cornejo I, Mora-Gonzalez J, Rodriguez-Ayllon M, Plaza-Florido A, Vanrenterghem J, Ortega FB. A systematic review on biomechanical characteristics of walking in children and adolescents with 270 overweight/obesity: Possible implications for the development of musculoskeletal disorders. Obesity Reviews Blackwell Publishing Ltd; 2019; 70. Backholer K, Wong E, Freak-Poli R, Walls HL, Peeters A. Increasing body weight and risk of limitations in activities of daily living: a systematic review and meta-analysis. Obesity Reviews 2012;13(5):456–468. doi: 10.1111/j.1467-789X.2011.00970.x 71. Wearing SC, Hennig EM, Byrne NM, Steele JR, Hills AP. The biomechanics of restricted movement in adult obesity. Obes Rev; 2006 Feb;7(1):13–24. 72. Neri SGR, Oliveira JS, Dario AB, Lima RM, Tiedemann A. Does Obesity Increase the Risk and Severity of Falls in People Aged 60 Years and Older? A Systematic Review and Meta- analysis of Observational Studies. J Gerontol A Biol Sci Med Sci; 2020 Apr 17;75(5):952– 960. 73. Weerdesteyn V, Hollands KL, Hollands MA. Gait adaptability. Handb Clin Neurol; 2018 Jan 1;159:135–146. 74. Berard JR, Vallis LA. Characteristics of single and double obstacle avoidance strategies: a comparison between adults and children. Exp Brain Res; 2006 Oct;175(1):21–31. 75. Kanmounye US, Robertson FC, Sebopelo LA, Senyuy WP, Sichimba D, Keke C, Endalle G, Graffeo CS. Bibliometric Analysis of the 200 Most Cited Articles in WORLD NEUROSURGERY. World Neurosurg Elsevier; 2021 May 1;149:226-231.e3. 76. Mamdapur GMN, Nema NK, Kumaranth