A systematic review and meta-analysis on the effects of exercise training versus hypocaloric diet: distinct effects on body weight and visceral adipose tissue: Effects of exercise versus diet on visceral fat

Abstract

Exercise training ('exercise') and hypocaloric diet ('diet') are frequently prescribed for weight loss in obesity. Whilst body weight changes are commonly used to evaluate lifestyle interventions, visceral adiposity (VAT) is a more relevant and stronger predictor for morbidity and mortality. A meta-analysis was performed to assess the effects of exercise or diet on VAT (quantified by radiographic imaging). Relevant databases were searched through May 2014. One hundred seventeen studies (n = 4,815) were included. We found that both exercise and diet cause VAT loss (P < 0.0001). When comparing diet versus training, diet caused a larger weight loss (P = 0.04). In contrast, a trend was observed towards a larger VAT decrease in exercise (P = 0.08). Changes in weight and VAT showed a strong correlation after diet (R(2) = 0.737, P < 0.001), and a modest correlation after exercise (R(2) = 0.451, P < 0.001). In the absence of weight loss, exercise is related to 6.1% decrease in VAT, whilst diet showed virtually no change (1.1%). In conclusion, both exercise and diet reduce VAT. Despite a larger effect of diet on total body weight loss, exercise tends to have superior effects in reducing VAT. Finally, total body weight loss does not necessarily reflect changes in VAT and may represent a poor marker when evaluating benefits of lifestyle-interventions.

Full text

Etiology and Pathophysiology
A systematic review and meta-analysis on the effects of
exercise training versus hypocaloric diet: distinct
effects on body weight and visceral adipose tissue
R. J. H. M. Verheggen,
1
M. F. H. Maessen,
1
D. J. Green,
2,3
A. R. M. M. Hermus,
4
M. T. E. Hopman
1
and
D. H. T. Thijssen
1,2
1
Department of Physiology, Radboud
University Medical Centre, Nijmegen, The
Netherlands,
2
Research Institute for Sport and
Exercise Sciences, Liverpool John Moores
University, Liverpool, UK,
3
School of Sport
Science, Exercise and Health, the University of
Western Australia, Crawley, Western Australia,
Australia, and
4
Department of Internal
Medicine, Division of Endocrinology, Radboud
University Medical Centre, Nijmegen, The
Netherlands
Received 4 November 2015; revised 25
January 2016; accepted 12 February 2016
Address for correspondence: Rebecca
Verheggen, MD, MSc, Department of
Physiology (392), Radboud University Medical
Center, PO Box 9101, Nijmegen, 6500 HB, The
Netherlands.
E-mail: rebecca.verheggen@radboudumc.nl
Summary
Exercise training (‘exercise’) and hypocaloric diet (‘diet’) are frequently prescribed
for weight loss in obesity. Whilst body weight changes are commonly used to
evaluate lifestyle interventions, visceral adiposity (VAT) is a more relevant and
stronger predictor for morbidity and mortality. A meta-analysis was performed to
assess the effects of exercise or diet on VAT (quantified by radiographic imaging).
Relevant databases were searched through May 2014. One hundred seventeen
studies (n= 4,815) were included. We found that both exercise and diet cause
VAT loss (P<0.0001). When comparing diet versus training, diet caused a larger
weight loss (P= 0.04). In contrast, a trend was observed towards a larger VAT
decrease in exercise (P= 0.08). Changes in weight and VAT showed a strong
correlation after diet (R
2
= 0.737, P<0.001), and a modest correlation after
exercise (R
2
= 0.451, P<0.001). In the absence of weight loss, exercise is related
to 6.1% decrease in VAT, whilst diet showed virtually no change (1.1%). In
conclusion, both exercise and diet reduce VAT. Despite a larger effect of diet on
total body weight loss, exercise tends to have superior effects in reducing VAT.
Finally, total body weight loss does not necessarily reflect changes in VAT and
may represent a poor marker when evaluating benefits of lifestyle-interventions.
Keywords: Exercise training, hypocaloric diet, obesity, visceral adipose tissue.
obesity reviews (2016)
Introduction
The worldwide prevalence of obesity, characterized by an
excess in adipose tissue, has grown to pandemic proportions
(1,2). Multiple reviews have demonstrated that accumulation
of adipose tissue in general, and in the visceral area in
particular, is strongly and positively correlated with all-cause
morbidity and mortality (3). Because obesity is an important,
but also modifiable, risk factor for cardiovascular and
metabolic diseases (4,5), the World Health Organization has
recommended lifestyle interventions to aim at 5–10%
reduction in body weight as treatment for obesity (6).
Caloric restriction and exercise training cause a reduction
in body weight by inducing a negative energy balance in
which energy expenditure exceeds caloric intake. When
comparing hypocaloric diet and exercise training, previous
meta-analyses revealed that dietary restriction has superior
effects on weight reduction (7,8). However, a growing body
of evidence shows that excess visceral adipose tissue (VAT)
may result in more detrimental obesity-related health effects
than excess body weight (9). Indeed, increased VAT is
strongly associated with insulin resistance, atherogenic
dyslipidemia, and cardiovascular disease (3,10,11).
Moreover, a reduction in VAT improves cardiovascular
obesity reviews doi: 10.1111/obr.12406
© 2016 World Obesity 1

and metabolic risk (3,12). Hence, changing VAT is
considered to be more important than weight reduction in
the management of obesity.
In patients with obesity, physical exercise training leads to a
healthier metabolic and cardiovascular phenotype (13–15).
Whilst exercise training does not always aim to reduce body
weight, exercise training in general and aerobic exercise
training in particular have potent effects on reducing VAT
(16–18). Previous meta-analyses have evaluated only the
effects of caloric restriction and aerobic exercise on weight
loss. The effects of these interventions on VAT have not yet
been compared. Therefore, we aimed to conduct a systematic
review and meta-analysis to investigate the effect of caloric
restriction versus aerobic exercise training on visceral adiposity
loss in overweight and obese adults. For this purpose, we
included studies that examined VAT after (i) caloric restriction
only, (ii) exercise training only and (iii) exercise training versus
caloric restriction. We hypothesize that, in marked contrast to
body weight loss, caloric restriction and exercise training have
comparable effects on reducing VAT. With the use of a meta-
regression analysis, we aimed to further explore the impact
of intervention (e.g. duration, intensity and frequency) and
subject (e.g. age, sex, baseline body weight) characteristics on
the magnitude of changes in VAT.
Several international guidelines recommend lifestyle
interventions aimed at a reduction in body weight of at least
5% as treatment for obesity (6,19,20). Previous work,
however, demonstrated that a reduction in body weight is a
poor marker for VAT change (9). Accordingly, changes in
VAT may occur irrespective of changes in body weight. A
hypocaloric diet causes a reduction in skeletal muscle mass,
which along with a reduction in fat mass, contributes to
weight loss (21,22). Aerobic exercise training, however, may
be associated with an increase in lean body mass and/or
plasma volume (23–25). Assuming that fat mass decreases
with exercise training, training may still not lead to weight
loss (24,26). Therefore, we hypothesize that the relation
between changes in body weight and changes in VAT differs
between caloric restriction and exercise interventions.
Methods
Data sources and searches
The systematic literature search and documentation of
literature was performed with the use of the preferred
reporting items for systematic reviews and meta-analysis
statement (27). Databases systematically searched were
Pubmed, Cochrane, Web of Science and Embase. The
following search strategy was used, with adaption for each
database: (("Energy Intake"OR"Diet Therapy"OR"
(calori*AND restrict*)"OR(low AND calori*)OR"dietary
intervention*"OR"diet intervention*)"AND ("Overweight"
OR"obes*")AND("Abdominal Fat"OR("Adipose Tissue"
AND("intra-abdom"*ORintraabdom*ORabdom*ORvisce-
ral*))OR"Body Composition"OR"abdominal adipos*OR
visceral adipos*ORintra-abdominal fat"OR"abdominal
fat"OR"total body fat"OR"adipose tissue distribution))OR
(("Overweight"OR"obes*")AND("Motor Activity”OR"
Exercise"OR"Running"OR"Swimming"OR"Walking"OR"-
Warm-Up Exercise"OR"Exercise Therapy"OR"Motion
Therapy, Continuous Passive"OR"Sports”OR "Athletic
Performance"OR"Bicycling"OR"Physical Exertion"OR"
running" OR"bicycling"OR"cycling"OR"walking"OR"
swimming"OR"training"OR"physical activity"OR"exercis*
"OR"cardio-training")AND("Abdominal Fat"OR("Adipose
Tissue" AND (intra-abdom*OR"intraabdom*"OR"abdom*
"OR"visceral*"))OR"Body Composition" OR"abdominal
adipos"*OR"visceral adipos"*OR"intra-abdominal fat"OR"
abdominal fat"OR"total body fat"OR"adipose tissue
distribution")). Randomized controlled trials (RCTs), non-
randomized controlled trials (non-RCTs) or clinical trials
published in English, German and Dutch were included from
1 January 1987 to 5 May 2014. Reference lists of included
articles were manually checked by R. V. for possible eligible
studies that were missed during the literature search (Fig. 1).
This represents a valid and frequently used method to further
increase the number of potentially eligible studies.
Study selection
To standardize the selection procedure by two independent
reviewers (R. V. and M. M.), investigators received a
standardized protocol previous to the selection of studies.
After the elimination of duplicates, one investigator (R. V.)
screened study titles for eligibility with use of the inclusion
and exclusion criteria in the review protocol, which are
listed later. Two reviewers (R. V., M. M.) independently
screened the abstracts of the remaining studies. Three
hundred eighty-nine studies were assessed in full text
(Fig. 1). Inter-reviewer disagreements were resolved through
consensus or by consulting a third reviewer (M. H.). When
study characteristics or viable information was missing, an
attempt was made to request missing information from the
authors by email (n= 6 studies; authors of n= 2 studies
provided requested information). Studies were included
when the mean age at entry was ≥18 years and mean body
mass index was ≥25 kg m
2
. Studies of HIV-infected
individuals were excluded because of the interference of
anti-retroviral drugs with abdominal adipose tissue (16).
Because spinal cord injuries are associated with changes in
body composition, studies conducted in spinal cord injured
individuals were also excluded (28). Studies with one or
more arms assigned to an aerobic exercise intervention or
a hypocaloric diet were eligible for inclusion. For the first
aim, clinical trials and RCTs with one arm assigned to
exercise or caloric restriction were selected. Furthermore,
in order to directly compare duration-matched and energy
2Effects of exercise versus diet on visceral fat R. J. H. M. Verheggen et al. obesity reviews
© 2016 World Obesity

deficit-matched exercise training with caloric restriction,
RCTs with an exercise and a diet arm were included. To
identify exercise and subject characteristics that predict the
magnitude of change in VAT using the meta-regression
analysis, clinical trials and RCTs with one arm assigned to
exercise or caloric restriction were selected. Finally, diet
and exercise studies that provided baseline and post-
intervention results for VAT and weight were included for
the correlation analysis. Exercise training was defined as a
programme including voluntary aerobic exercise at a low
to vigorous intensity for at least two times per week during
a minimum period of 4 weeks and with a minimum duration
of 20 min per session. Caloric restriction was defined as a
daily reduction in energy (caloric) intake of at least 10%
of the habitual intake (2,000 kcal for women, 2,500 kcal
for men) during a minimum period of 4 weeks.
Interventions combining exercise and diet therapy or adding
resistance exercise or bariatric surgery to an intervention
arm were excluded. Studies in which a pharmacological
dietary supplement was used were excluded from our
analysis. Studies were eligible when VAT was measured with
the use of computerized tomography or magnetic resonance
imaging, which are both considered to be the gold standard
for the quantitative measurement of VAT (29). Studies that
used another measurement technique were excluded.
Data extraction and quality assessment
Baseline and post-intervention mean VAT area or volume
and standard deviation or standard error was independently
recorded by two authors (R. V., M. M.). When VAT was
measured at multiple sites, the measurement at the fourth
Figure 1 PRISM flowchart of outcomes of search strategy.
Effects of exercise versus diet on visceral fat R. J. H. M. Verheggen et al. 3obesity reviews
© 2016 World Obesity

and/or fifth lumbar vertebrae was recorded for further
analysis, because this region is most strongly correlated with
body adiposity (28). Based on changes in visceral
abdominal fat area or volume, percentage change in VAT
for each study was calculated by one of the authors (R. V.)
for the correlation analysis. Percentage weight loss was also
calculated based on pre-intervention and post-intervention
values. Furthermore, publication year, journal, study
design, sample size, age, sex, weight, body mass index and
intervention details (duration, intensity, frequency [exercise
studies], caloric deficit [diet studies]) were extracted from
all included studies. When results were depicted in figures
only (n= 14 studies), data were extracted with the use of
GetData Graph Digitizer. A request by email was send to
the authors, when key information was not included in the
published manuscript (n= 6 studies). Two out of six authors
responded to our repeated email requests; thus, the
remaining four studies were excluded from further analysis.
The quality of each eligible study was independently
assessed by two authors (R. V. and M. M.), with the use of
a modified version of The Critical Review Form for
Quantitative Studies, from Law et al. (30). One item
(‘contamination was avoided’) was not applicable for the
studies included in this meta-analysis and was therefore
removed for analysis. Only studies with a minimum score
of 10 out of 14 items were eligible for inclusion (Fig. 1).
Data synthesis and analysis
To account for potential heterogeneity between studies, a
random-effects model (specified a priori) was used to
determine the overall effect size of the intervention (exercise
training or hypocaloric diet) on VAT. Effect sizes for RCTs
and clinical trials were calculated as the standardized mean
difference (SMD) with corresponding 95% confidence
interval (CI). A correlation of 0.5 between the outcomes
measured in each study arm (i.e. exercise, diet or control)
was assumed. When a study contained multiple study arms,
all were included in the statistical analysis, whereby the
different intervention groups were individually compared
against the control group. Analyses to assess the following
comparisons (i) diet versus control, (ii) exercise versus
control and (iii) diet versus exercise were performed. The
Cochrane’s Q statistic and I
2
were calculated to assess the
degree of heterogeneity across studies. Publication bias
was assessed using visual analysis of the funnel plot
asymmetry using the ‘trim and fill’and the ‘Classic fail ‘n
safe’algorithms. All calculations and plots were performed
in CMA-2 (Comprehensive Meta-analysis second version;
Biostat, Englewood, NJ, USA).
Meta-regression analysis
To assess the effects of subject and intervention
characteristics on VAT loss, random-effects meta-regression
analysis with SMD as dependent variable was calculated.
The weighted inverse variance (with correction for total n)
was used as weight factor. For the purpose of meta-
regression analysis, the aerobic exercise arms (n= 86) were
separated from the hypocaloric diet arms (n= 87). In both
study types, duration of the exercise training or diet
intervention (weeks), measurement technique (computerized
tomography or magnetic resonance imaging), body weight
at baseline, age and sex were defined as a covariate.
Duration was assessed as a categorical variable (duration
<16 weeks versus duration of ≥16 weeks). In the exercise
studies, intensity of the intervention was examined as a
covariate. Intensity was categorized in ‘vigourous intensity’
(i.e. largely performed at 70% of maximal heart rate
[maxHR], >55% of maximal oxygen uptake [VO2max] or
60–80% of the heart rate reserve), ‘moderate intensity’
(60–70% of maxHR, 45–55% of VO2max or at the lactate
threshold) and ‘low intensity’(<60% of maxHR or <45%
of VO2max) based on previous work (18). This
categorization is somewhat different from the often used
and more practical categories based on metabolic
equivalents of task (METs) as proposed in the American
College of Sports Medicine (ACSM) and American Heart
Association guidelines (i.e. light [<3.0 METs], moderate
[3.0–6.0 METs] and vigorous [>6.0 METs]) (31,32). Only
two studies included in our meta-analysis provided data on
METs. Therefore, we adopted the aforementioned strategy
to divide studies based on intensity. In hypocaloric diet
studies, ‘intensity’was divided in ‘very low calorie diets’
(reduction to maximal 800 kcal d
1
) and ‘low calorie diets
(caloric restriction to 800–2,000 kcal d
1
). Lastly, frequency
(times spent in training per week) was added as covariate in
exercise studies.
Correlation analysis
To examine correlations between weight loss and VAT
improvement, a Pearson correlation coefficient was
calculated. The formula of the corresponding trend line
was retrieved with the use of linear regression. Meta-
regression analyses and correlation analysis were conducted
with use of SPSS version 22.0 (IBM, Armonk, NY, USA).
Results
Selection of studies for the meta-analysis
The original search resulted in 15,964 studies. Eleven more
studies were found from the reference lists of the included
full text papers. After removal of duplicates and elimination
of papers based on the eligibility criteria and quality
assessment, 50 aerobic exercise studies and 59 hypocaloric
diet studies were included (Fig. 1). For the analysis of a
direct comparison between caloric restriction and exercise
training, eight studies were included (Table 1). One study,
which directly compared exercise training with caloric
4Effects of exercise versus diet on visceral fat R. J. H. M. Verheggen et al. obesity reviews
© 2016 World Obesity

Table 1 Overview of the characteristics of the included exercise training (n= 50) and hypocaloric diet (n= 59) studies
Exercise training studies
Reference Groups n(M/F) Age (years)
BMI
(kg m
2
) Intensity
Frequency/
duration
per session
Duration
(weeks)
Assessment
VAT
Results VAT
(pre/post)
Weight (kg)
(pre/post)
Baria et al.
(36)
Centre-based
exercise
10 (10/0) 52.1 ±11.4 30.8 ± 5.1 Personal
ventilatory
treshold
3×/week/30–60 min 12 CT L4–L5 (mm) 113.1 ± 24.1/
106.6 ± 22.8
86.2 ± 19.4/
86.1 ± 20.7
Home-based
exercise
8 (8/0) 50.8 ± 7.7 30.9 ± 3.9 115.2 ± 20.5/
107.4 ± 17.0
90.9 ± 12.4/
89.3 ± 11.9
Control 10 (10/0) 53.4 ± 9.6 29. ± 1.9 92.1 ± 25.9/
97.0 ± 23.9
84.8 ± 7.8/
+1.5 kg
Boudou
et al. (37)
Exercise 8 (8/0) 42.9 ± 5.2 28.3 ± 3.9 75% of VO2peak
& 5 × 2 min, 85%
of VO2peak
alternated by 3×
50% of VO2peak
2×/week/45 min &
1×/week/19 min
8 MRI L4–L5
(cm
2
)
153.25 ± 38.55/
84.20 ± 21.30
86.90 ± 13.4/
85.00 ± 13.8
Control 8 (8/0) 47.9 ± 8.35 30.85 ± 5.2 156.85 ± 23.40 /
150.35 ± 23.3
85 ± 13.75/
88.75 ± 1.30
Cho et al.
(38)
Low-intensity
exercise
15 (0/15) 42.4 ± 7.6 25. 6 ± 1.7 40–50% of
VO2max, 70–75%
of VO2max
3×/week (duration
depending on energy
expenditure)
12 CT L4–L5
(cm
2
)
99 ± 41/
79 ± 40
64.4 ± 6.0/
62.3 ± 5.5
High-intensity
exercise
15 (0/15) 45.6 ± 4.6 25.1 ± 2.0 90 ± 26/
83 ± 30
63.2 ± 6.4/
60.4 ± 6.4
Control 15 (0/15) 49.2 ± 8.7 26.1 ± 2.7 106 ± 33/
103 ± 28
63.0 ± 7.8/
64.5 ± 7.0
Cuff et al.
(39)
Aerobic exercise 9 (0/9) 59.4 ± 1.9 32.5 ± 1.4 60–75% maxHR 3×/week/75 min 16 CT L4–L5 (cm
2
) 215.7 (25.8)/
8.8 (5.4)
81.2 ± 3.8/
1.2 (0.7)
Control 9 (0/9) 60.0 ± 2.9 36.7 ± 2.0 225.8 (8.9)/
0.4 (12.0)
95.6 ± 6.5 /
+2.0 (1.2)
Davidson
et al. (40)
Aerobic exercise 37 (17/20) 68.8 ± 6.0(m) 29.9 ± 3.0 60–75% of
VO2peak
7×/week/30 min 26 MRI (kg) 11.0 (1.9)% NR/2.7
(3.1)%69.1 ± 6.5 (f) 29.2 ± 3.7
Control 28 (11/17) 67.4 ± 3.8(m) 30.5 ± 2.0 0.7 (2.5)% NR/0.1
(0.7)%66.7 ± 3.7(f) 30.4 ± 3.2
Dekker et al.
(41)
Obese with T2D 8 (8/0) 51.0 (3.0) 29.9 (1.2) 60% VO2max 5×/week/60 min 12 MRI L4–L5
(kg)
3.8 (0.3)/
3.1(0.4)
93.5 (2.9)/
93.9 (3.2)
Obese 8 (8/0) 47.1 (3.1) 32.4 (0.6) 4.0 (0.4)/
3.4 (0.4)
97.6 (3.4)/
97.2 (0.6)
Despres et al.
(42)
Aerobic exercise 13 (0/13) 38.8 ± 5.3 34.5 ± 4.3 55% of VO2max 4–5×/week/90 min 12 CT L4–L5
(cm
2
)
124.7 ± 48.6/
121.3 ± 45.5
90.0 ± 11.8/
86.3 ± 9.6
Dipietro et al.
(43)
Aerobic exercise 9 (2/7) 72 (1) 27.5 (2.7) 55% of maxHR
during 1 month,
75% during 3
months
4×/week/40–60 min 17 CT L4–L5
(cm
2
)
116 (31)/
106 (24)
65 (5)/64(4)
Control 7 (1/6) 73 (1) 26.8 (1.5) 136 (28)/
118 (27)
69 (4)/69 (4)
Continues
Effects of exercise versus diet on visceral fat R. J. H. M. Verheggen et al. 5obesity reviews
© 2016 World Obesity

Table 1. (Continued)
Exercise training studies
Reference Groups n(M/F) Age (years)
BMI
(kg m
2
) Intensity
Frequency/
duration
per session
Duration
(weeks)
Assessment
VAT
Results VAT
(pre/post)
Weight (kg)
(pre/post)
Donges et al.
(44)
Aerobic exercise 13 (13/0) 45.4 (1.7) 32.0 (1.3) 75% of age-
predicted maxHR
during first 4
weeks, thereafter
80% of maxHR
3×/week/40–50 min 12 CT L4 (cm
2
) 1,371 (113)/
1,222 (100)
103.1 (4.6)/
1.9 (0.7)%
Control 8 (8/0) 49.5 (2.6) 29.6 (2.1) 1,383 (164)/
1,349 (145)
92.2 (6.9)/
+0.1 (0.6)%
Donges et al.
(45)
Aerobic 41 (16/25) NR 30.0 ± 5.5 70–75% of max
HR
3×/week/30–50 min 10 DEXA (kg) 1.49 ± 0.55/
1.38 ± 0.58
84.8 ± 18.6/
0.8 ± 1.9
Control 26 (13/13) 28.3 ± 4.1 1.44 ± 0.43/
1.44 ± 0.45
83.2 ± 13.4/
+0.6 ± 1.3 kg
Donnelly et al.
(46)
Exercise Group
men
16 (16/0) 22 ± 4 29.7 ± 2.9 60% of HRR
with a gradual
increase
to 75% at 6 months
5×/week/20–45 min 65 CT L4–L5 (cm
2
) 97.9 ± 22.5/
75.5 ± 18.3
94.0 ± 12.6/
88.8 ± 9.5
Control Group
men
15 (15/0) 24 ± 4 29.0 ± 3.0 91.7 ± 29.7/
85.4 ± 39.7
94.1 ± 11.4/
93.16 ± 11.6
Exercise group
women
25 (25/0) 24 ± 5 28.7 ± 3.2 60.6 ± 25.5/
57.4 ± 28.4
77.0 ± 11.4/
77.6 ± 12.8
Control group
women
18 (18/0) 21 ± 4 29.3 ± 2.3 62.9 ± 21.8/
66.0 ± 13.9
79.9 ± 8.1/
82.8 ± 9.2
Friedenreich
et al. (47)
Aerobic exercise 160 (0/160) 61.2 ± 5.4 29.14.5 70–80% of maxHR 3.6×/week/45 min 52 CT umbilicus
(cm
2
)
101.4 ± 55.4/
16.5
75.6 ± 13.0/
2.3
Control 160 (0/160) 60.6 ± 5.7 29.3 ± 4.3 103.2 ± 56/
1.6
76.3 ± 12.7/
0.5
Gan et al.
(48)
Aerobic exercise 18 (0/18) 37.4 (1.3) 30.9 (0.7) 55–70% VO2max 4–5×/week/40 min 9.7 MRIL4–L5 (l) 2.23 (0.12)/
2.11 (0.12)
94.1 (2.0)/
92.8 (2.0)
Giannopoulou
et al. (49)
Aerobic exercise 11 (0/11) 57 (entire
study)
35.9 (2.2) 70% HRR 3×/week/60–75 min 12 MRI (cm
3
) 5,204 (598)/
4,675 (550)
92.9 (6)/
91.2 (5.6)
Halverstadt
et al. (50)
Aerobic exercise 83 (34/49) 57.9 ± 0.6 36.0 ± 1.1
(% body fat)
50% of VO2max
with a gradual
increase to 70% of
VO2max (for at
least 14 weeks)
3×/week/20–40 min
and addition of one
extra low intensity
exercise session
24 CT (cm
2
) 127.8 (4.5)/
14.4 (2.4)
80.6 ± 1.6/
1.1 (0.3)
Haus et al.
(51)
Aerobic exercise 16 (5/11) 65 ± 1 33 ± 1 60-65% max HR
with a gradual
increase to 80–85%
Week 4
5×/week/50–60 min 12 CT (cm
2
) 182.4 ± 21.5/
134.5 ± 15.9
95.7 ± 4.1/
91.9 ± 3.8
Heydari
et al. (52)
Aerobic exercise 25 (25/0) 24.7 ± 4.8 28.4 ± 0.5 80–90% of max HR
during 8-s sprint,
3×/week/20 min 12 CT L4/L5 (g) 62.6 (6.2)/
51.8 (5.1)
87.8 ± 2.7/
86.3 ± 2.7
Continues
6Effects of exercise versus diet on visceral fat R. J. H. M. Verheggen et al. obesity reviews
© 2016 World Obesity

Table 1. (Continued)
Exercise training studies
Reference Groups n(M/F) Age (years)
BMI
(kg m
2
) Intensity
Frequency/
duration
per session
Duration
(weeks)
Assessment
VAT
Results VAT
(pre/post)
Weight (kg)
(pre/post)
whereafter 12-s
recovery
Control 21 (21/0) 25.1 ± 3.9 29 ± 0.9 69.7 (9.7)/
67.3 (8.4)
89 ± 2.9/
89.4 (3.1)
Hutchison
et al. (53)
Obese 8 (0/8) NR 36.9 (2.1) 75–85% of maxHR
OR HIIT: 6–8 × 5 min
at 95-100% of
maxHR –1–2 min
recovery
3×/week/60 min
(alternating between
HIIT and continuous)
12 CT L4–L5 (cm
2
) 135.1 (15.7)/
132.7 (18.1)
99.4 (5.4)/
96.9 (4.5)
PCOS 14 (0/14) 119.5 (16.1)/
107.6 (15.1)
96.9 (4.8)/
95.3 (4.8)
Irving et al.
(54)
Low-intensity
exercise
11 (0/11) 51 ± 9
(entire group)
34.7 ± 7.5 At lactate threshold,
midway between
lactate threshold and
VO2max (3 d);
lactate threshold (2 d)
5×/week/duration
depended on energy
expenditure
16 CT L4/L5 (cm
2
) 153 ± 51/
146 ± 49
97.2 ± 22/
95.1 ± 19.3
High-intensity
exercise
9 (0/9) 34.7 ± 6.8 173 ± 73/
148 ± 59
93.5 ± 18.3/
90.0 ± 15.6
Controls 7 (0/7) 32.7 ± 3.8 157 ± 71/
155 ± 71
89.6 ± 11.2/
88.7 ± 10.6
Irwin et al.
(55)
Exercise 87 (0/87) 60.7 ± 6.7 30.4 ± 4.1 Start 40% of maxHR
with a gradual
increase to 60-75%
by week8
5×/week/45 min 52 CT L4–L5
(g/cm
2
)
147.6 (134.3–
161)/8.5
81.4 ± 14.1/
1.3%
Control 86 (0/86) 60.6 ± 6.8 30.5 ± 3.7 147.6 (135.4–
159.8)/+0.1
81.7 ± 12.1/
0.1%
Janssen
et al. (56)
Aerobic exercise
in black men
84 (84/0) Not depicted
for entire
groups
27.0 ± 4.8 75% of VO2max 3×/week/ 50 min 20 CT L4–L5
(cm
2
)
77.5 ± 5.1/
71.9 ± 52.2
83.9 ± 16.3/
0.5 ± 2.4
Aerobic exercise in
white men
255 (255/0) 26.7 ± 4.9 109.5 ± 63.6/
102.4 ± 61.2
84.3 ± 16.3/
0.3 ± 2.1
Aerobic exercise in
black women
160 (0/160) 28.2 ± 6.1 69.1 ± 40.8/
65.4 ± 37.9
73.8 ± 16.3/
0.4 ± 3.0
Aerobic exercise in
white women
243 (0/243) 24.9 ± 4.8 75.4 ± 52.7/
72.2 ± 49.1
67.0 ± 13.6/
0.1 ± 2.1
Johnson
et al. (57)
Aerobic exercise 12 (N.R.) 49.1 (2.3) 32.2 (0.8) Week 1: 50% of
VO2p, Week 2: 60%
VO2p, Weeks 3 and
4: 70% VO2p
3×/week/30–45 min
(interval:15-min
training, 5-min rest)
4 MRI L4–L5
(cm
2
)
154.3 (18.3)/
143.6 (18.7)
94.4 (3.8)/
94.1 (4.0)
Stretching control 7 (N.R.) 47.3 (3.6) 31.1 (1.1) 154.3 (21.2)/
158.6 (23.9)
98.8 (6.0)/
98.6 (6.3)
Jung et al.
(58)
Moderate intensity 8 (0/8) 56.8 ± 8.2 25.5 ± 1.5 Goal: intensity at
3.5–5.2 METs, goal:
intensity at >5.3
METs
5×/week/60 min
(moderate intensity)
vs. 30 min (vigorous
intensity)
12 CT L4–L5
(cm
2
)
15,784.6 ±
4,662.7/
13,262.5 ±
3,217.8
63.7 ± 5.0/
2.9% ±
2.5%
Continues
Effects of exercise versus diet on visceral fat R. J. H. M. Verheggen et al. 7obesity reviews
© 2016 World Obesity

Table 1. (Continued)
Exercise training studies
Reference Groups n(M/F) Age (years)
BMI
(kg m
2
) Intensity
Frequency/
duration
per session
Duration
(weeks)
Assessment
VAT
Results VAT
(pre/post)
Weight (kg)
(pre/post)
Vigorous intensity 8 (0/8) 48.4 ± 6.1 25.9 ± 1.6 13,726.6 ±
3,011.8/
12,447.4 ±
2,252.6
62.9 ± 4.4/
2.5% ± 2.3%
Control 12 (0/12) 55.5 ± 7.6 27.7 ± 3.4 17,790.2 ±
5,621.7/
17,372.7 ±
5,235.7
67.3 ± 9.8/
1.5% ± 1.6%
Karstoft
et al. (59)
Continuous walking
group
12 (8/4) 60.8 ± 2.2 29.9 ± 1.6 >55% of peak
energy expenditure,
walking at 70% of
peak energy
expenditure for 3 min,
alternated with
3 min of slow
walking
5×/week/60 min 17 MRI, below
diaphragm (l)
4.5 ± 0.3/
4.2 ± 0.4
88.2 ± 4.7/
87.5 ± 4.8
Interval walking
group
12 (7/5) 57.5 ± 2.4 29.0 ± 1.3 4.7 ± 0.8/
4.2 ± 0.7
84.9 ± 4.9/
80.7 ± 4.1
Control group 8 (5/3) 57.1 ± 3.0 29.7 ± 1.9 4.7 ± 0.4/
4.6 ± 0.4
88.5 ± 4.7/
89.2 ± 5.2
Kim et al. (60) Aerobic exercise 24 (24/0) 49.4 ± 9.6 30.7 ± 3.3 Gradual increase of
50–60% of maxHR
to 60–70%
3×/week/60 min 12 CT L4–L5
(cm
2
)
197.1 ± 61.9 /
165.7 ± 57.0
87.7 ± 11.2 /
-4.2%
Ku et al. (61) Aerobic exercise 15 (0/15) 55.7 ± 7.0 27.1 ± 2.4 40–50% of maximal
exercise capacity
5×/week/60 min 12 CT (g) 15,890 ± 4,593/
15,038 ± 3,369
66.3 ± 6.0/
1.9 ± 1.2
Control 16 (0/16) 57.8 ± 8.1 27.4 ± 2.8 17,530 ± 4,747/
17,362 ± 4,728
67.6 ± 7.5/
0.6 ± 0.7
Kwon et al.
(62)
Aerobic exercise 13 (0/13) 55.5 ± 7.5 27.0 ± 2.5 Anaerobic threshold 5×/week/60 min 12 CT L4–L5 16,291.5 ± 4,808/
14,682.7 ± 3,494
66.3 ± 6.5/NR
Control 14 (0/14) 57.5 ± 8.6 27.5 ± 3.0 17,204.5 ± 4,674/
17,216.3 ± 4,560
68.0 ± 7.9/NR
Lee et al. (63) Obese 8 (8/0) 47.1 ± 8.1 32.4 ± 1.6 ~60% of VO2peak 5×/week/60 min 13 MRI 5 cm below
to 15 cm above
L4–L5 (kg)
9.2 ± 1.2/
8.3 ± 1.1
97.6 ± 8.9/
97.2 ± 8.9
T2D 9 (9/0) 51.0 ± 8.0 29.9 ± 3.2 7.5 ± 1.3/
6.7 ± 1.5
93.5 ± 7.6/
93.9 ± 8.5
Liao et al.
(64)
Aerobic exercise 32 (9/23) 55.8 (1.8) 25.6 (0.8) 50% of HRR, with
a gradual increase
to 70%
3×/week/60 min 26 CT (cm
2
) 86.3 (8.1)/
16.1
66.1 (2.9)/
2.7 (0.4)
Stretching control
group
32 (17/15) 52.2 (1.8) 26.6 (0.8 112.3 (9.9)/
14.5
69.7 (2.6)/
0.9 (0.3)
Continues
8Effects of exercise versus diet on visceral fat R. J. H. M. Verheggen et al. obesity reviews
© 2016 World Obesity

Table 1. (Continued)
Exercise training studies
Reference Groups n(M/F) Age (years)
BMI
(kg m
2
) Intensity
Frequency/
duration
per session
Duration
(weeks)
Assessment
VAT
Results VAT
(pre/post)
Weight (kg)
(pre/post)
Malin et al.
(65)
Aerobic exercise 35 (16/19) 66.8 ± 0.8 35.1 ± 0.7 60–65% of maxHR
first 4 weeks,
thereafter 80–85%
5×/week/50–60 min 12 CT (cm
3
) 151.4 (14)/
30.6
99.0 ± 2.4/
8.1 ± 0.7
Malin et al.
(66)
Impaired fasting
glucose
12 (8/4) 65.1 ± 0.6
(entire group)
33.8 ± 1.0 60–65% of maxHR
first 4 weeks,
thereafter increase
to 80–85%
5×/week/50–60 min 12 CT (cm
2
) 139.9 ± 16.8/
86.6 ± 14.4
100/89.9
IGT 9 (4/5) 32.7 ± 1.1 215.9 ± 76.6/
140.9 ± 45.2
94.5/87.3
Combined glucose
intolerance
22 (7/15) 35.6 ± 1.0 187.7 ± 19.1/
172.2 ± 19.9
96.9/90.1
Normal glucose
tolerant
15 (4/11) 32.3 ± 1.2 137.4 ± 23.9/
90.5 ± 21.2
90.1/84.5
Type 2 diabetes 18 (7/11) 34.1 ± 1.3 139.9 ± 23.7/
109.0 ± 18.1
94/90.4
McKenzie
et al. (67)
Males, GG
genotype
29 (29/0) 58 ± 1 28.7 ± 0.7 50–70% of HRR 3×–4×/week/20–
40 min
24 CT (cm
2
) 150 (129-175)/
20.1 (5.6)
91.1 ± 2.7/
1.3
Males, GT + TT
genotype
21 (21/0) 61 ± 1 27.3 ± 0.8 131 (110-156)/
29.9 (9.2)
86.7 ± 3.1/2.3
Females, GG
genotype
38 (0/38) 57 ± 1 27.7 ± 0.7 110 (100-121)/
7.9 (3.1)
73.8 ± 2.0/0.4
Females, GT + TT
genotype
20 (0/20) 58 ± 1 27.9 ± 1.0 111 (97-127)/
0.2 (5.6)
76.0 ± 2.8/1.1
McTiernan
et al. (68)
Women, aerobic
exercise
49 (0/49) 54.4 ± 7.1 28.9 ± 5.5 60–85% of maxHR 6×/week/60 min 52 CT L4–L5 (cm
2
) 105.9 ± 60.8/
100.1 ± 58.8
78 ± 17.8/
1.4 ± 1.8%
Women, controls 51 (0/51) 53.7 ± 5.6 28.5 ± 4.5 102.6 ± 55.8/
104.2 ± 59.6
77.9 ± 12.8/
+0.7 ± 0.9%
Men, exercisers 51 (51/0) 56.2 ± 6.7 29.7 ± 3.7 161.8 ± 66.3/
149.6 ± 76.6
94.8 ± 14.9/
1.8 ± 1.9%
Men, controls 51 (51/0) 56.6 ± 7.6 30.1 ± 4.8 176.7 ± 79.1/
170.5 ± 73.3
97.4 ± 18.2/
+0.7 ± 0.9%
Miyatake
et al. (69)
Aerobic exercise 25 (25/0) NR 28.5 ± 2.3 60% of maximum
HR and walking of
an extra 1,000
steps d
1
1×/week supervised
and daily walking/
duration NR
52 CT (cm
2
) 109.8 ± 57.2/
82.7 ± 42.6
81.3 ± 7.9/
78.1 ± 7.4
Moghadesi
et al. (70)
Aerobic exercise 8 (8/0) NR 30.3 ± 2.1 Walking 2 miles on
40–59% VO2max
4×/week/30 min 12 MRI L4–L5
(cm
3
)
651.1 ± 31.8/
602.2 ± 13.7
86.1 ± 4.6/
84.1 ± 4.3
Continues
Effects of exercise versus diet on visceral fat R. J. H. M. Verheggen et al. 9obesity reviews
© 2016 World Obesity

Table 1. (Continued)
Exercise training studies
Reference Groups n(M/F) Age (years)
BMI
(kg m
2
) Intensity
Frequency/
duration
per session
Duration
(weeks)
Assessment
VAT
Results VAT
(pre/post)
Weight (kg)
(pre/post)
Control 8 (8/0) 32.0 ± 5.3 688.4 ± 106.2/
692.2 ± 108.8
90.4 ± 13.9/
90.6 ± 14.1
O’Leary
et al. (71)
Aerobic exercise 16 (5/11) 63 (1) 33.2 (1.4) Start at 60–65% of
maxHR with a
gradual increase to
80–85%
5×/week/50–60 min 12 CT L4–L5 (cm
2
) 175.6 (20.2)/
136.2 (16.9)
94.1 (4.3)/
90.9 (4.0)
Park et al.
(72)
Aerobic exercise 10 (0/10) 42.2 ± 1.91 25.3 ± 1.74 60–70% of maxHR 6×/week/60 min 24 CT umbilicus 195.0 ± 12.55/
112.4 ± 10.50
63.7 ± 2.58/
4.7 kg
Control 10 (0/10) 43.1 ± 1.67 25.5 ± 0.86 182.9 ± 16.81/
190.4 ± 15.74
65.2 ± 1.87/
+0.6 kg
Prior et al.
(73)
Aerobic exercise 34 (34/0) 62 ± 1 28.9 ± 0.7 50–70% of VO2max 3×/week/20–45 min 26 CT L4–L5 (cm
2
) 154 (13)/138.3 91.4 ± 2.4/
1.6%
Pritchard
et al. (74)
Aerobic exercise 14 (14/0) 21.0 ± 0.8 26.2 ± 5.5 50–55% of VO2max 7×/week/57 min 13 CT L4–L5 (cm
2
) 80.8 ± 19.0/
52.1 ± 22.4
82.1 ± 19.9/
77.1 ± 19.0
Redman
et al. (75)
Aerobic exercise 8 (0/8) 25 ± 1 32.0 ± 1.6 55% of VO2max 5×/week/23 min
Weeks 1–4; gradual
increase to 58 min
Weeks 12–16
16 MRI (kg) 1.3 (0.9–1.9)/
1.2 (0.7–1.7)
84.6 ± 5.8/
1±2%
Reichkendler
et al. (76)
Moderate dose
aerobic exercise
18 (18/0) 30 ± 2 28.6 ± 0.4 VO2max >70%,
VO2max 50–70%
3×/week, 4×/week/
(duration depended
on EE)
11 MRI L4–L5 (kg) 2.2 ± 0.8 kg/
1.9 ± 0.6 kg
93.2 ± 1.9/
89.6 ± 2.0
High dose aerobic
exercise
18 (18/0) 28 ± 1 27.6 ± 0.3 2.0 ± 0.7 kg/
1.6 ± 0.4 kg
91.3 ± 1.7/
88.8 ± 1.6
Control 17 (17/0) 31 ± 1 28.0 ± 0.6 2.0 ± 0.6 kg/
2.1 ± 0.6 kg
92.8 ± 2.1/
92.9 ± 2.1
Sasai et al.
(77)
Moderate intra-
abdominal fat
33 (33/0) 52.9 ± 10.6 29.2 ± 3.1 Anaerobic treshold 3×/week/90 min 12 CT (cm
2
) 149.7 ± 35.4/
134.6 ± 43.1
80.9 ± 10.1/
2.3 ± 2.2
High intra-
abdominal fat
24 (24/0) 53.5 ± 9.5 30.3 ± 3.1 242.4 ± 34.4/
199.1 ± 39.7
88.8 ± 11.3/
3.2 ± 3.0
Sasai et al.
(78)
Low volume
exercise
19 (19/0) 49.7 ± 8.2 31.0 ± 4.1 65–80% of maxHR 3×/week/30–60 min 12 CT (cm
2
) 188.1 ± 53.9/
170.3 ± 46.6
89.8 ± 13.4/
2.7 ± 3.1
High volume
exercise
18 (18/0) 45.4 ± 8.6 29.3 ± 2.0 167.9 ± 44.3/
137.9 ± 40.6
85.7 ± 9.6/
3.4 ± 2.6
Schwartz
et al. (79)
Young men 13 (13/0) 28.2 ± 2.4 26.0 ± 3.5 50–60% of HRR with
a gradual
increase to 85%
5×/week/45 min 27 CT (cm
2
) 66.3 ± 37.1/
54.8 ± 33.6
85.1 ± 15.0/
84.6 ± 13.4
Older men 15 (15/0) 67.5 ± 5.8 26.2 ± 2.7 144.5 ± 49.4/
109.0 ± 44.9
79.6 ± 7.9/
77.1 ± 7.8
Aerobic exercise 10 (10/0) 47 ± 3 27.6 ± 0.6 60–85% of VO2max 3x/week/ >20 min 6 CT L4–L5
(cm
2
)
169.8 ± 13.1/
139.2 ± 10.0
87.4 ± 2.8/
87.6 ± 2.6
Continues
10 Effects of exercise versus diet on visceral fat R. J. H. M. Verheggen et al. obesity reviews
© 2016 World Obesity

Table 1. (Continued)
Exercise training studies
Reference Groups n(M/F) Age (years)
BMI
(kg m
2
) Intensity
Frequency/
duration
per session
Duration
(weeks)
Assessment
VAT
Results VAT
(pre/post)
Weight (kg)
(pre/post)
Shojaee-
Moradie
et al. (80)
Control 7 (7/0) 55 ± 4 27.6 ± 0.9 197.0 ± 25.6/
181.4 ± 26.7
84.1 ± 2.5/
83.3 ± 2.4
Sigal et al.
(81)
Aerobic training
group
60 (39/21) 53.9 ± 6.6 35.6 ± 10.1 60–75% of max HR 3×/week/15–45 min 22 CT L4–L5
(cm
2
)
257 ± 161/
244 ± 161
103.5 ± 31.0/
100.9 ± 30.2
Control 63 (41/22) 54.8 ± 7.2 35.0 ± 9.5 252 ± 147/
250 ± 147
101.3 ± 28.6/
101.0 ± 27.8
Slentz et al.
(82)
Low Amount,
moderate
intensity
40 (22/18) 54.0 ± 5.5 29.8 ± 3.2 40–55% of VO2max
in order to reach
walking 19.2 km
week
1
,65–80% of
VO2max in order to
reach jogging
19.2 km week
1
,
65–80% of VO2max
in order to reach
levels of jogging
32.0 km week
1
Duration and
frequency
depended on
set goal for
distance/intensity
34–39 CT at L4
pedicle
173 ± 72/
+1.7 ± 19.7%
88.0 ± 16.3/
0.7%
Low Amount,
vigorous
intensity
46 (23/23) 53.0 ± 7.0 29.7 ± 3.1 154 ± 55/
+2.5 ± 21.3%
85.0 ± 13.4/
0.8%
High amount,
vigorous
intensity
42 (23/19) 51.5 ± 5.3 29.1 ± 2.4 168 ± 64/
6.9 ± 20.8%
85.7 ± 12.2/
2.6%
Control 47 (23/24) 52.3 ± 7.7 29.8 ± 3.0 165 ± 68/
+8.6 ± 17.2%
86.9 ± 14.2/
1.0%
Solomon
et al. (83)
Aerobic exercise
and low glycemic
index isocaloric
diet
10 (2/7) 67 (2) 34.9 (1.1) ~85% of maximum
heart rate
5×/week/60 min 12 CT (cm
2
) 106.9 (12.7) /
78.7 (12.1)
97.4 (3.8)/
89.6 (3.4)
Aerobic exercise
and high glycemic
index isocaloric
diet
12 (5/7) 64 (1) 34.1 (1.1) 117.5 (26.3)/
73.0 (18.5)
94.7 (4.4)/
85.7 (4.1)
Yassine
et al. (84)
Aerobic exercise 12 (NR) 64 ± 2 35.3 ± 5.8 Initially 60–65 of
maxHR with a
gradual increase
to 80–85%
5×/week/50–60 min 12 CT (cm
2
) 192.3 ± 104.3/
158.4 ± 87.0
99.7 ± 15.7/
95.9 ± 14.6
Yoshimura
et al. (85)
High liver fat group 13 (5/8) NR 30.2 ± 5.7 Lactate treshold 3×/week/60 min 12 CT L4–L5 (cm
2
) 213 ± 63/
187 ± 66
78.3 ± 17.1/
3.6%
Low liver fat group 14 (6/8) 25.5 ± 3.2 139 ± 59/
116 ± 61
66.0 ± 11.8/
3.3%
Continues
Effects of exercise versus diet on visceral fat R. J. H. M. Verheggen et al. 11obesity reviews
© 2016 World Obesity

Table 1. (Continued)
Exercise training studies
Reference Groups n(M/F) Age (years)
BMI
(kg m
2
) Intensity
Frequency/
duration
per session
Duration
(weeks)
Assessment
VAT
Results VAT
(pre/post)
Weight (kg)
(pre/post)
Hypocaloric diet studies
Reference Groups N (M/F) Age (years) BMI (kg/m
2
) Caloric
restriction
Duration
(weeks)
Assessment
VAT
Results VAT
(pre/post)
Weight (kg)
(pre/post)
Alvarez
et al. (86)
Obese, old 6 (6/0) 60 (2.7) 28.9 (1.1) Reduction of
500–800 kcal d
1
13 CT (cm
2
) 184 (27)/
140 (31)
91.2 (4.1)/
83.9 (4.0)
Obese, young 6 (10/0) 32.9 (2.3) 30.4 (1.0) 135 (17)/
107 (14)
97.9 (4.3)/
90.2 (3.8)
Banasik
et al. (87)
VLCD 15 (2/13) 39.6 ± 13.4 36.2 ± 6.3 Restriction to
800 kcal/ d
1
4CTL4–L5 (cm
2
) 139.8 ± 82/
120.8 ± 85.9
104.1 ± 26.8/
97.3 ± 26.4
Bosy-Westphal
et al. (88)
LCD 30 (0/30) 31.4 ± 6.0 35.5 ± 4.9 Restriction to
800–1,000 kcal d
1
14.2 MRI (cm
3
) 1,757 ± 826/
1,530 ± 755
101.0 ± 18.3/
91.2 ± 17.4
Brochu
et al. (89)
LCD 71 (0/71) 58.0 ± 4.7 32.2 ± 4.6 Reduction of
500-800 kcal of
baseline resting
metabolic rate
(determined by
indirect calorimetry)
26 CT L4–L5 (cm
2
) 186 ± 56/
23 ± 30
83.6 ± 14.4/
5,1 ± 4,7
Chan
et al. (90)
Hypocaloric diet 20 (20/0) 46 ± 8
(entire group)
35 ± 1.0 reduction in energy
intake by ~33%
16 MRI (kg) 7.1 (0.5)/5.4 (0.4) 109 (2)/96 (3)
Isocaloric diet 15 (15/0) 31 ± 0.7 6.9 (0.4)/6.7 (0.4) 105 (3)/109 (2)
Colles
et al. (91)
VLCD 32 (19/13) 47.5 ± 8.3 47.3 ± 5.5 Restriction to
456–680 kcal d
1
12 CT and MRI
L2–L3 (cm
2
)
346.3 ± 103.3/
285.1 ± 89.3
139.8 ± 11.0/
125.0 ± 11.7
Collins
et al. (92)
LCD 30 (3/27) 53 56.0 (1.0) Restriction to
800 kcal d
1
9 CT (cm
2
) 388.0 (31.2)/
342.1 (23)
NR
Conway
et al. (93)
VLCD and LCD in
black women
8 (0/8) 34.8 ± 7.2 40.0 ± 5.0 During first
12 weeks:
restriction to
800 kcal d
1
,
during week 12–24:
restriction to
1,200–1,500 kcal d
1
24 CT L4–L5 (cm
2
) 105 (25)/
74 (23)
NR
VLCD and LCD in
white women
10 (0/10) 38.6 ± 6.3 38.2 ± 8.1 160 (70)/
105 (63)
Cooper
et al. (94)
LCD (2/43) 47.5 ± 6.2 44.0 ± 6.6 Restriction to
1,200–2,100 kcal d
1
52 CT (cm
2
) 186.9 ± 62.9/
28.7 ± 46.
118.6 ± 16.6/
8.8 ± 5.9
Dengo
et al. (95)
LCD 36 (15/11)
(combined
groups)
61.2 (0.8) 30.0 (0.6) Restriction to
1,200–1,500 kcal d
1
12 CT (cm
2
) 177 (15)/
133 (12)
84.6 (2.6)/
77.5 (2.2)
Control 66.1 (1.9) 31.8 (1.4) 188 (18)/
186 (17)
91.0 (4.8)/
90.4 (4.9)
Trussardi Fayh
et al. (96)
LCD only 18 (6/12) 30.1 ± 5.5 34.7 ± 2.4 Reduction of
500–1,000 kcal d
1
11.4 CT L4–L5 (cm
2
) 136.1 ± 64.0/
112.5 ± 54.0
95.8 ± 13.7/
91.5 ± 14.2
Continues
Table 1. (Continued)
12 Effects of exercise versus diet on visceral fat R. J. H. M. Verheggen et al. obesity reviews
© 2016 World Obesity

Table 1. (Continued)
Hypocaloric diet studies
Reference Groups N(M/F) Age (years)
BMI
(kg m
2
) Caloric restriction
Duration
(weeks)
Assessment
VAT
Results VAT
(pre / post)
Weight (kg)
(pre/post)
Fisher
et al. (97)
LCD 29 (0/29) NR 28 ± 1 Restriction to
800 kcal d
1
8CTL4–L5 (cm
2
) 93 ± 35/
58 ± 26
78 ± 8/66 ± 7
Fujioka
et al. (98)
LCD in
visceral fat
obesity
14 (0/14) 39.6 ± 9.4 34.3 ± 3.2 Gradual decrease
over 8 weeks to
800 kcal d
1
restriction, and rise
to ~1,100 kcal d
1
before discharge
8 CT (l) 6.9 ± 3.1/
4.3 ± 2.9
83.9 ± 12.8/
71.9 ± 10.4
LCD in
subcutaneous
fat obesity
26 (0/26) 37.1 ± 9.9 36.0 ± 5.7 3.9 ± 1.7/
2.6 ± 1.1
87.6 ± 17.3/
75.3 ± 15.1
Gasteyger
et al. (99)
LCD in women 85 (0/85) Median Median Restriction to
800–1,000 kcal d
1
8 MRI L4–L5
(cm
2
)
123 (44-288)/
23.7%
Only % loss:
6±5%
LCD in men 26 (26/0) 43 (21-67)
41 (20-61)
37.3 (31.4
-48.8)
36.6 (33.5 –
41.9)
162 (73-265)/
38.4%
0±2%
Giannopoulou
et al. (49)
LCD 11 (0/11) 57 (no SE) 35.9 (2.2) Reduction of
600 kcal d
1
14 MRI (cm
3
) 4,785 (480)/
4,425 (435)
92.4 (5.9)/
88.8 (5.7)
Goss
et al. (100)
High glycemic
load LCD
29 (14/15) 34.6 ± 8.1 30.9 ± 4.5 8 weeks eucaloric
diet, 8 weeks
hypocaloric diet with
a 1,000 kcal-deficit
8CTL4–L5
(cm
2
)
80.6 ± 48.3/
82.4 ± 57.9
94.3 ± 20.4/
89.4 ± 20.9
Low glycemic
load LCD
40 (17/23) 35.6 ± 4.3 32.4 ± 4.1 89.5 ± 46.3/
81.5 ± 49.4
98.4 ± 17.9/
92.9 ± 18.1
Gray
et al. (101)
VLCD 10 (0/10) 37 ± 4 35.1 ± 2.1 Restriction to
650 kcal d
1
10 MRI (cm
2
) 96 ± 36/
70 ± 26
90.6 ± 8.1/
10.6 ± 3.8
Gu
et al. (102)
VLCD 46 (27/19) NR 32.6 ± 0.6 Restriction to
<800 kcal/diet
8 MRI L4–L5
(cm
2
)
113.9 (5.8)/
79.8 (3.7)
96.1 (2.7)/
87.4 (2.5
Haufe
et al. (103)
Reduced
carbohydrate
LCD
52 (8/44) Subgroups:
42 ± 9 and
45 ± 8
Subgroups:
32.0 ± 3.3
and 35.6 ± 4.7
Reduction of ~30%
baseline food (to
a minimum of
1,200 kcal)
26 MRI (kg) 1.8 ± 1.1/
1.4 ± 0.9
95.0 ± 15.9/
89.5 ± 14.9
Reduced fat LCD 50 (10/40) 44 ± 9 and
46 ± 9
31.9 ± 3.9
and 33.9 ± 3
1.9 ± 1/
1.5 ± 0.9
93.6 ± 17.3/
89.4 ± 17.0
Ibanez
et al. (104)
LCD 12 (0/12) 51.4 ± 5.5 34.6 ± 3.4 Reduction of
500 kcal d
1
16 MRI (cc) 3,340 ± 977/
2,724 ± 1,052
88.0 ± 15.2/
82.3 ± 14.0
Control 9 (0/9) 50.2 ± 6.8 35.0 ± 3.6 3,175 ± 1,122/
3,157 ± 1,073
88.9 ± 11.4/
88.8 ± 10.5
Jang
et al. (105)
LCD 177 (NR) 40.0 (1.04) 27.1 (0.22) Reduction of
300 kcal d
1
12 CT L4 (cm
2
) 88.3 (2.81)/
77.8 (2.58)
71.1 (0.69)/
67.8 (0.58)
Janssen
et al. (106)
Men, LCD 10 (10/0) 45.6 (2.1) 31.6 (0.9) Reduction of
1,000 kcal d
1
from baseline
isocaloric diet
16 MRI 5 cm below
L4–L5 to 15 cm
above L4–L5
(cm
2
)
188 (22)/
58 (10)
98.1 (3.5)/
12%
Continues
Effects of exercise versus diet on visceral fat R. J. H. M. Verheggen et al. 13obesity reviews
© 2016 World Obesity

Table 1. (Continued)
Hypocaloric diet studies
Reference Groups N(M/F) Age (years)
BMI
(kg m
2
) Caloric restriction
Duration
(weeks)
Assessment
VAT
Results VAT
(pre / post)
Weight (kg)
(pre/post)
Women, LCD 10 (0/10) 39.6 (2.4) 34.5 (1.4) 142 (17)/
51 (7)
92.9 (5.0)/
12%
Kanai
et al. (107)
LCD 26 (0/26) 50 ± 13 33.7 ± 3.1 Restriction to
1,200 kcal d
1
12 CT umbilicus
(cm
2
)
168 ± 12 /
124 ± 65
81.3 ± 12.1 /
71.9 ± 10.0
Kim
et al. (108)
Kim
et al. (108)
LCD in
wild type
224 (144/110)
(entire study)
52.7 (1.31) 25.9 (0.29) Reduction of
300 kcal d
1
12 CT L1 (cm
2
) 274.1 (10.4)/
254.0 (10.6)
69.3 (1.17)/
65.9 (1.17)
LCD in only
UCP3 variant
52.4 (1.05) 25.8 (0.29) 296.8 (10.5)/
276.7 (9.6)
69.4 (1.06)/
66.1 (1.04)
LCD in only
β3-AR variant
55.4 (1.52) 25.9 (0.64) 281.9 (10.5)/
273.2 (9.6)
67.4 (1.69)/
63.9 (1.68)
LCD in both
variants
54.3 (1.65) 25.4 (0.51) 281.0 (10.5)/
272.3 (10.5)
70.0 (2.13)/
66.7 (2.09)
Kim
et al. (109)
LCD 27 (27/0) 45.8 (1.7) 30.5 (0.7) Average
restriction
to 1,547 kcal d
1
12 CT umbilicus
(cm
2
)
195.1 (14.2)/
129.4 (10.9)
89.4 (2.4)/
79.9 (2.7)
Kockx
et al. (110)
LCD 50 (25/25) 38.4 ± 5.5 31.3 ± 4.5 Reduction of
1,000 kcal d
1
13 MRI (cm
2
) 98 ± 31/
66 ± 26
85.9 ± 8.8/
74.9 ± 8.9
Laaksonen
et al. (111)
VLCD 20 (9/11) 46.7 ± 8.7 35.8 ± 9.5 Restriction to
800 kcal d
1
9 CT L4 (cm
2
) 216 ± 49/
148 ± 31
101.3 ± 12.0/
86.4 ± 9.6
Langendonk
et al. (112)
VLCD in lower
body obese
8 (0/8) 35.0 (1.7) 33.2 (1.6) Restriction to
478 kcal d
1
17 MRI L4–L5
(cm
2
)
303 (37)/
155 (25)
93.4 (5.0)/
79.2 (4.7)
VLCD in upper
body obese
8 (0/8) 38.3 (2.9) 33.9 (1.1) 583 (77)/
359 (47)
94.1 (3.0)/
79.7 (2.3)
Larson-Meyer
et al. (113)
Control 11 (5/6) 37 (7) 27. 8 (2.0),
27.8
Reduction of
25%
from baseline
energy
requirements
24 CT L4–L5 (kg) 2.9 (0.4)/
2.8 (0.4)
81.8 (2.8)/
81.9 (2.8)
LCD 12 (6/6) 39 (5) (1.4) 3.2 (0.5)/
2.3 (0.4)
81.0 (3.3)/
72.6 (3.1)
Lee
et al. (114)
LCD 33 (0/33) 32.4 ± 8.5 27.1 ± 2.3 Restriction to
1,200 kcal d
1
12 CT L4–L5 (cm
2
) 79.6 ± 28.3/
76.9 ± 29.1
70.2 ± 8.2/
68.2 ± 6.4
Leenen
et al. (115)
LCD in women 33 (0/33) 39 ± 5 31.3 ± 2.2 Reduction of
1,000 kcal d
1
13 MRI (cm
2
) 103 ± 35/
33 ± 21
86.9 ± 7.6/
12.4 ± 4.3
LCD in men 27 (27/0) 40 ± 6 30.7 ± 2.2 155 ± 38/
61 ± 26
97.4 ± 8.0/
13.5 ± 3.5
Maki
et al. (116)
LCD with
diacylglycerol
supplements
65 (25/40) 49.9 ± 11.4 34.5 ± 3.7 Individual diet
with reduction of
500–800 kcal/ d
1
24 CT L4–L5 (cm
2
) 150.4 ± 10.7/
38 ± 3
NR
Continues
14 Effects of exercise versus diet on visceral fat R. J. H. M. Verheggen et al. obesity reviews
© 2016 World Obesity

Table 1. (Continued)
Hypocaloric diet studies
Reference Groups N(M/F) Age (years)
BMI
(kg m
2
) Caloric restriction
Duration
(weeks)
Assessment
VAT
Results VAT
(pre / post)
Weight (kg)
(pre/post)
LCD with
triacylglycerol
supplements
62 (25/38) 48.1 ± 11.2 33.9 ± 3.7 160.6 ± 9.9/
17 ± 8
Murakami
et al. (117)
LCD 18 (10/8) 48.2 (1.9) 27.8 (0.5) Restriction to
1,000–1,500
kcal d
1
(women);
1,500–1,700
kcal d
1
(men)
12 CT (cm
2
130.6 (16.1)/
97.9 (11.4)
72.5 (2.2)/
66.4, 71.5
(2.0)/62.9 (1.8)
Ng et al.
(118)
LCD 20 (20/0) NR 35.2 (1.0) Restriction to
1,467 kcal d
1
14 MRI (kg) 7.1 (0.5)/
5.4 (0.4)
109.3 (2.3)/
96.0 (2.7)
Nicklas
et al. (119)
LCD 34 (0/100) 58.4 ± 6.0 33.9 ± 4.0 Reduction of
400 kcal d
1
20 CT L4–L5 (cm
3
) 2,369 ± 870/
612 ± 338
91.8 ± 10.4/
11.8 ± 4.1
Okhawara
et al. (120)
LCD 9 (9/0) 50.1 ± 12.9 27.9 ± 2.3 Restriction to
1,680 kcal d
1
13 CT umbilicus
(cm
2
)
186 ± 41.9/
97 ± 17.7
81.1 ± 5.6/
69.4 ± 4.4
Okura
et al. (121)
LCD in intra-
abdominal
fat obesity
31 (0/31) NR 29.4 ± 3.2 Restriction to
1,130 kcal d
1
14 CT L4–L5 (cm
2
) 148 ± 41/
37 ± 19
71.5 ± 8.8/
7.0 ± 2.4
LCD in
subcutaneous
fat obesity
34 (0/34) 27.8 ± 2.0 68 ± 24/
23 ± 17
67.5 ± 5.9/
7.9 ± 3.6
Pierce
et al. (122)
LCD 26 (15/11) 49.5 (2.5) 29 (1) Individualized diet
with pre-set weight
loss goal (minimum
calories 1,200
kcal d
1
)
12 CT L4–L5 (cm
2
) 128 (10)/
84 (7)
85 (3)/76 (2)
Control 14 (9/5) 40.8 (3.3) 31 (1) 150 (19)/
154 (19)
94 (3)/95 (3)
Purnell
et al. (123)
LCD 21 (21/0) 65 (60-75) 31 (27–37) Restriction to
1,200 kcal d
1
13 CT umbilicus
(cm
2
)
201 ± 51/
153 ± 49
96 ± 11/
86 ± 11
Purnell
et al. (124)
LCD 13 (5/8) NR 35 ± 4.8 Restriction to
1,000 kcal d
1
for
3 months, thereafter
gradual transition
during 2 weeks to
a solid diet
13 CT umbilicus
(cm
2
)
146 ± 57/
77 ± 47
99 (no SD) / 82
Riches
et al. (125)
LCD 12 (12/0) NR 34.1 (1.0) Restriction to
1,200 kcal d
1
14 MRI L3 (cm
2
) 322.8 (23.4)/
222.1 (22.1)
106.3 (4.1)/
95.9 (4.0)
Continues
Effects of exercise versus diet on visceral fat R. J. H. M. Verheggen et al. 15obesity reviews
© 2016 World Obesity

Table 1. (Continued)
Hypocaloric diet studies
Reference Groups N(M/F) Age (years)
BMI
(kg m
2
) Caloric restriction
Duration
(weeks)
Assessment
VAT
Results VAT
(pre / post)
Weight (kg)
(pre/post)
Isocaloric diet 14 (14/0) 34.6 (0.7) 309.6 (20.3)/
296.7 (15.1)
108.2 (2.4)/
109.1 (2.6)
Ross
et al. (26)
LCD 11 (11/0) 46.8 ± 7.6 31.6 ± 2.7 Reduction of
1,000 kcal d
1
16 MRI (l) 4.7 ± 1.6/
1.5 ± 0.8
Only %loss:
11.5%
Rossi
et al. (126)
LCD 24 (13/11) 46.7 ± 14.3 35.4 ± 4.5 Reduction of
500 kcal
below daily
energy
expenditure
13-26 MRI L4–L5
(cm
2
)
174.8 ± 94.7/
118.9 ± 76.3
98.4 ± 15.9/
89.7 ± 14.8
Ryan
et al. (127)
LCD in NGT 29 (0/29) 60 (1) 32.8 (0.9) Reduction of
500 kcal d
1
26 CT L4–L5 (cm
2
) 146.9 (12.6)/
127.1 (11.1)
88.3 (2.8)/
81.9 (2.9)
LCD in IGT 17 (0/17) 65 (2) 32.7 (1.2) 148.7 (11.6)/
126.5 (9.7)
84.4 (3.7)/
77.0 (3.3)
Ryan
et al. (128)
LCD 23 (0/23) 56 (1) Range:
25–48
Reduction of
250–350 kcal d
1
26 CT L4–L5
(cm
2
)
140.4 (12.1)/
115.1 (11.5)
88.8 (3.8)/
83.6 (3.7)
Saiki
et al. (129)
LCD 22 (16/6) 53.6 ± 8.4 30.4 ± 5.3 Restriction to
740 or 970 kcal d
1
4CTL4–L5
(cm
2
)
233.1 ± 66.5/
191.0 ± 67.0
85.2 ± 17.0/
79.0 ± 17.2
Shin
et al. (130)
LCD in MAO 106 (0/106) 39.8 ± 12.2 28.0 ± 2.6, Reduction of
300 kcal d
1
12 CT L4 (cm
2
) 95.1 ± 34.0/
89.5 ± 33.4
71.2 ± 8.3/
3.16 ± 4.08%
LCD in MHO 23 (0/23) 36.4 ± 11.2 27.2 ± 1.94 69.0 ± 18.5/
63.6 ± 15.5
70.5 ± 5.1/
2.83 ± 2.74%
Snel
et al. (131)
VLCD 14 (8/6) 53 (2) 35.2 (1.1) Restriction to
450 kcal d
1
16 MRI L5 (ml) 553 (47)/
228 (46)
107 (4)/83 (4)
Stallone
et al. (132)
LCD 11 (0/11) 52 (no SD) 37.0 ± 4.5 3 months restriction
400–800 kcal d
1
,
2 months refeeding,
1 month
1,200–1,500 kcal d
1
26 CT L4 (cm
2
) 148 ± 75.4 /
52.9 ± 38.0
94.8 ± 10.8 /
18.8 ± 6.9
Svendsen
et al. (133)
VLCD 10 (0/10) Median
(range)
34 (28–27)
NR (minimum
for each
subject: 28)
Restriction to
500–600 kcal d
1
8 CT umbilicus
(cm
2
)
125.9 ± 115.2/
109.8 ± 90.3
Only %loss:
11%
Tchernof
et al. (134)
LCD 25 (0/25) 57.2 ± 5.5 35.3 ± 4.0 Restriction to
1,200 kcal d
1
13.9 CT L4–L5 (cm
2
) 202 ± 73/
128 ± 57
93.0 ± 10.7/
79.5 ± 11.0
Tiikainen
et al. (135)
Women with
high liver fat
11 (0/11) 37 (1) 33 (1) Reduction of
600-800 kcal d
1
18–19 MRI (cm
3
) 1,665 ± 141/
383 ± 67
Only %loss:
8.4 (0.2)%
Women with
low liver fat
12 (0/12) 37 (2) 32 (10) 1,497 ± 167/
441 ± 122
8.3 (0.2)%
Continues
16 Effects of exercise versus diet on visceral fat R. J. H. M. Verheggen et al. obesity reviews
© 2016 World Obesity

Table 1. (Continued)
Hypocaloric diet studies
Reference Groups N(M/F) Age (years)
BMI
(kg m
2
) Caloric restriction
Duration
(weeks)
Assessment
VAT
Results VAT
(pre / post)
Weight (kg)
(pre/post)
Toledo
et al. (136)
LCD 7 (3/7) 46.1 (2.0) 33.4 (1.2) Reduction of 25%
of calorie intake
(both groups)
19.2 CT L4–L5 (cm
2
) 207.9 (24.7) /
172.1 (32)
95.0 (4.3) /
84.4 (2.7)
Van Dam
et al. (137)
VLCD in ovalutory
responders
9 (0/9) 30 (2.5) 37.5 (1.6) Restriction to
470 kcal d
1
8 MRI L4–L5 (cm
2
) 138 (17)/
91 (18)
NR
VLCD in ovalutory
non-responders
6 (0/6) 30 (1.8) 41.9 (3.6) 166 (29)/
114 (217)
Van der Kooy
et al. (138)
Obese women, 40 (0/40) 39 ± 6 31.3 ± 2.3 Reduction of
1,000 kcal d
1
13 MRI (cm
2
) 106 ± 50/
37 ± 29
86.5 ± 8.7/
12.6 ± 3.9
Obese men 38 (38/0) 40 ± 6 30.7 ± 2.3 154 ± 40/
61 ± 25
98.3 ± 7.2/
13.3 ± 3.0
Viljanen
et al. (139)
VLCD 16 (4/12) 45 (2.5) 33.3 (1.1) Restriction to
550 kcal d
1
6 MRI L2/L3 (kg) 1.6 (0.2)/
1.2 (0.1)
95.7 (3.3)/
84.6 (2.9)
Vissers
et al. (140)
LCD 20 (5/15) 45.5 ± 13.1 32.9 ± 3.1 Reduction of
-600 kcal d
1
(for all diet groups)
26 CT L4–L5 (cm
2
) 134.8 ± 57.3/
26/3 ± 29.2
92.1 ± 11.1/
6.1 ± 4.6
Control 21 (5/16) 44.8 ± 11.4 30.8 ± 3.4 111.5 ± 47.6/
3.6 ± 20.5
88.6 ± 15.9/
+0.9 ± 3.4
Wahlroos
et al. (141)
VLCD (n= 13) 13 (0/13) 45 ± 7 Restriction to
450–800 kcal d
1
6 MRI L4–L5
(mm
2
)
22,400 ±
11,300/8,
300 ± 8,700
118.8 ± 16.6/
110.0 ± 17.5
Weinsier
et al. (142)
LCD in white
women
23 (0/23) 37.0 ± 5.9 29.0 ± 1.5 Restriction to
800 kcal d
1
22 CT L4–L5 (cm
2
) 113.0 ± 39.2/
67.0 ± 23.8
79.1 ± 5.0/
66.0 ± 4.8
LCD in black
women
23 (0/23) 35.5 ± 5.9 28.7 ± 1.8 67.6 ± 18.0/
41.8 ± 16.9
78.2 ± 8.9/
65.6 ± 7.7
Zamboni
et al. (143)
VLCD and LCD 16 (0/16) 38.8 ± 14.1 38.2 ± 6.9 First 2-week
restriction
to 307 kcal d
1
(VLCD), LCD for
a mean duration of
14 weeks with
restriction to
1,003 kcal d
1
16 CT L4 (cm
2
) 167 ± 80.3/
93.3 ± 61.6
104.3 ± 18.1/
88.1 ± 11.6
Data depicted as: Mean ± standard deviation or Mean (standard error). Post value –(x) represents absolute decrease in VAT or weight (unless stated otherwise).
Abbreviations: BMI, body mass index; CT, computed tomography; F, female; HRR, heart rate reserve; IGT, impaired glucose tolerance; LCD, low calorie diet; M, male; maxHR, maxium heart rate; min, minutes;
MRI, magnetic resonance imaging; NR, not reported; VAT, visceral adiposity; VLCD, very low calorie diet.
Effects of exercise versus diet on visceral fat R. J. H. M. Verheggen et al. 17obesity reviews
© 2016 World Obesity

restriction, was excluded as duration and energy deficit did
not match between the two intervention arms. This study
was included for the separate analysis of diet or exercise
training only.
Cohort characteristics
A total number of 4,815 individuals (2,404 in the exercise
studies and 2,411 in the hypocaloric diet studies)
participated in the interventions (Table 1). In the eight RCTs
that directly compared exercise training and caloric
restriction, a total of 400 individuals were included (200
in the exercise arm and 200 in the diet arm). (Table 2); 28
studies exclusively included male subjects, whereas in 39
studies, female subjects were exclusively included. Fifty-five
studies included both sexes. Some studies recruited specific
populations, which included older (aged 50–80 years)
individuals (n= 4), patients with type 2 diabetes (n= 11),
impaired glucose tolerance (n= 3) and metabolic syndrome
(n= 3) (Table 1).
Meta-analysis
The SMD of change in VAT after exercise training was
0.47 (95% CI 0.56 to 0.39, P<0.0001). (Figure S1)
Heterogeneity analysis showed significant heterogeneity
(Cochran’sQ= 265.4; I
2
= 68.0). Through a funnel plot of
standard error by Hedge’s g and the Trim ‘nFill algorithm’,
publication bias was assessed. With the use of the Classic
Fail ‘nSafe approach’, it became clear that there was no
significant publication bias because 7,427 missing studies
would be required to achieve a P-value above 0.05. The
SMD of change in VAT after caloric restriction was 0.63
(95% CI 0.71 to 0.55, P<0.0001) (Figure S2), whilst
significant heterogeneity was present (Cochran’s
Q= 236.0; I
2
= 63.6). In these studies, no publication bias
was present because there would be 4,096 studies required
to achieve a P-value above 0.05.
Based on the studies that directly compared exercise
training and caloric restriction, exercise training caused a
non-significantly larger decrease in VAT (0.59, 95% CI
1.248 to 0.071; P= 0.08), whilst caloric restriction caused
a significantly larger weight loss than exercise training
(SMD 0.308, 95% CI 0.02 to 0.60; P= 0.04) (Fig. 2).
Heterogeneity analysis showed significant heterogeneity
(Cochran’sQ= 51.9; I
2
= 86.5). Publication bias was
assessed with the Trim ‘nFill method’and showed no
change in SMD when adding trimmed studies, for both
the weight loss as VAT loss data.
Meta-regression analysis
No effect of measurement technique on the SMD was
observed for studies that performed exercise training or diet
(data not shown). In the exercise studies, univariate analysis
revealed that the SMD for VAT improvement was
significantly influenced by sex (R
2
= 0.11; 95% CI 0.06 to
0.472; P= 0.012); duration (R
2
= 0.073; 95% CI 0.449
to 0.055; P= 0.013) and frequency (R
2
= 0.084; 95% CI
0.157 to 0.030; P= 0.004). The multivariate regression
analysis, which included the factors that revealed a
significant impact in the univariate analysis, identified an
impact of male sex on SMD (R
2
= 0.20; 95% CI 0.066 to
0.467; P= 0.01). In hypocaloric diet studies, univariate
analysis showed a significant effect of male sex only
(R
2
= 0.09; 95% CI 0.116 to 0.632; P= 0.005).
Correlation analysis
For exercise studies, a moderate correlation was found
between changes in weight versus changes in VAT after
exercise training (R
2
= 0.453, P<0.001), whilst diet-
interventions showed a strong correlation between the
change in weight versus change in VAT (R
2
= 0.737,
P<0.001) after caloric restriction. Exercise training showed
a somewhat steeper slope compared with diet (3.04x
versus 2.41x, respectively), and a larger Y-axis intercept
(-6.1a versus -1.1, respectively, Fig. 3).
Discussion
The present work is the first meta-analysis to compare the
effect of caloric restriction and aerobic exercise training on
visceral adipose tissue (VAT) loss in overweight and obese
individuals. We present the following findings. First, our
results confirm that both caloric restriction and exercise
training successfully reduce VAT. Second, in studies that
provided a direct comparison of caloric restriction and
exercise training, a hypocaloric diet resulted in significantly
larger weight loss. Interestingly, these studies reveal a different
story for VAT. Exercise training tends to show a larger
decrease in VAT compared to caloric restriction. The distinct
effects of both interventions on total body weight and VAT
are supported by the correlation analysis. Only a moderate
correlation was found for the exercise training cohort
between changes in weight and VAT. Furthermore, in the
absence of weight loss, exercise training results in a 6.1%
decrease in VAT, whilst a hypocaloric diet leads to virtually
no change (1.1%). This suggests that evaluating only total
body weight changes could lead to spurious conclusions when
evaluating the efficacy of a lifestyle intervention in overweight
and obese individuals because health benefits occur
independent of body weight changes. Indeed, even in the
absence of weight loss after exercise training, health benefits
such as a reduction in VAT are present.
In line with previous meta-analyses, we found caloric
restriction to have a larger effect on weight loss than
exercise training (7,8). We extended this finding by a direct
comparison of studies with matched duration and energy
deficit in order to more accurately compare the impact of
both interventions. In marked contrast to the superior effect
18 Effects of exercise versus diet on visceral fat R. J. H. M. Verheggen et al. obesity reviews
© 2016 World Obesity

Continues
Table 2 Characteristics of included studies (n= 8) that directly compared exercise training with hypocaloric diet
Reference Groups N (M/F)
Age
(years) BMI (kg m
2
)
Intensity (exercise
studies) Caloric
restriction (hypocaloric
diet studies)
Frequency/duration
per session
(for exercise only) Duration (weeks)
Assessment
VAT
Results VAT
(pre/post)
Results
weight (kg)
(pre/post)
Christiansen
et al. (144)
Aerobic
exercise
19 (9/10) 37.2 ± 7 33.3 ± 4 70% of HRR 60–75 min per
session, 3×/week
12, 12 (4-week
maintenance)
MRI (cm
3
) 3,038.3 ± 1,086./
18.4% ± 2.8
100.9/3.5 kg
LCD 19 (10/9) 35.6 ± 7 35.3 ± 4 restriction to 600 kcal
during 8 weeks
3,437.5 ± 1,516.2/
30.2% ± 3.2
107.8/12.3
Coker et al.
(145)
Aerobic
exercise
6 (2/4) 55 (2) 32 (1) 50% of VO2peak Depending on energy
expenditure (Week 1:
1,000 kcal with a
gradual increase to
2,500 kcal week
1
)
12 CT (cm
2
) 245 (31)/228 (24) 91 (3)/91 (3)
LCD 6 (3/3) 58 (2) 30 (0) reduction of 1,000 kcal week
1
in Week 1, and a further
addition of 500 kcal each
week until a reduction of
2,500 kcal week
1
was
reached
199 (12)/170 (11) 86 (2)/81 (2)
Control 5 (3/2) 59 (2) 31 (1) 198 (17)/170 (11) 89 (4)/91 (4)
Koo et al. (146) LCD 19 (0/19) 57 ± 8 27.1
(no SD)
Restriction 1,200 kcal d
1
7 d week
1
, 120 min 12 CT L4–L5 (cm
2
) 157.8/151.7 67.4 (no SD)
62.4
Aerobic
exercise
13 (0/13) 59 ± 4 25.5 depending on energy
expenditure
162.4/146.9 64.0/62.4
Control 18 (0/18) 57 ± 8 28.5 172.4/163.4 66.0/65.8
Nordby et al.
(147)
Aerobic
training
12 (12/0) 28 (1) 28.3 (0.3) 65% HRR, alternated with
HIIT (bouts at 85% HRR)
reduction of 600 kcal d
1
7 d week
1
, duration
depended on energy
expenditure (600 kcal
per session)
12 MRI T11-L5 (L) 1.60 (0.12/0.53 94.5 (2.3)/
88.6 (2.3)
LCD 12 (12/0) 32 (2) 28.0 (0.4) 1.83 (0.18)/0.25 91.2 (1.8)/
85.9 (2.2)*
Control 12 (12/0) 31 (2) 28.0 (0.4) 2.12 (0.21)/0.02 92.2 (2.7)/
92.1 (2.5)
Oh et al. (148) Aerobic
exercise
108 (108/0) NR (adults) 29.2 (0.3) 60–85% of maxHR 3 d week
1
,40–60 min 12 CT (cm
2
) 178.1 (5.5)/
156.4 (5.0
85.2 (1.0)/
82.6 (1.0)
LCD 104 (104/0) 29.4 (0.4) restriction to 1,680 kcal d
1
159.0 (6.2)/
123.3 (5.2)
84.9 (1.3)/
77.7 (1.2)
Racette et al.
(149)
LCD 19 (7/12) 55.6 (0.8) 27.2 (0.6) Reduction of 16% of caloric
intake 3 months reduction
of 20% 9 months
7 d week
1
, duration
depending on energy
deficit
52 MRI (cm
3
) 824.7 ± 143,4/
633.5 ± 95.6
78.5 (2.3)/
70.5 (2.3)
Aerobic
exercise
19 (7/12) 58.8 (0.6) 27.2 (0.4) depending on energy deficit
(same reduction as diet groups)
1,123.5 ± 131.5/
513.9 ± 107.6
77.5 (2.4)/
71.0 (2.4)
Control 10 (4/6) 56.0 (0.9) 27.9 (0.4) 1,159.4 ± 203.4/
1,004 ± 155
81.9 (3.7)/
80.0 (3.7)
Ross et al.
(150)
LCD 15 (0/15) 43.9 ± 4.9 31.9 ± 2.8 Reduction of 500 kcal d
1
7 d week
1
, 63 min 14 MRI (kg) 2.4 ± 1.2/
1.9 ± 1.0
86.6 ± 10.9/
80.1 ± 11.2
Effects of exercise versus diet on visceral fat R. J. H. M. Verheggen et al. 19obesity reviews
© 2016 World Obesity

of caloric restriction on weight loss, no difference in VAT
reduction was observed between caloric restriction and
exercise training. In fact, exercise training tended to have a
superior effect on VAT reduction compared with caloric
restriction. A possible mechanism underlying these different
effects on weight and VAT could relate to distinct changes in
body composition during these lifestyle interventions.
During caloric restriction, both muscle mass and fat mass
are lost, resulting in a marked decline in weight (21,22).
During exercise training, however, lean body mass and
circulating plasma volume increase, whilst fat mass
decreases (21,23,25,26,33). Previous work that directly
measured these factors indeed showed that an increase in
lean body mass counteracts loss of fat mass after 8 weeks
of exercise training (34). These opposing effects resulted in
the absence of total body weight loss (34). Appreciating
and understanding these effects are important to
acknowledge that exercise training effectively reduces VAT,
despite the absence of a reduction in body weight.
In this meta-analysis, a large number of studies were
included. Multivariate meta-regression analysis on these
data showed that male sex is associated with a larger
decrease in VAT, in both exercise and diet interventions.
Other subject and intervention characteristics did not
influence the magnitude of VAT loss in the multivariate
model. A possible explanation that underlies the larger effect
of exercise training and caloric restriction on VAT in men is
that men typically have larger VAT stores than women. As
a result, this makes male participants more likely to lose
VAT than female participants (35). However, our meta-
regression analysis showed no effect of baseline VAT area
on the magnitude of VAT decrease. The exact underlying
mechanisms should be subject for future research.
The distinct effects of diet and exercise training on weight
and VAT suggest the presence of a different correlation
between changes in body weight and VAT after caloric
restriction in comparison with exercise training. Indeed,
whilst a strong correlation between changes in body weight
and VAT was found after caloric restriction, this correlation
was only moderate for exercise training studies. This means
that a change in weight after hypocaloric diet predicts a
substantial effect on VAT, whereas changes in weight after
exercise training only modestly predict the change in VAT.
Furthermore, the trend lines for these correlations show
important differences. The Y intercept for the correlation
of exercise studies is 6.1%, meaning that the absence of
weight loss after exercise training is still correlated with a
significant and meaningful reduction in VAT of 6.1%. In
marked contrast, studies examining the impact of
hypocaloric diet revealed a Y-intercept of only 1.1%, which
means that in the absence of weight loss only 1.1% of VAT
is lost. Furthermore, the steepness of the correlation for
exercise training is slightly higher than that observed after
hypocaloric diet. Taken together, these data strongly
Table 2. (Continued)
Reference Groups N (M/F)
Age
(years) BMI (kg m
2
)
Intensity (exercise
studies) Caloric
restriction (hypocaloric
diet studies)
Frequency/duration
per session
(for exercise only) Duration (weeks)
Assessment
VAT
Results VAT
(pre/post)
Results
weight (kg)
(pre/post)
Aerobic
exercise
17 (0/17) 43.2 ± 5.1 32.8 ± 3.9 ~80% maxHR 2.3 ± 0.8/
1.6 ± 0.7
86.8 ± 10.9/
80.9 ± 10.8
Control 10 (0/10) 43.7 ± 6.4 32.4 ± 2.8 2.3 ± 0.9/
2.2 ± 0.9
88.1 ± 8.2/
88.6 ± 7.4
Ross et al.
(151)
LCD 14 (14/0) 42.6 ± 9.7 30.7 ± 1.9 Reduction of 700 kcal d
1
7 d week
1
, 60.4 min 14 MRI L4-L5 (kg) 3.2 ± 1.0/
25.2 (2.0)%
96.1 ± 8.7/
7.7 (0.2)%
Aerobic
exercise
16 (16/0) 45.0 ± 7.5 32.3 ± 1.9 ~75% max HR 3.9 ± 1.0/
27.5 (1.9)%
101.5 ± 7.7/
7.5 (0.3)%
Control 8 (8/0) 46.0 ± 10.9 30.7 ± 1.6 4.1 ± 1.7/
1.9 (2.7)%
96.7 ± 9.0/
0.2 (0.4)%
Data depicted as: Mean ± standard deviation or Mean (standard error). Post value –(x) represents absolute decrease in VAT or weight (unless stated otherwise).
Abbreviations: BMI = body mass index; CT = computed tomography; F = female; HRR = heart rate reserve; LCD = low calorie diet; M = male; maxHR = maxium heart rate; min = minutes; MRI = magnetic
resonance imaging; NR = not reported; VAT = visceral adiposity.
20 Effects of exercise versus diet on visceral fat R. J. H. M. Verheggen et al. obesity reviews
© 2016 World Obesity

indicate that a change in weight, which is currently
recommended by international guidelines for the management
of obesity, does not necessarily reflect changes in VAT.
Limitations
The presence of heterogeneity of the included studies may
represent a potential limitation when interpreting the results
of this review. However, to correct for this heterogeneity
a random effect approach was selected to perform the
meta-analyses, which was specified a priori. Furthermore,
analysis of publication biaswith use of the Classic Fail ‘n Safe
method showed that an unrealistically large number of
studies is needed to influence the significant results obtained
in our meta-analyses. Therefore, we are confident that the
heterogeneity observed in the studies included in this analysis
does not impact the major conclusions of our study. Another
limitation might be that our study provides no insight into the
potential impact of ethnicity on our observation, since this
subject information was often lacking in the included studies.
However, our analysis is not biased by the inclusion of a single
Figure 2 Forest plot of the effect size (SMD) of (a) exercise training versus caloric restriction on weight loss and (b) exercise training versus caloric
restriction on visceral adiposity (VAT) loss. The effect size (SMD) and 95% confidence interval for individual studies and the pooled estimate (assessed
with the use of random effects model) are depicted.
Figure 3 Correlation between % visceral adiposity improvement and %weight loss for exercise studies (R
2
= 0.4531, P<0.001; trendline:
y=3.03x6.1), and caloric restriction studies (R
2
= 0.737, P<0.001; trendline: y= -2.46x1.1).
Effects of exercise versus diet on visceral fat R. J. H. M. Verheggen et al. 21obesity reviews
© 2016 World Obesity

ethnic group only, because we included studies that were
conducted on all continents.
Clinical relevance
As treatment for obesity, international guidelines including
World Health Organization and ACSM guidelines
recommend a minimum of 5% loss of body weight loss
(4,6,20). Although in common clinical practice, a
combination of training and hypocaloric diet is often
prescribed, it is highly relevant to understand the separate
effects of these interventions. Indeed, our study reveals that
effects on weight loss and VAT loss are different in training
and diet interventions. For example, a 5% reduction in
body weight after hypocaloric diet has a different effect on
VAT than a similar reduction in body weight after exercise
training. Indeed, 5% loss in body weight is associated with
21.3% reduction in VAT after exercise training, but only
with 13.4% reduction in VAT after a hypocaloric diet. To
reduce VAT by 13.4% after exercise training, weight loss
of only 2.4% is needed. Moreover, the absence of a
reduction in body weight after exercise training may lead
physicians to incorrectly conclude that the intervention has
failed. This is in accordance with the ACSM position
statement on appropriate physical intervention strategies
for weight loss, which also emphasized that exercise
training entails health benefits beyond the effects on body
weight (20). In fact, it is likely that a clinically relevant
VAT reduction (of 6.1%) is present in the absence of weight
loss after exercise training, which may lead to reductions in
cardiovascular risk and improvement in metabolic health.
Therefore, it seems incorrect to recommend a 5% weight
loss for all lifestyle interventions.
In conclusion, our systematic review and meta-analysis
provide evidence that exercise training, despite smaller
effects on reducing body weight, tends to have superior
effects on reducing visceral adipose tissue compared with
diet interventions in overweight and obese subjects. This
suggests that changes in body weight represent a poor
marker for adaptation in visceral adipose tissue, especially
when performing exercise training. Our data therefore
strongly indicate that, in clinical practice, caution should
be taken when interpreting (lack in) changes of body weight
after exercise training interventions. Incorrect conclusions
can potentially lead to recommendations or suggestions that
the exercise intervention was unsuccessful, despite the
presence of a marked effect on body composition. Setting
the correct targets for evaluating the health benefits of
lifestyle interventions is therefore recommended.
Acknowledgements
We would like to thank Alice Tillema, BSc for her assistance
during the literature search. We would also like to thank
Hans Groenewoud, MSc for his assistance with the
statistical analyses.
Conflict of interest statement
No conflict of interest was declared.
Authors’contributions statement
R.J. V., D. J. G., M. T. H., D. H. T. contributed on the
conception and design of research. R. J. V. and M. F.M.
contributed on the data acquisition and analysis. R. J. V., M.
F. M., A. R. H., M. T. H., D. H. T. contributed on the
interpretation results of research. R. J. V. and M. F. M.
contributed on the preparation figures. R. J. V. contributed
on the drafted manuscript. All authors edited and revised the
manuscript. All authors approved final version of manuscript
and agree to be accountable for all aspects of the work.
Supporting information
Additional Supporting Information may be found in the
online version of this article, http://dx.doi.org/10.1111/
obr.12406
Figure S1. Forest plot of the effect size (SMD) of exercise
training on VAT loss. The effect size (SMD) and 95% CI
for individual studies and the pooled estimate (assessed with
the use of Random Effects Model) are depicted.
Figure S2. Forest plot of the effect size (SMD) of hypocaloric
diet on VAT loss. The effect size (SMD) and 95% CI for
individual studies and the pooled estimate (assessed with
the use of Random Effects Model) are depicted.
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