A Systematic Review and Meta-Analysis of The Effect of Aerobic Vs Resistance Exercise Training On Visceral Fat

obesity reviews
doi: 10.1111/j.1467-789X.2011.00931.x
Obesity Treatment/Management
A systematic review and meta-analysis of the effect of

aerobic vs. resistance exercise training on visceral fat
obr_
931
68..9168..91
I. Ismail1, S. E. Keating1, M. K. Baker2,3 and N. A. Johnson1,3
Discipline 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;
3
Boden 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 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.
Keywords: Aerobic training, obesity, physical activity, strength training.
obesity reviews (2012) 13, 6891
Financial support: none.
68
2011 The Authors

obesity reviews 2011 International Association for the Study of Obesity 13, 6891
obesity reviews
Introduction
The increased risk of cardiovascular and metabolic morbidity 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 infarction (2) and insulin resistance (24). 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 magnetic resonance imaging (MRI) has shown that the synergy
of aerobic exercise training and calorie restriction positively affects VAT content when weight loss approximating
49% 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 (~23 kg)
but increases (~57.5 kg) with exercise levels up to
420 min/week (911). However, there is an emerging
acceptance that even with intensive programmes, weight
loss in excess of 34 kg is difficult to sustain (1214),
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 interventions 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)
Exercise for visceral fat
I. Ismail et al. 69
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 keywords: (strength training, weight training, resistance training, 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 distribution). Reference lists of all retrieved papers were manually
searched for potentially eligible papers. Randomized controlled trials (RCTs) were reviewed while non-RCTs, uncontrolled 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 populations were excluded because of specific medications affecting abdominal fat (5).
2011 The Authors

70 Exercise for visceral fat
obesity reviews
I. Ismail et al.
Figure 1 Flowchart of outcomes of search

strategy.
Outcome measures
Selection of studies
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 quantification 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.
After eliminating duplications, the search results were

screened by one investigator (II) against the eligibility criteria, 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
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I. Ismail et al. 71
insufficient information, attempts were made to contact

authors to obtain missing details.
analyses were conducted using Comprehensive Metaanalysis, version 2 (Biostat Inc, Englewood, NJ).
Data extraction and calculations
Results
Data relating to participant characteristics (age, sex, body

mass index {BMI]} ), exercise details (mode of exercise,
nutritional intervention, exercise frequency, intensity, duration and intervention duration) and visceral fat quantification (measurement technique and region) were extracted
independently by two researchers (II, SK), with disagreements 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 calculated. Between-study variability was examined using the I2
measure of inconsistency. This statistic, expressed as a percentage between 0100, provides a measure of how much
of the variability between studies is due to heterogeneity
rather than chance. Publication bias was assessed by examining asymmetry of funnel plots (precision vs. ES) using
Eggers 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
Identification and selection of studies

The original search netted 12 196 studies. Three more
studies were found from the reference lists of the manuscripts retrieved. After removal of duplicates and elimination 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). Seventeen studies exclusively recruited female participants
(1733), five studies exclusively recruited male participants
(3438), with 11 studies recruiting both men and women
(9,3948). Sex was not reported in one study (49). The mean
age of participants ranged from 2883 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 participants 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 commonly 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
4055% in initial weeks progressing to 6090% in the final
weeks of the programmes. The most commonly prescribed
intensity was 6075% 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
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obesity reviews
I. Ismail et al.
Table 1 Participant characteristics

Reference
Subjects
Binder et al. 2005 (39)
91; Older sedentary with physical frailty
% Male
BMI
C: 45%
C: 55
C: 83.0(4.0)
C: 26.0(4.0)
PRT: 53
PRT: 83.0(3.0)
PRT: 27.0(5.0)
45.4(7.2)
29.6(4.6)
Boudou et al. 2003 (34)
16; Men with type 2 diabetes
100.0
107; Postmenopausal women
Carr et al. 2005 (40)
62; Japanese-Americans with impaired

glucose tolerance
Coker et al. 2009 (41)
18; Overweight elderly
Cuff et al. 2003 (18)
28; Postmenopausal with type-2

diabetes
16; Healthy older
Age
PRT: 47
Brochu et al. 2009 (17)
DiPietro et al. 1998 (42)
% Female
0.0
100
C: 58.0(4.7)
C: 32.2(4.6)
C: 53.1
C: 46.9
56.5(10.2)
C: 26.6(2.5)
A: 40
A: 60
50
50
100
18.8
81.3
A: 25.7(4.5)
71.0(4.2)
30(4.2)
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)
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
Giannopoulou et al. 2005

(19)
22; Obese post menopausal women

with type 2 diabetes
100
Hunter et al. 2010 (20)
69; Healthy premenopausal women
100
Ibanez et al. 2010 (21)
25; Obese women
100
Irving et al. 2008 (22)
16; Obese women with metabolic

syndrome
100
Irwin et al. 2003 (23)
173; Overweight postmenopausal

women
100
Janssen et al. 1999 (43)
60; Upper body obese
38; Premenopausal obese women
50
100
Women: 24.0(5.0)
Women: 28.7(3.2)
5070
34.6(3.3)
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)
C:54.4(5.5)
C: 34.6(3.4)
PRT: 48.6(6.4)
PRT: 35.0(3.1)
51.0(9.0)
34.0(6.0)
C: 60.6(7.1)
C: 30.6(3.8)
A + PRT: 61.0(6.9)
A: + PRT 30.5(4.3)
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)
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)
19; Obese sedentary
Kim et al. 2008 (25)
20; Women of advanced age with

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

type 2 diabetes
Kwon et al. 2010 (27)
28; Overweight type 2 diabetics
100
56.4 (7.1)
27.4(2.5)
Kwon et al. 2010 (28)
27;Obese type 2 diabetics
100
56.6(8)
27.3(2.7)
McTiernan et al. 2007 (44)
202; Sedentary
21; NIIDM
Nicklas et al. 2009 (29)
72; Overweight and obese
Park et al. 2003 (30)
30; Middle-aged obese women
32.0
C: Men: 29.0(3.0), Women: 29.3(2.3)

A: Men29.7(2.9),
Johnson et al. 2009 (14)
Mourier et al. 1997 (49)
68.0
50
C: Men: 24.0(4.0), Women: 21.0(4.0)

A: Men: 22.0(4.0),
C: 47.3(9.5)
31.1(2.9)
100
>75
C: 25.7(2.8)
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)
A + PRT: 26.0(2.4)
50.5
49.5
NR
0
100
100
postmenopausal women
Poehlman et al. 2000 (31)
Rice et al. 1999 (35)
51; Non-obese younger women
29; Obese men
100
100
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)
45.0(9.8)
30.2(4.4)
C: 58.4(6.0)
C: 33.9(4.0)
A: 59.0(5.0)
A: 32.9(3.7)
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)
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)
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)
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I. Ismail et al. 73
Table 1 Continued
Reference
Subjects
% Male
Ross et al. 2000 (36)
24; Obese men
100
Ross et al. 2004 (32)
Ross et al. 1996 (37)
Schmitz et al. 2007 (33)
Short et al. 2003 (45)
27; Premenopausal women with

abdominal obesity
33; Obese men
133; Overweight or obese
102; Healthy sedentary men and
% Female
100
100
52
100
48
Age
C: 46.0 (10.9)
C: 30.7(1.9)
A: 45.0 (7.5)
A:32.3(1.9)
C: 43.7(6.4)
C: 32.4(2.8)
A:43.2(5.1)
A: 32.8(3.9)
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)
C: 36.0(6.0)
C: 29.4 (0.4)
PRT: 37.0(5.0)
PRT: 29.4 (0.4)
2187
women
Sigal et al. 2007 (46)
Slentz et al. 2005 (47)
Stewart et al. 2005 (48)
251; Type 2 diabetes
BMI
C: 25.7(2.4)
A:26.6 (1.8)
63.7
89; Sedentary overweight with mild to

moderate dyslipidemia
52
104;
49
36.3
48
51
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)
C: 52.7(6.5)
C: 29.6(3.0)
A: 51.5(5.3)
A: 29.1(2.4)
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
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.
studies (17,20,21,25,27,30,31,39,48) ranged between

30100% 1 RM. Two studies (24,43) prescribed one set of
812 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 participants 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:
0.131.67), with two of these reaching statistical significance. 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).
2011 The Authors

Carr et al. 2005

(40)
Brochu et al.
2009 (17)
Boudou et al.
2003 (34)
Isocaloric with 30% fat (<7%

saturated), 50% CHO, 20%
protein with <300 mg
cholesterol/d
Isocaloric with 30% fat (10%
saturated), 55% CHO, 15%
protein with <200 mg
cholesterol/d
A: n = 32; walking or jogging on a

treadmill
55% CHO; 30% fat; 15%

protein
C: n = 32: Stretching exercises
PRT: n = 36; leg press, chest

press, lat pull down, shoulder
press, arm curls, triceps
extensions
C: n = 71
A: n = 8; bicycle ergometer
60 rpm
C: n = 8; bicycle ergometer at
machine. + shortened version of

phase 1.
balance coordination, speed of

reaction. Phase 2: PRT, knee
extension, flexion, seated bench
press, seated row, leg press,
biceps curl on weightlifting
Maintain usual diet (~50%

CHO, 30% lipids, 20%
proteins).
Supplemental calcium and

vitamin D
C: n = 38; 9 of 22 exercises in
phase 1, primary focus on
flexibility.
Binder et al.
2005 (39)
PRT: n = 53; Phase 1: flexibility,
Nutritional intervention
Mode
Reference
Table 2 Exercise details
3/7
3/7
3/7
3/7
1/7
sessions/each phase.
3/7 for 36
23/7
Frequency
70% HRR
NR
Four progressive phases:

1 (3 weeks): 15 reps/65% 1 RM,
23 sets per exercise, 90120 s
rest b/w sets
2 (5 weeks): 12 reps/70% 1 RM,
23 sets per exercise, 90 s rest
b/w sets3 (9 weeks):
10 reps/7580% 1 RM, 24 sets
per exercise, 120180 s rest b/w
sets
4 (8 weeks): 1012 reps/7075%
1 RM, 24 sets per exercise
6090 s rest b/w sets.
NR
Continuous 75% VO2peak 2/7 and

intermittent exercise at 85%:50%
for 2 min:3 min, respectively, 1/7
Low intensity (30 W)
at 65% of 1 RM to progress to 3
sets of 812 at 85100% of initial
1 RM
Phase 2: PRT, 12 sets of 68 reps
Intensity
60 min
NR
Continuous: 45 min;
Intermittent: NR
20 min
Phase 2: 6090 min
Session duration
24 months
6 months
8 weeks
months/phase
6 months: 3
6 months
Intervention
duration
I. Ismail et al.
-1.8(2.7)
0.6 (2.8)
-5.8(4.9)
-5.1(4.7)
-1.9(19.2)
-1.7(16.1)
0.0(0.0)
0.0(0.0)
Weight
change
(kg)
obesity reviews
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2011 The Authors

Giannopoulou
et al. 2005 (19)
Donnelly et al.
2003 (7)
DiPietro et al.
1998 (42)
testing period
Refrain from any type

of regular physical
activity during study
3/7
3.6(27.2)
-5.5(27.2)
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
M: -5.2(15.8)
F: 0.6(17.1)
NR
A: n = 41; Treadmill, stationary

bike or elliptical trainer
M: -0.5(16.3)
F: 2.9(12.3)
Maintain usual dietary intake
C: n = 33;
4/7
4/7
-1.2(2.1)
0.0(15.0)
3/7
-2.9(4.1)
45/7
Maintain habitual
physical activity
Frequency
Continue with current

physical activity
patterns
3/7
2.0(3.6)
-1.0(19.2)
NR
Continue with current diet

patterns
A: n = 9; mini trampoline
C: n = 7; stretching, yoga, stretch

bands
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
C: n = 9
NR
controlled feeding prior to

baseline and post intervention
A: n = 6; cycle ergometer
Cuff et al. 2003

(18)
NR
Mixed diet (35% fat, 20%

protein, 45% CHO) during 4 d
C: n = 6
Coker et al. 2009

(41)
Weight
change
(kg)
Mode
Reference
Table 2 Continued
6570% VO2peak
60% HRR at baseline to 75% at 6

months
Maintain usual physical activity
5560% HR max for 1 month; 75%

HR max for 3 months
HR did not exceed 90 bpm
A: 6075% HRR;
PRT: 2 sets of 12 reps.
A: 6075% HRR
75% of VO2peak
Caloric expenditure matched at
1,000 kcal/7
Intensity
50 min
20 min at baseline to
45 min at 6 months
2040 min 1st month

progressing to 60 min for
3 months
60 min
75 min
75 min
NR
Session duration
14 weeks
16 months
4 months
16 weeks
12 weeks
Intervention
duration
obesity reviews
I. Ismail et al. 75
Janssen et al.
1999 (43)
Irwin et al. 2003

(23)
Irving et al. 2008

(22)
Ibez et al.
2010 (21)
5/7
3/7
M: -11.4(3.8)
F: -11.5(3.2)
M: -12.7(3.8)
F: -10.0(2.8)
1 set of 812 reps to volitional

fatigue
5085% MHR
A: 40% HR max progressing to

6075% HR max by week 8
PRT: 2 sets of 10 reps
NR
RPE 1517 on 3/7 and 1012 on

2/7
30 min
15 min progressing to
maximum of 60 min.
45 min
45 min
Time to expend 300 kcal

in weeks 12, 350 kcal in
weeks 34, and 400 kcal
in weeks 516
4560 min
NR
2040 min
Session duration
16 weeks
12 months
16 weeks
16 weeks
1 year
Intervention
duration
I. Ismail et al.
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
NR
M: -11.7(3.5)
F: -10.7(3.8)
Weight maintenance energy

intake reduces by
1,000 kcal/d. Limit dietary fat
intake to <30%.
C: n = 20; Diet only
1/7
5/7
0.1 (NR)
Weeks 12: 3/7

Weeks 34: 4/7
Weeks 516: 5/7
-1.3 (NR)
Maintain usual diet
Week 18: 5070% 1 RM; Week

916: 7080% 1 RM + 20% of leg
extensor and bench press sets
with 3050% 1 RM.
between sets; 80% of 1 RM
Week 14: 1 set of 10 reps then 2

sets of 10 reps. 2 min rest
Week 1: 67% HR max progressing

to 80% HR max in week 8.
Intensity
Maintain current level of physical activity
2/7
NR
23/7
NR
Frequency
A + PRT: n = 87; A: treadmill

walking, stationary bike. PRT: leg
extensions, leg curls, leg press,
chest press, seated dumbbell
row.
C: n = 86; stretching sessions
-0.9(15.4)
-3.5(24.0)
NR
-7.1(16.7)
-5.7(20.7)
3.9(11.5)
3.1(8.8)
6.4(9.4)
(kg)
Weight
change
A: n = 9; Walk/run on indoor or
outdoor track
C: n = 7;
PRT: n = 13; Diet + bilateral leg

press, bilateral knee extension,
bench press, and 45 exercises
for main muscle groups of body;
all on resistance machines
C: Diet only
leg sit ups
triceps extension, lateral pull

down, bench press, military
press, lower back extension, bent
PRT: n = 21; squats, leg

extension, leg curl, elbow flexion,
55% CHO, 15% protein, 30%

fat, 500 kcal/d
800 k/cal per day (2022% fat,

1822% protein, 5862%
CHO)
C: n = 30
Hunter et al.
2010 (20)
A: n = 18; walking or jogging on a

treadmill
Mode
Reference
Table 2 Continued
obesity reviews
2011 The Authors

2011 The Authors

Ku et al. 2010
(26)
Kim et al. 2008

(25)
Johnson et al.
2009 (15)
Reduce weight maintenance

energy intake by 1,000 kcal/d,
limit dietary fat intake to <30%
C: n = 13; dietary intervention
Janssen et al.
2002 (24)
5/7
-1.1(1.3)
-1.9(1.2)
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
A: n = 15; walking
Maintain sedentary
lifestyle
-0.6(1.7)
C: n = 16; diabetes education
4/7
NR
3/7
3/7
3/7
5/7
-0.3(8.8)
Maintain standard calorific

intake (ideal body weight
(kg) 30 kcal/kg/d)
NR
C: n = 10
Intensity
4050% max
3.65.2 METs
Week 1: -4: 4055% HRR, week

58: 5565%, week 912: 6575%
PRT 75% 1 RM
Week 1: 50% VO2peak

Week 2: 60% VO2peak
Week 3&4: 70% VO2peak
fatigue
1 set of 812 reps until volitional
50% progressing to 85% of HR

max
Maintain pre-study physical activity levels.
Frequency
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
0.57(8.8)
-0.2(16.2)
-0.3(19.2)
Consume habitual diet

for 3 d before and after
intervention provided with diet
(60% CHO, 20% protein, 20%
fat)
C: n = 7; stretching
-10.0(3.0)
-11.1(4.4)
-10.0(3.9)
Weight
change
(kg)
A: n = 12; cycle ergometer
press, shoulder press, triceps

extension, biceps curl, sit ups.
intervention + leg extension, leg

flexion, super pullover, bench
intervention + treadmill, cycle

ergometer or stair stepping.
PRT: n = 14; dietary
A: n = 11; dietary
Mode
Reference
Table 2 Continued
3 sets, 1520 reps
60 min
60 min; 30 min aerobics,

15 min Resistance, 15 min
Yoga
3045 min (15 min bouts

with intervening 5 min
rests)
30 min
Approx. 30 min
60 min.
Session duration
12 weeks
12 weeks
4 weeks
16 weeks
Intervention
duration
obesity reviews
I. Ismail et al. 77
Nicklas et al.
2009 (53)
Mourier et al.
1997 (49)
McTiernan et al.
2007 (44)
Kwon et al. 2010

(28)
C: n = 34; Calorie restriction
A: n = 38; Calorie
restriction + treadmill walking
Total calorie deficit of

400 kcal/d, 2530% fat,
1520% protein, 5060% CHO
-12.3(4.9)
-11.8(4.1)
-1.5(17.3)
0.2(21.4)
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)
C: n = 11
A: n = 10; Ergocycle
M: -1.8(21.0)
F: -1.4(24.9)
A: n = 100; Treadmills, stationary

bikes, elliptical machines and
rowers
M: -0.1(25.2)
F: 0.7(18.6)
Asked not to change dietary

habits
C: n = 102
NR
NR
C: n = 14
0.7(10.5)
1.1(6.4)
Weight
change
(kg)
A: n = 13; Walking
NR
NR
C: n = 15
PRT: n = 13; Bicep curls, triceps
extensions, upright rows,
Kwon et al. 2010

(27)
shoulder press, chest press,

seated rows, leg press, hip
flexion, leg flexion, leg extension,
side bends with resistance bands
Mode
Reference
Table 2 Continued
3/7
Not to alter sedentary lifestyle
1/7
intermittent
Trial: 2/7 continuous

exercise
Pre-training 3/7
1/7
6/7
Asked not to change

exercise habits
5/7
Maintain routine activity
No exercise
3/7
Frequency
7075% HRR
Intermittent
85% V02peak
for 2 min 50% V02peak
for 3 min x five exercises
Pre-training
75%
Continuous: 75%V02peak
Low intensity
6085% HR max
Anaerobic threshold
4050% 1 RM
Intensity

30 min by end of 6th
week
NR
Continuous: 45 min
NR
20 min45 min
60 min
60 min
3 sets 10-15 reps for

40 min plus 10 min warm
up and cool down
Session duration
20 weeks
2 weeks
pre-training
8 weeks
12 months
12 weeks
12 weeks
Intervention
duration

I. Ismail et al.
obesity reviews
2011 The Authors

2011 The Authors

Rice et al. 1999
Poehlman et al.
2000 (31)
PRT: n = 10; diet

flexion, super pullover, bench
press, shoulder press, triceps
extension, biceps curl, sit ups
-13.6(4.1)
-11.5(3.9)
-12.1(3.4)
Energy intake reduced by

1,000 kcal/d, limit dietary fat
intake to <30%
C: n = 9; diet intervention only
A: n = 10; diet
intervention + treadmill walking,
stationary cycle or stair stepping
2.0(8.5)
PRT: n = 17; leg press, bench

press, leg extension, shoulder
press, sit up, seated row, tricep
extension, arm curls, leg curls
1.0(10.6)
0.0(7.1)
C: n = 20
A: n = 14; jogging
-6.4(6.6)
-4.7(4.7)
0.6(2.3)
(kg)
Weight
change
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
double kick
scissor double, hop and jump,

jumping jack, side kick, full turn,
turn, Cha cha, Mambo rock,

diamond step, single hamstring
walking, heel touch, sit up, push
up. Week 1324: fast walking,
turn round, heel side, knee up,
NR
NR
C: n = 10
Park et al. 2003

(30)
A: n = 10; Aerobics: week 112:

side by side, step touch, lunge
side, v-step, grape vine, pivot
Mode
Reference
Table 2 Continued
3/7
5/7
NR
3/7
NR
6/7
6/7
NR
Frequency
1 set of 812 reps
19 min progressing to 60 min
3 sets 10 reps, 11.5 min between

sets
Weeks 116: 5% increase in HR

max each week progressing to
90% HR max
Weeks 1728:
Mon: 80% HR max
Wed: 95% HR max
Fri: 7580% HR max.
By last session at 85% HRmax
A (3/7) 6070% HR max

PRT (3/7) Week 112 60% 1 RM,
Week 1324 70% 1 RM
6070% HR max
Intensity
~30 min
50% progressing to
85%HR max
80% 1 RM
Weeks 116: 25 min

progressing to 40 min
Weeks 1728:
Mon: 45 min
Wed: 4 5 min bouts with
3 min rests
Fri: 45 min.
By last session: 60 min
60 min
Session duration
16 weeks
6 months
24 weeks
Intervention
duration
obesity reviews
I. Ismail et al. 79
Schmitz et al.
2007 (33)
Ross et al. 1996

(37)
Ross et al. 2004

(32)
C: n = 63; Walking programme as

per AHA guidelines
PRT: n = 70; isotonic variable
resistance machines and freeweight exercises for quadriceps,
hamstrings, gluteal, pectoral,
erector spinae, latissimus dorsi,
rhomboid, deltoid, bicpes, triceps
A: n = 11; Diet
intervention + stationary cycle,
treadmill or stair stepping
PRT: n = 11; Diet
flexion, superpullover, chest
press and cross, shoulder press,
triceps extension and biceps curl
on Nautilus weight training
stations and Sit ups
C: n = 11; Diet intervention only
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
700 kcal/d
jogging on motorized treadmill.

maintain isocaloric diet and
perform exercise that expended
No changes to diet
Energy intake reduced by

1,000 kcal/d and limit dietary
fat intake to <30% of total
energy intake
Weight maintenance diet

(5060% CHO, 1520%
protein, 2030% fat) for 4- to
5-week baseline period
Weight maintenance diet

(5560% CHO, 1520%
protein, 2025% fat) for 4- to
C: n = 8; Maintain body weight
Ross et al. 2000

(36)
A: n = 16; Brisk walking or light
Mode
Reference
Table 2 Continued
1.4(0.6)
Most days of the

week
2/7
3/7
-13.2(4.1)
2.0(0.7)
5/7
NR
NR
7/7
7/7
NR
Frequency
-11.6(3.7)
-11.4(3.5)
0.5(11. 0)
-5.9(15.3)
-7.5(NR)
0.1(NR)
Weight
change
(kg)
Year 1: 3 sets, 810 reps

Year 2: 2 sets and maintain the
highest weight lifted each exercise
Moderate intensity
1 set of 12 reps
NR
80% of HRmax
<70% VO2peak (80% MHR)
Intensity
Year 1: 1 h
Year 2: 45 min
30 min
NR
60 min.
Time required to expend

500 kcal.
Time taken to expend

700 kcal
Session duration
2 years
16 weeks
14 weeks
12 weeks
Intervention
duration

I. Ismail et al.
obesity reviews
2011 The Authors

2011 The Authors

Weight maintenance diet for
consisting of 5560% CHO,
1520% protein, 2025% fat
Matched exercise expenditure
with additional 700 kcal/d
C: n = 8
A: n = 14; Perform exercise that

expended 700 kcal/d; brisk
walking or light jogging on a
motorized treadmill
Thong et al. 2000

(38)
7/7
80% HR max
Time required to expend

700 kcal
A: 45 min
PRT: NR
Expend 23 kcal/kg/week
12 weeks
6 months
8 months
6 months
26 weeks
16 weeks
Intervention
duration
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.
-7.6(0.4)
NR
3/7
M: -2.2(2.7)
F: -2.3(3.4)
A: 6090% HR max
PRT: 2 sets, 1015 reps of 50%
1 RM
National Institute of Aging Guidelines for Exercise
M: -0.63
F: -0.5(2.3)
6580% VO2peak
AHA Step 1 diet; Maintain

normal caloric intake
0.1(0.8)
NR
1545 min
40 min
Session duration
Combined aerobic and resistance training programmes
23 sets of 79 reps
6075% HR max
HR max
70% HR max progressing to 80%
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
Equivalent to jogging
20 miles/week
NR
3/7
activity levels
Revert to pre-study
3/7 progressing to 4/7
Stewart et al.
2005 (48)
0.87(NR)
Intensity
Flexibility exercises to perform at home; maintain regular lifestyle
Frequency
-2.3(NR)
-2.6(43.0)
Not to diet/change their diet
-0.8(43.0)
-2.6(43.3)
-0.3(39.9)
A + PRT: n = 64
intake 90% estimated

weight maintenance
requirement
Recommended diet that would

not cause weight loss.
Prescribed energy
C: n = 47
PRT: n = 64; 7 different machine

weight exercises
A: n = 60; treadmills or bicycle

ergometers
C: n = 63
-1.5(18.2)
0.3(17.3)
Weight
change
(kg)
A: n = 42; treadmills, elliptical

trainers, cycle ergometers
Slentz et al. 2005

(47)
Sigal et al. 2007

(46)
Weight maintaining diet

(55%CHO, 30%fat and 15%
protein)
C: n = 37
Short et al. 2003

(45)
A: n = 65; stationary bicycle
Mode
Reference
Table 2 Continued
obesity reviews
I. Ismail et al. 81
1. Hypothesis
stated
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Study

Carr et al. 2005 (40)
Cuff et al. 2003 (18)
Giannopoulou et al. 2005 (19)
Ibez et al. 2010 (21)
Kim et al. 2008 (25)
Ku et al. 2010 (26)
Kwon et al. 2010 (27)
Kwon et al. 2010 (28)
Park et al. 2003 (30)
Rice et al. 1999 (35)
Ross et al. 2000 (36)
Ross et al. 2004 (32)
Ross et al. 1996 (37)
Table 3 Quality ratings of study
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
2. Main
outcomes
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
3. Participants
characteristics
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
4. Interventions
described
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
6. Main
findings
described
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
7. Variability
estimates
Y
N
N
N
N
N
N
Y
N
N
N
N
N
N
N
N
N
N
N
N
Y
N
Y
N
Y
N
Y
N
N
N
N
Y
N
Y
N
8. Adverse
events reported
Y
N
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
9. Patients
lost to
follow up
Y
Y
Y
Y
N
N
N
Y
N
N
N
Y
Y
N
N
Y
Y
Y
Y
Y
Y
N
Y
N
N
N
N
N
N
N
N
Y
Y
N
N
10. Actual
P value
reported

I. Ismail et al.
obesity reviews
2011 The Authors

2011 The Authors

Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
N
Y
N
N
N
N
N
Y
N
N
N
N
N
N
N
N
N
N
N
N
N

Carr et al. 2005 (40)
Cuff et al. 2003 (18)
Giannopoulou et al. 2005 (19)
Ibez et al. 2010 (21)
Kim et al. 2008 (25)
Ku et al. 2010 (26)
Kwon et al. 2010 (27)
Kwon et al. 2010 (28)
Park et al. 2003 (30)
Rice et al. 1999 (35)
Ross et al. 2000 (36)
Ross et al. 2004 (32)
Ross et al. 1996 (37)
N
N
N
N
N
N
N
N
N
N
N
N
N
N
Y
Y
N
N
N
N
N
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
14. Participants
blinded
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
18. Statistical
tests
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
20. Accurate
measures
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
U
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
21. Same
population
recruited
U
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
U
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
U
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
22. Same time

recruitment
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
24. Randomized
to groups
Y
Y
Y
Y
Y
N
Y
Y
Y
N
Y
Y
Y
Y
Y
Y
N
Y
Y
Y
Y
Y
Y
N
N
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
25. Adequate
description of
control
Y
Y
Y
N
Y
N
N
N
Y
Y
Y
Y
N
N
Y
Y
N
N
N
N
Y
Y
Y
N
Y
N
N
N
Y
N
N
N
Y
Y
N
26. Reliability
of VAT measure
reported
Y, Yes; N, No; U, Undeterminable; VAT, visceral adipose tissue.
11. Representative
participants
Study
Table 3 Continued
obesity reviews
I. Ismail et al. 83
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I. Ismail et al.
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) cm2
NR
-3.8(29.0)
195.0 (104.0) cm2
NR
-7.0(43.0)
MRI
Umbilicus (L4-L5)
NR
PRT (n = 53)
Boudou et al.
C: n = 8
2003 (34)
A: n = 8
Brochu et al.
2009
PRT: n = 36
Carr et al. 2005

(40)
C: n = 71
C: n = 32
CT
CT
L4-L5 vertebral disc using a scout

image of the body
At level of umbilicus
C: n = 6
A: n = 6
Cuff et al. 2003

(18)
A + PRT: n = 10
C: n = 9
CT
L4-L5 vertebral disc space
CT
Donnelly et al.
2003 (7)
C: n = 33
A: n = 41
CT
Giannopoulou
et al. 2005 (19)
C: n = 11
MRI
CT
A: n = 11
CT
A: n = 18
PRT: n = 21
Ibez et al.
2010 (21)
Irving et al. 2008

(22)
Irwin et al. 2003

(23)
C: n = 12
MRI
PRT n = 13
C: n = 7
CT
A: n = 9
C: n = 86
NR
183.0 (52.0) cm2
NR
cm2
-23.0(30.0) cm2
-23.0(34.0) cm2
112.7(58.8)
cm2
87.2(40.0) cm2
75.0(43.3) cm2
NR
NR
-1.6(39.0) cm2
-10.6(19.2) cm2
C: 5(14.7)
L4/L5 vertebral disc space
259.1 (103.2) cm2
-0.4(36.0) cm2
NR
-26.3 (23.4) cm2
215.7 (77.4) cm2
A: n = 9
C: n = 30
186.0 (56.0) cm2
251.1 (72.4) cm2
DiPietro et al.
1998 (42)
Hunter et al.
2010 (20)
84.20(21.30) cm2
A: -39.0(26.9)cm2
A: n = 9
C: n = 7
150.35(23.25) cm2
112.3(56.0)
A: n = 30
Coker et al. 2009

(41)
156.85 (23.4) cm2

153.25 (38.55) cm2
CT
-8.8 (16.2) cm2
136.0(74.1)cm2
118.0(71.4)cm2
116.0(93.0)cm2
106.0(72.0)cm2
L4-5 vertebral 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)
66.0(13.9)
75.5(18.3)
57.4(28.4)
From superior portion of head of

femur to most superior part of
kidneys
4785.0(1,592.0) cm3
4425.0(1,442.7) cm3
NR
cm3
5152.0(1,456.0) cm3
-12.8%
Supine position with arms

stretched above head; at levels of
L4 and L5
50.0(20.8) cm2
62.4(28.2) cm2
12.4 cm2,
48.0(17.7) cm2
48.8(20.1) cm2
0.8 cm2,
43.7(14.4) cm2
43.3(15.5) cm2
4th to 5th lumbar body
Abdominal and thigh; Supine

position with both arms parallel
along sides of the body
L4-L5 intervertebral disc space at
midpoint between inguinal crease
and top of patella
L4-L5 intervertebral space
5912.0(1,605.2)
NR
cm2
cm2
cm2
cm2
NR
0.8 cm2, -0.4 cm2

2
3340.0(977.0) cm
2724.0(1,052.0) cm
3290.0 (1,141.0) cm2
2633.0 (1,000.0) cm2
157.0(71.0) cm2
155.0(71.0) cm2
cm2
cm2
173.0(73.0)
147.6(57.7) g/cm2
148.0(59.0)
NR
147.6(63.5) g/cm2
A + PRT: n = 87
NR
-2.0 cm2
-24.0 cm2
0.1(31.5) g/cm2
-8.5(40.7) g/cm2
cm2
cm2
cm2
cm2
cm2
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)
-51.0(22.1)
-67.0(37.9)
-37.0(22.1)
-50.0(47.4)
-15.0(19.0)
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
C: n = 7
MRI
L4-L5 intervertebral space
154.3(56.1) cm2
158.6(63.2) cm2
NR
164.3(63.4) cm2
143.6(64.8) cm2
Johnson et al.
2009 (15)
A: n = 12
Kim et al. 2008

(25)
A + PRT: n = 10
Ku et al. 2010
(26)
A: n = 15
C: n = 10
C: n = 16
CT
CT
L4 vertebrae close to umbilicus
Abdominal
PRT: n = 13
Kwon et al. 2010
(27)
C: n = 15
Kwon et al. 2010

(28)
C: n = 14
CT
PRT: n = 13
A: n = 13
CT
391.9(206.7)
408.4(189.7)
16.5
387.7(111.3)
356.9(93.0)
-30.80
17 530.0(4,747.0)g
17 362.0(4,728.0)g
-168.0(1,801.0)g
15 890.0(4,593.0)g
15 038.0(3,369.0)g
-852.0(2,839.0)g
15 658.0(4,754.0)g
14 678.0(3,456.0)g
-980.0(2,353.0)g
10 mm line from lumbar vertebrae

4 and 5 to bellybutton
17 268.7(5,060.9)mm2
17 745.1(4,715.0)mm2
4.4%
15 657.8(4,753.6)mm2
14 677.8(3,455.9)mm2
NR
Cross-sectional area of L4-L5

vertebrae
17 204.5(4,674.4)mm2
17 216.3(4,560.8)mm2
0.9%
16 291.5(4,808.5)mm2
14 682.7(3,494.7)mm2
8.4%
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I. Ismail et al. 85
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
-6.2(-3.5)%
1.6(1.6)%
100.1(58.8) cm2
-12.2(7.5)%
-5.8(-5.5)%
NR
Mourier et al.
1997 (49)
Nicklas et el.
2009 (29)
C: n = 11
MRI
Level of the umbilicus
A: n = 10
C: n = 34
CT
Within 15 mm centres at L4-L5

level
Poehlman et al.
2000 (31)
Rice et al. 1999

(35)
2369.0(870.0) cm3
NR
-612.0(338.0)
cm3
-630.0(298.0)
cm3
182.9(16.8) cm3
190.4(15.7) cm3
7.5 cm3
112.4(10.5) cm3
-82.6 cm3
A + PRT: n = 10
201.6(28.0) cm3
108.6(17.9) cm3
-93.0 cm3
C: n = 20
CT
CT
L4 close to umbilicus
L4-L5 vertebral level
36.0(13.0)
cm2
41.0(15.0)
cm2
A: n = 14
40.0(11.0) cm2
41.0(13.0) cm2
PRT: n = 17
36.0(17.0) cm2
36.0(13.0) cm2
4.6(1.6)L
NR
C: n = 9
MRI
A: n = 10
C: n = 8
A: n = 16
Ross et al. 2004

(32)
A: n = 17
C: n = 10
C: n = 11
MRI
MRI
MRI
A: n = 11
PRT: n = 11
Schmitz et al.
2007 (33)
C: n = 63
Short et al. 2003

(45)
C: n = 37
Slentz et al. 2005

(47)
80.4(22.1) cm2
195.0(12.6) cm3
C: n = 10
PRT: n = 10
Sigal et al. 2007

(46)
134.9(33.8) cm2
A: n = 10
Ross et al. 2000

(36)
Ross et al. 1996

(37)
139.4(36.8) cm2
156.1(47.4) cm2
2509.0(737.0) cm3
A: n = 38
Park et al. 2003

(30)
104.2(59.6) cm2
149.6(76.6) cm2
CT
4.1(2.4)L
Whole body
198.0(71.0) cm2
198.0 cm2
186.0(59.0) cm2
134.0 cm2
-1.8(1.0)L
4.6(1.5)L
Two sets from L4-L5 to upper

thorax and one extended from
L4-L4 to approximate level of
femoral head
-1.5(0.7)L
2.3(0.9)kg
2.2(0.9)kg
NR
1.6(0.7)kg
-0.7(0.5)
4.7(1.6)L
NR
-1.5(0.8)L
-1.8(1.0)L
-1.4(0.7)
3.9(2.3)L
L2-L3 interspace
67.4 (36.5) cm
L4-L5 intevertebral space
A: n = 65
81.8
cm2
76.9 cm2
7.05 (5.1) %
122.0(79.1) cm2
121.0(73.0) cm2
NR
133.0(88.7) cm2
124.0(88.7) cm2
252.0 (147.0) cm2
250.0(147.0) cm2
244.0(161.0) cm2
PRT: n = 64
228.0(156.0) cm2
218.0(156.0) cm2
A + PRT: n = 64
246.0(159.0) cm2
224.0 (159.0) cm2
CT
Transverse cut at L4-L5
C: n = 47
CT
L4 pedicle
A: n = 42
Stewart et al.
C: n = 53
2005 (48)
A + PRT: n = 51
Thong et al. 2000

(38)
C: n = 8
MRI
One slice below, at and above

umbilicus
MRI
Whole body
A: n = 16
21.36 (5.3) %
71.8(36.8) cm2
257.0(161.0) cm2
C: n = 63
A: n = 60
NR
2.3(0.8)kg
4.6(1.4)L
PRT: n = 70
CT
-1.5(0.9)L
1 image below and 4 images

above the L4-L5 intervertebral
space
Whole body
NR
NR
165.0(68.0)
179.2
8.6(17.2)%
168.0(64.0)
156.4
-6.9(20.8)%
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
4.1(1.7)kg
NR
3.9(0.8)kg
-0.003(0.3)
-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.
Effect of exercise therapy on visceral adiposity

(Meta-analyses)
The effect of exercise therapy on visceral adiposity is summarized in Table 4 and Figs 25.
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 heterogeneity among studies was observed (I2 = 71.0%, P < 0.001).
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I. Ismail et al.
obesity reviews
Figure 2 Forest plot for AEx studies (n = 29). Graph depicts ES and 95% CI for individual studies and the pooled estimate.
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I. Ismail et al. 87
Figure 3 Forest plot for PRT studies (n = 14). Graph depicts ES and 95% CI for individual studies and the pooled estimate.
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). Analysis 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 (10 subjects per
group). After re-analysis with this outlier removed using
random effects the pooled ES did not reach statistical significance (-0.28, 95% CI: -0.69 to 0.14; P = 0.19)
(Fig. 5).
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I. Ismail et al.
obesity reviews
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.
2011 The Authors

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 reduction 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 statistical significance. From available studies in which combined interventions using both AEx and PRT were
employed, the pooled effect size was not significantly different 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 overweight or obese populations, predominantly with female
cohorts. Twelve of the studies specifically included participants 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 recommended exercise guidelines for the prevention and management 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 differences 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 interventions 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 expenditure 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,
I. Ismail et al. 89
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 following 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 heterogeneity 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, frequency 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 resistance 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 modification. 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
2011 The Authors

90
obesity reviews
Exercise for visceral fat I. Ismail et al.
investigation comply with current recommendations for

improvement in cardiorespiratory fitness (150 min/week
of moderate intensity aerobic activity) (51), these recommendations 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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2011 The Authors


A Systematic Review and Meta-Analysis of The Effect of Aerobic Vs Resistance Exercise Training On Visceral Fat

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obesity reviews

A systematic review and meta-analysis of the effect of

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

Discipline of Exercise and Sport Science,

University of Sydney, Sydney, New South

Boden Institute of Obesity, Nutrition and

Exercise, University of Sydney, Sydney,

Received 19 June 2011; revised 25 July 2011;

Address for correspondence: Dr N Johnson,

Financial support: none.

2011 The Authors

Exercise for visceral fat

combined aerobic and PRT therapy vs. control on VAT

2011 The Authors

70 Exercise for visceral fat

Figure 1 Flowchart of outcomes of search

Studies were selected if the effect of exercise alone on visceral

After eliminating duplications, the search results were

2011 The Authors

Exercise for visceral fat

insufficient information, attempts were made to contact

Data extraction and calculations

Data relating to participant characteristics (age, sex, body

Assessment of methodological quality

Identification and selection of studies

2011 The Authors

72 Exercise for visceral fat

Table 1 Participant characteristics

Binder et al. 2005 (39)

91; Older sedentary with physical frailty

Boudou et al. 2003 (34)

16; Men with type 2 diabetes

107; Postmenopausal women

Carr et al. 2005 (40)

62; Japanese-Americans with impaired

Coker et al. 2009 (41)

18; Overweight elderly

Cuff et al. 2003 (18)

28; Postmenopausal with type-2

16; Healthy older

Brochu et al. 2009 (17)

DiPietro et al. 1998 (42)

A + PRT: 63.4 (7.0)

Donnelly et al. 2003 (7)

74; Sedentary overweight and

Giannopoulou et al. 2005

22; Obese post menopausal women

Hunter et al. 2010 (20)

69; Healthy premenopausal women

Ibanez et al. 2010 (21)

25; Obese women

Irving et al. 2008 (22)

16; Obese women with metabolic

Irwin et al. 2003 (23)

173; Overweight postmenopausal

Janssen et al. 1999 (43)

Janssen et al. 2002 (24)

60; Upper body obese

38; Premenopausal obese women

Male: C: 45.6 (6.6); A: 47.4 (6.6); PRT:

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

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