Effect of exercise training on weight loss, body

composition changes, and weight maintenance in adults

with overweight or obesity: An overview of 12
systematic reviews and 149 studies
Alice Bellicha, Marleen van Baak, Francesca Battista, Kristine Beaulieu, John
Blundell, Luca Busetto, Eliana Carraça, Dror Dicker, Jorge Encantado,
Andrea Ermolao, et al.

To cite this version:

Alice Bellicha, Marleen van Baak, Francesca Battista, Kristine Beaulieu, John Blundell, et al.. Effect
of exercise training on weight loss, body composition changes, and weight maintenance in adults with
overweight or obesity: An overview of 12 systematic reviews and 149 studies. Obesity Reviews, Wiley,
2021, pp.e13256. �10.1111/obr.13256�. �hal-03220826�

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Received: 19 March 2021 Accepted: 29 March 2021
DOI: 10.1111/obr.13256

SUPPLEMENT ARTICLE

Effect of exercise training on weight loss, body composition

changes, and weight maintenance in adults with overweight or
obesity: An overview of 12 systematic reviews and 149 studies

Alice Bellicha1,2 | Marleen A. van Baak3 | Francesca Battista4 |

5 5 6,7
Kristine Beaulieu | John E. Blundell | Luca Busetto | Eliana V. Carraça8 |
Dror Dicker6,9 | Jorge Encantado10 4
| Andrea Ermolao |
Nathalie Farpour-Lambert6,11 | Adriyan Pramono3 | Euan Woodward6 |
Jean-Michel Oppert12
1
INSERM, Nutrition and obesities: systemic approaches, NutriOmics, Sorbonne University, Paris, France
2
UFR SESS-STAPS, University Paris-Est Créteil, Créteil, France
3
NUTRIM School of Nutrition and Translational Research in Metabolism, Department of Human Biology, Maastricht University Medical Centre+, Maastricht,
Netherlands
4
Sport and Exercise Medicine Division, Department of Medicine, University of Padova, Padova, Italy
5
Appetite Control and Energy Balance Group (ACEB), School of Psychology, Faculty of Medicine and Health, University of Leeds, Leeds, UK
6
Obesity Management Task Force (OMTF), European Association for the Study of obesity (EASO)
7
Department of Medicine, University of Padova, Padova, Italy
8
Faculdade de Educaç~ao Física e Desporto, CIDEFES, Universidade Luso
fona de Humanidades e Tecnologias, Lisbon, Portugal
9
Department of Internal Medicine D, Hasharon Hospital, Rabin Medical Center, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
10
APPsyCI—Applied Psychology Research Center Capabilities and Inclusion, ISPA—University Institute, Lisbon, Portugal
11
Obesity Prevention and Care Program Contrepoids; Service of Endocrinology, Diabetology, Nutrition and Patient Education, Department of Internal Medicine,
University Hospitals of Geneva and University of Geneva, Geneva, Switzerland
12
Assistance Publique-Hôpitaux de Paris (AP-HP), Pitié-Salpêtrière hospital, Department of Nutrition, Institute of Cardiometabolism and Nutrition, Sorbonne
University, Paris, France

Correspondence
Alice Bellicha, Service de Nutrition, Hôpital Summary
Pitié-Salpêtrière, 47-83 Boulevard de l'Hôpital, This overview of reviews aimed to summarize the effects of exercise training pro-
75013 Paris, France.
Email: [email protected] grams on weight loss, changes in body composition, and weight maintenance in adults
with overweight or obesity. A systematic search of systematic reviews and meta-
Funding information
European Association for the Study of Obesity analyses (SR-MAs) published between 2010 and December 2019 was performed.
(EASO) Only SR-MAs of controlled trials were included. The mean difference (MD) or stan-
dardized MD (SMD) were extracted from SR-MAs. Twelve SR-MAs (149 studies)
were included. Exercise led to a significant weight loss (4 SR-MAs, MDs ranging from
−1.5 to −3.5 kg), fat loss (4 SR-MAs, MDs ranging from −1.3 to −2.6 kg) and visceral
fat loss (3 SR-MAs, SMDs ranging from −0.33 to −0.56). No difference in weight, fat,
and visceral loss was found between aerobic and high-intensity interval training as

This is an open access article under the terms of the Creative Commons Attribution License, which permits use, distribution and reproduction in any medium,
provided the original work is properly cited.
© 2021 The Authors. Obesity Reviews published by John Wiley & Sons Ltd on behalf of World Obesity Federation.

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2 of 13 BELLICHA ET AL.

long as energy expenditure was equal. Resistance training reduced lean mass loss dur-
ing weight loss (1 SR-MA, MD: 0.8 [95%CI: 0.4–1.3] kg). No significant effect of exer-
cise was found on weight maintenance (1 SR-MA). These findings show favorable
effects of exercise training on weight loss and body composition changes in adults
with overweight or obesity. Visceral fat loss may lead to benefits for cardiometabolic
health. More research is needed to identify training modalities that promote weight
maintenance.

KEYWORDS
body composition, exercise, weight loss, weight maintenance

1 | I N T RO DU CT I O N 2 | METHODS

Physical activity is recognized as an integral part of the management 2.1 | Overview of reviews
of persons with overweight or obesity in combination with diet,
behavioral support, and treatment of comorbidities.1–3 Expected ben- This overview of reviews follows the guidelines outlined by the
efits of physical activity, or exercise, in this setting include positive Cochrane Handbook14 and is registered in the PROSPERO database
effects on weight loss, but also fat loss together with preservation of (registration number CRD42019157823).
lean mass during weight loss, as well as subsequent maintenance of
weight loss.1–3 Well-conducted systematic reviews and meta-analyses
published in the 2000s provided evidence of such effects of exercise 2.1.1 | Search strategy
on weight loss and body composition, but also acknowledged a lack of
evidence on the effects of exercise on weight maintenance.4–6 Over Three electronic databases (PubMed, Web of Science and Cochrane
the last decade, there has been growing interest in the effects of exer- Library) were searched for systematic reviews and meta-analyses (SR-
cise on visceral adipose tissue and in the preservation of lean body MAs) published between 2010 and December 2019 using the strategy
mass in older adults with obesity.7–10 High-intensity interval training “obesity AND physical activity AND age AND weight loss” (Table S1).
(HIIT) has also emerged as a promising exercise modality in adults in Limits were set to include SR-MAs published in English. Reference
10,11
general as well as in those with obesity. Finally, relations between lists from the resulting reviews and articles were also screened to
physical activity and weight maintenance have been widely investi- identify additional articles.
gated although recent reviews pointed out a lack of controlled trials
that would be needed to provide more robust evidence.12,13
In response to the increasing number of systematic reviews publi- 2.1.2 | Study selection, inclusion, and exclusion
shed, overviews of reviews (also termed umbrella reviews or reviews
of reviews) have been proposed as an effective strategy to provide a SR-MAs were included in the overview if: (1) all original studies
broad picture of evidence synthesis on a given topic.14 Overviews of included in the SR-MA assessed the effect of exercise training pro-
reviews summarize existing evidence from systematic reviews without grams, that is, aerobic and/or resistance and/or high-intensity interval
further analyses and are therefore a rapid means to inform guide- training (HIIT), (2) all original studies compared either exercise training
lines.15 Given the amount of evidence published on the effects of with no intervention or usual care, or exercise training in combination
exercise on body weight, body composition and specific fat depots with other interventions (e.g., exercise + diet) with appropriate con-
such as visceral adipose tissue, an overview of reviews on these topics trols (e.g., diet only), (3) at least two thirds of original studies involved
appears timely. adults (≥18 years including older adults) with overweight
Therefore, in the context of the European Association for the (BMI ≥ 25 kg/m2) or obesity (BMI ≥ 30 kg/m2), (4) at least one of the
Study of Obesity (EASO) Physical Activity Working Group (see sum- following outcomes was reported: weight loss, fat loss, visceral fat
mary paper for details), the aim of the present study was to conduct loss, lean mass loss, or weight maintenance. Presence of obesity com-
an overview of reviews examining the impact of exercise training pro- orbidities such as type 2 diabetes, hypertension, dyslipidemia, meta-
grams on weight loss, changes in body composition and weight main- bolic syndrome, liver disease (NAFLD/NASH), and osteoarthritis was
tenance in individuals with overweight or obesity. We had a specific not an exclusion criterion (see summary paper for details). Abstracts
interest in effects on visceral adipose tissue as an outcome of exercise and full texts were assessed for eligibility independently by two
training and in the effects of different training modalities authors (AB, JMO) with uncertainty regarding eligibility discussed
including HIIT. among authors.
BELLICHA ET AL. 3 of 13

2.1.3 | Data extraction and synthesis analysis. A global rating was determined based on the number of fatal
flaws: good quality (0 fatal flaw), fair quality (1 fatal flaw), or poor
Data were extracted by one author (AB) using standardized forms and quality (≥2 fatal flaws).
then checked by a second author (JMO). The characteristics of each
SR-MA included: reference, design of original studies, population
characteristics (age, gender, comorbidities), number of original studies 3 | RE SU LT S
and participants included in intervention and control groups, descrip-
tion of intervention (program duration, type of exercise training) and 3.1 | Overview of reviews
comparison, and outcomes. The findings pertaining to weight loss, fat
mass loss, visceral adipose tissue loss, lean mass loss and weight main- The database search yielded 3320 articles (2492 after removing dupli-
tenance of each included SR-MA are reported as mean difference cates), 2337 of which were eliminated based on titles and abstracts
(MD) or standardized mean difference (SMD). In addition, the study alone (Figure 1A). The full text was retrieved from 123 reviews and
author's conclusion was extracted, and an overview of the quality of 12 satisfied the inclusion criteria. From these reviews, a total of
the original studies and current authors' assessment of conclusion is 182 unique original articles corresponded to our inclusion criteria.
provided. Effect sizes were considered large, medium, small or negligi- Among these articles, 149 were included in meta-analyses. A total of
ble when SMD was >0.8, between 0.5 and 0.8, between 0.2 and 0.5, 105, 94, 38, 37, and 3 unique original studies assessed the effect of
or below 0.2, respectively.16 The overlap between SR-MAs was exam- exercise on weight loss, fat loss, lean mass/fat-free mass loss, visceral
ined for each outcome. The overlap was defined a priori as significant adipose tissue loss and weight maintenance, respectively. Lean mass/
when more than 15% of original studies reporting the same outcome fat-free mass loss was assessed with DXA scans in 31 studies, bioelec-
were included in two or more SR-MAs. In this case, the SR-MA with trical impedance analysis in four studies, underwater weighing in two
the highest number of original studies included, typically the most studies, and both DXA scans and BOD POD in one study. Of the
recent SR-MA, was selected. 31 studies that used DXA, 28 and 3 studies reported the change in
lean body mass and fat-free mass, respectively. Therefore, 28 (74%)
of studies reported lean body mass changes as assessed by DXA. The
2.1.4 | Quality assessment number of SR-MAs included for each outcome, and the number of
original articles included in these SR-MA are presented in Table S2.
Study quality was assessed with a standardized tool including eight The overlap between original studies ranged from 3% to 24%.
criteria, as previously described.1 Study quality was defined as good,
fair and poor when 0, 1, or ≥2 criteria were not filled. Study quality
was assessed by one author (AB) using this standardized tool and this 3.2 | SR-MAs characteristics
assessment was then checked by a second author (JMO). Any dis-
agreement between the reviewers was resolved through discussion The characteristics of the included SR-MAs are presented in Table 1.
(with a third author where necessary). The quality of original studies SR-MAs were published between 2011 and 2019 and included ran-
included in SR-MAs was reported as assessed by the authors of SR- domized controlled trials (RCTs) only (N = 7) or both randomized and
MAs. non-randomized controlled trials (n = 4). One SR-MA also included
single-group interventions but imputed data, that is, the weighted
average of all available studies, when no data from a control group
2.2 | Additional systematic review focusing on was available.9 The median (range) number of original studies included
weight maintenance was 12 (2-48). Most SR-MA involved adults of both genders, one SR-
MA included post-or peri-menopausal females18 and one included
The most recent SR-MA focusing on weight maintenance that was older adults.7 Duration of exercise training ranged from 2 weeks to
included in the overview was published in 2014.17 Therefore, an addi- 12 months. Aerobic training was performed in four SR-MAs,19–22
tional search for original studies published between 2010 and July resistance training in three SR-MAs,7,19,21 either aerobic or resistance
2020 was performed (see Table S1 for search terms). Inclusion criteria training or a combination of both in three SR-MAs,17,18,24 and HIIT in
were as follows: (1) randomized or non-randomized controlled trial four SR-MAs.9,16,23,25 Seven SR-MAs compared exercise training with
assessing the effect of exercise training programs, (2) participants no intervention or usual care,9,16,18–20,22,24 five SR-MAs compared
were assigned to exercise training (vs. no exercise) after an initial different modalities of exercise9,19,21,23,25 and three SR-MAs com-
weight-loss phase with the aim to compare changes in body weight pared a combination of exercise and a weight-loss diet with a weight-
during the weight maintenance phase (3), participants were adults loss diet only.7,17,18 Weight loss and fat mass loss were both reported
with overweight or obesity. Study quality was assessed with a in eight SR-MAs, visceral adipose tissue loss in three SR-MAs, lean
1
14-criteria form. Three of these criteria represented fatal flaws if mass loss in five SR-MAs and weight maintenance in one SR-MA.
answered “No” or “Not reported” or “Cannot determine” Except for one SR-MA that assessed weight maintenance up to two
(i) randomization, (ii) dropout rate <20%, and (iii) intent-to-treat years after initial weight loss,17 all SR-MA focused on
4 of 13 BELLICHA ET AL.

F I G U R E 1 Flow diagram.
(A) Overview of reviews flow
diagram. (B) Systematic review
flow diagram
TABLE 1 Characteristics of included systematic reviews

Reference Population characteristics Intervention and comparison Outcomes Number of participants

9
Andreato et al. Original studies included: N = 48 Intervention duration: 2 to 24 weeks -Body mass HIIT/non-exercise/MICT:
BELLICHA ET AL.

- Adult (18–65 years) males and females Intervention: HIIT (80–100% VO2max) -Body fat (%) -Body mass: 579/589/589
-N (%) studies including adults: Control #1: non-exercise group -Abdominal visceral fat area -Body fat: 427/406/445
• with overweight/obesity: 37 (81%) Control #2: MICT -Visceral adipose tissue: 39/36/39
• inactive/untrained: 8 (17%)
• with metabolic syndrome: 3 (6%)
Batacan et al.16 Original studies included: N = 6 Intervention duration: <12 weeks -Body fat (%) HIIT/control:
-Adult (≥18 years) males and females Intervention: Short-term HIIT (≥85% - Body fat: 68/70
-N (%) studies including adults: VO2max)
• with overweight/obesity: 4 (67%) Control: non-exercise group
• non-obese adults: 2 (33%)
Cheng et al.18 Original studies included: N = 11 Intervention duration: 12 weeks to - Body mass Exercise/non-exercise (3 studies):
- Peri- and post-menopausal females 12 months - Fat mass -Body mass: 215/140
- N (%) studies including adults: Intervention #1: Aerobic or resistance - Lean body mass -Fat mass: 214/140
• with overweight/obesity: 11 (100%) training -Lean body mass:
Control #1: Non-exercise group 214/140Diet + exercise/diet (10 studies):
Intervention #2: Weight-loss diet + aerobic -Body mass: 382/380
or resistance training -Fat mass: 314/316
Control #2: Weight-loss diet -Lean body mass: 325/346
Ismail et al.19 Original studies included: N = 31 Intervention duration: 8 weeks to -Visceral adipose tissue Aerobic/control (26 studies):
-Adult (≥18 years) males and females 12 months -Visceral adipose tissue:
-N (%) studies including adults: Intervention #1: Aerobic training 539/533Resistance/control (13 studies):
• with overweight/obesity: 23 (74%) Control #1: Non-exercise group -Visceral adipose tissue: 355/366Aerobic/
• non-obese, inactive: 5 (16%) Intervention #2: Resistance training resistance (8 studies):
• with type 2 diabetes: 3 (10%) Control #2: Non-exercise group -Visceral adipose tissue: 159/170
Intervention #3: Resistance training
Control #3: Aerobic training
Johansson Original studies included: N = 3 Intervention duration: 3 to 16 weeks -Weight maintenance (2 years after Exercise/control:
et al.17 -Adult (≥18 years) males and females Intervention: Initial weight-loss period initial weight loss) -Weight loss maintenance: 169/178
-N (%) studies including adults: followed by aerobic (walking) or resistance
• with overweight/obesity: 3 (100%) training + diet counseling
Control: Same initial weight-loss period
followed by diet counseling
Mabire et al.20 Original studies included: N = 22 Intervention duration: 10 weeks to -Body mass Exercise/control:
-Adult (18–65 years) males and females 12 months -Fat mass -Body mass: 864/511
-N (%) studies including adults: Intervention: Brisk walking -Body fat (%) -Fat mass: 281/181
• with overweight/obesity: 18 (82%) Control: Non-exercise group -Fat-free mass -Body fat: 707/366
• with type 2 diabetes or metabolic -Fat-free mass: 305/184
syndrome: 4 (18%)
Sardeli et al.7 Original studies included: N = 6 Intervention duration: 12 to 24 weeks -Body mass Exercise/control:
-Older (mean age >57 years) males and Intervention: Resistance training + weight- -Fat mass -Body mass: 108/184
females loss diet -Lean body mass -Fat mass: 108/184
-N (%) studies including adults: Control: Weight-loss diet -Lean body mass: 93/184
5 of 13

• with overweight/obesity: 6 (100%)

(Continues)
 6 of 13

TABLE 1 (Continued)

Reference Population characteristics Intervention and comparison Outcomes Number of participants

Schwingshackl Original studies included: N = 14 Intervention duration: 8 to 24 weeks -Body mass Aerobic/resistance (14 studies):
et al.21 -Adult (≥19 years) males and females Intervention #1: Aerobic training -Fat mass -Body mass: 273/287
-N (%) studies including adults: Control #1: Resistance training -Lean body mass -Fat mass: 199/216
• with overweight/obesity: 10 (71%) Intervention #2: Aerobic + resistance training -Lean body mass: 173/162
• inactive: 2 (14%) Control #2: Resistance training Aerobic + resistance/resistance (3 studies):
• with metabolic syndrome: 1 (7%) -Body mass: 82/91
• with older adults: 1 (7%) -Fat mass: 82/91
Thorogood Original studies included: N = 5 Intervention duration: 3 to 12 months -Body mass 6-month aerobic/control (3 studies):
et al.22 -Adult (≥18 years) males and females Intervention #1: 6-month aerobic training -Body mass: 403/380
-N (%) studies including adults: Control #1: Non-exercise group 12-month aerobic/control (2 studies):
• with overweight/obesity: 5 (100%) Intervention #2: 12-month aerobic training -Body mass: 136/129
Control #2: Non-exercise group
Turk et al.23 Original studies included: N = 18 Intervention duration: 2 weeks to 6 months -Body mass HIT + MICT:
-Adult (18–60 years) males and females Intervention #1: HIT (≥85% maxHR) -Body fat (%) -Body mass: 386
-N (%) studies including adults: Control #1: MICT -Body fat (%): 296HIIT + MICT:
• with overweight/obesity: 15 (83%) Intervention #2: HIIT (≥85% maxHR) -Body mass: 153
• with metabolic syndrome or glucose Control #2: MICT -Body fat (%): 157
intolerance: 2 (11%) The original studies included in the meta-
• inactive: 1 (6%) analysis were not reported. We were not
able to identify the number of participants
included in each group
Vissers et al.24 Original studies included: N = 9 Intervention duration: 10 weeks to -Visceral adipose tissue Exercise/control:
-Adult (≥18 years) males and females 12 months -Visceral adipose tissue: 533/457
-N (%) studies including adults: Intervention: Aerobic or resistance training,
• with overweight/obesity: 6 (67%) or combination of both
• with normal weight to obesity: 1 (11%) Control: Non-exercise group
• inactive: 1 (11%)
• with type 2 diabetes: 1 (11%)
Wewege et al.25 Original studies included: N = 13 Intervention duration: 5 to 16 weeks -Body mass 13 studies included
-Adult (18–45 years) males and females Intervention: HIIT (≥85% maxHR) -Fat mass N participants in HIIT/MICT:
-N (%) studies including adults: Control: MICT -Lean body mass -Body mass: 210/205
• with overweight/obesity: 10 (77%) -Fat mass: 180/178
• inactive: 3 (23%) -Lean body mass: 118/120

Note: Articles are presented in alphabetical order, and articles reporting results from the same trial are presented together.
Abbreviations: HIIT: high-intensity interval training; HIT, high-intensity training; MICT, moderate-intensity continuous training.
BELLICHA ET AL.
BELLICHA ET AL. 7 of 13

T A B L E 2 Overview of reviews on the effect of exercise training on weight loss, fat mass loss, and weight maintenance in adults with
overweight or obesity

Abbreviations: AET, aerobic training; EE, energy expenditure; HIIT, high-intensity interval training; MICT, moderate-intensity continuous training; NR,
not reported; RES, resistance training; WL diet, weight-loss diet.
*P < 0.05; **P < 0.01; ***P < 0.001.
8 of 13 BELLICHA ET AL.

post-intervention effect, that is, effect measured immediately after Andreato et al. directly compared HIIT and moderate-intensity
the intervention period. Findings of each included SR-MAs are pres- continuous training (MICT).9 When energy expenditure was equalized,
ented in Table S3. HIIT led to a larger weight loss but, when energy expenditure was not
equalized, MICT led to a larger weight loss. In both cases, the mean
difference was ≤700 g. No significant difference in fat loss was
3.3 | Quality of SR-MAs and original studies observed whether energy expenditure was equalized or not.
Schwingshackl et al. reported a higher weight and fat loss with aerobic
Study quality was rated as “good,” “fair,” and “poor” in three, eight, training vs. resistance training, and with a combination of aerobic and
and one SR-MAs, respectively (Table S4). All SR-MAs presented an resistance training vs. resistance training alone.21
adequate research question, predefined and specified eligibility Two SR-MAs compared a weight-loss diet with or without exer-
criteria, used a systematic search strategy and listed the main study cise. Cheng et al. included aerobic or resistance training or a combina-
characteristics and results. Most SR-MAs performed dual screening, tion of both and reported a significant additional weight and fat
assessed publication bias and heterogeneity, but only seven SR-MA loss.18 Sardeli et al. focused on resistance training and found no signif-
performed dual quality assessment. Diverse tools were used by the icant effect whatever outcome.7
authors of SR-MAs to assess the quality of original studies. Among
the seven SR-MAs that provided an overall score of study quality, the
median (range) percentage of original studies with “good” or “high” 3.4.2 | Visceral adipose tissue loss
quality was 23 (0 to 100)%.
Three SR-MAs reported a significant loss of visceral adipose tissue as
measured by imaging techniques (CT scan or MRI) after aerobic train-
3.4 | Effectiveness of exercise training ing19 or after aerobic, resistance or a combination of both24 or HIIT
(Table 3).9 No significant effect was found after resistance training.19
3.4.1 | Weight and fat loss No significant difference was found between aerobic and resistance
training (P = 0.07) and between HIIT and MICT when energy expendi-
All SR-MAs reported a significant weight loss in the exercise group ture was equalized.9
vs. a non-exercise control group, whatever the type of exercise train-
ing performed, that is, aerobic training,20,22 aerobic or resistance train-
ing or both18 and HIIT9 (Table 2). Mean weight loss ranged from −1.5 3.4.3 | Lean mass loss
to −3.5 kg. Two out of four SR-MAs reported a significant fat loss
after aerobic training20 and HIIT,9 with a mean effect ranging from Two SR-MAs reported no significant difference in lean mass loss in an
−1.3 to −2.6 kg. exercise group vs. a non-exercise control group, in spite of significant

TABLE 3 Overview of reviews on the effect of exercise training on visceral adipose tissue in adults with overweight or obesity

Abbreviations: AET, aerobic training; EE, energy expenditure; HIIT, high-intensity interval training; MICT, moderate-intensity continuous training; NR,
not reported; RES, resistance training; WL diet, weight-loss diet.
*P < 0.05; **P < 0.01; ***P < 0.001.
BELLICHA ET AL. 9 of 13

TABLE 4 Overview of reviews on the effect of exercise training on lean mass loss in adults with overweight or obesity

Abbreviations: AET, aerobic training; EE, energy expenditure; HIIT, high-intensity interval training; MICT, moderate-intensity continuous training; NR, not
reported; RES, resistance training; WL diet, weight-loss diet.
*P < 0.05; **P < 0.01; ***P < 0.001.

weight loss in the exercisers only18,20 (Table 4). One SR-MA reported control (n = 34) or a 12-month weight maintenance intervention
a lower decrease in lean body mass after resistance vs. aerobic (n = 36). The intervention included two to three supervised sessions
training,21 and one found no difference between HIIT and MICT.25 of resistance training per week. Study quality of this RCT was rated as
During a weight loss diet, one SR-MA reported a lower loss in lean fair. No significant difference was observed between groups for
body mass after resistance training only.7 Another SR-MA also during changes in body weight, fat mass, visceral adipose tissue and lean
a weight-loss diet, found a larger loss in lean body mass with exercise body mass during the weight maintenance phase.
training using various forms (either aerobic, resistance, or both) with-
out analyzing the specific effect of each of them.18
4 | DI SCU SSION/CO N CLUSIO N

3.4.4 | Weight maintenance This overview of reviews summarized the evidence published since
2010 on the effects of exercise on weight loss, changes in body com-
The SR-MA included reported no significant effect of either aerobic position and weight maintenance in adults with overweight or obesity
(n = 2 studies) or resistance training (n = 2 studies) on the amount of based on 12 SR-MAs including a total of 149 unique individual stud-
weight regain after a low-calorie diet17 (Table 2). ies. Weight and fat loss were reported in the highest number of stud-
ies, that is, 105 and 94 studies, respectively. All four SR-MAs that
compared weight loss in an exercise training group vs. a non-exercise
3.5 | Additional systematic review focusing on control group reported greater weight loss of 1.5 to 3.5 kg on average
weight maintenance in the exercise group.9,18,20,22 Also, one of two SR-MAs found an
additional weight loss of about 1 kg when adding exercise to a dietary
The search yielded 2422 articles (1419 after removing duplicates), intervention, compared to the dietary intervention alone.7,27 These
1400 of which were eliminated based on titles and abstracts alone results were extracted from five SR-MAs of which four were rated as
(Figure 1B). The full text was retrieved from 13 articles and one satis- good or fair quality and three included only RCTs, and therefore pro-
26
fied the inclusion criteria. This RCT published in 2018 included vide a reasonably high degree of confidence in this overview's conclu-
70 post-menopausal women with overweight or obesity who, after sions. They also align with literature from the previous decade4,5,28
completing a 6-month energy-deficit diet, were randomized into a and recent systematic reviews29 concluding that participation in an
10 of 13 BELLICHA ET AL.

exercise training program does favor weight loss, although of only to exercise and 13% in response to diet.36 Considering the specific
modest magnitude. It needs to be reminded that outcomes of meta- role of visceral adiposity in increased cardiometabolic risk, especially
analyses are average values that may mask or underestimate high when ≥100 cm2, such reduction is likely to provide important health
inter-individual variability in response to exercise training of weight- benefits in patients with overweight or obesity.37
30
related outcomes. For clinical purposes, it would be of interest to Another important aim of this overview was to summarize the
investigate further the predictors of higher weight loss with exercise. effect of exercise on lean body mass in adults with overweight or obe-
Compared to controls without exercise, aerobic training was con- sity. Two SR-MAs compared the change in lean mass in an exercise
sistently found to be effective on weight loss, which was not the case group and in a non-exercise control group, and both reviews found no
for resistance training.7 Comparing one to the other, a significantly difference between groups despite a higher weight loss in the exercise
greater weight and fat loss of about 1 kg for each outcome was group.18,20 Given the well-known reduction of lean mass after weight
21
reported after aerobic vs. resistance training. As previously loss,38,39 the lack of significant difference in lean mass change
suggested, the higher energy expended through aerobic compared to between an exercise group who experienced weight loss and a
resistance training might explain this difference.4 Interestingly, aerobic weight-stable control group could be viewed as actual preservation of
training (MICT) and HIIT led to similar weight and fat loss provided lean mass. These findings should, however, be interpreted with cau-
9
energy expenditure was equalized. Overall, these data emphasize the tion. A more common objective is to assess whether exercise training
importance of aerobic exercise but provide no evidence on the superi- during diet-induced weight loss helps preserve lean mass, especially in
ority of HIIT over MICT (or the reverse) to achieve weight and fat loss, older adults with obesity.40 The SR-MA by Sardeli et al.7 reported a
as long as the amount of energy expenditure is the same. Therefore, significantly lower decrease in lean mass in older adults after resis-
authors have suggested that the choice between training modalities tance training. In contrast, when assessing various forms of exercise
should rely on individual preferences.9 While HIIT is usually consid- (aerobic, resistance or both), Cheng et al. reported a higher reduction
ered a time-efficient exercise strategy compared to MICT, concern in lean mass in the exercise group.18 These findings are in agreement
has been raised about the feasibility and sustainability of HIIT in with the extensive literature showing the superiority of resistance
patients with obesity who seem to experience lower pleasure and training over other exercise modalities to stimulate muscle protein
enjoyment during HIIT than MICT.31 In addition, although HIIT is usu- synthesis and thus increase or maintain muscle mass.41
32
ally considered safe, even in adults with cardiovascular disease, its The final aim of this overview of reviews was to assess the evi-
safety in patients with obesity has not been addressed in published dence on whether exercising after weight loss may help prevent
SR-MAs, which has been attributed to insufficient reporting of weight regain, which is so common in this setting. Contrary to our
adverse events related to training.9,10,23 As recommended in persons expectations, our literature search identified only one SR-MA includ-
with chronic diseases, a thorough medical assessment should be con- ing three RCTs17 and one additional RCT published in 2018.26 These
ducted before starting HIIT in patients with obesity, and even more so studies reported no evidence of a beneficial effect of exercise on
with severe obesity, to help identify any contra-indication to partici- weight maintenance. It should be noted that the widely cited system-
pation.33 Importantly, no SR-MA focused specifically on patients with atic review by Washburn et al. was not included because these
severe obesity (BMI over 35 kg/m2) and the present findings might authors did not perform a meta-analysis.42 This previous review
therefore not be adapted to such patients. In practice, the relevance focused on the effect of exercising during the weight loss phase
of HIIT should be discussed on an individual basis after taking into (i.e., in addition to a dietary intervention) on long-term weight loss.
account the patient's motivations and the presence of comorbidities. Seven out of nine trials included reported no significant difference in
This overview of reviews also provided evidence on significant body weight between groups approximately one year after the end of
effects of exercise on visceral adiposity as measured by imaging tech- the dietary intervention.42 Overall, these findings are in line with
niques such as CT scan or MRI in patients with overweight or obesity. reviews published before 2010 stating that, at the time, well-designed
Two SR-MAs of high quality, and including almost exclusively RCTs, RCTs did not provide evidence on the effectiveness of physical activ-
reported a significant loss in visceral adipose tissue after aerobic train- ity for weight maintenance.4,6 As recently summarized,13 this is in
ing or after a combination of aerobic and resistance training.19,24 contrast with retrospective analyses of these RCTs that consistently
Although the effect of HIIT was assessed in only two original studies, showed that individuals who engaged in greater amounts of exercise
HIIT was found to be effective at decreasing visceral adiposity com- experienced less weight regain, with a dose–response relationship,
pared to a control group and equally effective as MICT when energy and that relatively large volumes of exercise (≥250 min/week) might
expenditure was equalized.9 Resistance training was the only exercise be needed to prevent weight regain.43–45 A systematic analysis of
19
modality that failed to significantly decrease visceral adipose tissue. weight control registries also found a consistent association between
When expressed in absolute values, the amount of visceral fat loss physical activity volume and weight maintenance.46 However, the
2 24
can reach 30 to 40 cm . Interestingly, there is convincing evidence recently published results of the METPOWeR trial that evaluated the
that reduction in visceral adipose tissue in response to exercise can be effectiveness of three different volumes of aerobic exercise (i.e., 150,
34,35
obtained in the absence of substantial weight loss. During moder- 225, and 300 min/week), in addition to a behavioral weight mainte-
ate weight loss, for example, 5% of initial body weight, the associated nance program, on the prevention of weight regain over 12 months
loss in visceral adipose tissue has been estimated at 21% in response after a ≥5% weight loss showed no significant difference in weight
BELLICHA ET AL. 11 of 13

regain across exercise groups.47 Overall, 88% of participants across considering the specific effects of aerobic and resistance training on
groups maintained a 5% weight loss at 12 months, and the mean one side, the well-proven benefits of HIIT on the other, but also
weight regain ranged from 1.1 kg in the low-volume exercise group to the lack of data on the safety of HIIT in adults with obesity, we
2.8 kg in the high-volume exercise group.47 Authors of this study con- recommend the careful assessment of initial health status to precisely
clude that minimal volume of exercise may favor successful weight define clinical objectives and to take into account individual
maintenance, although the study was not designed to show equiva- preferences when designing exercise training programs in adults with
47
lence between interventions. Poor adherence to exercise protocols overweight or obesity.
has been cited as the main reason why RCTs fail to demonstrate an
effect of exercise on weight maintenance.6,13,47 Finding effective ACKNOWLEDG MENTS
strategies to improve patients' adherence to exercise is therefore The authors would like to thank the European Association for the
required to provide more robust evidence on the effect of exercise on Study of Obesity (EASO) for support in conducting this work.
weight maintenance in participants with overweight or obesity, a cru-
cial issue in long-term obesity management. CONFLIC T OF INT ER E ST
No conflict of interest statement.

4.1 | Limitations AUTHOR CONTRIBU TIONS

AB and JMO performed the literature search, study selection, data
This overview of reviews synthetizes the literature on the effect of extraction, and quality assessment. All authors participated in the
exercise training programs on weight loss, body composition changes interpretation of data. AB and JMO drafted the manuscript, and all
including visceral adipose tissue, and weight maintenance. Two impor- authors critically revised the manuscript.
tant research questions were not addressed in this overview. First, we
did not assess the effect of exercise according to the duration of the OR CID
program. Even though the program duration was highly variable Alice Bellicha https://orcid.org/0000-0002-5572-487X
across original studies included in the various SR-MAs (e.g., from Nathalie Farpour-Lambert https://orcid.org/0000-0001-6478-7269
2 weeks to 6 months in the SR-MA by Andreato et al.9), only one SR- Jean-Michel Oppert https://orcid.org/0000-0003-0324-4820
MA stratified the analysis by duration of the program.22 A mean
weight loss of 1.6 and 1.7 kg was reported after a 6-month or a RE FE RE NCE S
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