What Aerobic Exercise-Training Program Should Be Recommended for Optimal Reductions in Visceral Fat - Literature review Example

What aerobic exercise-training program should be recommended for optimal reductions in visceral (intraabdominal) fat? Affiliation Background information Aerobic exercise is a common and effective non-pharmacological intervention for the reduction of visceral fat. Exercise is an important part of lifestyle intervention aimed at weight loss. (Thorogood, et al., 2011) (Keating, Hackett, George, & Johnson, 2012) (Kim, et al., 2009). Aerobic exercise is important and necessary part of modification of lifestyle in postmenopausal women. C-reactive protein, serum amyloid A and tissue cell adhesion molecule reduce with exercise and weight loss (Ryan, et al., 2014) Determining the quantity of abdominal fat and its regional distribution is vital in assessing other diseases such as cardiovascular risk. (Idoate, et al., 2011). In addition to weight management, aerobic exercises have been proven to be beneficial to health in general. Changes in body weight due to exercise induces health improvements. (King, Hopkins, Caudwell, Stubbs, & Blundell, 2009) In a controlled genetic liability and childhood environment, aerobic exercise is a vital factor in avoiding accumulation fat over time. Prevention and treatment of visceral fat should emphasize on the role of regular aerobic exercises. (Leskinen, et al., 2009) (Mahabadi, et al., 2009) Introduction Accumulation of visceral fat can be caused by insufficient physical activity in the daily life pattern. Obesity is a major threat in the world. Abdominal fat is associated with diabetes, cardiovascular diseases and other metabolic diseases. Intra-abdominal fat increases with age in males and increases noticeably after menopause. Accumulation of visceral fat is due to lack of exercise and westernized diet pattern according to lifestyle change. (Kwon, et al., 2010) Reducing visceral fat in overweight chronic kidney disease is effectively done by center-based aerobic exercise therefore promoting relevant clinical benefits (Baria, et al., 2014) Studies also indicate that regular aerobic exercise reduces intra-abdominal fats even in the absence of weight reduction. Physical activity should be strongly recommended for the management of visceral fat since the benefits are not centered on body weight loss. (Johnson, et al., 2009) CT scan is used to analyze body fat and establish visceral fat obesity. Intra-abdominal fat accumulation has a role in the development of atherosclerosis, hypertension, lipid disorder, diabetes and some types of cancers. Adipose tissue, particularly visceral adipose tissue is expressed mostly in cytokines, growth factors and complements which are genes encoding bioactive substances. Adiponectin, which is a collagen-like protein present in plasma at a high concentration is indirectly associated with visceral fat accumulation (Matsuzawa, 2010). Calorie restriction induced loss of weight with aerobic exercise has been established to decrease liver fat (Yoshimura, et al., 2014) Prescription To achieve affirmative results, public health institutions such as the American College of Sports Medicine for physical activity that is frequency, intensity, time and type of exercise (Emerenziani, et al., 2013). Precise prescription of aerobic exercise is necessary to ensure maximum benefits of cancer which can be caused by accumulation of visceral fats (Kirkham, Campbell, & McKenzie, 2013). In order to ensure good health, adults aged 18-65 years require moderate intensity aerobic physical activity for a minimum of 30 minutes on five days a week. (Haskell, et al., 2007) Studies indicate that a 12-week training program comprising of aerobic exercise, at moderate intensity for 30 minutes, five days a week would result in improvements in reducing visceral fat compared to no exercise with no weight loss. Aerobic exercise produces benefits for loss of weight, fat loss and cardio-respiratory fitness (Ho, Dhaliwal, Hills, & Pal, 2012) (Heijden, et al., 2010). It is important to commence with small amounts of physical activity and slowly increasing duration, frequency and intensity. Frequency Frequencies of more than or equal to three days are beneficial (Georgia, 2011). Exercise frequency is related to the exercise duration and intensity but may vary depending on the goals of the study, time constraints and the functional capacity of subjects in the study (Whaley, Brubaker, Otto, & Armstrong, 2006). Estimating frequency is subject to bias during self-report of physical activity (Troiano, et al., 2008). Regular physical activity helps to prevent chronic diseases (Warburton, Nicol, & Bredin, 2006) Other studies indicate that aerobic exercise of more than 150 minutes per week is associated with reduction of HbA1c (Umpierre, et al., 2011). High frequency of exercise reduces overweight prevalence among older people (Berke, Koepsell, Moudon, Hoskins, & Larson, 2007). Environmental factors have been found to influence people’s health, for instance, Lower socio-economic status have reduced access to society which is in turn associated with reduced physical activity leading to elevated weights (Gordon-Larsen, Nelson, Page, & Popkin, 2006) Table 1: Fat loss following a 12 week program of diet and exercise Method Weight loss Aerobic exercise 1.3kg (2.9lb) Restricted calorie diet 6.8kg (15lb) Exercise and diet 7.2kg (15.8lb) Intensity Daily moderate intensity aerobic exercise is effective at reduction abdominal fat mass whereas high intensity exercise improve cardiopulmonary function (Westerterp, 2001). Other studies indicate that High Intensity Intermittent Exercise (HIIE) is more effective at reducing abdominal body fat than other types of exercise (Boutcher, 2011). Higher intensity or longer duration of exercise causes substantial fat loss. However, this may have a poor long term compliance (Rankin, 2013) It has also been established that medium intensity intermittent exercise is more efficient than continuous exercise in weight loss and overweight women (Alizadeh, et al., 2013). Persons with old age are required to maintain moderate to higher levels of activity and maybe a threshold of at least moderate activity for significant outcomes (Paterson & Waburton, 2010). People who perform high-intensity exercise on a regular basis had a lower subcutaneous skinfold thickness and waist-to-hip ratio (Tremblay, et al., 2001). Table 2: List of moderate aerobic exercise Moderate exercise Calories Burned 130LBS 180LBS 230LBS Walking 103 142 235 Vigorous cleaning 133 184 288 Bicycling 177 245 313 Ballroom dancing 163 225 288 Golf 147 203 260 Swimming leisurely 177 245 313 Low impact aerobics 147 203 260 Type Types of activity include, recreational, occupational and household activities (Irwin, et al., 2008). Moderate duration activities are those that cause a slight increase in breathing and heart rate. Types of moderate activities are golfing and fishing. They are unlikely to result in sustained energy deficits. Other moderate physical activity include; walking and stretching among obese people. Vigorous activity includes vigorous walking and stair climbing among overweight adults (Spees, Scott, & Taylor, 2012) Excessive body fat has been connected with numerous diseases. Individuals who store body fat in the abdominal region are at higher risks of disease compared to individuals who store body fat in the hip and thigh regions (Thomas & Bell, 2002). Storage of visceral fat around vital body organs increases the risk of disease. Visceral fat is optimally reduced through daily exercise (Finucane, Horton & Purslow, 2009). The type of exercise that an individual who aspires to reduce abdominal fat undertakes has a huge bearing on its reduction (Janiszewski, Saunders & Ross, 2008). Abdominal fat, precisely visceral fat is a fat store, which is very metabolically active (Hewitt, et al., 2008). To be physically active is to mean taking part in activities, which ensure that the whole human body is taking part in an exercise. Aerobic exercise has a partial effect on visceral fat (Jarosz & Bellar, 2008). Various types of aerobic exercises have varying effects on the reduction of visceral fat. The point about the type of aerobic exercise is not about quantity of time an individual takes training (So, et al., 2012). However, it is about the effectiveness of the type of aerobic exercise. If the type of exercise is effective, then the effect it has on reduction of visceral fat is optimal and benefits the individual (Braith & Stewart, 2006). The type of exercise should primarily focus on burning body fat, reducing visceral fat and enhancing body metabolism. This way, visceral fat is reduced (Han &Lean, 2011) Long, slow distance aerobic exercise is effective in reduction of visceral fat (Freedland, 2004). This type of exercise involves slow running over a long distance or jogging. It is recommended that it is undertaken in the morning or away from strong sunlight (Miller, et al., 2013). This type of activity specifically involves type I muscle fibers that are involved in aerobic energy production (Cetin & Nasr, 2014). It does not have an effect on the reduction of visceral fat at all. In fact, it causes an increase in visceral fat (Viscers, et al, 2013). Undertaking long slow distance aerobic exercise for long durations does not increase the chances of visceral fat reduction. An effective type of aerobic exercise that has an optimal effect on reduction of visceral fat is an interval training exercise (Damaso, 2014). It is most effective for reduction of visceral fat and in general body fat. Many studies go on to ascertain the importance of interval training exercise in reduction of body fat, in specific visceral fat (Klein, 2007). The journal Metabolism takes note of a study undertaken in 1994 that evaluated the effects of various types of exercises on body fat and metabolism. The study had two groups. One group undertook long slow distance aerobic exercise while the other undertook interval training exercise. It was found that interval the training group had a significant body fat loss while the long slow distance aerobic exercise group lost more calories but had no significant body fat loss. Volume and Progression Exercise volume is proportional to progression. As one progresses in exercise, so does the volume of exercise grow (Kilen, et al., 2014). This is due to body adaptation to physical activity involved with exercise. The highest progression in aerobic exercises is when a person burns more calories as a person adapts to the aerobic exercise (Kujala, 2011). In exercise, progress means that an individual is taking exercises everyday in a continuous manner without fail (Hallmark, et al., 2014). It does not mean that a person is undertaking more and more aerobic exercises. Latest studies that included individuals participating in exercises that were measured every week, that is fifteen to twenty hours per week and were all under a strict and controlled diet indicated that the loss of visceral fat was higher in the group of individuals who undertook the highest exercise volume (Keating, 2014). The study included 100 individuals at the age of between fifty and seventy years. They were divided into separate groups of individuals who undertook training exercises of varying degrees of volume. The first group undertook very high training exercise volume; the second undertook high training exercise volume and the third group undertook moderate training exercise volume. The whole study took one year and of the 100 participants, 78 of them undertook the total training exercise. Loss of visceral fat was greatest in the group that undertook very high training exercise followed by high and finally the moderate training exercise volume. It was found that coupling the intensity of the training exercises with high training volume increased degree of visceral fat loss. This indicated that regular high volume training aerobic exercises that are undertaken consistently have the greatest yields in terms visceral fat loss. However, optimal results result on coupling aerobic training exercises with intensity (Lee & Kim, 2013). Time To assess days and duration of physical activity, a validated Global Physical Activity Questionnaire (GPAQ) can be used (Guthold, et al., 2011). An International Physical Activity Questionnaire (IPAQ-LF) with accelerometry is an acceptable validity in detecting participants’ ability to meet activity guidelines based on exercise duration (Boon, Hamlin, Steel, & Ross, 2010). The duration of most physical activity intervention is 10 to 15 minutes in length daily. Integrating physical activity in everyday life has shown consistent benefits. It is important that short intervals of physical exercise be part of organizational routine to aid loss of visceral fat (Barr-Anderson, Au-Young, Whitt-Glover, Glenn, & Yancey, 2011) Mortality can be reduced being physically active. Moving from no activity to low levels of physical activity is highly beneficial (Woodcock, Franco, Orsini, & Roberts, 2010) Menopausal women are at a high risk of accumulating visceral fat, therefore using telephone short message service is efficient in ensuring physical activity (Fjeldsoe, Miller, & Marshall, 2010). Studies have indicated that exercise duration and exercise intensity function reversely in that an increase in exercise intensity means an exercise of a shorter duration, failure to which it will lead to over exercising which does not have positive results in terms of weight loss (Irving, 2008). It has been found that the best duration for an aerobic exercise that will result to optimal visceral fat reduction is one that takes at least 150 minutes per week. For optimal results, such an exercise should be of fair intensity (Lee, et al., 2012). This exercise should progress to at least 250 minutes per week with moderate intensity. Such exercise durations can be divided into several sessions (Ribeiro, et al., 2014). However, the main thing is that any division should be of equal durations with equal intensity and frequency. This will ensure uniformity in the aerobic exercise (Sclentz, et al., 2011). This recommendation is against the belief that aerobic exercises of long durations coupled with low intensity result into optimum visceral fat reduction (Jansen, et al., 2002). The fact is that fat is normally the main source of fuel in the body during long durations of exercise (Merrick, et al., 2014). However, the main point is creating a shortfall in calories in spite of the fuel been used (Ohkawara et al., 2007). It is this deficit in calories that results in visceral fat reduction in the long run. Hence, aerobic exercises of longer durations and low intensities result in optimal visceral fat reduction (Donges et al., 2013). It is wise to note that many individuals who are faced with the issue of excess visceral fat need time to adapt to the aerobic exercise (Miller, 2013). Hence, an aerobic exercise that is of low intensity and long duration will permit adaptation to the aerobic exercise offering higher chances of achieving optimal visceral fat reduction (Killen, et al., 2014). Long duration exercises offer safer means to exercise and loss visceral fat as they reduce the risks associated with aerobic exercises such as muscle and joint injuries that are associated with short duration, high intensity aerobic exercises (Hatle, et al., 2014). Summary This review has been undertaken to find out the best method to undertake for optimal results in visceral fat reduction. It is based on FITT – VP principles which can be applied into aerobic training exercise. The review does not seek to discriminate against other forms of exercise such as resistance training. However, it seeks to promote aerobic exercise training among individuals who find other forms of exercises such as resistance training treacherous. The review has been able to identify, describe and support the best method practices for an appropriate aerobic exercise that aids an individual in burning visceral fat to ensure its optimal reduction. In fact, it aids individuals to set realistic training aims which if undertaken, they will offer the most realistic chance of optimal visceral fat reduction. The connection between the various principles which include frequency, intensity, time, type, volume and progression are well outlined in the essay. The best combinations of these principles are stated for whichever aerobic exercise individuals choose to undertake (Balducci, et al., 2012). In spite of the ease and benefits that any combination of an aerobic exercise practice as outlined in these review offers, it still remains a challenge to adopt a strict aerobic exercise that offers optimal visceral fat reduction. However, a habit is a disease; a daily routine of a preferred aerobic exercise will lead to optimal results. Conclusion Visceral fat is one of the main sources of chronic conditions that are connected with obesity (Tjonna, et al., 2013). Excess visceral fat may have negative consequences on the major vital organs (Egger, et al., 2013). Aerobic training exercise as outlined in this review is one way to correct the abnormality and hinder accumulation of visceral fat (Dobrosielski, et al., 2013). Measurement of excess fat can tell an individual of their status concerning visceral fat (Boyd, et al., 2013). The recommended training regime concerning aerobic exercises is one full of regularity and consistency (LaPier & Rodnick, 2001). A regular aerobic exercise regime will ensure progression (Marcus, et al., 2008). Consistency shall allow for body adaptation, which is important in preventing negative impacts on the body during aerobic exercising (Strasser, Arvandi & Siebert, 2012). The aerobic exercise deemed fit as per this review is one of high volume and step by step progression, long duration and low intensity coupled with moderate frequency and intervals during the exercise (Buchan, et al., 2013). Future Research Needs It was noted that the amount of evidence on the near perfect aerobic exercise is wanting. There is no specified near perfect aerobic exercise which offers the best optimal results in visceral fat reduction. This means that further research is needed to ascertain and develop a clear model with the near perfect aerobic exercise which will lead to optimal results in visceral fat reduction. Various recommendations are needed in future research so that specifications such as sex and individual can be established and incorporated into the FITT – VP principles used to undertake a particular aerobic exercise. References Alizadeh, Z., Kordi, R., Rostami, M., Mansournia, M. A., Hosseinzadeh-Attar, S. M., & Fallah, J. (2013). Comparison Between the Effects of Continuous and Intermittent Aerobic Exercise on Weight Loss and Body Fat Percentage in Overweight and Obese Women: A Randomized Controlled Trial. International Journal of Preventive Medicine, 881-888. American Society for Nutrition; and the American Diabetes Association 1’2’3’4. American Journal of Clinical Nutrition, 85(5), 1197 – 1202. Balducci, S., Zanuso, S., Cardelli, P., et al., (2012). Effect of High- versus Low-Intensity Supervised Aerobic and Resistance Training on Modifiable Cardiovascular Risk Factors in Type 2 Diabetes; The Italian Diabetes and Exercise Study (IDES). PLoS ONE, 7(11), e49297. doi:10.1371/journal.pone.0049297 Baria, F., Kamimura, M. A., Aoike, D. T., Ammirati, A., Rocha, M. L., Mello, M. T., & Cuppari, L. (2014). Randomized controlled trial to evaluate the impact of aerobic exercise on visceral fat in overweight chronic kidney disease patients . Oxford Journals. Barr-Anderson, D. J., Au-Young, M., Whitt-Glover, M. C., Glenn, B. A., & Yancey, A. K. (2011). Integration of Short Bouts of Physical Activity Into Organizational Routine: A Systematic Review of the Literature. American Journal of Preventive Medicine, 76-93. Berke, E. M., Koepsell, T. D., Moudon, A. V., Hoskins, R. E., & Larson, E. B. (2007). Association of the Built Environment With Physical Activity and Obesity in Older Persons. American Journal of Public Health, 486-492. Boon, R. M., Hamlin, M. J., Steel, G. D., & Ross, J. J. (2010). Validation of the New Zealand Physical Activity Questionnaire (NZPAQ-LF) and the International Physical Activity Questionnaire (IPAQ-LF) with accelerometry. Br J Sports, 741-746. Boyd, J. C., Simpson, C. A., Jung, M. E. & Gurd, B. J. (2013). Reducing the Intensity and Volume of Interval Training Diminishes Cardiovascular Adaptation but Not Mitochondrial Biogenesis in Overweight/Obese Men. PLoS ONE, 8(7), e68091. doi:10.1371/journal.pone.0068091 Boutcher, S. H. (2011). High-Intensity Intermittent Exercise and Fat Loss. Journal of Obesity. Braith, R. W. & Stewart, K. J. (2006). Contemporary Reviews in Cardiovascular Medicine. Resistance Exercise Training: Its Role in the Prevention of Cardiovascular Disease. Circulation, 113, 2642 – 2650. doi: 10.1161/​CIRCULATIONAHA.105.584060 Buchan, D. S., Ollis, S., Young, J. D., et al. (2013). High intensity interval running enhances measures of physical fitness but not metabolic measures of cardiovascular disease risk in healthy adolescents. BMC Public Health, 13, 498. doi:10.1186/1471-2458-13-498 Cetin, D. C. & Nasr, G. (2014). Obesity in the elderly: More complicated than you think. Cleveland Clinic Journal of Medicine, 81(1), 51 – 61. doi: 10.3949/ccjm.81a.12165 Damaso, A. R., Campos. R. M. D. S., Carant, D. A., et al. (2014). Aerobic plus resistance training was more effective in improving visceral adiposity, metabolic profile and inflammatory markers than aerobic training in obese adolescents. Journal of Sports Sciences, 32(12), 1101 – 1201. DOI:10.1080/02640414.2014.900692 Dobrosielski, D. A., Gibbs, B. B., Chaudhari, S., et al. (2013). Diabetes and endocrinology: Effect of exercise on abdominal fat loss in men and women with and without type 2 diabetes. BMJOpen, 3(11), e003897. doi:10.1136/bmjopen-2013-003897 Donges, C. E. , Duffield, R., Guelfi, K. K., et al. (2013). Comparative effects of single – mode vs. duration – matched concurrent exercise training on body composition, low – grade inflammation, and glucose regulation in sedimentary, overweight, middle aged men. Applied Physiology, Nutrition & Metabolism, 38(7), 779 -788. DOI: 10.1139/apnm-2012-0443 Egger, A., Kreis, R., Allemann, S., et al. (2013). The Effect of Aerobic Exercise on Intrahepatocellular and Intramyocellular Lipids in Healthy Subjects. PLoS ONE, 8(8), e70865. doi:10.1371/journal.pone.0070865 Emerenziani, G. P., Migliaccio, S., Gallotta, M. C., Lenzi, A., Baldari, C., & Guidetti, L. (2013). Physical exercise intensity prescription to improve health and fitness in overweight and obese subjects: A review of the literature. Scientific Research Publisher, 113-121. Fjeldsoe, B. S., Miller, Y., & Marshall, A. L. (2010). MobileMums: A Randomized Controlled Trial of an SMS-Based Physical Activity Intervention. Annals of Behavioral Medicine, 101-111. Finucane, F. M., Horton, J., Purslow, L. R., (2009). Randomized controlled trial of the efficacy of aerobic exercise in reducing metabolic risk in healthy older people: The Hertfordshire Physical Activity Trial. BMC Endocrine Disorders, 9(15), n.p. doi:10.1186/1472-6823-9-15 Freedland, E. C. (2004). Role of a critical visceral adipose tissue threshold (CVATT) in metabolic syndrome: implications for controlling dietary carbohydrates: a review. Nutrition & Metabolism, 1(12), n.p. doi:10.1186/1743-7075-1-12 Georgia, A. (2011). Physical Activity for Health: What Kind? How Much? How Intense? On Top of What? Public Health, 349-365. Gordon-Larsen, P., Nelson, M. C., Page, P., & Popkin, B. M. (2006). Inequality in the Built Environment Underlies Key Health Disparities in Physical Activity and Obesity. Pediatrics, 417-424. Guthold, R., Louazani, S. A., Riley, L. M., Cowan, M., Bovet, P., Damasceno, A., . . . Armstrong, T. P. (2011). Physical Activity in 22 African Countries: Results from the World Health Organization STEPwise Approach to Chronic Disease Risk Factor Surveillance. American Journal of Preventive Medicine, 52-60. Hallmark, R., Patrie, J. T., Liu, Z., et al. (2014). The Effect of Exercise Intensity on Endothelial Function in Physically Inactive Lean and Obese Adults. PLoS ONE, 9(1), e85450. doi:10.1371/journal.pone.0085450 Han, T. S., Tajar, A. & Lean, M. E. J. (2011). Obesity and weight management in the elderly. British Medical Bulletinbmb, 97(1), 169 – 196. doi: 10.1093/bmb/ldr002 Haskell, W. L., Lee, I.-M., Pate, R. R., Powell, K. E., Blair, S. N., Franklin, B. A., . . . Bauman, A. (2007). Physical activity and public health: Updated recommedation for aduktsa from the american college of sports medicine and the american heart association. Circulation, 1081-1093. Hatle, H., Stobakk, P. K., Molmen, H. E., et al. (2014). Effect of 24 Sessions of High- Intensity Aerobic Interval Training Carried out at Either High or Moderate Frequency, a Randomized Trial. PLoS ONE, 9(2), e88375. doi:10.1371/journal.pone.0088375 Heijden, G.-J. v., Wang, Z. J., Chu, Z. D., Sauer, P. J., Morey, H. W., Rodriguez, L. M., & Sunehag, A. L. (2010). A 12-Week Aerobic Exercise Program Reduces Hepatic Fat Accumulation and Insulin Resistance in Obese, Hispanic Adolescents. Obesity, 384-390. Hewitt, J. A., Whyte, G. P., Moreton, M., Someren, K. A. V. & Levine, T. S. (2008). The effects of a graduated aerobic exercise programme on cardiovascular disease risk factors in the NHS workplace: a randomised controlled trial. Journal of Occupational Medicine and Toxicology, 3(7), n.p. doi:10.1186/1745-6673-3-7 Ho, S. S., Dhaliwal, S. S., Hills, A. P., & Pal, S. (2012). The effect of 12 weeks of aerobic, resistance or combination exercise training on cardiovascular risk factors in the overweight and obese in a randomized trial. BMC Public Health. Idoate, F., Ibanez, J., Gorostiaga, E. M., Garcia-Unciti, M., Martinez-Labari, C., & Izquierdo, M. (2011). Weight-loss diet alone or combined with resistance training induces different regional visceral fat changes in obese women. International Journal of Obesity, 700-713. Irwin, M. L., Smith, A. W., McTiernan, A., Ballard-Barbash, R., Cronin, K., Giliiland, F. D., . . . Bernstein, L. (2008). Influence of Pre- and Postdiagnosis Physical Activity on Mortality in Breast Cancer Survivors: The Health, Eating, Activity, and Lifestyle Study . American Society of Clinical Oncology, 3958-3964. Irving, B. A., Davis, C. K., Brock, D. W., et al., (2008). Effect of Exercise Training Intensity on Abdominal Visceral Fat and Body Composition. Medicine and Science in Sports and Exercise, 40(11), 1863 – 1872. Janseen, I., Fortier, A., Hudson, R. & Ross, R. (2002). Effects of an Energy-Restrictive Diet With or Without Exercise on Abdominal Fat, Intermuscular Fat, and Metabolic Risk Factors in Obese Women. Diabetes Care, 25(3), 431 – 438. doi: 10.2337/diacare.25.3.431 Janiszewski, P. M., Saunders, T. J. & Ross, R. (2008). Themed Review: Lifestyle Treatment of the Metabolic Syndrome. American Journal of Lifestyle Medicine, 2(2), 99 – 108. Jarosz, P. A. & Bellar A. (2008). Age – Appropriate Obesity Treatment. The Nurse Practitioner: The American Journal of Primary Health Care, 33(5), 24 – 31. Johnson, N. A., Sachinwalla, T., Walton, D. W., Smith, K., Armstrong, A., Thompson , M. W., & George, J. (2009). Aerobic exercise training reduces hepatic and visceral lipids in obese individuals without weight loss. Hepatology, 1105-1112. Keating, S. E., Machan, E. A., O’’Connor, H. T., et al. (2014). Clinical Study: Continuous Exercise but Not High Intensity Interval Training Improves Fat Distribution in Overweight Adults. Journal of Obesity, 12 ps. http://dx.doi.org.org/10.1155/2014/8348865. Keating, S. E., Hackett, D. A., George, J., & Johnson, N. A. (2012). Exercise and non-alcoholic fatty liver disease: A systematic review and meta-analysis. Journal of Hepatology, 157-166. Kilen, A., Larsson, T. J., Jorgensen, M., et al., (2014). Effects of 12 Weeks High-Intensity & Reduced-Volume Training in Elite Athletes. PLoS ONE, 9(4), e95025. doi:10.1371/journal.pone.0095025 Kim, M.-K., Tomita, T., Kim, M.-J., Sasai, H., Maeda, S., & Tanaka, K. (2009). Aerobic exercise training reduces epicardial fat in obese men. Journal of Applied Physiology, 5-11. King, N. A., Hopkins, M., Caudwell, P., Stubbs, R. J., & Blundell, J. E. (2009). Beneficial effects of exercise: shifting the focus from body weight to other markers of health. British Journal of Sports Medicine, 924-927. Klein, S., Allison, D. B., Heymsfield, S. B., Kelley, D. E., et al. (2007). Waist circumference and cardiometabolic risk: a consensus statement from Shaping Americas Health: Association for Weight Management and Obesity Prevention; NAASO, The Obesity Society; the Kirkham, A. A., Campbell, K. L., & McKenzie, D. C. (2013). Comparison of aerobic exercise intensity prescription methods in breast cancer. Medicine and Science in Sports and Exercise, 1443-1450. Kujala, U. M., Jokelainen, J., Oksa, H., et al. (2011). Diabetes and endocrinology: Increase in physical activity and cardiometabolic risk profile change during lifestyle intervention in primary healthcare: 1-year follow-up study among individuals at high risk for type 2 diabetes. BMJ Open, 1(2), e000292. doi:10.1136/bmjopen-2011-000292 Kwon, H. R., Min, K. W., AAhn, H. J., Seok, H. G., Koo, K. B., Kim, H. C., & Han, K. A. (2010). Effects of Aerobic Exercise on Abdominal Fat, Thigh Muscle Mass and Muscle Strength in Type 2 Diabetic Subject. Diabetes & Metabolism Journal, 23-31. LaPier, T. L. K. & Rodnick, K. J. (2001). Effects of Aerobic Exercise on Energy Metabolism in the Hypertensive Rat Heart. Physical Therapy, 81(4), 1006 – 1017. Lee, S. & Kim, Y. (2013). Effects of Exercise Alone on Insulin Sensitivity and Glucose Tolerance in Obese Youth. Diabetes & Metabolism Journal, 37(4), 225 – 232. http://dx.doi.org/10.4093/dmj.2013.4.225 Lee, S., Bacha, F., Hannon, T., Kuk, J. L., Boesch, C, & Arslanian, S. (2012). Effects of Aerobic Versus Resistance Exercise Without Caloric Restriction on Abdominal Fat, Intrahepatic Lipid, and Insulin Sensitivity in Obese Adolescent Boys. Diabetes, 61(11), 2787 – 2795. doi: 10.2337/db12-0214 Leskinen, T., Sipila, S., Alen, M., Cheng, S., Pietilainen, H., Usenius, J. P., . . . Kujala, U. M. (2009). Leisure-time physical activity and high-risk fat: a longitudinal population-based twin study. International Journal of Obesity, 1211-1218. Mahabadi, A. A., Massaro, J. M., Rosito, G. A., Levy, D., Murabito, J. M., Wolf, P. A., . . . Hoffmann, U. (2009). Association of pericardial fat, intrathoracic fat, and visceral abdominal fat with cardiovascular disease burden: the Framingham Heart Study . European Heart Journal, 850-856. Marcus, R. L., Smith, S., Morrell, G., et al. (2008). Comparison of Combined Aerobic and High-Force Eccentric Resistance Exercise With Aerobic Exercise Only for People With Type 2 Diabetes Mellitus. Physical Therapy, 88(11), 1345 – 1354. doi: 10.2522/​ ptj.20080124 Matsuzawa, Y. (2010). Establishment of a concept of visceral fat syndrome and discovery of adiponectin. Physical andBiological Science, 131-141. Merrick, J., Bachar, A., Carmelli, E., & Kodesh, E. (2013). Effects of Aerobic Exercise on Body Composition and Muscle Strength in Over – Weight to Obese Old Women with Intellectual Disability:A Pilot Study. The Open Rehabilition Journal, 6, 43 – 48. Miller, C. T., Fraser, S. F. Levinger, I., et al., (2013). The Effects of Exercise Training in Addition to Energy Restriction on Functional Capacities and Body Composition in Obese Adults during Weight Loss: A Systematic Review. PLOSONE, 8(11), e86192. doi:10.1371/journal.pone.0081692 Ohkawara, K., Tanaka, S.,, Miyachi, M., Ishikawa - Takata, K. & Tabata, I. (2007). A dose– response relation between aerobic exercise and visceral fat reduction: systematic review of clinical trials. International Journal of Obesity, 31, 1786 -1797. doi:10.1038/sj.ijo.0803683 Paterson, D. H., & Waburton, D. E. (2010). Physical activity and functional limitations in older adults: a systematic review related to CanadasPhysical Activity Guidelines. International Journal of Behavioral Nutrition and Physical Activity, 1-22. Rankin, J. W. (2013). Effective Diet and Exercise Interventions to Improve Body Composition in Obese Individuals. American Journal of Lifestyle Medicine, 20-26. Ribeiro, J.C., Sa, M. S. C., Santos, P, et al. (2009). Patterns of Moderate to Vigorous Physical Activities and daily Compliance with Guidelines for Youth. The Open Sports Sciences Journal, 2, 71 – 75. Ryan, A. S., Ge, S., Blumenthal, J. B., Serra, M. C., Prior, S. J., & Goldberg, A. P. (2014). Aerobic Exercise and Weight Loss Reduce Vascular Markers of Inflammation and Improve Insulin Sensitivity in Obese Women. Journal of the American Geriatrics Society , 607-614. Sclentz, C. A., Bateman, L. A., Willis, L. H., et al. (2011). Effects of aerobic vs. resistance training on visceral and liver fat stores, liver enzymes, and insulin resistance by HOMA in overweight adults from STRRIDE AT/RT. American Journal of Physiol Endocrinol Metab., 301(5), E1033 – 9. doi: 10.1152/ajpendo.00291.2011 So, R., Matsuo, T., Sasai, H., et al. (2012). Best single-slice measurement site for estimating visceral adipose tissue volume after weight loss in obese, Japanese men. Nutrition and Metabolism, 9(56) n.p. doi:10.1186/1743-7075-9-56 Spees, C. K., Scott, J. M., & Taylor, C. A. (2012). Differences in the Amounts and Types of Physical Activity by Obesity Status in US Adults. American Journal of Health and Behaviour, 56-65. Strasser, B., Arvandi, A. & Siebert, U. (2012). Resistance training, visceral obesity and inflammatory response: a review of the evidence. Obesity Reviews, 13(7), 578 – 591. DOI: 10.1111/j.1467- 789X.2012.00988.x Thomas, E. L. & Bell, J. D. (2002). Influence of undersampling on magnetic resonance imaging measurements of intra-abdominal adipose tissue. International Journal of Obesity, 27, 211 – 218. doi:10.1038/sj.ijo.802229 Thorogood, A., Mottillo, S., Shimony, A., Filion, K. B., Joseph, L., Genest, J., . . . Eisenberg, M. J. (2011). Isolated Aerobic Exercise and Weight Loss: A Systematic Review and Meta-Analysis of Randomized Controlled Trials . The American Journal of Medicine, 747-756. Tjonna, A. E., Leinan, I. M., Bartnes, A. T., et al. (2013). Low- and High-Volume of Intensive Endurance Training Significantly Improves Maximal Oxygen Uptake after 10-Weeks of Training in Healthy Men. PLoS ONE, 8(5), e65382. doi:10.1371/journal.pone.0065382 Tremblay, A., Despres, J. P., Leblanc, C., Craig, C. L., Ferris, B., Stephens, T., & Bouchard, C. (2001). Effect of intensity of physical activity on body fatness and fat distribution. The American Journal of Clinical Nutrition, 153-157. Troiano, R. P., Berrigan, D., Dodd, K. W., Masse, L. C., Tilert, T., & McDowell, M. (2008). Physical Activity in the United States Measured by Accelerometer. Official Journal of the American College of Sports Medicine, 181-188. Umpierre, D., Ribeiro, P. A., Kramer, K. C., Leitao, C. B., Zucatti, A. T., Azevedo, M. J., . . . Schaan, B. D. (2011). Physical Activity Advice Only or Structured Exercise Training and Association With HbA1c Levels in Type 2 Diabetes. The Journal of the American Medical Association, 1790-1799. Vissers, D., Hens, W., Taeymans, J., et al. (2013). The Effect of Exercise on Visceral Adipose Tissue in Overweight Adults: A Systematic Review and Meta-Analysis . PLOS ONE, 8(2), e56415. doi:10.1371/journal.pone.0056415 Warburton, D. E., Nicol, C. W., & Bredin, S. S. (2006). Health benefits of physical activity: the evidence. CMAJ, 801-809. Westerterp, K. R. (2001). Pattern and intensity of physical activity. Journal home, 410. Whaley, M. H., Brubaker, P. H., Otto, R. M., & Armstrong, L. E. (2006). ACSMs guidelines for exercise testing and prescription. Lippincott Williams & Wilkins. Woodcock, J., Franco, O. H., Orsini, N., & Roberts, I. (2010). Non-vigorous physical activity and all-cause mortality: systematic review and meta-analysis of cohort studies. The International Journal of Epidemiology, 121-138. Yoshimura, E., Kumahara, H., Tobina , T., Matsuda, T., Ayabe, M., Kiyonaga, A., . . . Tanaka, H. (2014). Lifestyle Intervention Involving Calorie Restriction with or without Aerobic Exercise Training Improves Liver Fat in Adults with Visceral Adiposity. Journal of Obesity. . Read More