ArticlePDF AvailableLiterature Review

A systematic review and meta-analysis of the effect of aerobic vs. Resistance exercise training on visceral fat

September 2011
Obesity Reviews 13(1):68-91

DOI:10.1111/j.1467-789X.2011.00931.x

Source
PubMed

Authors:

Irfan Ismail

National Institute of Education (NIE), Singapore

Shelley E Keating

The University of Queensland

Michael K Baker

Australian Catholic University

Nathan A Johnson

The University of Sydney

It is increasingly recognized that the location of excess adiposity, particularly increased deposition of visceral adipose tissue (VAT), is important when determining the adverse health effects of overweight and obesity. Exercise therapy is an integral component of obesity management, but the most potent exercise prescription for VAT benefit is unclear. We aimed to evaluate the independent and synergistic effects of aerobic exercise (AEx) and progressive resistance training (PRT) and to directly compare the efficacy of AEx and PRT for beneficial VAT modulation. A systematic review and meta-analysis was performed to assess the efficacy of exercise interventions on VAT content/volume in overweight and obese adults. Relevant databases were searched to November 2010. Included studies were randomized controlled designs in which AEx or PRT in isolation or combination were employed for 4 weeks or more in adult humans, where computed tomography (CT) or magnetic resonance imaging (MRI) was used for quantification of VAT pre- and post-intervention. Of the 12196 studies from the initial search, 35 were included. After removal of outliers, there was a significant pooled effect size (ES) for the comparison between AEx therapy and control (-0.33, 95% CI: -0.52 to -0.14; P < 0.01) but not for the comparison between PRT therapy and control (0.09, 95% CI: -0.17 to -0.36; P = 0.49). Of the available nine studies which directly compared AEx with PRT, the pooled ES did not reach statistical significance (ES = 0.23, 95% CI: -0.02 to 0.50; P = 0.07 favouring AEx). The pooled ES did not reach statistical significance for interventions that combined AEx and PRT therapy vs. control (-0.28, 95% CI: -0.69 to 0.14; P = 0.19), for which only seven studies were available. These data suggest that aerobic exercise is central for exercise programmes aimed at reducing VAT, and that aerobic exercise below current recommendations for overweight/obesity management may be sufficient for beneficial VAT modification. Further investigation is needed regarding the efficacy and feasibility of multi-modal training as a means of reducing VAT.

Flowchart of outcomes of search strategy.

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Participant characteristics

Forest plot for PRT studies (n = 14). Graph depicts ES and 95% CI for individual studies and the pooled estimate.

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Obesity Treatment/Management

A systematic review and meta-analysis of the effect of

aerobic vs. resistance exercise training on visceral fatobr_

931 68..9168..91

I. Ismail1, S. E. Keating1, M. K. Baker2,3 and N. A. Johnson1,3

1Discipline of Exercise and Sport Science,

University of Sydney, Sydney, New South

Wales, Australia; 2School of Exercise and

Health Sciences, Edith Cowan University,

Joondalup, Western Australia, Australia;

3Boden Institute of Obesity, Nutrition and

Exercise, University of Sydney, Sydney,

New South Wales, Australia

Received 19 June 2011; revised 25 July 2011;

accepted 26 July 2011

Address for correspondence: Dr N Johnson,

Discipline of Exercise and Sport Science,

Faculty of Health Sciences, The University of

Sydney, C42 Cumberland Campus,

Lidcombe, NSW 2141, Australia. E-mail:

nathan.johnson@sydney.edu.au

Summary

It is increasingly recognized that the location of excess adiposity, particularly

increased deposition of visceral adipose tissue (VAT), is important when deter-

mining the adverse health effects of overweight and obesity. Exercise therapy is an

integral component of obesity management, but the most potent exercise prescrip-

tion for VAT beneﬁt is unclear. We aimed to evaluate the independent and

synergistic effects of aerobic exercise (AEx) and progressive resistance training

(PRT) and to directly compare the efﬁcacy of AEx and PRT for beneﬁcial VAT

modulation. A systematic review and meta-analysis was performed to assess the

efﬁcacy of exercise interventions on VAT content/volume in overweight and obese

adults. Relevant databases were searched to November 2010. Included studies

were randomized controlled designs in which AEx or PRT in isolation or combi-

nation were employed for 4 weeks or more in adult humans, where computed

tomography (CT) or magnetic resonance imaging (MRI) was used for quantiﬁ-

cation of VAT pre- and post-intervention. Of the 12196 studies from the initial

search, 35 were included. After removal of outliers, there was a signiﬁcant pooled

effect size (ES) for the comparison between AEx therapy and control (-0.33, 95%

CI: -0.52 to -0.14; P<0.01) but not for the comparison between PRT therapy

and control (0.09, 95% CI: -0.17 to -0.36; P=0.49). Of the available nine

studies which directly compared AEx with PRT, the pooled ES did not reach

statistical signiﬁcance (ES =0.23, 95% CI: -0.02 to 0.50; P=0.07 favouring

AEx). The pooled ES did not reach statistical signiﬁcance for interventions that

combined AEx and PRT therapy vs. control (-0.28, 95% CI: -0.69 to 0.14;

P=0.19), for which only seven studies were available. These data suggest that

aerobic exercise is central for exercise programmes aimed at reducing VAT, and

that aerobic exercise below current recommendations for overweight/obesity

management may be sufﬁcient for beneﬁcial VAT modiﬁcation. Further investi-

gation is needed regarding the efﬁcacy and feasibility of multi-modal training as a

means of reducing VAT.

Keywords: Aerobic training,obesity,physical activity,strength training.

obesity reviews (2012) 13, 68–91

Financial support: none.

obesity reviews doi: 10.1111/j.1467-789X.2011.00931.x

Introduction

The increased risk of cardiovascular and metabolic mor-

bidity and mortality as result of obesity has been well

described. However, it is increasingly recognized that

the location of excess adiposity, particularly increased

deposition of visceral adipose tissue (VAT), is of greater

importance in determining the adverse health effects of

overweight and obesity. VAT volume is an independent

predictor of elevated blood pressure (1), myocardial infarc-

tion (2) and insulin resistance (2–4). Lifestyle interventions

incorporating restriction of caloric intake and/or increased

energy expenditure via exercise reduce VAT content,

thereby ameliorating this risk. Serial quantiﬁcation of VAT

content/volume by computed tomography (CT) and mag-

netic resonance imaging (MRI) has shown that the synergy

of aerobic exercise training and calorie restriction posi-

tively affects VAT content when weight loss approximating

4–9% of body weight is achieved (5), and larger reductions

in VAT have also been shown following a mean 10%

reduction in body weight (6).

Current physical activity recommendations suggest that

~250 min of weekly aerobic-type exercise is required for

body weight management (7) (8). The actual reduction of

weight (and body fat) with this dose of regular exercise in

overweight and obese individuals is often small (~2–3 kg)

but increases (~5–7.5 kg) with exercise levels up to

420 min/week (9–11). However, there is an emerging

acceptance that even with intensive programmes, weight

loss in excess of 3–4 kg is difﬁcult to sustain (12–14),

highlighting the need for alternative strategies and further

rationale for promotion of VAT reduction as opposed to

weight loss per se. A systematic review of the available

randomized control trials to 2006 suggested that interven-

tions involving increased aerobic exercise can beneﬁcially

alter VAT in overweight and obese individuals, and that

this may occur independent of weight loss (5). Recent

evidence has shown that aerobic exercise training (AEx)

programmes of lower energy expenditure than current

guidelines can induce a clinically signiﬁcant reduction in

VAT, even in the absence of weight loss (15). Although

there are currently no guidelines for progressive resistance

exercise training (PRT) in the management of obesity, PRT

is known to positively affect insulin sensitivity and other

processes associated with VAT accumulation (16), and

there is evidence that despite incurring a signiﬁcantly lower

energy expenditure than aerobic exercise therapy, PRT may

directly reduce VAT (5).

The aim of this study was to conduct a systematic review

with meta-analysis of randomized controlled trials to assess

the efﬁcacy of exercise interventions on visceral adiposity in

adults. Speciﬁcally, we aimed to evaluate the effect of (i)

aerobic exercise therapy vs. control; (ii) PRT therapy vs.

control; (iii) aerobic exercise vs. PRT therapy; and (iv)

combined aerobic and PRT therapy vs. control on VAT

change. We hypothesized that, when compared with a

control condition, both aerobic and PRT therapies would

signiﬁcantly reduce VAT. Secondly, we hypothesized that

aerobic exercise would have a greater effect than PRT

therapy on VAT. We further hypothesized that combined

aerobic exercise and PRT therapy would have a greater

effect on VAT than either therapy in isolation.

Methods

Design

Electronic database searches were performed in AMED,

MEDLINE, MEDLINE Daily Update, PREMEDLINE (via

OvidSP), SPORTDiscus, CINAHL (via EBSCO), EMBASE

and Web of Science from earliest record to November

2010. The search strategy combined terms covering the

areas of strength training, aerobic exercise training and

visceral fat (Fig. 1).

The database searches were performed using the key-

words: (strength training, weight training, resistance train-

ing, progressive training, progressive resistance, weight

lifting) or (aerobic exercise, endurance exercise, aerobic

training, endurance training, cardio training, exercise,

physical endurance, physical exertion) and (visceral,

abdominal fat, abdominal adiposity, abdominal lipid,

regional adiposity, intra-abdominal, adipose tissue distribu-

tion). Reference lists of all retrieved papers were manually

searched for potentially eligible papers. Randomized con-

trolled trials (RCTs) were reviewed while non-RCTs, uncon-

trolled trials and cross-sectional studies were excluded

from analysis. Manuscripts published in all languages were

included. Theses were not included in this systematic review.

Interventions

Studies were included if the exercise intervention was of 4

weeks or more. This cut-off was established to differentiate

studies examining the acute effects of exercise from those

examining training adaptations. Trials where participants

were randomized to an intervention involving either AEx

or PRT, or both, were included. Studies involving dietary

control/intervention were included only if the diet was the

same between the exercise and control groups.

Participants

Studies with adult participants greater than or equal to 18

years were considered. Studies of individuals with type 2

diabetes were included but those of HIV-infected popula-

tions were excluded because of speciﬁc medications affect-

ing abdominal fat (5).

obesity reviews Exercise for visceral fat I. Ismail et al.69

Outcome measures

Studies were selected if the effect of exercise alone on visceral

fat was presented, and if computed tomography (CT) or

magnetic resonance imaging (MRI) was used for quantiﬁ-

cation of visceral fat area/volume. Studies providing

outcome measures of visceral fatness/trunk adiposity using

any other method such as ultrasound or dual energy X-ray

absorptiometry (DXA) were excluded.

Selection of studies

After eliminating duplications, the search results were

screened by one investigator (II) against the eligibility cri-

teria, and those references which could not be eliminated

by title or abstract were retrieved and independently

reviewed by two reviewers (II, NJ) in an unblinded manner.

Disagreements were resolved by discussion or by a third

researcher (MB). In cases where journal articles contained

Figure 1 Flowchart of outcomes of search

strategy.

70 Exercise for visceral fat I. Ismail et al.obesity reviews

insufﬁcient information, attempts were made to contact

authors to obtain missing details.

Data extraction and calculations

Data relating to participant characteristics (age, sex, body

mass index {BMI]} ), exercise details (mode of exercise,

nutritional intervention, exercise frequency, intensity, dura-

tion and intervention duration) and visceral fat quantiﬁca-

tion (measurement technique and region) were extracted

independently by two researchers (II, SK), with disagree-

ments resolved by discussion or by a third researcher (NJ).

For one study which presented data graphically, mean and

standard deviation were estimated in duplicate manually.

One author was contacted and provided standard deviation

data that were missing from the study.

Assessment of methodological quality

Included studies met a minimum quality threshold, deﬁned

as having met all inclusion criteria. Study quality was

further assessed by two researchers (II, SK) in a blinded

manner using a modiﬁed assessment scale created by

Downs & Black (17). The scale was modiﬁed to include

criteria for adequate description of control and whether

CT/MRI reliability for VAT quantiﬁcation was reported.

Analyses

The between-trial standardized mean difference, or effect

size (ES) and 95% conﬁdence intervals (CIs) were calcu-

lated. Between-study variability was examined using the I2

measure of inconsistency. This statistic, expressed as a per-

centage between 0–100, provides a measure of how much

of the variability between studies is due to heterogeneity

rather than chance. Publication bias was assessed by exam-

ining asymmetry of funnel plots (precision vs. ES) using

Egger’s test. Relationships were analyzed using simple

linear regression.

Meta-analyses

Pooled estimates of the effect of exercise on VAT, using ES,

were obtained using ﬁxed- and random-effects models. We

presumed a correlation of 0.5 between outcomes measured

within each comparison group. If we identiﬁed studies

where there were two interventions of different exercise

intensity, the intervention of higher intensity was selected.

If we identiﬁed studies where there were two interventions

of identical exercise intensity, the intervention of highest

volume (exercise duration x weekly frequency) was

selected. We performed four analyses to compare the effect

of i) AEx vs. Control; ii) PRT vs. control; iii) AEx vs. PRT;

iv) combined AEx and PRT vs. control on VAT change. All

analyses were conducted using Comprehensive Meta-

analysis, version 2 (Biostat Inc, Englewood, NJ).

Results

Identiﬁcation and selection of studies

The original search netted 12 196 studies. Three more

studies were found from the reference lists of the manu-

scripts retrieved. After removal of duplicates and elimina-

tion of papers based on the eligibility criteria, 35 studies

remained (Fig. 1).

Cohort characteristics

When combined, 2145 individuals (702 male; 1422 female;

21 not reported) participated in the trials (Table 1). Seven-

teen studies exclusively recruited female participants

(17–33), ﬁve studies exclusively recruited male participants

(34–38), with 11 studies recruiting both men and women

(9,39–48). Sex was not reported in one study (49). The mean

age of participants ranged from 28–83 years, and 11 studies

did not report mean age. On the basis of body mass index

(BMI) classiﬁcation criteria (50), 18 studies had participants

who were classiﬁed on average as obese, 15 as overweight

and two within normal range. Fourteen studies speciﬁcally

recruited obese participants, nine studies recruited partici-

pants with type 2 diabetes, three studies with metabolic

syndrome and two studies recruited Asian-only cohorts.

Exercise characteristics

Cycle ergometry was the most common mode of AEx while

resistance training on a weight machine was most com-

monly used for PRT (Table 2). Within the 27 studies that

conducted AEx training, the frequency of AEx was most

commonly 3 d per week (10 of 27 studies) followed by 5 d

per week (7 of 27 studies). The frequency for PRT was

most commonly 3 d per week (9 of 13 studies), with three

studies training with PRT 2 d per week (20,21,33). Six

studies combined AEx and PRT training, three of which

conducted training on 3 d per week (18,46,48) and one

study conducted on 4 d (25), 5 d (23) and 6 d per week

(30), respectively.

Aerobic exercise intensities, expressed as a percentage

of maximal heart rate, percentage of heart rate reserve or

peak rate of oxygen consumption (VO2peak) ranged from

40–55% in initial weeks progressing to 60–90% in the ﬁnal

weeks of the programmes. The most commonly prescribed

intensity was 60–75% of maximal heart which is classiﬁed

as ‘moderate intensity’. Rating of Perceived Exertion (RPE)

and metabolic equivalents (METs) were also used to

express intensity. The intensity of PRT, quantiﬁed as a

percentage of one-repetition maximum (1-RM) in most

obesity reviews Exercise for visceral fat I. Ismail et al.71

Table 1 Participant characteristics

Reference Subjects % Male % Female Age BMI

Binder et al. 2005 (39) 91; Older sedentary with physical frailty C: 45% C: 55 C: 83.0(4.0) C: 26.0(4.0)

PRT: 47 PRT: 53 PRT: 83.0(3.0) PRT: 27.0(5.0)

Boudou et al. 2003 (34) 16; Men with type 2 diabetes 100.0 0.0 45.4(7.2) 29.6(4.6)

Brochu et al. 2009 (17) 107; Postmenopausal women 0 100 C: 58.0(4.7) C: 32.2(4.6)

Carr et al. 2005 (40) 62; Japanese-Americans with impaired

glucose tolerance

C: 53.1 C: 46.9 56.5(10.2) C: 26.6(2.5)

A: 40 A: 60 A: 25.7(4.5)

Coker et al. 2009 (41) 18; Overweight elderly 50 50 71.0(4.2) 30(4.2)

Cuff et al. 2003 (18) 28; Postmenopausal with type-2

diabetes

0 100 C: 60.0(8.7) C: 36.7(6.0)

A+PRT: 63.4 (7.0) A +PRT: 33.3(4.7)

A: 59.4 (5.7) A: 32.5(4.2)

DiPietro et al. 1998 (42) 16; Healthy older 18.8 81.3 73.0(4.0) C: 73.0(5.3)

A: 27.7(7.1)

Donnelly et al. 2003 (7) 74; Sedentary overweight and

moderately obese

41.9 58.1 C: Men: 24.0(4.0), Women: 21.0(4.0) C: Men: 29.0(3.0), Women: 29.3(2.3)

A: Men: 22.0(4.0), A: Men29.7(2.9),

Women: 24.0(5.0) Women: 28.7(3.2)

Giannopoulou et al. 2005

(19)

22; Obese post menopausal women

with type 2 diabetes

0 100 50–70 34.6(3.3)

Hunter et al. 2010 (20) 69; Healthy premenopausal women 0 100 C: 34.8(5.6) C: 23.9(1.1)

A: 34.7(8.4) A: 23.5(1.0)

PRT: 34.1(7.2) PRT: 23.9(1.0)

Ibanez et al. 2010 (21) 25; Obese women 0 100 C:54.4(5.5) C: 34.6(3.4)

PRT: 48.6(6.4) PRT: 35.0(3.1)

Irving et al. 2008 (22) 16; Obese women with metabolic

syndrome

0 100 51.0(9.0) 34.0(6.0)

Irwin et al. 2003 (23) 173; Overweight postmenopausal

women

0 100 C: 60.6(7.1) C: 30.6(3.8)

A+PRT: 61.0(6.9) A: +PRT 30.5(4.3)

Janssen et al. 1999 (43) 60; Upper body obese 50 50 Male: C: 45.6 (6.6); A: 47.4 (6.6); PRT:

37.9 (13.3)

Male: C: 31.6(2.8); A: 33.0(3.5); PRT:

33.6(4.4)

Female: C: 39.6(7.6); A: 39.0(6.3); PRT:

37.3(4.4)

Female: C: 34.5(4.4); A: 35.5 (6.6);

PRT: 32.5 (4.7)

Janssen et al. 2002 (24) 38; Premenopausal obese women 0 100 C: 40.1(6.7) C: 33.7(4.1)

A: 37.5(6.0) A: 36.0(7.1)

PRT: 34.8(5.8) PRT: 31.6(4.3)

Johnson et al. 2009 (14) 19; Obese sedentary 68.0 32.0 C: 47.3(9.5) 31.1(2.9)

Kim et al. 2008 (25) 20; Women of advanced age with

metabolic syndrome

0 100 >75 C: 25.7(2.8)

A+PRT: 26.0(2.4)

Ku et al. 2010 (26) 44; Overweight Korean women with

type 2 diabetes

0 100 C: 57.8 (8.1) C: 27.4(2.8)

A: 55.7(7.0) A:27.1(2.4)

PRT:55.7(6.2) PRT: 27.1(2.3)

Kwon et al. 2010 (27) 28; Overweight type 2 diabetics 0 100 56.4 (7.1) 27.4(2.5)

Kwon et al. 2010 (28) 27;Obese type 2 diabetics 0 100 56.6(8) 27.3(2.7)

McTiernan et al. 2007 (44) 202; Sedentary 50.5 49.5 C: Men: 56.6(7.6), Women: 53.7(5.6) C: Men: 30.1(4.8), Women: 28.5(4.8)

A: Men: 56.2(6.7), Women: 54(7.1) A: Men: 29.7(3.7), Women: 28.9(5.5)

Mourier et al. 1997 (49) 21; NIIDM NR 45.0(9.8) 30.2(4.4)

Nicklas et al. 2009 (29) 72; Overweight and obese

postmenopausal women

0 100 C: 58.4(6.0) C: 33.9(4.0)

A: 59.0(5.0) A: 32.9(3.7)

Park et al. 2003 (30) 30; Middle-aged obese women 0 100 C: 43.1(1.7) C: 25.5(0.9)

A: 42.2(1.9) A: 25.3(1.7)

A+PRT: 43.4(1.0) A +PRT: 25.8(1.4)

Poehlman et al. 2000 (31) 51; Non-obese younger women 0 100 C:28.0(4.0) C: 22.0(2.0)

A:29.0(5.0) A: 22.0(2.0)

PRT: 28.0(3.0) PRT: 22.0(2.0)

Rice et al. 1999 (35) 29; Obese men 100 0 C: 44.4(6.1) C: 31.9(2.8)

A: 47.4(6.1) A: 32.2(3.7)

PRT: 39.8(13.2) PRT: 33.8(4.2)

72 Exercise for visceral fat I. Ismail et al.obesity reviews

studies (17,20,21,25,27,30,31,39,48) ranged between

30–100% 1 RM. Two studies (24,43) prescribed one set of

8–12 repetitions until volitional fatigue.

Ten studies stated that diet was not controlled, nine

studies required participants to recall/record diet and

analysis was reported, and eight studies required the par-

ticipants to follow a prescribed diet. Eight studies did not

report on dietary intervention or control.

Methodological quality

Assessment of the study quality is presented in Table 3. All

included studies speciﬁed their hypotheses, main outcomes,

participant characteristics, interventions, main ﬁndings,

variability estimates, statistical tests, accuracy of measures

and randomization procedure. Eight studies did not report

adverse events while ﬁve studies did not provide an

adequate description of the control group. Eighteen studies

reported the reliability of the VAT measure. Only two

studies made an attempt to blind study participants to the

intervention they received (15,49), and only two studies

made an attempt to blind those measuring the main

outcome of the intervention (15,46).

Study outcomes

All studies provided sufﬁcient data to enable calculation

of mean differences, ES and 95% CIs (Table 4). For AEx,

26 of the 29 studies showed an ES favouring aerobic

exercise therapy, ranging from – 0.07 to -6.09. Five of

these studies showed a statistically signiﬁcant effect

for aerobic exercise. None of the four studies with an

ES favouring the control intervention (ES range: 0.10–

0.61) reached statistical signiﬁcance. For PRT, seven

of the 14 studies showed an ES favouring resistance

exercise training, ranging from -0.04 to -0.58, with only

one of these studies showing a statistically signiﬁcant

effect for resistance exercise. Five studies favoured the

control intervention vs. resistance exercise (ES range:

0.13–1.67), with two of these reaching statistical signiﬁ-

cance. Of the nine studies comparing AEx with PRT,

seven favoured aerobic exercise vs. resistance training,

ranging from 0.02 to 1.02, two of which were statistically

signiﬁcant. None of the two studies which reported an

ES favouring resistance training vs. aerobic exercise

reached statistical signiﬁcance. Six of the seven studies

which combined AEx with PRT, reported an ES favouring

the intervention group, half of these reached statistical

signiﬁcance (range: -0.13 to -4.62). One study showed a

statistically signiﬁcant ES for control vs. combined AEx

plus PRT.

A linear regression analysis was performed to assess the

relationship between VAT reduction and change in weight

in all of the exercise groups (AEx, PRT and AEx +PRT). A

signiﬁcant relationship between VAT reduction and weight

loss was found (r =0.42, P=0.014).

Table 1 Continued

Reference Subjects % Male % Female Age BMI

Ross et al. 2000 (36) 24; Obese men 100 0 C: 46.0 (10.9) C: 30.7(1.9)

A: 45.0 (7.5) A:32.3(1.9)

Ross et al. 2004 (32) 27; Premenopausal women with

abdominal obesity

0 100 C: 43.7(6.4) C: 32.4(2.8)

A:43.2(5.1) A: 32.8(3.9)

Ross et al. 1996 (37) 33; Obese men 100 0 C: 46.8(7.6) C: 31.6(2.7)

A: 47.6(6.4) A: 32.6(3.6)

PRT: 39.0(12.9) PRT: 33.5(4.1)

Schmitz et al. 2007 (33) 133; Overweight or obese 0 100 C: 36.0(6.0) C: 29.4 (0.4)

PRT: 37.0(5.0) PRT: 29.4 (0.4)

Short et al. 2003 (45) 102; Healthy sedentary men and

women

52 48 21–87 C: 25.7(2.4)

A:26.6 (1.8)

Sigal et al. 2007 (46) 251; Type 2 diabetes 63.7 36.3 C: 54.8(7.2) C: 35.0(9.5)

A: 53.9(6.6) A: 35.6(10.1)

PRT:54.7(7.5) PRT: 34.1(9.6)

A+PRT: 53.5(7.3) A +PRT: 35.0 (9.6)

Slentz et al. 2005 (47) 89; Sedentary overweight with mild to

moderate dyslipidemia

52 48 C: 52.7(6.5) C: 29.6(3.0)

A: 51.5(5.3) A: 29.1(2.4)

Stewart et al. 2005 (48) 104; 49 51 63.6(5.7) C: Male: 29.7(3.8), Female: 29.6(6.1)

A+PRT: Male: 29.7(3.0),

Thong et al. 2000 (38) 24; Obese men 100 0 C: 46.0(10.7) C: 30.7(1.7)

A: 45.0(7.6) A: 32.3(2.0)

All data reported as means ⫾SD. Studies reporting age and BMI as range only are reported in that format.

BMI, body mass index; A, aerobic exercise training; PRT, progressive resistance training; C, controls; NR, not reported.

obesity reviews Exercise for visceral fat I. Ismail et al.73

Table 2 Exercise details

Reference Mode Nutritional intervention Weight

change

(kg)

Frequency Intensity Session duration Intervention

duration

Binder et al.

2005 (39)

C: n=38; 9 of 22 exercises in

phase 1, primary focus on

ﬂexibility.

Supplemental calcium and

vitamin D

0.0(0.0) 2–3/7 6 months

PRT: n=53; Phase 1: ﬂexibility,

balance coordination, speed of

reaction. Phase 2: PRT, knee

extension, ﬂexion, seated bench

press, seated row, leg press,

biceps curl on weightlifting

machine. +shortened version of

phase 1.

0.0(0.0) 3/7 for 36

sessions/each phase.

Phase 2: PRT, 1–2 sets of 6–8 reps

at 65% of 1 RM to progress to 3

sets of 8–12 at 85–100% of initial

1RM

Phase 2: 60–90 min 6 months: 3

months/phase

Boudou et al.

2003 (34)

C: n=8; bicycle ergometer at

60 rpm

Maintain usual diet (~50%

CHO, 30% lipids, 20%

proteins).

-1.7(16.1) 1/7 Low intensity (30 W) 20 min 8 weeks

A: n=8; bicycle ergometer -1.9(19.2) 3/7 Continuous 75% VO2peak 2/7 and

intermittent exercise at 85%:50%

for 2 min:3 min, respectively, 1/7

Continuous: 45 min;

Intermittent: NR

Brochu et al.

2009 (17)

C: n=71 55% CHO; 30% fat; 15%

protein

-5.1(4.7) 3/7 NR NR 6 months

PRT: n=36; leg press, chest

press, lat pull down, shoulder

press, arm curls, triceps

extensions

-5.8(4.9) Four progressive phases:

1 (3 weeks): 15 reps/65% 1 RM,

2–3 sets per exercise, 90–120 s

rest b/w sets

2 (5 weeks): 12 reps/70% 1 RM,

2–3 sets per exercise, 90 s rest

b/w sets3 (9 weeks):

10 reps/75–80% 1 RM, 2–4 sets

per exercise, 120–180 s rest b/w

sets

4 (8 weeks): 10–12 reps/70–75%

1 RM, 2–4 sets per exercise

60–90 s rest b/w sets.

Carr et al. 2005

(40)

C: n=32: Stretching exercises Isocaloric with 30% fat (<7%

saturated), 50% CHO, 20%

protein with <300 mg

cholesterol/d

0.6 (2.8) 3/7 NR 60 min 24 months

A: n=32; walking or jogging on a

treadmill

Isocaloric with 30% fat (10%

saturated), 55% CHO, 15%

protein with <200 mg

cholesterol/d

-1.8(2.7) 3/7 70% HRR

74 Exercise for visceral fat I. Ismail et al.obesity reviews

Table 2 Continued

Reference Mode Nutritional intervention Weight

change

(kg)

Frequency Intensity Session duration Intervention

duration

Coker et al. 2009

(41)

C: n=6 Mixed diet (35% fat, 20%

protein, 45% CHO) during 4 d

controlled feeding prior to

baseline and post intervention

testing period

NR Maintain habitual

physical activity

12 weeks

A: n=6; cycle ergometer NR 4–5/7 75% of VO2peak

Caloric expenditure matched at

1,000 kcal/7

Cuff et al. 2003

(18)

C: n=9

A+PRT n=10 Aerobic exercise

on treadmills, stationary bicycles,

recumbent steppers, ellipitical

trainers and rowing machines.

Resistance training on leg press,

leg curl, hip extension, chest

press, latissimus pulldown

A: n=9 as above exercise with

low impact low intensity dynamic

movement

Continue with current diet

patterns

2.0(3.6)

-2.9(4.1)

-1.2(2.1)

Continue with current

physical activity

patterns

3/7

A: 60–75% HRR;

PRT: 2 sets of 12 reps.

A: 60–75% HRR

75 min

16 weeks

DiPietro et al.

1998 (42)

C: n=7; stretching, yoga, stretch

bands

NR 0.0(15.0) 4/7 HR did not exceed 90 bpm 60 min 4 months

A: n=9; mini trampoline -1.0(19.2) 4/7 55–60% HR max for 1 month; 75%

HR max for 3 months

20–40 min 1st month

progressing to 60 min for

3 months

Donnelly et al.

2003 (7)

C: n=33; Maintain usual dietary intake M: -0.5(16.3)

F: 2.9(12.3)

NR Maintain usual physical activity 16 months

A: n=41; Treadmill, stationary

bike or elliptical trainer

M: -5.2(15.8)

F: 0.6(17.1)

60% HRR at baseline to 75% at 6

months

20 min at baseline to

45 min at 6 months

Giannopoulou

et al. 2005 (19)

C: n=11; Hypocaloric

monounsaturated fat diet (40%

fat (30% monounsaturated, 5%

polyunsaturated, 5% saturated),

40% CHO (15% simple, 25%

complex) and 20% protein with

600 kcal/d deﬁcit.

A: n=11 walking

40% fat, 40% CHO, 20%

protein

3.6(27.2)

-5.5(27.2)

Refrain from any type

of regular physical

activity during study

3/7 65–70% VO2peak 50 min

14 weeks

obesity reviews Exercise for visceral fat I. Ismail et al.75

Table 2 Continued

Reference Mode Nutritional intervention Weight

change

(kg)

Frequency Intensity Session duration Intervention

duration

Hunter et al.

2010 (20)

C: n=30 800 k/cal per day (20–22% fat,

18–22% protein, 58–62%

CHO)

6.4(9.4) NR 1 year

A: n=18; walking or jogging on a

treadmill

PRT: n=21; squats, leg

extension, leg curl, elbow ﬂexion,

triceps extension, lateral pull

down, bench press, military

press, lower back extension, bent

leg sit ups

3.1(8.8)

3.9(11.5)

2–3/7 Week 1: 67% HR max progressing

to 80% HR max in week 8.

Week 1–4: 1 set of 10 reps then 2

sets of 10 reps. 2 min rest

between sets; 80% of 1 RM

20–40 min

Ibáñez et al.

2010 (21)

C: Diet only

PRT: n=13; Diet +bilateral leg

press, bilateral knee extension,

bench press, and 4–5 exercises

for main muscle groups of body;

all on resistance machines

55% CHO, 15% protein, 30%

fat, 500 kcal/d

-5.7(20.7) NR 16 weeks

-7.1(16.7) 2/7 Week 1–8: 50–70% 1 RM; Week

9–16: 70–80% 1 RM +20% of leg

extensor and bench press sets

with 30–50% 1 RM.

45–60 min

Irving et al. 2008

(22)

C: n=7; NR -0.9(15.4) Maintain current level of physical activity 16 weeks

A: n=9; Walk/run on indoor or

outdoor track

-3.5(24.0) Weeks 1–2: 3/7

Weeks 3–4: 4/7

Weeks 5–16: 5/7

RPE 15–17 on 3/7 and 10–12 on

2/7

Time to expend 300 kcal

in weeks 1–2, 350 kcal in

weeks 3–4, and 400 kcal

in weeks 5–16

Irwin et al. 2003

(23)

C: n=86; stretching sessions Maintain usual diet 0.1 (NR) 1/7 NR 45 min 12 months

A+PRT: n=87; A: treadmill

walking, stationary bike. PRT: leg

extensions, leg curls, leg press,

chest press, seated dumbbell

row.

-1.3 (NR) 5/7 A: 40% HR max progressing to

60–75% HR max by week 8

PRT: 2 sets of 10 reps

45 min

Janssen et al.

1999 (43)

C: n=20; Diet only Weight maintenance energy

intake reduces by

1,000 kcal/d. Limit dietary fat

intake to <30%.

M: -11.7(3.5)

F: -10.7(3.8)

NR 16 weeks

A: n=20; brisk walking on a

treadmill, stationary cycling or

stair stepping

PRT: n=20; Leg extension, leg

ﬂexion, super pullover (latissimus

dorsi), bench press, shoulder

press, triceps extension, bicep

curl and sit ups

M: -11.4(3.8)

F: -11.5(3.2)

M: -12.7(3.8)

F: -10.0(2.8)

5/7

3/7

50–85% MHR

1 set of 8–12 reps to volitional

fatigue

15 min progressing to

maximum of 60 min.

30 min

76 Exercise for visceral fat I. Ismail et al.obesity reviews

Table 2 Continued

Reference Mode Nutritional intervention Weight

change

(kg)

Frequency Intensity Session duration Intervention

duration

Janssen et al.

2002 (24)

C: n=13; dietary intervention Reduce weight maintenance

energy intake by 1,000 kcal/d,

limit dietary fat intake to <30%

-10.0(3.9) Maintain pre-study physical activity levels. 16 weeks

A: n=11; dietary

intervention +treadmill, cycle

ergometer or stair stepping.

PRT: n=14; dietary

intervention +leg extension, leg

ﬂexion, super pullover, bench

press, shoulder press, triceps

extension, biceps curl, sit ups.

-11.1(4.4)

-10.0(3.0)

5/7

3/7

50% progressing to 85% of HR

max

1 set of 8–12 reps until volitional

fatigue

15 min progressing to

60 min.

Approx. 30 min

Johnson et al.

2009 (15)

C: n=7; stretching Consume habitual diet

for 3 d before and after

intervention provided with diet

(60% CHO, 20% protein, 20%

fat)

-0.2(16.2) 3/7 30 min 4 weeks

A: n=12; cycle ergometer -0.3(19.2) 3/7 Week 1: 50% VO2peak

Week 2: 60% VO2peak

Week 3&4: 70% VO2peak

30–45 min (15 min bouts

with intervening 5 min

rests)

Kim et al. 2008

(25)

C: n=10 NR 0.57(8.8) NR 12 weeks

A+PRT: n=10; A: speedy

walking, V step, Cha cha step,

Mambo step, step aerobics, Gait

training with dance. PRT: Push

up, sit up, sit down and up, leg

raise, leg extension, leg curl, leg

press on free weights. Asana

Yoga

-0.3(8.8) 4/7 Week 1: -4: 40–55% HRR, week

5–8: 55–65%, week 9–12: 65–75%

PRT 75% 1 RM

60 min; 30 min aerobics,

15 min Resistance, 15 min

Yoga

Ku et al. 2010

(26)

C: n=16; diabetes education Maintain standard caloriﬁc

intake (ideal body weight

(kg) ¥30 kcal/kg/d)

-0.6(1.7) Maintain sedentary

lifestyle

A: n=15; walking -1.9(1.2) 5/7 3.6–5.2 METs 60 min 12 weeks

PRT: n=13; elastic band

exercises including bicep curl,

triceps extension, upright row,

shoulder chest press, trunk side

bending, seated row, leg press,

hip ﬂexion, leg ﬂexion, leg

extension

-1.1(1.3) 40–50% max 3 sets, 15–20 reps

obesity reviews Exercise for visceral fat I. Ismail et al.77

Table 2 Continued

Reference Mode Nutritional intervention Weight

change

(kg)

Frequency Intensity Session duration Intervention

duration

Kwon et al. 2010

(27)

C: n=15

PRT: n=13; Bicep curls, triceps

extensions, upright rows,

shoulder press, chest press,

seated rows, leg press, hip

ﬂexion, leg ﬂexion, leg extension,

side bends with resistance bands

NR 0.7(10.5)

1.1(6.4)

No exercise

3/7 40–50% 1 RM

3 sets 10-15 reps for

40 min plus 10 min warm

up and cool down

12 weeks

Kwon et al. 2010

(28)

C: n=14 NR NR Maintain routine activity 12 weeks

A: n=13; Walking NR 5/7 Anaerobic threshold 60 min

McTiernan et al.

2007 (44)

C: n=102 Asked not to change dietary

habits

M: -0.1(25.2)

F: 0.7(18.6)

Asked not to change

exercise habits

12 months

A: n=100; Treadmills, stationary

bikes, elliptical machines and

rowers

M: -1.8(21.0)

F: -1.4(24.9)

6/7 60–85% HR max 60 min

Mourier et al.

1997 (49)

C: n=11 Maintain usual diet

50% of C and A group

supplemented with BCAA

(46% leucine, 24% isoleucine,

30% valine; protein intake

0.6 g/kg/d)

0.2(21.4) 1/7 Low intensity 20 min–45 min 2 weeks

pre-training

8 weeks

A: n=10; Ergocycle -1.5(17.3) Pre-training 3/7

Trial: 2/7 continuous

exercise

1/7

intermittent

Pre-training

75%

Continuous: 75%V02peak

Intermittent

85% V02peak

for 2 min 50% V02peak

for 3 min x ﬁve exercises

Continuous: 45 min

Nicklas et al.

2009 (53)

C: n=34; Calorie restriction Total calorie deﬁcit of

400 kcal/d, 25–30% fat,

15–20% protein, 50–60% CHO

-11.8(4.1) Not to alter sedentary lifestyle 20 weeks

A: n=38; Calorie

restriction +treadmill walking

-12.3(4.9) 3/7 70–75% HRR 10–15 min progressing to

30 min by end of 6th

week

78 Exercise for visceral fat I. Ismail et al.obesity reviews

Table 2 Continued

Reference Mode Nutritional intervention Weight

change

(kg)

Frequency Intensity Session duration Intervention

duration

Park et al. 2003

(30)

C: n=10 NR 0.6(2.3) NR 24 weeks

A: n=10; Aerobics: week 1–12:

side by side, step touch, lunge

side, v-step, grape vine, pivot

turn, Cha cha, Mambo rock,

diamond step, single hamstring

walking, heel touch, sit up, push

up. Week 13–24: fast walking,

turn round, heel side, knee up,

scissor double, hop and jump,

jumping jack, side kick, full turn,

double kick

-4.7(4.7) 6/7 60–70% HR max 60 min

A+PRT: n=10; Aerobic

programme +bench press, side

raise, tricep push down, barbell

curl, leg curl, leg extension, leg

press, leg raise, abdominal

crunch, latissimus pull down

-6.4(6.6) 6/7 A (3/7) 60–70% HR max

PRT (3/7) Week 1–12 60% 1 RM,

Week 13–24 70% 1 RM

Poehlman et al.

2000 (31)

C: n=20 NR 1.0(10.6) NR 6 months

A: n=14; jogging 0.0(7.1) 3/7 Weeks 1–16: 5% increase in HR

max each week progressing to

90% HR max

Weeks 17–28:

Mon: 80% HR max

Wed: 95% HR max

Fri: 75–80% HR max.

By last session at 85% HRmax

Weeks 1–16: 25 min

progressing to 40 min

Weeks 17–28:

Mon: 45 min

Wed: 4 ¥5 min bouts with

3 min rests

Fri: 45 min.

By last session: 60 min

PRT: n=17; leg press, bench

press, leg extension, shoulder

press, sit up, seated row, tricep

extension, arm curls, leg curls

2.0(8.5) 3 sets 10 reps, 1–1.5 min between

sets

80% 1 RM

Rice et al. 1999 C: n=9; diet intervention only Energy intake reduced by

1,000 kcal/d, limit dietary fat

intake to <30%

-12.1(3.4) NR 16 weeks

A: n=10; diet

intervention +treadmill walking,

stationary cycle or stair stepping

-11.5(3.9) 5/7 19 min progressing to 60 min 50% progressing to

85%HR max

PRT: n=10; diet

intervention +leg extension, leg

ﬂexion, super pullover, bench

press, shoulder press, triceps

extension, biceps curl, sit ups

-13.6(4.1) 3/7 1 set of 8–12 reps ~30 min

obesity reviews Exercise for visceral fat I. Ismail et al.79

Table 2 Continued

Reference Mode Nutritional intervention Weight

change

(kg)

Frequency Intensity Session duration Intervention

duration

Ross et al. 2000

(36)

C: n=8; Maintain body weight Weight maintenance diet

(55–60% CHO, 15–20%

protein, 20–25% fat) for 4- to

5-week baseline period

0.1(NR) NR 12 weeks

A: n=16; Brisk walking or light

jogging on motorized treadmill.

maintain isocaloric diet and

perform exercise that expended

700 kcal/d

-7.5(NR) 7/7 <70% VO2peak (80% MHR) Time taken to expend

700 kcal

Ross et al. 2004

(32)

C: n=10; Maintain body weight

A: n=17; Brisk walking or light

jogging on motorized treadmill;

maintain isocaloric diet and

expend 500 kcal/d with exercise

Weight maintenance diet

(50–60% CHO, 15–20%

protein, 20–30% fat) for 4- to

5-week baseline period

0.5(11. 0)

-5.9(15.3)

7/7

80% of HRmax Time required to expend

500 kcal.

14 weeks

Ross et al. 1996

(37)

C: n=11; Diet intervention only Energy intake reduced by

1,000 kcal/d and limit dietary

fat intake to <30% of total

energy intake

-11.4(3.5) NR 16 weeks

A: n=11; Diet

intervention +stationary cycle,

treadmill or stair stepping

PRT: n=11; Diet

intervention +leg extension, leg

ﬂexion, superpullover, chest

press and cross, shoulder press,

triceps extension and biceps curl

on Nautilus weight training

stations and Sit ups

-11.6(3.7)

-13.2(4.1)

5/7

3/7

1 set of 12 reps

15 min progressing to

60 min.

Schmitz et al.

2007 (33)

C: n=63; Walking programme as

per AHA guidelines

PRT: n=70; isotonic variable

resistance machines and free-

weight exercises for quadriceps,

hamstrings, gluteal, pectoral,

erector spinae, latissimus dorsi,

rhomboid, deltoid, bicpes, triceps

No changes to diet 2.0(0.7)

1.4(0.6)

Most days of the

week

2/7

Moderate intensity

Year 1: 3 sets, 8–10 reps

Year 2: 2 sets and maintain the

highest weight lifted each exercise

30 min

Year 1: 1 h

Year 2: 45 min

2 years

80 Exercise for visceral fat I. Ismail et al.obesity reviews

Table 2 Continued

Reference Mode Nutritional intervention Weight

change

(kg)

Frequency Intensity Session duration Intervention

duration

Short et al. 2003

(45)

C: n=37 Weight maintaining diet

(55%CHO, 30%fat and 15%

protein)

0.3(17.3) Flexibility exercises to perform at home; maintain regular lifestyle 16 weeks

A: n=65; stationary bicycle -1.5(18.2) 3/7 progressing to 4/7 70% HR max progressing to 80%

HR max

20 min progressing to

40 min

Sigal et al. 2007

(46)

C: n=63 Recommended diet that would

not cause weight loss.

Prescribed energy

intake ⱖ90% estimated

weight maintenance

requirement

-0.3(39.9) Revert to pre-study

activity levels

26 weeks

A: n=60; treadmills or bicycle

ergometers

-2.6(43.3) 3/7 60–75% HR max 15–45 min

PRT: n=64; 7 different machine

weight exercises

-0.8(43.0) 2–3 sets of 7–9 reps NR

A+PRT: n=64 -2.6(43.0) Combined aerobic and resistance training programmes

Slentz et al. 2005

(47)

C: n=47 Not to diet/change their diet 0.87(NR) NR 6 months

A: n=42; treadmills, elliptical

trainers, cycle ergometers

-2.3(NR) Equivalent to jogging

20 miles/week

65–80% VO2peak Expend 23 kcal/kg/week 8 months

Stewart et al.

2005 (48)

C: n=53

A+PRT: n=51; aerobic:

treadmill, stationary cycle, stair

stepper; PRT: bench press,

shoulder press, seated

mid-rowing, lat-pulldown, leg

extension, leg curl, leg press

AHA Step 1 diet; Maintain

normal caloric intake

M: -0.63

F: -0.5(2.3)

National Institute of Aging Guidelines for Exercise 6 months

M: -2.2(2.7)

F: -2.3(3.4)

3/7 A: 60–90% HR max

PRT: 2 sets, 10–15 reps of 50%

1RM

A: 45 min

PRT: NR

Thong et al. 2000

(38)

C: n=8 Weight maintenance diet for

4–5-week baseline period

consisting of 55–60% CHO,

15–20% protein, 20–25% fat

0.1(0.8) NR 12 weeks

A: n=14; Perform exercise that

expended 700 kcal/d; brisk

walking or light jogging on a

motorized treadmill

Matched exercise expenditure

with additional 700 kcal/d

-7.6(0.4) 7/7 80% HR max Time required to expend

700 kcal

n, number of subjects; mg, milligram, kcal, kilocalorie, BMI, body mass index; A, aerobic training; PRT, progressive resistance training; C, controls; NR, not reported; HRR, heart rate reserve; HR, heart rate; RM, maximal repetition; CHO,

carbohydrates; PRO, proteins; FAT, fats; VO2peak, peak oxygen consumption.

obesity reviews Exercise for visceral fat I. Ismail et al.81

Table 3 Quality ratings of study

Study 1. Hypothesis

stated

2. Main

outcomes

3. Participants

characteristics

4. Interventions

described

6. Main

ﬁndings

described

7. Variability

estimates

8. Adverse

events reported

9. Patients

lost to

follow up

10. Actual

Pvalue

reported

Binder et al. 2005 (39) Y Y Y Y Y Y Y Y Y

Boudou et al. 2003 (34) Y Y Y Y Y Y N N Y

Brochu et al. 2009 (17) Y Y Y Y Y Y N Y Y

Carr et al. 2005 (40) Y Y Y Y Y Y N Y Y

Coker et al. 2009 (41) Y Y Y Y Y Y N Y N

Cuff et al. 2003 (18) Y Y Y Y Y Y N Y N

DiPietro et al. 1998 (42) Y Y Y Y Y Y N Y N

Donnelly et al. 2003 (7) Y Y Y Y Y Y Y Y Y

Giannopoulou et al. 2005 (19) Y Y Y Y Y Y N Y N

Hunter et al. 2010 (20) Y Y Y Y Y Y N Y N

Ibáñez et al. 2010 (21) Y Y Y Y Y Y N Y N

Irving et al. 2008 (22) Y Y Y Y Y Y N Y Y

Irwin et al. 2003 (23) Y Y Y Y Y Y N Y Y

Janssen et al. 1999 (43) Y Y Y Y Y Y N Y N

Janssen et al. 2002 (24) Y Y Y Y Y Y N Y N

Johnson et al. 2009 (15) Y Y Y Y Y Y N Y Y

Kim et al. 2008 (25) Y Y Y Y Y Y N Y Y

Ku et al. 2010 (26) Y Y Y Y Y Y N Y Y

Kwon et al. 2010 (27) Y Y Y Y Y Y N Y Y

Kwon et al. 2010 (28) Y Y Y Y Y Y N Y Y

McTiernan et al. 2007 (44) Y Y Y Y Y Y Y Y Y

Mourier et al. 1997 (49) Y Y Y Y Y Y N Y N

Nicklas et al. 2009 (29) Y Y Y Y Y Y Y Y Y

Park et al. 2003 (30) Y Y Y Y Y Y N Y N

Poehlman et al. 2000 (31) Y Y Y Y Y Y Y Y N

Rice et al. 1999 (35) Y Y Y Y Y Y N Y N

Ross et al. 2000 (36) Y Y Y Y Y Y Y Y N

Ross et al. 2004 (32) Y Y Y Y Y Y N Y N

Ross et al. 1996 (37) Y Y Y Y Y Y N Y N

Schmitz et al. 2007 (33) Y Y Y Y Y Y N Y N

Short et al. 2003 (45) Y Y Y Y Y Y N Y N

Sigal et al. 2007 (46) Y Y Y Y Y Y Y Y Y

Slentz et al. 2005 (47) Y Y Y Y Y Y N Y Y

Stewart et al. 2005 (48) Y Y Y Y Y Y Y Y N

Thong et al. 2000 (38) Y Y Y Y Y Y N Y N

82 Exercise for visceral fat I. Ismail et al.obesity reviews

Table 3 Continued

Study 11. Representative

participants

14. Participants

blinded

18. Statistical

tests

20. Accurate

measures

21. Same

population

recruited

22. Same time

recruitment

24. Randomized

to groups

25. Adequate

description of

control

26. Reliability

of VAT measure

reported

Binder et al. 2005 (39) Y N Y Y Y U Y Y Y

Boudou et al. 2003 (34) Y N Y Y Y Y Y Y Y

Brochu et al. 2009 (17) Y N Y Y Y Y Y Y Y

Carr et al. 2005 (40) Y N Y Y Y Y Y Y N

Coker et al. 2009 (41) Y N Y Y Y Y Y Y Y

Cuff et al. 2003 (18) Y N Y Y Y Y Y N N

DiPietro et al. 1998 (42) Y N Y Y Y Y Y Y N

Donnelly et al. 2003 (7) Y N Y Y Y Y Y Y N

Giannopoulou et al. 2005 (19) Y N Y Y Y Y Y Y Y

Hunter et al. 2010 (20) Y N Y Y Y Y Y N Y

Ibáñez et al. 2010 (21) Y N Y Y Y Y Y Y Y

Irving et al. 2008 (22) Y N Y Y Y Y Y Y Y

Irwin et al. 2003 (23) Y N Y Y Y U Y Y N

Janssen et al. 1999 (43) Y N Y Y Y Y Y Y N

Janssen et al. 2002 (24) N Y Y Y Y Y Y Y Y

Johnson et al. 2009 (15) Y Y Y Y Y Y Y Y Y

Kim et al. 2008 (25) N N Y Y Y Y Y N N

Ku et al. 2010 (26) N N Y Y Y Y Y Y N

Kwon et al. 2010 (27) N N Y Y Y Y Y Y N

Kwon et al. 2010 (28) N N Y Y Y Y Y Y N

McTiernan et al. 2007 (44) N N Y Y Y Y Y Y Y

Mourier et al. 1997 (49) Y Y Y Y Y Y Y Y Y

Nicklas et al. 2009 (29) N Y Y Y Y Y Y Y Y

Park et al. 2003 (30) N Y Y Y U U Y N N

Poehlman et al. 2000 (31) N Y Y Y Y Y Y N Y

Rice et al. 1999 (35) N Y Y Y Y Y Y Y N

Ross et al. 2000 (36) N Y Y Y Y Y Y Y N

Ross et al. 2004 (32) N Y Y Y Y Y Y Y N

Ross et al. 1996 (37) N Y Y Y Y Y Y Y Y

Schmitz et al. 2007 (33) N Y Y Y Y Y Y Y N

Short et al. 2003 (45) N Y Y Y Y Y Y Y N

Sigal et al. 2007 (46) N Y Y Y Y Y Y Y N

Slentz et al. 2005 (47) N Y Y Y Y Y Y Y Y

Stewart et al. 2005 (48) N Y Y Y Y Y Y Y Y

Thong et al. 2000 (38) N Y Y Y Y Y Y Y N

Y, Yes; N, No; U, Undeterminable; VAT, visceral adipose tissue.

obesity reviews Exercise for visceral fat I. Ismail et al.83

Table 4 Outcomes of intervention studies for change in visceral fat

Reference Mode Measure Region Pre, mean (⫾SD) Post, mean (⫾SD) Change Score

Binder et al.

2005 (39)

C(n=38) MRI

(20 C,

34 PRT)

Serial images above and below the

L4-L5 interspace

179.0 (85.0) cm2NR -3.8(29.0)

PRT (n=53) 195.0 (104.0) cm2NR -7.0(43.0)

Boudou et al.

2003 (34)

C: n=8 MRI Umbilicus (L4-L5) 156.85 (23.4) cm2150.35(23.25) cm2NR

A: n=8 153.25 (38.55) cm284.20(21.30) cm2

Brochu et al.

2009

C: n=71 CT L4-L5 vertebral disc using a scout

image of the body

186.0 (56.0) cm2NR -23.0(30.0) cm2

PRT: n=36 183.0 (52.0) cm2NR -23.0(34.0) cm2

Carr et al. 2005

(40)

C: n=32 CT At level of umbilicus 112.3(56.0) cm2112.7(58.8) cm2-1.6(39.0) cm2

A: n=30 87.2(40.0) cm275.0(43.3) cm2-10.6(19.2) cm2

Coker et al. 2009

(41)

C: n=6 CT L4-L5 vertebral disc space NR NR C: 5(14.7)

A: n=6 A: -39.0(26.9)cm2

Cuff et al. 2003

(18)

C: n=9 CT L4/L5 vertebral disc space 259.1 (103.2) cm2NR -0.4(36.0) cm2

A+PRT: n=10 251.1 (72.4) cm2-26.3 (23.4) cm2

A: n=9 215.7 (77.4) cm2-8.8 (16.2) cm2

DiPietro et al.

1998 (42)

C: n=7 CT 4th to 5th lumbar body 136.0(74.1)cm2118.0(71.4)cm2NR

A: n=9 116.0(93.0)cm2106.0(72.0)cm2

Donnelly et al.

2003 (7)

C: n=33

A: n=41

CT L4-5 ver tebral space Men: 91.7(29.7) cm2

Women: 62.9(21.8) cm2

Men: 97.9(22.5) cm2

Women: 60.6(25.5) cm2

85.4(39.7) cm2

66.0(13.9) cm2

75.5(18.3) cm2

57.4(28.4) cm2

Giannopoulou

et al. 2005 (19)

C: n=11 MRI From superior portion of head of

femur to most superior part of

kidneys

4785.0(1,592.0) cm34425.0(1,442.7) cm3NR

A: n=11 5912.0(1,605.2) cm35152.0(1,456.0) cm3-12.8%

Hunter et al.

2010 (20)

C: n=30 CT Supine position with arms

stretched above head; at levels of

L4 and L5

50.0(20.8) cm262.4(28.2) cm212.4 cm2,

A: n=18 48.0(17.7) cm248.8(20.1) cm20.8 cm2,

PRT: n=21 43.7(14.4) cm243.3(15.5) cm20.8 cm2,-0.4 cm2

Ibáñez et al.

2010 (21)

C: n=12 MRI Abdominal and thigh; Supine

position with both arms parallel

along sides of the body

3340.0(977.0) cm22724.0(1,052.0) cm2NR

PRT n=13 3290.0 (1,141.0) cm22633.0 (1,000.0) cm2

Irving et al. 2008

(22)

C: n=7 CT L4-L5 intervertebral disc space at

midpoint between inguinal crease

and top of patella

157.0(71.0) cm2155.0(71.0) cm2-2.0 cm2

A: n=9 173.0(73.0) cm2148.0(59.0) cm2-24.0 cm2

Irwin et al. 2003

(23)

C: n=86 CT L4-L5 intervertebral space 147.6(57.7) g/cm2NR 0.1(31.5) g/cm2

A+PRT: n=87 147.6(63.5) g/cm2-8.5(40.7) g/cm2

Janssen et al.

1999 (43)

C: n=20

A: n=20

PRT: n=20

MRI Intervertebral space between L4

and L5 as point of origin

Male: 188.0(69.6)

Female: 142.0(53.8)

Male: 159.0(37.9)

Female: 128.0(31.6)

Male: 149.0(123.3)

Female: 89.0(28.5)

NR -58.0(31.6) cm2

-51.0(22.1) cm2

-67.0(37.9) cm2

-37.0(22.1) cm2

-50.0(47.4) cm2

-15.0(19.0) cm2

Janssen et al.

2002 (24)

C: n=13

A: n=11

PRT: n=14

MRI 5 cm below to 15 cm above L4-L5 2.3(1.1)kg,

131.0(50.0)cm2

1.9(0.9)kg,

120.0(42.0)cm2

1.50(0.59)kg,

84.0(27.0)cm2

NR -0.65(0.37) kg,

-51(21) cm2

-0.6(0.4) kg

-39.0(24.0) cm2

-0.4(0.2) kg

-19.0(16.0) cm2

Johnson et al.

2009 (15)

C: n=7 MRI L4-L5 intervertebral space 154.3(56.1) cm2158.6(63.2) cm2NR

A: n=12 164.3(63.4) cm2143.6(64.8) cm2

Kim et al. 2008

(25)

C: n=10 CT L4 vertebrae close to umbilicus 391.9(206.7) 408.4(189.7) 16.5

A+PRT: n=10 387.7(111.3) 356.9(93.0) -30.80

Ku et al. 2010

(26)

C: n=16 CT Abdominal 17 530.0(4,747.0)g 17 362.0(4,728.0)g -168.0(1,801.0)g

A: n=15 15 890.0(4,593.0)g 15 038.0(3,369.0)g -852.0(2,839.0)g

PRT: n=13 15 658.0(4,754.0)g 14 678.0(3,456.0)g -980.0(2,353.0)g

Kwon et al. 2010

(27)

C: n=15 CT 10 mm line from lumbar vertebrae

4 and 5 to bellybutton

17 268.7(5,060.9)mm217 745.1(4,715.0)mm24.4%

PRT: n=13 15 657.8(4,753.6)mm214 677.8(3,455.9)mm2NR

Kwon et al. 2010

(28)

C: n=14 CT Cross-sectional area of L4-L5

vertebrae

17 204.5(4,674.4)mm217 216.3(4,560.8)mm20.9%

A: n=13 16 291.5(4,808.5)mm214 682.7(3,494.7)mm28.4%

84 Exercise for visceral fat I. Ismail et al.obesity reviews

Effect of exercise therapy on visceral adiposity

(Meta-analyses)

The effect of exercise therapy on visceral adiposity is sum-

marized in Table 4 and Figs 2–5.

Aerobic exercise

There was a signiﬁcant pooled ES for the comparison

between aerobic exercise therapy and control (ES =-0.23,

95% CI: -0.35 to -0.12; P<0.001). Signiﬁcant heteroge-

neity among studies was observed (I2=71.0%, P<0.001).

Table 4 Continued

Reference Mode Measure Region Pre, mean (⫾SD) Post, mean (⫾SD) Change Score

McTiernan et al.

2007 (44)

C: n=102

A: n=100

CT L4-L5 space Men: 176.7(79.1) cm2

Women: 102.6(55.8)

cm2

Men: 161.8(66.3) cm2

Women: 105.9(60.8)

cm2

170.5(72.2) cm2

104.2(59.6) cm2

149.6(76.6) cm2

100.1(58.8) cm2

-6.2(-3.5)%

1.6(1.6)%

-12.2(7.5)%

-5.8(-5.5)%

Mourier et al.

1997 (49)

C: n=11 MRI Level of the umbilicus 139.4(36.8) cm2134.9(33.8) cm2NR

A: n=10 156.1(47.4) cm280.4(22.1) cm2

Nicklas et el.

2009 (29)

C: n=34 CT Within 15 mm centres at L4-L5

level

2369.0(870.0) cm3NR -612.0(338.0)

cm3

A: n=38 2509.0(737.0) cm3-630.0(298.0)

cm3

Park et al. 2003

(30)

C: n=10 CT L4 close to umbilicus 182.9(16.8) cm3190.4(15.7) cm37.5 cm3

A: n=10 195.0(12.6) cm3112.4(10.5) cm3-82.6 cm3

A+PRT: n=10 201.6(28.0) cm3108.6(17.9) cm3-93.0 cm3

Poehlman et al.

2000 (31)

C: n=20 CT L4-L5 vertebral level 36.0(13.0) cm241.0(15.0) cm2NR

A: n=14 40.0(11.0) cm241.0(13.0) cm2

PRT: n=17 36.0(17.0) cm236.0(13.0) cm2

Rice et al. 1999

(35)

C: n=9 MRI 1 image below and 4 images

above the L4-L5 intervertebral

space

4.6(1.6)L NR -1.5(0.9)L

A: n=10 4.6(1.5)L -1.8(1.0)L

PRT: n=10 4.1(2.4)L -1.5(0.7)L

Ross et al. 2000

(36)

C: n=8 MRI Whole body 198.0(71.0) cm2198.0 cm2NR

A: n=16 186.0(59.0) cm2134.0 cm2

Ross et al. 2004

(32)

C: n=10 MRI Whole body 2.3(0.9)kg 2.2(0.9)kg NR

A: n=17 2.3(0.8)kg 1.6(0.7)kg -0.7(0.5)

Ross et al. 1996

(37)

C: n=11 MRI Two sets from L4-L5 to upper

thorax and one extended from

L4-L4 to approximate level of

femoral head

4.7(1.6)L NR -1.5(0.8)L

A: n=11 4.6(1.4)L -1.8(1.0)L

PRT: n=11 3.9(2.3)L -1.4(0.7)

Schmitz et al.

2007 (33)

C: n=63 CT L2-L3 interspace 67.4 (36.5) cm281.8 cm221.36 (5.3) %

PRT: n=70 71.8(36.8) cm276.9 cm27.05 (5.1) %

Short et al. 2003

(45)

C: n=37 CT L4-L5 intevertebral space 122.0(79.1) cm2121.0(73.0) cm2NR

A: n=65 133.0(88.7) cm2124.0(88.7) cm2

Sigal et al. 2007

(46)

C: n=63 CT Transverse cut at L4-L5 252.0 (147.0) cm2250.0(147.0) cm2NR

A: n=60 257.0(161.0) cm2244.0(161.0) cm2

PRT: n=64 228.0(156.0) cm2218.0(156.0) cm2

A+PRT: n=64 246.0(159.0) cm2224.0 (159.0) cm2

Slentz et al. 2005

(47)

C: n=47 CT L4 pedicle 165.0(68.0) 179.2 8.6(17.2)%

A: n=42 168.0(64.0) 156.4 -6.9(20.8)%

Stewart et al.

2005 (48)

C: n=53

A+PRT: n=51

MRI One slice below, at and above

umbilicus

Male: 162.7(70.3) cm2

Female: 123.4(62.6)

cm2

Male: 186.5(63.4) cm2

Female: 109.6(47.7)

cm2

NR -7.4 (27.88) cm2

-0.3(23.1) cm2

-40.6(33.0) cm2

-14.5(23.2) cm2

Thong et al. 2000

(38)

C: n=8 MRI Whole body 4.1(1.7)kg NR -0.003(0.3)

A: n=16 3.9(0.8)kg -1.1(0.4)

All data reported as means ⫾SD.

BMI, body mass index; A, aerobic training; PRT, progressive resistance training; C, controls; NR, not reported.

obesity reviews Exercise for visceral fat I. Ismail et al.85

Figure 2 Forest plot for AEx studies (n=29). Graph depicts ES and 95% CI for individual studies and the pooled estimate.

86 Exercise for visceral fat I. Ismail et al.obesity reviews

Further examination of these showed that one study was an

outlier with much larger effect size. This study employed

high volume (6 d per week, ~60 min per session). After

re-analysis via random effects model with this outlier

removed, there remained a signiﬁcant pooled ES (-0.33,

95% CI: -0.52 to -0.14; P<0.01) (Fig. 2).

Progressive resistance therapies

The pooled ES for the comparison between resistance

exercise therapy and control did not reach signiﬁcance

(ES =0.05, 95% CI: -0.10 to 0.20; P=0.52). Signiﬁcant

heterogeneity among studies was observed (I2=61.7%,

P<0.01). After re-analysis via random effects model, the

pooled ES was 0.09 (95% CI: -0.17 to 0.36; P=0.49)

(Fig. 3).

Aerobic exercise vs. progressive resistance therapies

The pooled ES for the comparison between aerobic exercise

and resistance exercise therapies showed a non-signiﬁcant

effect which tended to favour aerobic training (ES =0.20,

95% CI: -0.02 to 0.42; P=0.08). Low heterogeneity

among studies was observed (I2=20.1%, P=0.26). Analy-

sis via random effects model showed that the pooled ES did

not reach statistical signiﬁcance (ES =0.23, 95% CI: -0.02

to 0.50; P=0.07) (Fig. 4).

Combined aerobic exercise and progressive

resistance therapies

There was a signiﬁcant pooled ES for interventions

that combined aerobic and resistance exercise therapy

vs. control (ES =-0.27, 95% CI: -0.46 to -0.08;

P<0.01). Signiﬁcant heterogeneity among studies was

observed (I2=87.1%, P<0.01). Further examination of

these showed that one study was an outlier with much

larger effect size and low precision. It is noteworthy that

this study had a low sample size (ⱕ10 subjects per

group). After re-analysis with this outlier removed using

random effects the pooled ES did not reach statistical sig-

niﬁcance (-0.28, 95% CI: -0.69 to 0.14; P=0.19)

(Fig. 5).

Figure 3 Forest plot for PRT studies (n=14). Graph depicts ES and 95% CI for individual studies and the pooled estimate.

obesity reviews Exercise for visceral fat I. Ismail et al.87

Figure 4 Forest plot for PRT vs. AEx studies (n=9). Graph depicts ES and 95% CI for individual studies and the pooled estimate.

Figure 5 Forest plot for combined AEx and PRT studies (n=6). Graph depicts ES and 95% CI for individual studies and the pooled estimate.

88 Exercise for visceral fat I. Ismail et al.obesity reviews

Discussion

This is the ﬁrst systematic review with meta-analyses to

investigate the independent and combined effects of aerobic

and resistance training modalities on visceral adiposity in

adults. The data show that when compared with a control

intervention, AEx therapy is effective in lowering VAT.

Resistance training itself failed to induce signiﬁcant reduc-

tion in VAT when compared with the control group. In

studies where AEx and PRT were directly compared, the

effect size favoured AEx training but did not reach statis-

tical signiﬁcance. From available studies in which com-

bined interventions using both AEx and PRT were

employed, the pooled effect size was not signiﬁcantly dif-

ferent from a control group.

This systematic review and meta-analyses combined 35

studies involving a total of 2145 adult participants. Of the

studies examined, the majority were conducted in over-

weight or obese populations, predominantly with female

cohorts. Twelve of the studies speciﬁcally included partici-

pants with type 2 diabetes or metabolic syndrome. Aerobic

training interventions ranged from four to 52 weeks in

duration and prescribed exercise on one to 7 d per week at

intensities between 49% and 85% of peak aerobic capacity.

Such interventions are consistent with current public health

recommendations for improving cardiorespiratory ﬁtness

(51), but the majority of studies fell below the recom-

mended exercise guidelines for the prevention and manage-

ment of overweight and obesity (52). Progressive resistance

training interventions ranged from 12 to 104 weeks in

duration and employed resistance exercise on two to 5 d

per week at intensities between 30% and 100% of one

repetition maximum (27,39). Most studies employed PRT

interventions, which were consistent with the minimum

frequency and volume of currently recommended for

improving muscular ﬁtness in adults (51).

Excess visceral adipose tissue is a well-established risk

factor for cardiovascular disease (53), and small differ-

ences in VAT area/volume can signiﬁcantly alter risk

proﬁle (54). The present data demonstrate that AEx itself

is effective in favourably modifying VAT, but that inter-

ventions involving PRT do not signiﬁcantly inﬂuence VAT.

It has been suggested that a doseresponse relationship

exists between exercise volume and VAT reduction, which

has been attributed to a greater amount of energy expen-

diture leading to greater weight loss. However, on the

basis of the present data, although there was a signiﬁcant

relationship between mean weight loss and VAT reduction

(r2=0.17, P<0.05) as expected, we found no evidence to

suggest a relationship between total weekly AEx volume

or mean intensity and VAT reduction (r2<0.15 for both),

and there are a number of examples of RCTs in which

VAT reduction occurred in the absence of signiﬁcant

weight loss (15,32,47). Other studies have found that,

when caloric expenditure of exercise is matched, higher

intensity exercise is more effective for reduction in VAT22

which has been attributed to the augmented secretion of

lipolytic hormones such as growth hormone (GH) (55).

GH acts to stimulate adipose tissue directly via hormone

sensitive lipase and also indirectly by enhancing insulin

sensitivity (56,57). Although resistance training induces

acute increases in GH secretion, chronic aerobic training

(particularly at higher intensities) can lead to chronic

increases in 24-h GH release (58). This is consistent with

our observation of a signiﬁcant reduction in VAT follow-

ing aerobic but not resistance exercise training. However,

our failure to observe a relationship between exercise

intensity and VAT reduction is likely to be due to hetero-

geneity in study duration, training frequency, modality

and cohort characteristics.

Several limitations exist which should be considered when

interpreting the results of this review. Although the majority

of the cohorts examined were overweight or obese, there

were two studies which included lean participants and others

with known metabolic disease. Furthermore, differences in

exercise prescription (intensity, duration, modality, fre-

quency and intervention length) contributed to heterogeneity.

Only one study in this review (15) attempted to blind the

control group using a sham-exercise design. Blinding of the

researcher/s conducting the baseline and post-intervention

assessment of the main outcome measures occurred in just

two studies (15,46). Other potential confounders included

differences in dietary intake and activity performed outside

of the interventions. Four of the 29 studies examined

reported non-signiﬁcant or near signiﬁcant effects of AEx

intervention on VAT and were likely limited by low subject

numbers. Our ﬁnding of a strong statistically signiﬁcant

effect for AEx on VAT highlights the relevance of a pooled

analysis approach for providing clarity on this effect.

Despite these limitations, this systematic review with

meta-analyses provides useful information for the clinical

application of exercise in the management of obesity. There

is strong evidence for the effectiveness of AEx therapy but

not for resistance exercise. However, the goal of reducing

visceral adiposity in isolation is unlikely in most obese

individuals in whom multiple cardiometabolic risk factors

are likely to be present, and PRT has been shown to be

effective for improving risk factors including insulin resis-

tance and dyslipidaemia (59). Although direct comparison

between AEx and PRT is problematic due to differences in

metabolic strain and appropriate dosage/volume, it is clear

from the present results that the aerobic component of

exercise therapy is central to exercise-induced VAT modi-

ﬁcation. The present study highlights the need for more

research examining the efﬁcacy of combined AEx and PRT

modalities but suggests that combined interventions should

not sacriﬁce an adequate volume of aerobic training for the

inclusion of PRT. Given that the studies reviewed in this

obesity reviews Exercise for visceral fat I. Ismail et al.89

investigation comply with current recommendations for

improvement in cardiorespiratory ﬁtness (ⱖ150 min/week

of moderate intensity aerobic activity) (51), these recom-

mendations appear sufﬁcient for favourably modifying

VAT despite being lower than speciﬁc overweight/obesity

management guidelines.

Conﬂict of Interest Statement

No conﬂict of interest was declared.

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obesity reviews Exercise for visceral fat I. Ismail et al.91

Long-Term Resistance-Endurance Combined Training Reduces Pro-Inflammatory Cytokines in Young Adult Females with Obesity

Article

Full-text available

Feb 2023

A sedentary lifestyle and an unhealthy diet increase the risk of obesity. People with obesity experience adipocyte hypertrophy and hyperplasia, which increases the production of pro-inflammatory cytokines, thereby increasing the risk of morbidity and mortality. Lifestyle modification using non-pharmacological approaches such as physical exercise prevents increased morbidity through its anti-inflammatory effects. The purpose of this study was to examine the effects of different types of exercise on decreased proinflammatory cytokines in young adult females with obesity. A total of 36 female students from Malang City aged 21.86 ± 1.39 years with body mass index (BMI) of 30.93 ± 3.51 kg/m 2 were recruited and followed three different types of exercise interventions: moderate-intensity endurance training (MIET), moderate-intensity resistance training (MIRT), and moderate-intensity combined training (MICT). The exercise was performed at a frequency of 3x/week for 4 weeks. Statistical analysis was performed using the Statistical Package for Social Science (SPSS) version 21.0, using the paired sample t-test. The results revealed that serum IL-6 and TNF-α levels were significantly decreased between pre-training and post-training in the three types of exercise (MIET, MIRT, and MICT) (p ≤ 0.001). The percentage change in IL-6 levels from pre-training in CTRL was (0.76 ± 13.58%), in MIET was (−82.79 ± 8.73%), in MIRT was (−58.30 ± 18.05%), in MICT was (−96.91 ± 2.39%), and (p ≤ 0.001). There was a percentage change in TNF-α levels from pre-training in CTRL (6.46 ± 12.13%), MIET (−53.11 ± 20.02%), MIRT (−42.59 ± 21.64%), and MICT (−73.41 ± 14.50%), and (p ≤ 0.001). All three types of exercise consistently reduced pro-inflammatory cytokines such as serum levels of IL-6 and TNF-α.

High-intensity interval training with or without chlorella vulgaris supplementation in obese and overweight women: effects on mitochondrial biogenesis, performance and body composition

Article

Mar 2023

The beneficial effects of high-intensity interval training (HIIT) and chlorella vulgaris (CV) on body composition and mitochondrial biogenesis have been shown in some mechanistic studies. This study aimed to determine the effects of CV and/or HIIT on mitochondrial biogenesis, performance and body composition among overweight/obese women. There was a significant reduction in the fat mass (FM) of the CV þ HIIT group, as compared with the placebo group (P = 0·005). A marginal significant increase in body water (P = 0·050) and PPAR-γ coactivator-1α (P = 0·050) was also found only in the CV þ HIIT group, as compared with the placebo. Relative (P < 0·001) and absolute (P < 0·001) VO 2max , as well as Bruce MET (P < 0·001), were significantly increased in the HIIT and HIIT þ CV groups. Besides, the synergistic effect of CV and HIIT on the Bruce MET increment was found (interaction P-value = 0·029). No significant changes were observed in BMI, fat-free mass, visceral fat, silent information regulator 1 and fibroblast growth factor-21. In this randomised clinical trial, forty-six overweight/obese women were assigned to four groups including CV þ HIIT and HIIT þ placebo groups that received three capsules of CV (300 mg capsules, three times a day) or corn starch, in combination with three sessions/week of HIIT. CV and placebo groups only received 900 mg of CV or corn starch, daily, for 8 weeks. Biochemical assessments, performance assessment and body composition were obtained at the beginning and end of the intervention. HIIT may be, therefore, effective in improving mitochondrial biogenesis, performance and body composition in overweight/obese women. Total body fat is associated with impaired mitochondrial function , thus indicating a strong relationship between body composition and mitochondrial energy metabolism (1). Mitochondria, as an important cell organelle, is involved in many crucial cell functions such as metabolism, regulating the maximal oxygen consumption (VO 2max), which is important for endurance performance (2). VO 2max is the maximum (max) amount of oxygen (O 2) a person utilises during his/her exercise; it is considered as a common measurement of aerobic power. Some characteristics including sex, age, body composition, exercise history and diet can affect VO 2max (3). Endurance exercise-induced adaptations in mitochondrial activity can improve the metabolic health and decrease the risk of obesity and other metabolic disturbances (4). Higher mitochondrial biogenesis is associated with aerobic performance as well as muscle oxidative capacity and regulated by transcriptional cofactors such as PPAR-γ coactivator-1α (PGC-1α) (5). Deacetylation of PGC-1α by silent information regulator 1 (SIRT1) which is an NAD-dependent deacetylase increases PGC-1α activity, resulting in the activation of mitochondrial bio-genesis (6,7). Besides, the gene expression of PGC-1α is up-regulated via fibroblast growth factor-21 (FGF-21) (8) .

Kraft und Krafttraining im Sport: Anwendungsbereiche, Diagnostik, Trainingsformen, Organisation, Methoden, Anpassungen

Chapter

Mar 2023

Sportmotorische Basisfertigkeiten wie Laufen, Springen, Werfen als auch Alltagsbewegungen wie Sitzen, Stehen, Gehen setzen ein bestimmtes Maß an Kraft bzw. Kraftfähigkeit voraus. Daher kommt der energetisch determinierten Kraftfähigkeit, der Strukturierung der jeweiligen trainingsmethodischen Differenzierung als auch der zielorientierten Umsetzung eine zentrale Rolle zu. Die Kraftfähigkeit spielt einerseits eine immer wichtigere Rolle im Hinblick auf allgemeine Fitness, Gesundheit und Rehabilitation, andererseits ist das Krafttraining seit Jahren in nahezu allen Sportarten und Disziplinen ein elementarer Bestandteil eines zielorientierten Trainings. Dieser Beitrag ist Teil der Sektion Sportmotorische Fähigkeiten und sportliches Training, herausgegeben vom Teilherausgeber Michael Fröhlich, innerhalb des Handbuchs Sport und Sportwissenschaft, herausgegeben von Arne Güllich und Michael Krüger.

Effects of High-Intensity Resistance Training on Visceral Adipose Tissue and Abdominal Aortic Calcifications in Older Men with Osteosarcopenia – Results from the FrOST Study

Article

Full-text available

Jan 2023
Clin Interv Aging

Purpose: To evaluate the effect of a high-intensity resistance training (HIT-RT) on visceral adipose tissue (VAT) and abdominal aortic calcifications (AAC). Patients and methods: We conducted a post hoc analysis of the Franconian Osteopenia and Sarcopenia Trial (FrOST). 43 community-dwelling men with osteosarcopenia aged 72 years and older were randomly allocated to a supervised high-intensity resistance training (HIT-RT) twice weekly for 18 months (EG; n=21) and a non-training control group (CG; n=22). Non-contrast enhanced 2-point Dixon MRI scans covering mid L2 to mid L3 were acquired to measure VAT volume inside the abdominal cavity. Volume of AAC and hard plaques in renal arteries, truncus celiacus and superior mesenteric artery was measured by computed tomography (CT) scans covering mid T12 to mid L3. Intention-to-treat analysis with imputation for missing data was used to determine longitudinal changes in VAT and AAC volume. Correlations were used to determine associations between VAT and AAC. Results: Significant reduction of VAT volume in the EG (-7.7%; p<0.001) combined with no change in the CG (-1.3%; p=0.46) resulted in a significant 6.4% between group effect (p=0.022). We observed a significant increase of AAC volume in EG (+10.3%; p<0.001) and CG (12.0%; p<0.001). AAC differences between groups were not significant (p=0.57). In vascular outlets increases in volume of the hard plaques were observed in both groups, however, not all of them were significant. There was no significant correlation between changes in VAT and AAC volumes. Conclusion: The study confirmed a positive impact of HIT-RT on the metabolic and cardiovascular risk profile with respect to reduction of VAT volume. No positive exercise effect on AAC was observed. However, there was a further progression of AAC volume independent of group affiliation. Whether different exercise regimen may show a positive effect on AAC remains subject to further studies.

Effects of exercise training on metabolic syndrome risk factors in post-menopausal women – A systematic review and meta-analysis of randomised controlled trials

Article

Full-text available

Jan 2023
CLIN NUTR

Background & Aims Alterations in the hormonal profiles as women transition to the menopause predisposes individuals to the metabolic syndrome (MetS). In post-menopausal women, this can be exacerbated by sedentary behaviour and physical inactivity. Physical activity can convey many health benefits including improvement in MetS risk factors. However, it remains to be elucidated how differing exercise intensities and its mode of delivery can ameliorate MetS risk factors and resultant progression amongst post-menopausal women. The purpose of this systematic review and meta-analysis was to investigate the effects and efficacy of exercise training on MetS risk factors in post-menopausal women. Methods Database searches using PubMed, Scopus, Web of Science and the Cochrane Central Register of Controlled Trials were conducted from inception to December 2021 for randomised controlled studies (RCTs) investigating exercise training (>8 weeks) in at least one of the MetS risk factors in post-menopausal women. Utilising the random-effects model, appropriate standardised mean differences (SMD) or mean differences (MD) with 95% confidence interval (CI) for each MetS risk factor were used to calculate the overall effect size between the exercise and control groups. Sub-group analyses were performed for exercise intensity, modality, and duration for each risk factor. Meta-regression was performed for categorical (health status) and continuous (body mass index) covariates. Results 39 RCTs (40 studies) involving 2,132 participants were identified as eligible. Overall, the meta-analysis shows that exercise training significantly improved all MetS risk factors: waist circumference (WC) [MD: -2.61 cm; 95% CI: -3.39 to -1.86 cm; p < 0.001; 21 studies]; triglycerides (TG) [SMD: -0.40 mmol/L; 95% CI: -0.71 to -0.09 mmol/L; p = 0.01; 25 studies]; high-density lipoprotein (HDL) [SMD: 0.84 mmol/L; (95% CI: 0.41 to 1.27 mmol/L; p < 0.001; 26 studies]; fasting glucose (BG) [SMD: -0.38 mmol/L (95% CI: -0.60 to -0.16 mmol/L; p < 0.001; 20 studies]; systolic blood pressure (SBP) [MD: -5.95 mmHg (95% CI: -7.98 to -3.92 mmHg; p < 0.001; 23 studies]; and diastolic blood pressure (DBP) [MD: -4.14 mmHg (95% CI: -6.19 to -2.08 mmHg; p < 0.001; 23 studies]. Furthermore, sub-group analyses identified that moderate intensity and combined exercise training significantly improved MetS risk factors (p < 0.05) except for HDL, with combined exercise being the most effective. Long duration (≥12 weeks) training also significantly improved MetS risk factors except for TG. Meta-regression revealed no moderating effects on any MetS risk variables. Conclusion This study reinforces the importance of regular physical activity as a non-pharmacological tool in the reduction of MetS risk in post-menopausal women, with significant metabolic improvements seen in interventions spanning 8 – 10 weeks. Moderate intensity and combined training significantly benefitted abdominal obesity, dyslipidaemia, dysglycaemia and hypertension in post-menopausal women. Improvements in at least one MetS risk were also seen with other exercise modalities and intensities.

Performing Group-Based Physical Activity (Gbpa) in the Work-Place: Survey and Sociological Considerations of the “Happy Bones” Project

Article

Full-text available

Dec 2022

The goal of the following work was to identify the effects, positive or negative, of performing group-based physical activity (GBPA) in the workplace. In addition, the scope of the present research was to investigate some social and relational aspects of medical origin associated with the Happy Bones project. The sample consisted of 28 women between 47 and 67 years old, employees of the University of Rome “Foro Italico”, in menopause, and inactive. The explorative nature of the investigation and the multidimensional aspect of the variables suggested the adoption of a qualitative method. Even though the survey did not fulfil the minimum standards of representativeness, interview analysis showed a positive trend in joining physical activity in the workplace, as shown by the good compliance of the participants with the proposed workplace training protocol. Personal motivation linked to the project itself or to the corresponding activity existed albeit to a secondary extent; the unifying element of the group existed regardless of the project and was due to the home institution, hence to the workplace.

Skinfold thickness variation and associations with cardiorespiratory fitness in male soccer players of different ages

Article

Full-text available

May 2023

OBJECTIVE: The aim of the present study was to examine skinfold thickness (SKF) distribution in youth and adult male soccer players regarding cardiorespiratory fitness (CRF) and the role of age. MATERIALS AND METHODS: Participants were youth (n=83, age 16.2 (1.0) years, mean (standard deviation)) and adult male soccer players (n=121, 23.2 (4.3) years), who were tested for SKF on 10 anatomical sites and Conconi test to assess vVO2max. RESULTS: A between-within subjects analysis of variance revealed a small interaction between the anatomical site and age group on SKF (p=0.006, η2=0.022), where adolescents had larger cheek (+0.7 mm; p=0.022; 95% confidence intervals – CI – 0.1, 1.3), triceps (+0.9 mm; p=0.017; 95% CI 0.2, 1.6) and calf (+0.9 mm; p=0.014; 95% CI 0.2, 1.5) SKF, while adults had larger chin (+0.5 mm; p=0.007; 95% CI 0.1, 0.8) SKF, and no difference was observed for the rest of the anatomical sites. No difference between adolescent and adult age groups was observed in average SKF (SKFavg) (9.0 (2.7) versus 9.1 (2.5) mm; difference -0.1 mm; 95% CI, -0.8, 0.6; p=0.738). Compared to adults, adolescents had a lower SKF coefficient of variation (SKFcv) (0.34 (0.10) versus 0.37 (0.09); difference-0.03; 95% CI, -0.06, -0.01; p=0.020) and subscapular-to-triceps ration (STR) (1.08 (0.28) versus 1.29 (0.37); difference-0.21; 95% CI, -0.31, -0.12; p<0.001). The largest Pearson moment correlation coefficient between vVO2max and SKF was shown in subscapular (r=-0.411; 95% CI, -0.537, -0.284; p<0.001) and the smallest in the patellar anatomical site (r=-0.221; 95% CI, -0.356, -0.085; p=0.002). In addition, vVO2max correlated moderately with SKFavg (r=-0.390; 95% CI, -0.517, -0.262; p<0.001) and SKFcv (r=-0.334; 95% CI, -0.464, -0.203; p<0.001). CONCLUSIONS: In summary, CRF was related to the thickness of specific SKF and the magnitude of thickness variation by the anatomical site (i.e., the smaller the variation, the better the CRF). Considering the relevance of specific SKF for CRF, their further use would be recommended for monitoring physical fitness in soccer players. Keywords: adiposity; age groups; anthropometry; exercise test, football; men

Not So Normal Unhealthy Lean

Chapter

Feb 2023

Not all women who have a normal weight are healthy. There are three main types of unhealthy lean including metabolically unhealthy normal weight (MUNW), normal weight with central obesity (NWCO), and normal weight obesity (NWO). These unhealthy lean individuals have an increased risk for cardiometabolic disease and mortality compared to healthy lean, but often, they are undiagnosed, since their body weight is considered “normal”. Some associations between age, sex, ethnicity, genetics, and lifestyle factors with unhealthy lean have been described. Lifestyle interventions including diet and exercise may help to improve the health of these individuals. However, there are many gaps in the past literature regarding etiology, pathophysiology, and interventions, because this is an understudied area. Furthermore, there is a lack of consensus regarding the definition of different types of unhealthy lean.

Exercise

Chapter

Jan 2023

Leisure-time physical activity is more strongly associated with cardiometabolic risk than occupational physical activity: Results from a workplace lifestyle modification program

Article

Dec 2022
PROG CARDIOVASC DIS

Background Regular physical activity (PA) plays a key role in the management and prevention of numerous chronic diseases. However, recent studies have suggested that occupational physical activity (OPA) may not always have health benefits. The aim of the present study was to examine the respective contributions of OPA vs. leisure-time physical activity (LTPA) to the variation in the cardiometabolic profile, including cardiorespiratory fitness (CRF) of employees involved in a workplace lifestyle modification program. Our study hypothesis was that LTPA would show a stronger association with indices of cardiometabolic health than OPA. Methods A mobile health assessment unit was used to assess 5145 workers (3397 men and 1748 women) on site at their workplace. Assessments included lifestyle questionnaires (overall diet quality, type of OPA and level of LTPA), blood pressure measurements, blood tests, anthropometric measurements, and a submaximal treadmill exercise test to assess CRF. Results were adjusted for education, household income and age. Results When workers were classified on the basis of their OPA (sedentary work, standing work, physical work, and heavy manual work), only a few significant differences in the cardiometabolic profile were observed in men, with those in the physical work category having more favorable values than sedentary workers. However, substantial and significant differences were observed among employees classified on the basis of their LTPA, these differences being observed in both men and women. For instance, waist circumference, the cholesterol/HDL cholesterol ratio, triglyceride concentrations and resting heart rate were lower in active individuals compared to inactive and moderately inactive individuals (p < 0.01). Furthermore, irrespective of whether or not employees were sedentary at work, a high level of LTPA was associated with a greater CRF (p < 0.001). Finally, we found that the lowest prevalence of hypertriglyceridemic waist (p < 0.01) and the highest score of overall diet quality (p < 0.001) were observed in active individuals, irrespective of their OPA category. Conclusion Levels of LTPA were more strongly associated with cardiometabolic health than OPA in a cohort of blue- and white-collar employees. Furthermore, high levels of LTPA were found to counteract the potentially deleterious effects of a sedentary work on cardiometabolic health.

Subcutaneous and visceral adipose tissue compartments and association with metabolic risk factors: The Framingham Heart Study

Conference Paper

Full-text available

Feb 2006

Physical Activity and Public Health: Updated Recommendation for Adults From the American College of Sports Medicine and the American Heart Association

Article

Full-text available

Aug 2007
CIRCULATION

In 1995 the American College of Sports Medicine and the Centers for Disease Control and Prevention published national guidelines on Physical Activity and Public Health. The Committee on Exercise and Cardiac Rehabilitation of the American Heart Association endorsed and supported these recommendations. The purpose of the present report is to update and clarify the 1995 recommendations on the types and amounts of physical activity needed by healthy adults to improve and maintain health. Development of this document was by an expert panel of scientists, including physicians, epidemiologists, exercise scientists, and public health specialists. This panel reviewed advances in pertinent physiologic, epidemiologic, and clinical scientific data, including primary research articles and reviews published since the original recommendation was issued in 1995. Issues considered by the panel included new scientific evidence relating physical activity to health, physical activity recommendations by various organizations in the interim, and communications issues. Key points related to updating the physical activity recommendation were outlined and writing groups were formed. A draft manuscript was prepared and circulated for review to the expert panel as well as to outside experts. Comments were integrated into the final recommendation. Primary recommendation: To promote and maintain health, all healthy adults aged 18 to 65 yr need moderate-intensity aerobic (endurance) physical activity for a minimum of 30 min on five days each week or vigorous-intensity aerobic physical activity for a minimum of 20 min on three days each week. [I (A)] Combinations of moderate- and vigorous-intensity activity can be performed to meet this recommendation. [IIa (B)] For example, a person can meet the recommendation by walking briskly for 30 min twice during the week and then jogging for 20 min on two other days. Moderate-intensity aerobic activity, which is generally equivalent to a brisk walk and noticeably accelerates the heart rate, can be accumulated toward the 30-min minimum by performing bouts each lasting 10 or more minutes. [I (B)] Vigorous-intensity activity is exemplified by jogging, and causes rapid breathing and a substantial increase in heart rate. In addition, every adult should perform activities that maintain or increase muscular strength and endurance a minimum of two days each week. [IIa (A)] Because of the dose-response relation between physical activity and health, persons who wish to further improve their personal fitness, reduce their risk for chronic diseases and disabilities or prevent unhealthy weight gain may benefit by exceeding the minimum recommended amounts of physical activity. [I (A)]

ACSM position stand on exercise and Type 2 diabetes

Article

Full-text available

Jan 2000
MED SCI SPORT EXER

Physical activity, including appropriate endurance and resistance training, is a major therapeutic modality for type 2 diabetes. Unfortunately, too often physical activity is an underutilized therapy. Favorable changes in glucose tolerance and insulin sensitivity usually deteriorate within 72 h of the last exercise session; consequently, regular physical activity is imperative to sustain glucose-lowering effects and improved insulin sensitivity. Individuals with type 2 diabetes should strive to achieve a minimum cumulative total of 1000 kcal · wk-1 from physical activities. Those with type 2 diabetes generally have a lower level of fitness (VO(2max)) than nondiabetic individuals, and therefore exercise intensity should be at a comfortable level (RPE 10-12) in the initial periods of training and should progress cautiously as tolerance for activity improves. Resistance training has the potential to improve muscle strength and endurance, enhance flexibility and body composition, decrease risk factors for cardiovascular disease, and result in improved glucose tolerance and insulin sensitivity. Modifications to exercise type and/or intensity may be necessary for those who have complications of diabetes. Individuals with type 2 diabetes may develop autonomic neuropathy, which affects the heart rate response to exercise, and as a result, ratings of perceived exertion rather than heart rate may need to be used for moderating intensity of physical activity. Although walking may be the most convenient low-impact mode, some persons, because of peripheral neuropathy and/or foot problems, may need to do non- weight-bearing activities. Outcome expectations may contribute significantly to motivation to begin and maintain an exercise program. Interventions designed to encourage adoption of an exercise regimen must be responsive to the individual's current stage of readiness and focus efforts on moving the individual through the various 'stages of change'.

Inactivity, Exercise, and Visceral Fat. STRRIDE: A Randomized, Controlled Study of Exercise Intensity and Amount.

Article

Mar 2006

Strength training and adiposity in premenopausal women: Strong, Healthy, and Empowered study

Article

Sep 2007

Background: American women aged 25-44 y gain 0.5-1 kg yearly, most of which is fat. Because few midlife women participate in strength training, this mode of activity may be a novel intervention for preventing age-associated fat increases in this population. Objectives: The primary aim was to assess the efficacy of twice-weekly strength training to avoid increases in percentage body fat and intraabdominal fat. Design: A randomized controlled trial was conducted in an ethnically diverse sample of 164 overweight and obese [body mass index (in kg/m(2)): 25-35] women aged 25-44 y. The treatment group did twice-weekly strength training for 2 y. The standard care comparison group was given brochures recommending aerobic exercise. Assessments at baseline, 1, and 2 y included intraabdominal fat by computed tomography scan and body fat and fat-free mass by dual-energy X-ray absorptiometry. Results: During 2 y, percentage body fat changes were -3.68 +/- 0.99% for the treatment group and -0.14 +/- 1.04% for the control group, P = 0.01. Two-year intraabdominal fat changes were 7.05 +/- 5.07% for the treatment group and 21.36 +/- 5.34% for the control group, P = 0.05. Conclusion: This study suggests that strength training is an efficacious intervention for preventing percentage body fat increases and attenuating intraabdominal fat increases in overweight and obese premenopausal women. This is relevant to public health efforts for obesity prevention because most weight gain can be assumed to be fat, including abdominal fat.

Physical Activity and Public Health: Updated Recommendation for Adults from the American College of Sports Medicine and the American Heart Association

Article

Jan 2007

Exercise and Type 2 Diabetes

Article

Jan 2010

The effects of combined exercise on functional fitness and risk factors of metabolic syndrome in the older women

Article

Apr 2008
JPN J PHYS FIT SPORT

The purpose of this study was to investigate the changes in functional fitness and risk factors for metabolic syndrome after 12 weeks of combined exercise in women of advanced age. Subjects consisted of twenty women of advanced age with metabolic syndrome (Control, 10 ; Combined, 10) whose age was over 75. The combined exercise program included stretching for 20 minutes, aerobic exercise for 30 minutes, resistance training for 15 minutes, and Asana yoga for 15 minutes. Subjects exercised 4 times a week for 12 weeks. We found that LBM (lean body mass) was significantly increased and visceral fat was significantly decreased after 12 weeks. Also, self-reliance fitness and the risk factors for metabolic syndrome were significantly improved after 12 weeks in the combined exercise group. Therefore, it appears that combined exercise plays a positive role in body composition and fitness and reduces the risk factors for metabolic syndrome in women of advanced age.

Effects of Resistance Training and Endurance Training on Insulin Sensitivity in Nonobese, Young Women: A Controlled Randomized Trial

Article

Jul 2000

E. T. Poehlman

Reduction in Obesity and Related Comorbid Conditions after Diet-Induced Weight Loss or Exercise-Induced Weight Loss in Men

Article

Jul 2000

Robert Ross

Background: The independent effects of diet- or exercise-induced weight loss on the reduction of obesity and related comorbid conditions are not known. The effects of exercise without weight loss on fat distribution and other risk factors are also unclear. Objective: To determine the effects of equivalent diet- or exercise-induced weight loss and exercise without weight loss on subcutaneous fat, visceral fat, skeletal muscle mass, and insulin sensitivity in obese men. Design Randomized, controlled trial. Setting: University research center. Participants: 52 obese men (mean body mass index [±SD], 31.3 ± 2.0 kg/m 2 ) with a mean waist circumference of 110.1 ± 5.8 cm. Intervention: Participants were randomly assigned to one of four study groups (diet-induced weight loss, exercise-induced weight loss, exercise without weight loss, and control) and were observed for 3 months. Measurements: Change in total, subcutaneous, and visceral fat; skeletal muscle mass; cardiovascular fitness; glucose tolerance and insulin sensitivity. Results: Body weight decreased by 7.5 kg (8%) in both weight loss groups and did not change in the exercise without weight loss and control groups. Compared with controls, cardiovascular fitness (peak oxygen uptake) in the exercise groups improved by approximately 16% (P 0.2). However, these values were significantly greater than those in the control and exercise without weight loss groups (P < 0.001). Conclusions: Weight loss induced by increased daily physical activity without caloric restriction substantially reduces obesity (particularly abdominal obesity) and insulin resistance in men. Exercise without weight loss reduces abdominal fat and prevents further weight gain.

A systematic review and meta-analysis of the effect of aerobic vs. Resistance exercise training on visceral fat

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