Effect of Exercise Training Intensity On Abdominal Visceral Fat and

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Med Sci Sports Exerc. Author manuscript; available in PMC 2009 November 1.
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Med Sci Sports Exerc. 2008 November ; 40(11): 18631872. doi:10.1249/MSS.0b013e3181801d40.
Effect of exercise training intensity on abdominal visceral fat and

body composition
Brian A. Irving, Ph.D.1,5, Christopher K. Davis, M.D., Ph.D.1,3, David W. Brock, Ph.D.1,5, Judy
Y. Weltman, M.S., Damon Swift, M.S., M.Ed.1, Eugene J. Barrett, M.D., Ph.D.2,4, Glenn A.
Gaesser, Ph.D.1,4, and Arthur Weltman, Ph.D.1,2,4
1Department of Human Services, University of Virginia, Charlottesville, Virginia 22908
2Department
of Internal Medicine, Division of Endocrinology and Metabolism, University of Virginia,

Charlottesville, Virginia 22908
3Department
of Pediatrics, Division of Cardiovascular Medicine, University of Virginia,

Charlottesville, Virginia 22908
4Department
of General Clinical Research Center, University of Virginia, Charlottesville, Virginia
22908
5Department
of Center for the Study of Complementary and Alternative Therapies , University of

Virginia, Charlottesville, Virginia 22908
Abstract
The metabolic syndrome is a complex clustering of metabolic defects associated with physical
inactivity, abdominal adiposity, and aging.
PurposeTo examine the effects of exercise training intensity on abdominal visceral fat (AVF)
and body composition in obese women with the metabolic syndrome.
MethodsTwenty-seven middle-aged, obese women (mean SD; age: 51 9 years and body mass
index: 34 6 kg/m2) with the metabolic syndrome completed one-of-three 16-week aerobic exercise
interventions: (i) No Exercise Training (Control): Seven participants maintained their existing levels
of physical activity, (ii) Low-Intensity Exercise Training (LIET): eleven participants exercised 5
days week-1 at an intensity lactate threshold (LT) (iii) High-Intensity Exercise Training (HIET):
nine participants exercised 3 days week-1 at an intensity > LT and 2 days week-1 LT. Exercise
time was adjusted to maintain caloric expenditure (400 kcalsession-1). Single-slice computed
tomography scans obtained at the L4-L5 disc-space and mid-thigh were used to determine abdominal
fat and thigh muscle cross-sectional areas. Percent body fat was assessed by air displacement
plethysmography.
ResultsHIET significantly reduced total abdominal fat (p<0.001), abdominal subcutaneous fat
(p=0.034) and AVF (p=0.010). There were no significant changes observed in any of these parameters
within the Control or LIET conditions.
Address for Correspondence: Arthur Weltman, Ph.D. Exercise Physiology Laboratory 203 Memorial Gymnasium University of
Virginia Charlottesville, VA 22904 Phone: (434) 924-6191 Fax: (434) 924-1389 E-mail: [email protected].
Current Address: Brian A. Irving, Ph.D. Endocrine Research Unit, Mayo Clinic, Rochester, MN David W. Brock, Ph.D School of
Public Health, University of Alabama Birmingham, Birmingham, AL Christopher K. Davis, M.D., Ph.D School of Medicine,
University of California at San Diego, San Diego, CA
Financial Disclosures: The authors have no financial disclosures to declare.
Clinical Trial Number: NCT00350064
Irving et al.
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ConclusionsThe present data indicate that body composition changes are affected by intensity
of exercise training with HIET more effective for reducing total abdominal fat, subcutaneous
abdominal fat and AVF in obese women with the metabolic syndrome.
Keywords
Physical Activity; Weight Loss; Metabolic Syndrome; Diabetes; Cardiovascular; Human
INTRODUCTION
The metabolic syndrome is a complex clustering of cardiometabolic abnormalities associated
with aging, physical inactivity, and abdominal adiposity (5;12;18). Globally, the incidence of
the metabolic syndrome and its associated increase in cardiometabolic risk has reached
pandemic proportions. Of the risk factors used to identify the metabolic syndrome, elevated
abdominal visceral fat (AVF) has consistently been shown to be associated with increased
cardiometabolic risk (30). The International Diabetes Federation (IDF) consensus statement
(2) identified central obesity as the unifying cardiometabolic risk factor among individuals
with the metabolic syndrome. Researchers and clinicians world-wide are intensively
investigating both pharmacological and non-pharmacological approaches to reduce visceral
adiposity and its related comorbidities.

Exercise training provides an economically viable, non-pharmacological approach for eliciting

beneficial adaptations in body composition and cardiometabolic risk. In support of this
contention, endurance training has been shown to be a powerful strategy for inducing
abdominal fat loss, particularly with respect to AVF loss (16;23;27;31). Despite much interest
in exercise-induced fat loss, the optimal exercise prescription to maximize fat loss remains
elusive. Only a limited number of exercise interventions have systematically examined the
impact of endurance training intensity on fat loss and in particular AVF loss under equivalent
energy expenditures (36;37). It may be postulated that high-intensity endurance training
(HIET) may induce greater fat loss, in particular AVF loss than low-intensity endurance
training (LIET) for several reasons. First, HIET induces secretion of lipolytic hormones
including growth hormone and epinephrine (32;33), which may facilitate greater post-exercise
energy expenditure and fat oxidation. Second, it has been reported that under equivalent levels
of energy expenditure HIET favors a greater negative energy balance compared to LIET (21).
In the present study we examined the impact of endurance training intensity on AVF under
equivalent caloric expenditure (2000 kcalweek-1). We hypothesized that sixteen weeks of
endurance training above the lactate threshold (LT) (i.e., high-intensity endurance training)
would result in a greater reduction in AVF and more favorable changes in body composition
than 16 weeks of endurance training below the LT (i.e., low-intensity endurance training) in
abdominally obese women with the metabolic syndrome.
METHODOLOGY
Participants
Twenty-seven middle aged (mean SD; 51 9 y) women who met the IDF criteria for the
metabolic syndrome (2) completed the present study. To meet the IDF criteria for the metabolic
syndrome each participant had to have an elevated waist circumference ( 80 cm) and at least
two of the following; elevated fasting blood glucose ( 100 mg/dL), low HDL-C ( 50 mg/
dL), hypertriglyceridemia ( 150 mg/dL), and/or elevated blood pressure ( 130/85 mm Hg)
(2). The participants were sedentary at baseline, reporting less than 2 days per week of
structured exercise. All participants underwent an initial eligibility screening in the University
of Virginias General Clinical Research Center (GCRC) (see below). The Institutional Review
Irving et al.
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Board, Human Investigation Committee of the University of Virginias Health System

approved this study, and each participant provided written informed consent.
Metabolic Syndrome and Medical Screening Protocol
Participants reported to the GCRC for screening after a 10 to 12 h fast at 0900 h. Participants
provided a detailed medical history and underwent a physical examination, which included an
assessment of the five risk factors associated with the metabolic syndrome as defined by the
IDF (2). In brief, waist circumference measurements were taken in triplicate to the nearest 0.1
cm using a non-elastic measuring tape, midway between the iliac crest and the lowest rib
(28). Seated blood pressure was assessed in duplicate using an automated sphygmomanometer
(Dynamap 100, General Electric, Tampa, FL) after participants sat quietly for 10 to 15 minutes.
Fasting blood samples were then drawn and serum was separated by centrifugation. Glucose,
triglycerides, and high-density lipoprotein cholesterol (HDL-C) concentrations were assessed
in serum. Glucose concentrations were determined by using an automated glucose analyzer
(YSI Instruments 2300 STAT Plus, Yellow Springs, OH). Triglycerides and HDL-C
concentrations were determined using an Olympus AU640 automatic analyzer (Olympus,
Melville, NY). All participants were asked to refrain from caffeine, alcohol, and vigorous
physical activity for 24 hours prior to testing. Exclusion criteria included a history of ischemic
heart disease, diabetes, pulmonary or musculoskeletal limitations to exercise, and the use of
vasoactive medications, oral hypoglycemics, insulin, glucocorticoids, anti-psychotics,
hormone replacement or birth control, and if pregnant, breast feeding, or unwilling to provide
written informed consent.
Study Design
Eligible participants were randomized to one of three 16-week exercise training conditions: (i)
no-exercise training (Control), (ii) low-intensity exercise training (LIET), or (iii) high-intensity
exercise training (HIET). Figure 1 presents the distribution of study participants. Participants
were assessed before and after the 16-week intervention. Participants were admitted to the
GCRC for 2 days during which the following evaluations were performed (see below). The
one exception was the cardiorespiratory fitness assessment, which was conducted as an
outpatient visit. To control for the effects of menstrual cycle on outcome variables,
premenopausal women were admitted between days 2-8 of their menstrual cycle.
Postmenopausal status was determined by the absence of menses for > 1 year. In the NOET
condition there was 1 premenopausal woman, 1 woman who underwent a hysterectomy
(menopausal status unknown), and 5 postmenopausal women, in the LIET condition there were
3 premenopausal women, 4 women who underwent a hysterectomy (menopausal status
unknown), and 4 postmenopausal women, and in the HIET there were 2 premenopausal were,
2 women who underwent a hysterectomy (menopausal status unknown), and 7 postmenopausal
women. Participants were asked to refrain from alcohol, caffeine, and cigarette smoking for at
least 72 h prior to their admission.
Body Composition Assessment
Body composition was measured using air displacement plethysmography (Bod-Pod, Life
Measurement Instruments, Concord, CA) corrected for thoracic gas volume as described
previously (7).
Single-slice computed tomography (CT) images were obtained at the level of L4-L5 intervertebral disc space and at the mid-point between the inguinal crease and the top of the patella
as previously described (22). All scans were performed using a General Electric Lightspeed
CT (GE Medical Systems, Milwaukee, WI) scanner and saved as DICOM images for analysis.
Standard CT procedures of 120 kV, 5 mm thickness and a 512 X 512 matrix were used for all
subjects. A single trained investigator analyzed each of the blinded CT images using the SliceMed Sci Sports Exerc. Author manuscript; available in PMC 2009 November 1.
Irving et al.
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O-Matic version 4.3 software (Tomovision, Montreal, Canada) package for the delineation and
quantification of cross-sectional areas of fat, muscle, and bone as previously described (22;
29). The measurement boundary for AVF was defined as the innermost aspect of the abdominal
and oblique muscle walls and the posterior aspect of the vertebral body, as described previously
(6). In addition, we also quantified abdominal subcutaneous fat area at the L4-L5 intervertebral
disc space. At the mid-thigh, we assessed the total mid-thigh fat area and the total mid-thigh
skeletal muscle area. The inter- and intra-investigator coefficient of variations for these
analyses in our laboratory are less than 5% (22).
Cardiorespiratory Fitness Assessment
Participants completed a continuous VO2 Peak treadmill protocol. The initial treadmill (Quinton
Q65, Seattle, WA) velocity was 60 mmin-1 and the velocity was increased by 10 mmin-1 every
3 minutes until volitional fatigue. Metabolic data were collected during the protocol using
standard open-circuit spirometric techniques (Viasys Vmax 229, Yorba Linda, CA) and heart
rate was assessed electrocardiographically (Marquette Max-1 electrocardiograph, Marquette,
WI). VO2 Peak was chosen as the highest VO2 attained during the exercise protocol. An
indwelling venous cannula was inserted in a forearm vein and blood samples were taken at rest
and at the end of each exercise stage for the measurement of blood lactate concentration (YSI
Instruments 2300 STAT Plus, Yellow Springs, OH). The LT was determined from the blood
lactate-velocity relationship and was defined as the highest velocity attained prior to the
curvilinear increase in blood lactate concentrations above baseline (43). A lactate elevation of
at least 0.2 mM (the error associated with the lactate analyzer) was required for LT
determination. Individual plots of VO2 vs. velocity allowed for the determination of the VO2
associated with the lactate threshold. The respiratory exchange ratio (RER), heart rate and
blood lactate responses were monitored to insure that participants attained peak values at the
point of volitional exhaustion. VO2 peak was chosen as the highest VO2 attained during the
test.
Physical Activity and Dietary Assessment
The time spent in physical activity at different intensities was assessed using the Aerobic Center
Longitudinal Studys Physical Activity Questionnaire (26). The questionnaire was
administered using an interview technique to increase accuracy (34). Total physical activity
was calculated as METHWeek-1 (1 MET = 3.5 mlkgmin-1), using the Compendium of
Physical Activities (1). Participants were instructed by a registered dietician on how to
complete a 3-day dietary record, which was analyzed using a commercially available nutrition
software program (The Food Processor SQL, ESHA Research, Salem, OR).
Basal Metabolic Rate (BMR)

After an overnight fast, participants were awakened at 0600 h, asked to void, return to bed and
remain awake in the supine position for 30 min in a quiet and thermo-neutral environment.
BMR was measured by indirect calorimetry (Sensor Medics Delta Trac metabolic cart and
ventilation hood) for 30 min.
Exercise Intervention
Participants were randomized to the one of the following three interventions: (i) no-exercise
training, (ii) low-intensity exercise training, or (iii) high-intensity.
a.
No-Exercise Training (Control): Participants maintained their current level of

physical activity for the duration of the study.
b. Low-Intensity Exercise Training (LIET): Participants completed a 16-week

supervised low-intensity exercise intervention. Participants were progressed to
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complete five exercise sessions (days) per week by week 5 at an intensity at or below
their LT (RPE 10-12). The duration of each exercise session was adjusted based
on each participants individual VO2-velocity relationship so that each participant
expended a total of 300 kcal per training session for weeks 1-2 (3 days/week), 350
kcal per session for weeks 3-4 (4 days/week), and 400 kcal per session for weeks 5-16
(5 days/week). As each participants fitness level improved the velocity required to
maintain her assigned RPE was increased, therefore the duration was readjusted to
maintain kcal requirement. Exercise was prescribed based on the rating of perceived
exertion obtained during the LT / VO2 Peak protocol and one of the investigators
monitored RPE during each training session.
c.
High-Intensity Exercise Training (HIET): Participants completed a 16-week

supervised moderate-high intensity exercise intervention. Participants were
progressed to five exercise sessions (days) per week by week 5. Three days per week
(e.g., M, W, F) participants exercised at an intensity midway between the LT and
VO2 peak (RPE 15-17) and the remaining two days (e.g., T, Th) they exercised at
or below their LT (RPE 10-12). The progression of caloric expenditures and
velocity and duration adjustments were made as described for LIET, with the
exception that participants always had 3 days/week > LT and one < LT training session
was added at week 3 and again at week 5.
All exercise training sessions were supervised by a member of the investigative team and took
place at the UVA indoor or outdoor track. Each participant was instructed to walk/run the
distance associated with their prescribed caloric expenditure based on each participants body
weight and associated caloric output from the Compendium of Physical Activity. If participants
lost weight the distance required to expend a given energy expenditure increased accordingly.
For example, a 90 kg woman would complete 3.5 miles per session to expend 400 kcal per
session, whereas, an 80 kg woman would complete 4.0 miles per session.
The rationale for using RPE as an index of training intensity comes from our previous data that
suggest that RPE is an accurate marker of the blood lactate response to exercise that is not
affected by gender, fitness, training state, mode of exercise, or intensity of training (20;35;
38) and that RPE can be used to produce a desired blood lactate concentration during 30-min
of treadmill running (38). Additionally, Jakicic et al. (24) reported that RPE provide a more
accurate marker of relative exercise intensity compared to % of heart rate reserve in obese
women before and after weight loss. Each participants RPE was monitored on a lap-by-lap
basis to assess the prescribed exercise intensity and the velocities to required to maintain the
assigned RPE were adjusted accordingly. Heart rate data were not collected during the exercise
sessions, however, as stated above RPE have been shown to be an accurate marker of relative
exercise intensity among obese adults.
Statistical Analysis
All statistical analyses were conducted using SAS software (SAS Version 9.1, Cary, NC). Since
measurements of the responses at 16 weeks were required for the participant to be included in
the analysis, our target study population with respect to statistical inference was the population
of individuals who met the study inclusion criteria and who successfully completed the 16week intervention. The frequency of patient dropouts was analyzed across the 3 interventions
to determine whether the dropout rate was at random or if it was associated with the
participants treatment assignment. Data are presented as means SDs.
The present study was powered to detect a 30 cm2 reduction in AVF (AVF = baseline minus
16-week AVF measurement) with 12 participants per group. Two-way, mixed-effects analysis
of covariance (ANCOVA) was employed to examine mean differences in pre- to posttraining
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values (14). The model specification included parameters to estimate the exercise intensity
main effect (Control, LIET, and HIET), the time main effect (pre- and posttraining), and their
interaction effect on the change in the dependent variables. Their baseline value served as the
covariate. In addition, the model included random effects which represented the between and
within-subject error terms. The model parameters were estimated based on the principles of
restricted maximum likelihood, with the variance-covariance structure estimated using
unstructured estimate. For all analyses, pair-wise comparisons of the means were conducted
when the main effect of group, time or the interaction between group*time were significant.
Fishers Restricted Least Significant Differences criterion was utilized to maintain the a
priori type I error rate of 0.05. In addition, we conducted ANCOVA analyses using menopausal
status as a covariate (data not shown). As we did not observe any significant effects of
menopausal status on any of the outcome measures group data are presented. Spearman rank
correlations were calculated to test the association among changes in weight, fat mass, waist
circumference, and the metabolic syndrome parameters.
RESULTS
Pretraining Characteristics and Exercise Adherence
Tables 1-3 present the mean SDs pre- and posttraining values for the metabolic syndrome
parameters, body composition, cardiorespiratory fitness, physical activity, and basal metabolic
rate by treatment condition. There were no significant differences among the three conditions
at baseline for any outcome measure (all p > 0.1; Tables 1-3). Table 4 presents the summary
data for exercise adherence, volume, and intensity. Both the LIET and HIET groups had similar
exercise adherence, with 79 3% and 83 3% of the assigned exercise sessions completed
within each exercise condition, respectively. We did not observe a differential rate in dropouts
among the three conditions (Figure 1). During LIET exercise sessions the mean RPE was
11; for HIET, the mean RPE was 15 during the HIET sessions and 12 during the LIET
sessions. By design, the mean velocity per session and the mean RPE per session were
significantly higher in the HIET group during their HIET days compared to the LIET group.
There were no statistically significant differences between the two training groups for the total
estimated caloric energy expenditure.
Metabolic Syndrome Parameters
By design, all participants had elevated waist circumference and at least two of the following;
elevated fasting blood glucose, low HDL-C, hypertriglyceridemia, and were normotensive to
mildly hypertensive at baseline (Table 1). HIET significantly reduced waist circumference (p
= 0.001), which was significantly greater than the reductions observed in response to Control
and LIET (p = 0.039 and p = 0.035, respectively; Table 1) after adjusting for the baseline values.
LIET significantly reduced systolic blood pressure (p = 0.002), which was significantly greater
than the reduction observed in response to Control (p = 0.023; Table 1) after adjusting for the
baseline values. However, the remaining metabolic syndrome parameters remained unchanged.
Body Composition
HIET significantly reduced total abdominal fat (p < 0.001, Table 2), AVF (p = 0.010; Table 2
and Figure 2c) and abdominal subcutaneous fat (p = 0.034; Table 2 and Figure 2d) after
adjusting for the baseline values. There were no significant changes observed in any of these
parameters within the Control or LIET conditions. The reductions in total abdominal fat and
abdominal subcutaneous fat cross-sectional areas in the HIET condition were significantly
greater than those observed in the LIET condition (p = 0.017 and p = 0.033, respectively) after
adjusting for the baseline values. Although the reduction in AVF within HIET condition (-24
cm2) was much greater than that observed within Control condition (-2 cm2) and the LIET
condition (-7 cm2) these differences did not reach the level of statistical significance across
Irving et al.
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conditions (p = 0.098 and p = 0.153, respectively). HIET also significantly reduced total midthigh fat (p = 0.001; Table 2 and Figure 2e). We did not observe a significant change in total
mid-thigh skeletal muscle among the three treatment conditions (p > 0.1; Table 2 and Figure
2d). HIET significantly reduced total body weight (p = 0.013), BMI (p = 0.009), and fat mass
(p = 0.011) (Table 2).
Cardiorespiratory Fitness
LIET and HIET significantly elevated VO2 Peak (p = 0.047, p = 0.004, respectively; Table 3).
The increase in VO2 Peak in the HIET condition exceeded that for Control and LIET conditions
(p = 0.016, p = 0.078, respectively; Table 3). VO2 LT was unchanged after training in all three
conditions (all p > 0.1; Table 3). LIET and HIET resulted in significant elevations in peak
treadmill velocity (p = 0.006, p < 0.001, respectively; Table 3). HIET induced a greater
elevation in peak treadmill velocity than Control and LIET (p = 0.005, p = 0.056, respectively;
Table 3).
BMR, Physical Activity and Diet
We did not observe any significant changes in the BMR (Table 3) or substrate oxidation
assessed using the basal respiratory exchange ratio (data not shown). We also did not observe
any significant changes in total physical activity in response to the three treatment conditions
(Table 3). A limitation of the present study is that due to incomplete dietary data we were
unable to adequately analyze the dietary records for pre- to posttraining changes in caloric
intake.
Spearman Correlation Analyses
Pooled Spearman correlation analyses (N = 27) were conducted to examine the relationships
among pre- to posttraining changes weight, percent fat, AVF, and the metabolic syndrome
parameters. Weight loss was positively associated with reductions in triglycerides (r = 0.56; p
= 0.002) and SBP (r = 0.44; p = 0.022). Fat mass loss was also positively associated with (r =
0.49; p = 0.009) triglycerides.
DISCUSSION
Body Composition
Published data on the effect of exercise training intensity on body composition and regional
body fat are mixed (4;15;17;27;36;41). With regard to total body fat loss, total caloric
expenditure appears to be the key factor (4;15;17;37). Slentz et al. (37) reported that lowamount/moderate-intensity and low-amount/vigorous-intensity endurance training (i.e.,
activity equivalent to 12 milesweek-1 of walking or jogging) were equally effective in
reducing % body fat, fat mass, waist circumference, and abdominal circumference in
previously sedentary, overweight, middle-aged adults. They also reported that high-amount/
vigorous intensity endurance training (activity equivalent to 20 milesweek-1 of jogging) was
more effective in reducing % body fat and fat mass compared to the two low-amount training
groups (37). Although the exercise intensity was not equated across training volumes, the
authors did effectively demonstrate a dose-response relationship between training volume and
amount of weight change using a pooled analysis (37).
Our results suggest that HIET may be an effective stimulus for inducing favorable changes in
body composition. Specifically, HIET significantly reduced body weight, BMI, % body fat,
fat mass and waist circumference (Table 1). Our results are consistent with those of Tremblay
et al. (42) who reported that high-intensity intermittent exercise training induced greater
subcutaneous fat loss compared to moderate-intensity exercise training under isocaloric
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training conditions. Similarly, Tremblay et al. (41), also reported results from the Canadian
Fitness Survey that indicated that vigorous-physical activity was associated with lower
subcutaneous skinfold thickness, which continued to remain significant after adjusting for total
energy expenditure. It should be realized that HIET was likely associated with slightly greater
exercise energy expenditure and total energy expenditure than LIET. The kcal per training
session was based on total energy expenditure (e.g. 300, 350 or 400 kcal per session) and resting
metabolism was part of the total. Therefore on the high intensity exercise days where duration
was 6 min shorter (Table 4), resting metabolism would contribute to a lower fraction of the
total energy expenditure. This resulted in an 400 kcal difference in exercise energy
expenditure between the high and low intensity groups over the 16 week time frame( 25 kcal/
week). In addition, it is likely that post-exercise oxygen consumption was higher on the HIET
days.
In view of previous work and the present findings, an interaction between exercise intensity
and training volume may exist with respect to changes in body composition. Further
investigations are warranted to examine the interaction between training volume and intensity
on changes in body composition.
Regional Body Fat

Exercise training, even in the absence of weight loss, is associated with a significant reduction
in AVF (27). Whether intensity of exercise is an important training variable for inducing
reductions in AVF is not clear, although data on responses to acute exercise suggest that higherintensity exercise may be more effective than low-to-moderate-intensity exercise for
mobilizing AVF by inducing secretion of lipolytic hormones, facilitating greater post-exercise
energy expenditure and fat oxidation, and by favoring a greater negative energy balance (21;
32;33). Our results indicate that HIET is an effective exercise abdominal subcutaneous fat (-47
cm2 vs. -11 cm2, adjusted for baseline) and AVF (-24 cm2 vs. -7 cm2, adjusted for baseline).
Data from Slentz et al. (36), however, suggest that low-amount/moderate-intensity or lowamount/vigorous-intensity exercise training were equally effective in preventing significant
increases in AVF associated with continued physical inactivity in sedentary, overweight,
middle-aged adults under isocaloric conditions. These authors also reported a significant
reduction in AVF in subjects who completed 8 months of high-amount/vigorous-intensity
exercise training (activity equivalent to 20 miles week-1 of jogging), indicating that training
volume may play a critical factor in exercise induced AVF loss (36). However, by not including
a high-amount/moderate-intensity exercise training group, the authors eliminated the
opportunity to determine whether an interaction between training volume and training intensity
exist for AVF loss. The training volume in the present study was equated across training
conditions and was similar to the training volume in the high-amount/vigorous-intensity
training condition reported by Slentz et al. (36). Taken together, these data suggest that an
interaction between training volume and training intensity may exist for AVF loss.
BMR, Physical Activity and Diet
Reported total physical activity and BMR remained unchanged. Unfortunately, due to
incomplete dietary data we were unable to adequately analyze changes in caloric intake and
composition. Although several studies suggest that some women gain weight (and body fat)
in response to exercise training, most of these studies have used low-to-moderate exercise
intensities (8;11). The present data indicate that exercise training above the LT (i.e., HIET)
may be an effective exercise intensity for inducing weight loss in obese women. Although not
measured, it is also likely that HIET resulted in increased post-exercise energy expenditure
which in turn was related to lower body fat deposition (44).
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Exercise Adherence
The present results demonstrate that endurance training intensity does not significantly impact
exercise adherence. The primary reasons given for missing exercise sessions in the present
cohort were related to time conflicts and personal travel. As the mean (and median) exercise
adherence was 80%, four days of structured endurance training (at 1600 kcal/week) appears
to be a more realistic goal in this cohort of obese women with the metabolic syndrome. All
participants were encouraged to make-up their missed training sessions when possible, and the
participants in the HIET condition were encouraged to complete all three HIET sessions per
week. Four days per week (at 1600 kcal/week) of endurance training would still remain within
the current recommendations (19). It is also important to realize that the HIET was a blend of
LIET (2 days per week) and HIET (3 days per week) and that participants were allowed to
initially complete the HIET sessions in a interval/intermittent type fashion. For example, for
the first few laps of each training session some subjects would perform one lap at an RPE of
16-17 and the subsequent then a lap at 13-14, with the majority of the laps performed at an
RPE 15. Moreover, the overall mean RPE for each HIET session was 15. The present
results also demonstrate that even very sedentary, unfit, obese women (people) can adhere to
a supervised program incorporating HIET.
Cardiorespiratory Fitness
Epidemiological data indicate that elevations in cardiorespiratory fitness (i.e., VO2 Peak) is
associated with an attenuation cardiometabolic risk among individuals with the metabolic
syndrome (25). It is well established that endurance training intensity is a primary determinant
for exercise induced improvements in cardiorespiratory fitness (3). HIET increased VO2 Peak
more than LIET (14% vs. 9%), and this difference approached statistical significance after
16 weeks (Table 1). It is possible that larger intensity-related differences in VO2 Peak
enhancement may take longer than 4 months in previously sedentary adults. We previously
reported that training-induced elevations in VO2 Peak and VO2 at the LT in response to training
at or above the LT were similar across the first four months of training in previously sedentary
women (43). However, training above the LT was more effective than training at the LT beyond
four months (43).
Metabolic Syndrome Parameters
Despite significant improvements in body composition, including significant reductions in

waist circumference and AVF, within the HIET condition the improvement in some
cardiometabolic risk factors associated with the metabolic syndrome (e.g., increased HDL-C,
decreased TG) did not reach statistical significance and did not appear to be related to exercise
training intensity. However, the present study was powered for changes in body composition
and not for cardiometabolic risk factors. As expected, exercise training induced reductions in
resting blood pressure. Typically, training-induced reductions in resting blood pressure are
reported to be independent of training intensity (13). The significantly greater reduction in
systolic blood pressure after LIET may have been due in part to the higher initial value, as
baseline blood pressure appears to be an important factor in the blood pressure response to
exercise (13). However, covarying for the baseline systolic blood pressure did not attenuate
the effect of LIET on systolic blood pressure.
Spearman Correlation Analyses
Weight loss was associated with reductions in triglycerides and systolic blood pressure, while
fat loss was only associated with reductions in triglycerides. Although not statistically
significant, AVF loss was associated with the expected reductions in triglycerides. The nonsignificant associations between AVF loss and the metabolic syndrome components (i.e.,
fasting glucose, HDL-C, triglycerides, and systolic and diastolic blood pressure) indicates that
Irving et al.
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it might take a greater AVF loss in our abdominally obese cohort to observe significant
improvements in these parameters. For example, recent data from Thamer et al. (39) indicated
that subjects with high AVF and high liver fat have a reduced chance in profiting from lifestyle
intervention and suggested that they may require intensified lifestyle intervention strategies
and/or pharmacological approaches to improve the metabolic profile. Moreover, it has been
previously reported that individuals with excessive AVF (e.g., > 130 cm2) often develop these
cardiometabolic risk factors (9;10). As the mean baseline AVF cross-sectional area for each
exercise condition was substantially elevated (> 153 cm2) and, although reduced as a result of
training, were still well above 130 cm2 (>146 cm2). It is possible that greater reductions in
AVF may be required in order to observe favorable changes in these metabolic syndrome
parameters.
Limitations
We recognize that a potential limitation of the present study is that the subjects in the HIET
group tended to have slightly higher levels of AVF at the onset of the study. However, adjusting
for baseline levels of AVF did not significantly attenuate the impact that HIET had on AVF.
It has been previously reported that the use of single-slice images to measure changes in AVF
are less precise than multi-slice images (40) and therefore, may also be a limitation of the
present study. However, a more precise measurement of the change in AVF likely would have
resulted in narrower 95% confidence intervals and significant between group differences with
respect to the change in AVF. Although the present study was initially powered to detect
significant changes in the AVF (30 cm2) with 12 participants per group, the present study
did not achieve this level of recruitment, because the number of drop outs exceeded our original
estimation. However, despite this limitation we did observe a statistically significant
improvement in body composition (including AVF) within the HIET condition. Finally, due
to incomplete dietary data, we were not able to adequately analyze the impact of reduced caloric
intake on changes in body composition. It has also been suggested that the use of RPE for
exercise prescription may be a limitation. For example, when subjects know they are supposed
to exercise at an RPE of 15-17 but they do not want to exercise that vigorously, this is a
circumstance that may be prone to inflating a given RPE. However, the training program used
did result in differentiated training effects for VO2 peak and peak treadmill velocity. Finally,
because of the issues related to statistical power, it is possible that some variables would have
reached the level of statistical significance if more subjects had been studied. Thus the nonsignificant results presented need to be interpreted with caution.
Summary
The results of the present investigation support our primary hypothesis that HIET would be
more effective than LIET for altering body composition in obese women with the metabolic
syndrome. Further investigations are warranted to determine the impact of training duration,
gender, race, age, and menopausal status on modulating the effect that exercise training
intensity has on AVF and associated cardiometabolic risk factors.
Acknowledgments
The results of the present study do not constitute endorsement by ACSM. The present study was funded in part by an
NIH grant to the General Clinical Research Center RR MO100847 and NIH training grant 5T32AT00052. The authors
have no other financial disclosures to declare. The authors wish to thank the staff of the GCRC at the University of
Virginia and all of the subjects who participated enthusiastically in the study. The authors would also like to thank
James T. Patrie for useful discussions on statistical considerations.
Grant Support: NIH Grant Numbers RR00847 and T32-AT-00052
Irving et al.
Page 11
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Irving et al.
Page 14

Figure 1.
Distribution of study participants.

Irving et al.
Page 15

Figure 2.
Effects 16 weeks of no exercise training (Control, n = 7), low-intensity exercise training (LIET,
n = 11), and high-intensity exercise training (HIET, n = 9) on abdominal subcutaneous
abdominal fat (B), visceral fat (A), total mid-thigh skeletal muscle (C) and total mid-thigh fat
(D) cross-sectional area. The values shown represent the individual percent change (% values
(open-circles), the mean %values (solid square), the median % values (box-split), the lower
(bottom of the box) and upper quartiles (top of the box), and the minimum and maximum %
values (lines) by condition.
Two-way, mixed-effects analysis of variance of covariance with repeated measures
(ANCOVA) was employed to examine mean differences in pre- to posttraining values, with
the baseline values serving as the covariate (see methods for details). For all analyses, linear
contrasts of the means were constructed to test our a priori hypotheses. Fishers Restricted
Least Significant Differences criterion was utilized to maintain the a priori type I error rate of
0.05.

129 12
75 7
Systolic Blood Pressure,

mm Hg
Diastolic Blood Pressure,

mm Hg
76 7
130 11
191.5 97.3
45.7 9.1
110.4 + 16.6
97.5 8.0
Posttraining
Significant treatment effect (post pre) compared with LIET (p <0.05)
Significant treatment effect (post pre) compared with NOET (p <0.05)
Significantly different from baseline (p <0.05)
NOET
82 12
135 17
241.9 202.4
44.6 6.6
106.7 + 13.5
103.8 10.6
Pretraining
LIET
78 10
124 10*,
213.8 135.8
49.0 10.4
104.0 + 10.8
102.6 10.4
Posttraining
76 8
124 16
152.1 43.9
50.9 10.7
110.2 + 20.6
103.7 16.8
Pretraining
HIET
52.1 9.1
74 8
123 15
126.7 40.0
(0.706, 0.469, 0.549)
(0.207, 0.087, 0.046)
(0.245, 0.175, 0.552)
(0.181, 0.085, 0.233)
(0.675, 0.066, 0.658)
(0.036, 0.020, 0.055)
98.1 13.3*
113.8 + 26.0
ANCOVA, p-value
(Treatment, Time,
Interaction)
Posttraining
Two-way, mixed-effects analysis of variance of covariance with repeated measures (ANCOVA) was employed to examine mean differences in pre-to posttraining values, with the baseline values
serving as the covariate (see methods for details). For all analyses, linear contrasts of the means were constructed to test our a priori hypotheses. Fishers Restricted Least Significant Differences
criterion was utilized to maintain the a priori type I error rate of 0.05.
42.7 6.7
187.3 77.0
Triglycerides, mg.dL-1
107.7 + 14.6
98.2 10.0
Pretraining
HDL-C, mg.dL-1
Fasting Blood Glucose,

mg.dL-1
Waist Circumference, cm

Table 1
The effects of 16-weeks of either no exercise training (Control, n = 7), low-intensity exercise training (LIET, n = 11), or high-intensity
exercise training (HIET, n = 9)on the parameters associated with the metabolic syndrome.
Irving et al.
Page 16

2
234 40
Mid-Thigh Skeletal Muscle,

cm2
236 35
273 81
155 71
480 73
644 75
40.1 6.3
48.7 8.8
45.0 3.7
32.4 3.8
88.7 10.6
Posttraining
Data were log transformed to produce symmetric distributions.
282 94
Mid-Thigh Fat Area, cm2
Control
274 66
308 127
153 51
486 143
647 116
43.1 11.5
54.2 11.5
44.0 4.9
34.7 7.5
97.2 22.0
Pretraining
LIET
292 57
294 117
146 49
475 138
636 121
41.8 11.2
53.3 9.4
43.6 4.1
33.9 6.5
95.1 19.3
Posttraining
258 43
329 157
173 73
513 163
683 183
41.0 7.2
52.2 7.2
43.5 4.8
34.7 6.8
93.5 18.3
Pretraining
HIET
(0.520, 0.220, 0.428)
(0.100, 0.004, 0.119)
286 123*
258 38
(0.250, 0.040, 0.208)
(0.063, 0.001, 0.043)

148 59*
467 151*
(0.057, <0.001, 0.045)
(0.203, 0.020, 0.296)

625 181*
(0.747, 0.233, 0.925)
38.2 10.7*
(0.181, 0.085, 0.233)
51.7 5.7
41.8 5.4
(0.370, 0.009, 0.366)
(0.294, 0.009, 0.427)
90.0 15.6*
33.4 5.6*
ANCOVA, p-value
(Treatment, Time,
Interaction)
Posttraining
157 71
496 80
672 92
Abdominal Visceral Fat,

cm2
Subcutaneous Fat, cm
Abdominal Fat, cm
40.4 6.2
Fat Mass, kg
2
49.2 6.5
Fat Free Mass, kg
32.7 3.8
45.1 3.3
-2
89.6 11.2
Pretraining
Body Fat, %
Body Mass Index, m.kg
Weight, kg

Table 2
The effects of 16-weeks of either no exercise training (Control, n = 7), low-intensity exercise training (LIET, n = 11), or high-intensity
exercise training (HIET, n = 9) on measures of body composition in obese women with the metabolic syndrome.
Irving et al.
Page 17

13.0 2.5
113 10
81 9
VO2 LT ,mlkg-1min-1
Treadmill VelocityPeak, mmin-1
Treadmill VelocityLT, mmin-1
1522 103
152.2 23.2
90 10
116 5
14.5 1.9
20.9 2.8
Posttraining
1578 150
Control
1688 294
127.7 53.5
84 7
114 13
13.0 2.1
21.0 3.5
Pretraining
LIET
1622 263
122 45
1671 284
123.9 56.6
84 10
116 + 10
87 5
13.8 2.3
124 14*
21.7 4.1
Pretraining
13.2 1.8
22.8 2.6*
Posttraining
HIET
1688 187
149 27
88 8
136 24*,,
14.6 2.4
24.7 4.6*,
Posttraining
(0.254, 0.574, 0.445)
(0.157, 0.157, 0.374)
(0.503, 0.003, 0.582)
(0.022, <0.001, 0.017)
(0.469, 0.042, 0.704)
(0.025, 0.023, 0.049)
ANCOVA, p-value
(Treatment, Time,
Interaction)
Basal Metabolic Rate,

Kcalday-1
MET-H.Week
118.7 46.6
21.6 4.1
Pretraining
VO2 Peak, mlkg-1min-1
-1

Table 3
The effects of exercise training intensity on various cardiometabolic risk factors in obese women with the metabolic syndrome following
16 weeks of either no exercise training (Control, n = 7), light-intensity exercise training (LIET, n = 11), or high-intensity exercise training
(HIET, n = 9).
Irving et al.
Page 18
Irving et al.
Page 19
Table
Mean (SEM)[median] exercise data by treatment group.
LIET
HIET
LIET
ANOVA
p-value
HIET
RPESession-1
11.1 (2.1)
[11.2]
12.2 (0.6) 15.4 (0.4)

[11.7]
[15.7],
<0.001
MilesSession-1
3.0 (0.2)
[3.0]
3.4 (0.2)
[3.2]
3.3 (0.2)
[3.1]
0.001
53 (3)
[50]
59 (2)
[60]
53 (2)
[52]
<0.001
3.4 (0.1)
[3.4]
3.4 (0.2)
[3.4]
3.7 (0.2)
[3.7],
<0.001
Time (min)
VelocitySession-1( MilesHour-1)
Session Adherence (%)
TotalKcal
79 (2)
[78]
82 (3)
[82]
NS
22,480 (705)
[22,308]
23,370 (716)
[23,452]
NS
The RPEsession-1, milessession-1, timesession-1, velocitysession-1 represent the mean exercise data. The session adherence is presented as the percent
of total sessions completed and total kcal is derived from the session adherence * total prescribed kcal (28600 kcal).
Significant treatment effect compared with NOET (p <0.05)
Significant treatment effect compared with LIET (p <0.05)


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