homework discourages physical exercise and contributes to obesity

Physical Activity

Exercise Can Help Control Weight

Obesity results from energy imbalance: too many calories in, too few calories burned. A number of factors influence how many calories (or how much “energy”) people burn each day, among them, age, body size, and genes. But the most variable factor-and the most easily modified-is the amount of activity people get each day.

Keeping active can help people stay at a healthy weight or lose weight. It can also lower the risk of heart disease, diabetes, stroke, high blood pressure, osteoporosis, and certain cancers, as well as reduce stress and boost mood. Inactive (sedentary) lifestyles do just the opposite.

Despite all the health benefits of physical activity, people worldwide are doing less of it-at work, at home, and as they travel from place to place. Globally, about one in three people gets little, if any, physical activity. ( 1 ) Physical activity levels are declining not only in wealthy countries, such as the U.S., but also in low- and middle-income countries, such as China. And it’s clear that this decline in physical activity is a key contributor to the global obesity epidemic, and in turn, to rising rates of chronic disease everywhere.

The World Health Organization, the U.S. Dept. of Health and Human Services, and other authorities recommend that for good health, adults should get the equivalent of two and a half hours of moderate-to-vigorous physical activity each week. ( 2 – 4 ) Children should get even more, at least one hour a day. There’s been some debate among researchers, however, about just how much activity people need each day to maintain a healthy weight or to help with weight loss, and the most recent studies suggest that a total of two and a half hours a week is simply not enough.

This article defines physical activity and explains how it is measured, reviews physical activity trends, and discusses the role of physical activity in weight control.

Definitions and Measurement

Though people often use physical activity and exercise interchangeably, the terms have different definitions. “Physical activity” refers to any body movement that burns calories, whether it’s for work or play, daily chores, or the daily commute. “Exercise,” a subcategory of physical activity, refers to -planned, structured, and repetitive- activities aimed at improving physical fitness and health. ( 5 ) Researchers sometimes use the terms “leisure-time physical activity” or “recreational physical activity” as synonyms for exercise.

Experts measure the intensity of physical activity in metabolic equivalents or METs. One MET is defined as the calories burned while an individual sits quietly for one minute. For the average adult, this is about one calorie per every 2.2 pounds of body weight per hour; someone who weighs 160 pounds would burn approximately 70 calories an hour while sitting or sleeping. Moderate-intensity physical activity is defined as activities that are strenuous enough to burn three to six times as much energy per minute as an individual would burn when sitting quietly, or 3 to 6 METs. Vigorous-intensity activities burn more than 6 METs.

It is challenging for researchers to accurately measure people’s usual physical activity, since most studies rely on participants’ reports of their own activity in a survey or daily log. This method is not entirely reliable: Studies that measure physical activity more objectively, using special motion sensors (called accelerometers), suggest that people tend to overestimate their own levels of activity. ( 6 )

Worldwide, people are less active today than they were decades ago. While studies find that sports and leisure activity levels have remained stable or increased slightly, ( 7 – 10 ) these leisure activities represent only a small part of daily physical activity. Physical activity associated with work, home, and transportation has declined due to economic growth, technological advancements, and social changes. ( 7 , 8 , 10 , 11 ) Some examples from different countries:

• United Kingdom. Over the past few decades, it’s become more common for U.K. households to own second cars and labor-saving appliances. ( 13 ) Work outside the home has also become less active. In 2004, about 39 percent of men worked in active jobs, down from 43 percent in 1991-1992. ( 11 )
• China. Between 1991 and 2006, work-related physical activity in China dropped by about 35 percent in men and 46 percent in women; women also cut back on physical activity around the house-washing clothes, cooking, cleaning-by 66 percent. ( 10 ) Transportation-related physical activity has also dropped-no surprise, perhaps, given that car ownership is on the rise: Sales of new cars in China have gone up by about 30 percent per year in recent years. ( 14 )

The flip side of this decrease in physical activity is an increase in sedentary activities-watching television, playing video games, and using the computer. Add it up, and it’s clear that globally, the “energy out” side of the energy balance equation is tilting toward weight gain.

How Much Activity Do People Need to Prevent Weight Gain?

Weight gain during adulthood can increase the risk of heart disease, diabetes, and other chronic conditions. Since it’s so hard for people to lose weight and keep it off, it’s better to prevent weight gain in the first place. Encouragingly, there’s strong evidence that staying active can help people slow down or stave off “middle-age spread”: ( 13 ) The more active people are, the more likely they are to keep their weight steady; ( 15 , 16 ) the more sedentary, the more likely they are to gain weight over time. ( 17 ) But it’s still a matter of debate exactly how much activity people need to avoid gaining weight. The latest evidence suggests that the recommended two and a half hours a week may not be enough.

The Women’s Health Study, for example, followed 34,000 middle-age women for 13 years to see how much physical activity they needed to stay within 5 pounds of their weight at the start of the study. Researchers found that women in the normal weight range at the start needed the equivalent of an hour a day of moderate-to-vigorous physical activity to maintain a steady weight. ( 18 )

Vigorous activities seem to be more effective for weight control than slow walking. ( 15 , 19 , 20 ) The Nurses’ Health Study II, for example, followed more than 18,000 women for 16 years to study the relationship between changes in physical activity and weight. Although women gained, on average, about 20 pounds over the course of the study, those who increased their physical activity by 30 minutes per day gained less weight than women whose activity levels stayed steady. And the type of activity made a difference: Bicycling and brisk walking helped women avoid weight gain, but slow walking did not.

How Much Activity Do People Need to Lose Weight?

In one study, for example, researchers randomly assigned 175 overweight, inactive adults to either a control group that did not receive any exercise instruction or to one of three exercise regimens-low intensity (equivalent to walking 12 miles/week), medium intensity (equivalent to jogging 12 miles/week), or high intensity (equivalent to jogging 20 miles per week). All study volunteers were asked to stick to their usual diets. After six months, those assigned to the high-intensity regimen lost abdominal fat, whereas those assigned to the low- and medium-intensity exercise regimens had no change in abdominal fat. ( 21 )

More recently, researchers conducted a similar trial with 320 post-menopausal women, randomly assigning them to either 45 minutes of moderate-to-vigorous aerobic activity, five days a week, or to a control group. Most of the women were overweight or obese at the start of the study. After one year, the exercisers had significant decreases in body weight, body fat, and abdominal fat, compared to the non-exercisers. ( 23 )

How Does Activity Prevent Obesity?

Researchers believe that physical activity prevents obesity in multiple ways: ( 24 )

• Physical activity increases people’s total energy expenditure, which can help them stay in energy balance or even lose weight, as long as they don’t eat more to compensate for the extra calories they burn.
• Physical activity decreases fat around the waist and total body fat, slowing the development of abdominal obesity .
• Weight lifting, push-ups, and other muscle-strengthening activities build muscle mass, increasing the energy that the body burns throughout the day-even when it’s at rest-and making it easier to control weight.
• Physical activity reduces depression and anxiety, ( 3 ) and this mood boost may motivate people to stick with their exercise regimens over time.

The Bottom Line: For Weight Control, Aim for an Hour of Activity a Day

Being moderately active for at least 30 minutes a day on most days of the week can help lower the risk of chronic disease. But to stay at a healthy weight, or to lose weight, most people will need more physical activity-at least an hour a day-to counteract the effects of increasingly sedentary lifestyles, as well as the strong societal influences that encourage overeating.

Keep in mind that staying active is not purely an individual choice: The so-called “built environment”-buildings, neighborhoods, transportation systems, and other human-made elements of the landscape-influences how active people are. ( 25 ) People are more prone to be active, for example, if they live near parks or playgrounds, in neighborhoods with sidewalks or bike paths, or close enough to work, school, or shopping to safely travel by bike or on foot. People are less likely to be active if they live in sprawling suburbs designed for driving or in neighborhoods without recreation opportunities.

Local and state governments wield several policy tools for shaping people’s physical surroundings, such as planning, zoning, and other regulations, as well as setting budget priorities for transportation and infrastructure. ( 27 ) Strategies to create safe, active environments include curbing traffic to make walking and cycling safer, building schools and shops within walking distance of neighborhoods, and improving public transportation, to name a few. Such changes are essential to make physical activity an integral and natural part of people’s everyday lives-and ultimately, to turn around the obesity epidemic.

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2. World Health Organization. Global recommendations on physical activity for health ; 2011. Accessed January 30, 2012.

3. U.S. Dept. of Health and Human Services. 2008 Physical Activity Guidelines for Americans ; 2008. Accessed January 30, 2012.

4. Haskell WL, Lee IM, Pate RR, et al. Physical activity and public health: updated recommendation for adults from the American College of Sports Medicine and the American Heart Association. Circulation . 2007; 116:1081-93.

5. Caspersen CJ, Powell KE, Christenson GM. Physical activity, exercise, and physical fitness: definitions and distinctions for health-related research. Public Health Rep . 1985; 100:126-31.

6. Troiano RP, Berrigan D, Dodd KW, Masse LC, Tilert T, McDowell M. Physical activity in the United States measured by accelerometer. Med Sci Sports Exerc . 2008; 40:181-8.

7. Juneau CE, Potvin L. Trends in leisure-, transport-, and work-related physical activity in Canada 1994-2005. Prev Med . 2010; 51:384-6.

8. Brownson RC, Boehmer TK, Luke DA. Declining rates of physical activity in the United States: what are the contributors? Annu Rev Public Health . 2005; 26:421-43.

9. Petersen CB, Thygesen LC, Helge JW, Gronbaek M, Tolstrup JS. Time trends in physical activity in leisure time in the Danish population from 1987 to 2005. Scand J Public Health . 2010; 38:121-8.

10. Ng SW, Norton EC, Popkin BM. Why have physical activity levels declined among Chinese adults? Findings from the 1991-2006 China Health and Nutrition Surveys. Soc Sci Med . 2009; 68:1305-14.

11. Stamatakis E, Ekelund U, Wareham NJ. Temporal trends in physical activity in England: the Health Survey for England 1991 to 2004. Prev Med . 2007; 45:416-23.

12. McDonald NC. Active transportation to school: trends among U.S. schoolchildren, 1969-2001. Am J Prev Med . 2007; 32:509-16.

13. Wareham NJ, van Sluijs EM, Ekelund U. Physical activity and obesity prevention: a review of the current evidence. Proc Nutr Soc . 2005; 64:229-47.

14. Kjellstrom T, Hakansta C, Hogstedt C. Globalisation and public health-overview and a Swedish perspective. Scand J Public Health Suppl . 2007; 70:2-68.

15. Mekary RA, Feskanich D, Malspeis S, Hu FB, Willett WC, Field AE. Physical activity patterns and prevention of weight gain in premenopausal women. Int J Obes (Lond) . 2009; 33:1039-47.

16. Seo DC, Li K. Leisure-time physical activity dose-response effects on obesity among US adults: results from the 1999-2006 National Health and Nutrition Examination Survey. J Epidemiol Community Health . 2010; 64:426-31.

17. Lewis CE, Smith DE, Wallace DD, Williams OD, Bild DE, Jacobs DR, Jr. Seven-year trends in body weight and associations with lifestyle and behavioral characteristics in black and white young adults: the CARDIA study. Am J Public Health . 1997; 87:635-42.

18. Lee IM, Djousse L, Sesso HD, Wang L, Buring JE. Physical activity and weight gain prevention. JAMA . 2010; 303:1173-9.

19. Mekary RA, Feskanich D, Hu FB, Willett WC, Field AE. Physical activity in relation to long-term weight maintenance after intentional weight loss in premenopausal women. Obesity (Silver Spring) . 2010; 18:167-74.

20. Lusk AC, Mekary RA, Feskanich D, Willett WC. Bicycle riding, walking, and weight gain in premenopausal women. Arch Intern Med . 2010; 170:1050-6.

21. Slentz CA, Aiken LB, Houmard JA, et al. Inactivity, exercise, and visceral fat. STRRIDE: a randomized, controlled study of exercise intensity and amount. J Appl Physiol . 2005; 99:1613-8.

22. McTiernan A, Sorensen B, Irwin ML, et al. Exercise effect on weight and body fat in men and women. Obesity (Silver Spring) . 2007; 15:1496-512.

23. Friedenreich CM, Woolcott CG, McTiernan A, et al. Adiposity changes after a 1-year aerobic exercise intervention among postmenopausal women: a randomized controlled trial. Int J Obes (Lond) . 2010.

24. Hu FB. Physical Activity, Sedentary Behaviors, and Obesity. In: Hu FB, ed. Obesity Epidemiology. New York: Oxford University Press; 2008:301-19.

25. Sallis JF, Glanz K. Physical activity and food environments: solutions to the obesity epidemic . Milbank Q . 2009; 87:123-54.

26. Khan LK, Sobush K, Keener D, et al. Recommended community strategies and measurements to prevent obesity in the United States. MMWR Recomm Rep . 2009; 58:1-26.

27. Robert Wood Johnson Foundation, Leadership for Healthy Communities. Action Strategies Toolkit . Accessed January 30, 2012.

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Effects of Physical Activity, Exercise, and Fitness on Obesity-Related Morbidity and Mortality

Lavie, Carl J. MD; Carbone, Salvatore PhD; Kachur, Sergey MD; O'Keefe, Evan L. BS; Elagizi, Andrew MD

1 Department of Cardiovascular Diseases, John Ochsner Heart and Vascular Institute, Ochsner Clinical School, The University of Queensland School of Medicine, New Orleans, LA

2 VCU Pauley Heart Center, Division of Cardiology, Department of Internal Medicine, Richmond, VA.

Address for correspondence: Carl J. Lavie, MD, FACC, FACP, FCCP, FESPM, John Ochsner Heart and Vascular Institute, Ochsner Clinical School, The University of Queensland School of Medicine, 1514 Jefferson Highway, New Orleans, LA 70121-2483; E-mail: [email protected] .

Obesity is associated with increased prevalence of cardiovascular (CV) disease (CVD) risk factors, which may adversely impact CV structure and function and may increase the prevalence of most CVD, particularly heart failure (HF) and coronary heart disease (CHD). Physical activity (PA), exercise training (ET) and cardiorespiratory fitness (CRF) are all associated with marked reductions in most CVD, including HF and CHD. Additionally, PA/ET and, especially CRF, markedly alter the relationship between adiposity and subsequent major CVD outcomes and dramatically impact the “obesity paradox,” which are all reviewed, including attention to the debate regarding “fitness versus fatness” for long-term prognosis, including in patients with established CVD.

Introduction

Overweight and obesity have reached epidemic levels in the United States and most of the Westernized world, with nearly three-fourths of adults in the United States ( 1,2 ). In fact, in 2016, the prevalence of obesity among U.S. adults based on body mass index (BMI) criteria (BMI ≥ 30 kg·m 2 ) was nearly 40%, and the prevalence of severe or class III obesity (BMI ≥ 40 kg·m 2 ) had reached almost 8% ( 2 ), resulting in huge health care costs and reduced productivity that exacts a heavy toll on many aspects of our society as well as the economy ( 1 ). Clearly, great efforts are needed to prevent overweightness and obesity in the first place and to prevent further weight gain in children and adults ( 1 ).

Obesity has been independently associated with an increased risk for most cardiovascular (CV) disease (CVD) risk factors, including dyslipidemia, hypertension (HTN), impairment of glucose metabolism (metabolic syndrome [MetS] and type 2 diabetes mellitus [T2DM]), as well as levels of systemic low-grade inflammation, markedly increasing the risk of coronary heart disease (CHD) ( 1,3 ). Obesity also has been associated with abnormal CV structure and function, ultimately leading to systolic and, especially, diastolic heart failure (HF) ( 1,3–6 ). Additionally, obesity is associated with a marked increase in atrial fibrillation (AF), a disease with increasing worldwide prevalence ( 7 ).

Despite the effects of obesity on increasing CVD risk ( 1,3,4,8–12 ), many individual studies and meta-analyses in HTN, CHD, HF, and AF have demonstrated an obesity paradox ( 13 ), where underweight and normal BMI patients with CVD have worse prognoses than do their heavier counterparts. However, in various commentaries and editorials, details about the obesity paradox have been questioned, including the potential for collider bias to impact the relationship between obesity and prognosis ( 14–18 ).

In this review, we will discuss the effects of physical activity (PA), exercise training (ET), and cardiorespiratory fitness (CRF) in modifying mortality and the effects of the obesity paradox. Additionally, we will review the controversial “fitness versus fatness” debate that has been ongoing now for over two decades.

Importance of PA, ET, and CRF

Although substantial evidence has emphasized the adverse effects of sedentary behavior and physical inactivity on CVD and overall survival, about 80% of U.S. adults and adolescents have low levels of PA ( 19 ), but also of ET and overall CRF, which is perhaps one of the strong, if not the strongest, CVD risk factors and predictors of CVD and all-cause mortality ( 20,21 ). The relationship is inverse, CV health is independently associated with high levels of PA, which is, in turn, associated with an increased risk of CVD ( 20–22 ). In fact, low PA is associated with between 6% and 10% of noncommunicable chronic diseases worldwide, including CHD, T2DM, as well as breast and colon cancer ( 22 ). Low levels of PA were estimated to account for more than 5.3 million global deaths in 2008, and in the United States, CVD-specific and all-cause mortality was advanced by 2.4 and 4 years, respectively, as a result of low PA ( 22,23 ). Clearly, low PA adversely impacts the MetS and almost all of the CVD/CHD risk factors ( 20,21,24 ).

PA and ET are associated with improvements in overall CV health and longevity; however, much of these benefits may result from the PA/ET-induced improvements in CRF, which is a much stronger predictor of prognosis than PA/ET alone ( 20,21,23–25 ). Although PA and ET are the major contributors to CRF, there also is a genetic nonexercise component of CRF that also impacts prognosis independently of PA/ET ( 20,21,23–25 ). Similar to high levels of PA/ET, high CRF also is associated with reduced CHD/CVD risk factors ( 20,21,23–25 ). More importantly, however, many studies have demonstrated the powerful impact of CRF levels on overall prognosis, which has been noted in large population-based studies, clinical cohorts, such as those who have high risk of CVD, as well as in CVD populations, such as CHD, HF, and AF ( 20,21,24–27 ). In fact, nearly a decade ago, Kodama and colleagues ( 28 ) found that every estimated metabolic equivalent (MET) increase in CRF was associated with 13% and 15% reductions in all-cause and CVD/CHD mortalities, respectively. Blair et al. ( 29 ) previously demonstrated that men who were rated in the bottom quintile of CRF on an earlier examination, but later improved their CRF on a second examination after approximately 5 years, had a 52% reduction in CVD mortality compared with men who remained unfit. Likewise, Lee and colleagues ( 30 ) demonstrated that individuals presenting with preserved or improved CRF after more than 6 years from their initial CRF assessment had a reduction in CVD mortality of 27% and 42%, respectively, and every 1 MET increase over time was associated with reductions in all-cause and CVD-related mortality of 15% and 19%, respectively.

Fitness Versus Fatness

Kennedy and colleagues have recently reviewed the decades-long debate about the relative effects of fitness versus fatness on prognosis ( 31 ). Their data suggested that high levels of CRF significantly attenuated or even completely eliminated the elevated risk of all-cause and CVD-related mortality among overweight and obese cohorts, a finding supported by several other publications ( 1,3,20,21,31 ). Of note, separating the individual effects of obesity from those of CRF is not an easy task, as most measures of CRF ( i.e., peak V˙O 2 ), also includes body weight ( i.e. , mL·kg −1 ·min −1 ). For such reason, the lean peak V˙O 2 , which uses fat-free mass instead of total body, has been proposed as a better measure of CRF in individuals with obesity ( 32 ).

Recently, Barry and colleagues ( 33 ) performed a meta-analysis on eight studies and nine independent cohorts to assess the joint impact of BMI and CRF on CVD mortality. Unfit individuals generally were associated with a two-fold to three-fold higher mortality across all levels of BMI. However, fitness did not completely abolish the adverse effects of BMI on prognosis. In fact, both overweight fit and obese fit were associated with a 25% and 42% increased mortality risk, respectively, compared with normal weight fit, but this was still considerably less than the over two-fold of the associated increased risk in the unfit individuals. Therefore, the constellation of findings still suggests that although both fitness and weight matter for long-term prognosis, the best scenario is for all individuals to remain fit across the lifespan ( 1,21,31,34 ). Given that fitness remains a stronger prognosticator than fatness/weight for long-term prognosis, it would be better to have excess weight and maintain high levels of CRF than be underweight with the same levels of CRF when looking at long-term prognosis ( 1,21,31,34 ).

We have recently reviewed the impact of obesity on the development of CVD, including HTN, CHD, HF, and AF, as well as on the prognosis of cohorts with these established forms of CVD ( 1,21 ). As mentioned earlier, obesity is associated with an increased risk of almost all of the CVD/CHD risk factors, which may adversely impact CV structure and function ( Fig. 1 ) ( Table 1 ) ( 1 ). Not surprisingly, obesity is associated with marked increases in the risk of most major CVD, including HTN, CHD, HF, and AF ( 1,3–5,8–12 ). However, in these cohorts with established CVD, many individual studies and large meta-analyses have repeatedly demonstrated a strong obesity paradox, where overweight and at least mildly obese subjects with CVD not only seem to have a much better prognosis than do the underweight CVD patients but also a better prognosis than those patients with “normal” BMI levels ( 1,3–5,7,9,11–13,20,35–37 ). Although the exact mechanisms for the obesity paradox remain unclear, some potential reasons are listed in Table 2 . In discussing the obesity paradox, it is important to remember that levels of CRF markedly impact prognosis, including in patients with CHD, HF, and more recently, AF ( 1,3–7,9,11,13,20,35,36,38 ).

In a study of nearly 10,000 patients with CHD followed up for an average of nearly 13 years, the unfit individuals defined as having CRF in the bottom tertile based on age and sex demonstrated a strong obesity paradox. In fact, in these individuals with CHD, higher measures of adiposity, including percent body fat, waist circumference, as well as BMI, were associated with improved prognosis compared with thinner unfit individuals ( Fig. 2 ) ( 39 ). However, the “relatively fit” individuals not falling into the bottom tertile of CRF had an excellent prognosis ( i.e. , all-cause mortality and CVD mortality), which was independent of the levels of adiposity (BMI, waist circumference, or percent body fat). These results suggest that increased adiposity was no longer protective among CHD patients with relatively preserved levels of CRF. A recent study from Norway also demonstrated that PA levels were stronger predictors of all-cause mortality than were levels of BMI or body weight ( 40 ). Although changes in PA modified mortality in CHD patients, changes in BMI ( i.e. , weight loss) did not ( 41 ). In an analysis of 14,486 patients with CHD, ET-based cardiac rehab was associated with a 26% reduction of cardiovascular mortality at 12 months ( 42 ). Taken together, these studies support the importance of PA, ET and increased CRF in reducing CVD and all-cause mortalities in patients with CHD, independently of obesity. Furthermore, it suggests that even in the setting of obesity and established CHD, clinicians should dedicate greater attention to the assessment of PA and CRF, and implement therapies aimed at improving both aspects.

Similar to the patients with CHD, levels of CRF may influence the impact of obesity on the risk for HF, especially those with HF and reduced ejection fraction (HFrEF) ( 3–6,43–46 ). In the largest randomized controlled study to date investigating the effects of aerobic ET on clinical events in >2,300 patients with HFrEF, ET was associated with a small 4% improvements on CRF, which was lower than the predicted improvements of 10% to 15% ( 47 ). Despite the lower than expected improvements in CRF, after adjustment for prespecified key clinical endpoint, ET induced with a significant 13% reduction for the primary composite endpoint of all-cause mortality and all-cause hospitalizations and a 15% reduction for the composite secondary end point of CVD mortality and HF hospitalizations ( 47 ). Of note, such effects were independent of BMI ( 48 ).

In a recent analysis of more than 20,000 male veterans, obesity was associated with a 22% increase in HF risk ( 46 ). However, this was no longer significant after adjustments for CRF ( 46 ), suggesting that the increased risk for HF conferred by obesity may be mediated by the marked reduction of CRF in this population. In a study of 2066 patients with HFrEF using a cardiopulmonary stress testing database, those with reduced CRF defined as peak exercise oxygen consumption (V˙O 2 ) < 14 mL·kg −1 ·min −1 , a strong obesity paradox was evident; after excluding the underweight patients with BMI < 18.5 kg·m 2 , who typically have the highest mortality, those with reduced CRF and normal BMI (18.5–25 kg·m 2 ) presented the highest mortality, followed by the overweight individuals, while the obese patients had the best survival ( Fig. 3 ) ( 48,49 ). However, among those with relatively preserved CRF (peak V˙O 2 14 mL·kg −1 ·min −1 ), survival rate was significantly greater than the low-fitness cohort and were independent of BMI. It should be noted, however, that almost all of the obese in this study were classified as having class I obesity (BMI, 30–34.9 kg·m 2 ), with only a few having class II obesity (BMI ≥ 35 kg·m 2 ), and none having severe obesity (BMI ≥ 40 kg·m 2 ). McAuley et al. ( 50 ) have recently studied 774 individuals with HF from Henry Ford Exercise Testing Project and also found that those HF patients with low CRF had an obesity paradox, with those with obesity presenting a lower mortality. However, in those individuals with average to high levels of CRF, there was no inverse association between obesity and mortality. In large studies from UCLA in patients with HF, high CRF levels were strongly protective against mortality, and again an obesity paradox was only noted among those with low levels of CRF ( 51 ). In regard to PA, although no large randomized controlled trials in HF have been conducted to date, in an analysis of 781 patients with HF with recent implantation of implantable cardioverter defibrillator or cardiac resynchronization therapy, greater early level of objectively measured PA were associated with a 4% reduction for the composite endpoint of all-cause mortality and HF hospitalization after approximately 15 months ( 52,53 ). Therefore, as in patients with CHD, the level of PA and CRF markedly alters the relationship between excess adiposity (obesity) and mortality risk in the HF population ( 49–51 ).

There also is evidence to suggest that PA is associated with small reductions in the risk of incident AF, even in the presence of overweightness ( 7,53,54 ). Also, CRF is a predictor of arrhythmia-free survival with or without specific rhythm control strategies for management of AF ( 7,55 ). In fact, higher baseline CRF, gain in CRF of ≥2 MetS from ET, and intentional weight loss were all associated with greater AF-free survival. A gain of ≥2 MetS resulted in a two-fold greater chance of AF-free survival ( 7,55 ). There is little current evidence for purposeful weight loss benefitting CHD and HF, at least with regard to major clinical CVD events. However, in AF reductions of weight > 10% with dietary/ET therapy was found to be associated with greater than six-fold probability of arrhythmia-free survival compared with those who lost 3% to 9% of body weight or <3% of body weight ( 7,56 ). Though it is important to note that weight fluctuations of ≥5%, often reported in patients with obesity attempting to lose weight, partially offset these benefits, with a two-fold increased risk of recurrence of AF ( 7,56 ).

Current PA/ET Recommendations

The current 2018 Physical Activity Guidelines suggest that 150 to 300 min·wk −1 of moderate PA or 75 min·wk −1 of vigorous PA are needed for all adults ( 57 ). While in the past a minimum of 10-min increments of PA was required to be included in the total daily PA, the most recent guidelines recommend that all movements and levels of PA also count. Adults also should do two or more sessions per week of resistance exercise or weight training, which has recently been shown to be associated with CVD mortality reductions independent of CRF ( 58,59 ). Older adults (over 80 years of age) also should do balance training. Children 3 to 5 years of age should be active throughout the day, and those 6 to 17 years should do at least 60 min·d −1 of moderate to vigorous PA on most days. Certainly, PA and ET which increase levels of CRF are even more beneficial than lower-intensity ET alone, as studies suggest that more vigorous PA, such as high-intensity interval training, has more beneficial effects on CV structure and function and on improving levels of CRF than do lower-intensity ET ( 20,21,24–27,60 ).

The impact of PA/ET on weight maintenance and weight loss has recently been reviewed in detail by Swift and colleagues ( 61 ). In overweight/obesity, PA <150 min·wk −1 may be associated with weight maintenance, but usually minimal to no significant weight loss. PA/ET of 150 to 225 min·wk −1 is often associated with weight loss of 2 kg to 3 kg; 225 to 420 min·wk −1 produces 5 to 7 kg of weight loss; and 200 to 300 min·wk −1 is often needed for weight maintenance after the desirable weight loss is achieved ( 61,62 ). Of course, as reviewed earlier, PA/ET that improve levels of CRF also will markedly improve the prognosis of overweight and obese patients, in addition to preventing further weight gain and even producing some weight loss ( 1,3–7,20,21,24–27,34 ).

Summary and Conclusions

In a perfect world, everyone would maintain a body weight within normal range and remain fit throughout the lifespan, which would be associated with marked reductions in CVD. However, this is far from the case in current society, with most gaining excess weight and losing fitness with age. Importantly, weight gain may be less deleterious than the loss of fitness throughout the lifespan, as the constellation of evidence suggests that fitness is more important than weight/fatness for predicting prognosis. Not only does PA/ET and CRF protect against developing CVD, it markedly impacts the prognosis of patients with established CVD, especially CHD and HF. Although we and others have described an obesity paradox among patients with CVD, this seems to be only present in those with low levels of CRF. In CHD and HF patients with relatively preserved CRF, survival is excellent regardless of adiposity. Therefore, therapies targeting improvements in CRF, such as PA and ET, are urgently needed to be implemented throughout society and the health care system for the primary and secondary prevention of CVD and all-cause mortality.

Salvatore Carbone is supported by a Career Development Award 19CDA34660318 from the American Heart Association. The authors declare no conflict of interest and do not have any additional financial disclosures.

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• Winter 2014 - Issue Number 97

Human metabolism and obesity: the influence of exercise

This article discusses the effects of physical activity and exercise programmes on human metabolism and obesity. it demonstrates how exercise and physical activity are important regardless of body weight or composition, and reports on a number of successful interventions including community-based exercise programmes that have reduced body fat and improved health outcome markers in overweight/obese individuals..

Dr Naomi Brooks & Dr Stuart Galloway Health & Exercise Sciences Research Group, University of Stirling, UK

https://doi.org/10.36866/pn.97.21

The rapid and continuing rise in obesity throughout both the developed and developing world is a current critical world health issue. Increased levels of obesity are a major challenge to public health with obesity contributing to increased cases of type 2 diabetes, cardiovascular disease, stroke, cancer and loss of quality of life. Metabolic syndrome and type 2 diabetes are also key factors influencing cardiovascular disease risk. Further, location of adipose tissue – i.e. abdominal adipose and intra-abdominal (visceral) adipose tissue – is associated with increases in the risk of cardiometabolic disease. Morbidity and mortality from cardiometabolic disease put a great burden on individuals, families and communities and put an increased financial burden on health care systems.

At its most simple, obesity is considered to be caused by increased energy intake without concomitant energy usage. However, it is not that simple. Environmental and behavioural factors including increased calorie consumption and food intake (foods high in sugar and fat) can influence the energy imbalance. Decreases in physical activity also contribute, some would argue more so, to the obesity crisis. Physical inactivity and sedentary lifestyle are independent risk factors for metabolic disorders. Adequate physical activity is required for metabolic health and acts to reduce risk factors associated with atherosclerosis and metabolic disorders, particularly rectifying high blood pressure, insulin resistance, glucose intolerance, low HDL-cholesterol, high LDL-cholesterol, and high triglycerides. Physical activity in addition to reduced sedentary time (sitting less) is therefore recommended in both prevention and treatment of these metabolic disorders.

An increased body mass, measured by body mass index (BMI: mass (kg)/height (m)2), has been consistently reported to be linked to increased mortality and morbidity throughout the lifespan. The recommended BMI for a healthy individual is 18.5–24.9 kg/m2; overweight is defined as BMI of 25–29.9 kg/m2 and obese is defined as ≥30 kg/m2. However, BMI does not take into consideration body composition or location of fat mass.

Obese individuals develop health complications due to an increasing number and size of adipocytes (increasing fat mass). The increased size and number of adipocytes leads to dysfunction and cellular stress which contributes to insulin resistance, increased inflammation and increases in circulating lipids (for detailed review see Capurso & Capurso, 2012). Obese individuals develop resistance to the cellular effects of insulin, which displays as an impaired ability of insulin to stimulate glucose uptake from plasma into fat and muscle cells. It is thought that increased fatty acids (FAs) combined with lipid metabolites/signalling molecules interfere with the insulin-signalling pathway and can impair the actions of insulin and contribute to insulin resistance (Fig. 1). The resistance to the action of insulin results in elevated plasma glucose concentration (see Table 1 for normal values). The pancreas continues to secrete insulin in an attempt to reduce blood glucose concentration and eventually the beta-cells fail, and individuals with type 2 diabetes then require insulin therapy.

The adipocytes themselves are not inactive cells but are extremely important in human metabolism. Adipocytes secrete metabolically active proteins (adipokines) such as leptin, adiponectin and resistin, which contribute to healthy metabolism and are altered with obesity. Alterations of adipokine secretion lead to pathological consequences such as insulin resistance and increases in plasma lipid concentration. Adipocytes also contribute to the increased systemic inflammation noted with obesity, including increases in tumor necrosis factor-α, interleukin-6 and C-reactive protein, which are associated with insulin resistance and CVD. In addition, the increase in circulating FAs and other lipids leads to increased storage of fat in other tissues such as triglycerides in skeletal muscle and liver. While an increase in fat storage in muscle provides an important fuel source for some (i.e. athletes), in others such as non-active obese individuals, this has been further linked to insulin resistance (Fig. 1). Indeed, the capacity to oxidise FA seems an important determinant of the impact of caloric excess and obesity on insulin resistance. It is now well recognised that increasing the capacity of skeletal muscle to oxidise lipids, through exercise induced increases in mitochondrial volume, can effectively restore insulin sensitivity. This effect would likely be larger if both caloric restriction and exercise were adopted.

Skeletal muscle is an extremely important metabolic tissue and uses glucose and fat as well as amino acids for energy production. Glucose is a key fuel utilised in skeletal muscle during exercise and this uptake and usage is independent of insulin action. Thus, individuals who are insulin resistant, such as those with type 2 diabetes, can reduce blood glucose by increased use of their skeletal muscle mass. Physical activity, particularly in the fasted state, can also reduce the pathological complications of metabolic dysfunction in obesity by increasing oxidation of blood borne and intramuscular FAs, reducing the impact of these FAs on insulin resistance. Chronic bouts of contraction of skeletal muscle (e.g. exercise training) lead to production of myokines and anti-inflammatory responses, which reduce reactive oxygen species, mitochondrial dysfunction and ER stress, all of which contribute to reducing metabolic dysfunction. Interestingly, there appears to be a relationship between intensity and volume of physical activity and the cardiovascular/metabolic health outcomes. Research from competitive athletes suggests that their physical activity volume is conducted predominantly at low intensity (~75–80%) and with very little at moderate exercise (~5–10%) and a larger amount at vigorous intensity (~15–20%). Adopting these activity durations/distributions can produce greater cardiovascular and metabolic adaptations (Neal et al. 2013) in well-trained recreational athletes, which suggests that targeting physical activity intensity at the light and vigorous intensity ends of the spectrum could be more beneficial for health. Vigorous activity produces health improvements such as reducing adiposity and risk markers of cardiovascular and metabolic diseases (e.g. increases aerobic capacity and reduces fat mass). Thus, there are strong associations between aerobic fitness, amount of vigorous activity, and adiposity that are important in reducing cardiovascular and metabolic disease risk markers.

Physical activity and exercise have consistently been shown to improve health outcomes in individual and group exercise programmes, albeit with varying degrees of individual responsiveness. While there is consistent evidence that BMI is a predictor of all-cause mortality, and therefore reducing BMI is of benefit health-wise, there are a number of paradoxes to this thinking. Of particular interest is the FIT FAT phenomenon recently reviewed by McAuley & Blair (2011), which suggests obesity is not a risk factor for mortality in fit individuals. The FIT FAT phenomenon is based on evidence that obese individuals who are fit are at no greater risk for mortality than normal weight fit individuals. However, the likelihood of being fit is also related to BMI, with higher numbers of normal weight individuals being considered to have higher fitness levels compared to overweight individuals (i.e. NHANES, Duncan et al . 2010). These observations further highlight the importance of exercise and particularly moderate to vigorous exercise in maintaining health, regardless of body mass or BMI. While weight loss is important to obese and overweight individuals, increasing physical activity and exercise to improve fitness is of importance to healthy outcomes regardless of weight loss. This is a key aspect often missed when interpreting results of exercise programmes and when planning interventions for improvements in health.

An excellent recent example of a successful public health intervention involving a research programme of lifestyle intervention has been running for the last 4 years in Scotland. The Football Fans in Training (FFIT) is a 12-week, gender-sensitised weight management and physical activity programme delivered to groups of men at Scottish Premier League clubs. The programme has been led by the University of Glasgow and was developed to use scientific approaches to weight loss, physical activity and diet, which are delivered to participants at their football clubs. The aim of the intervention was to encourage individuals to make lifestyle changes to reduce their risk of ill health by losing weight, becoming more physically active and consuming a healthier diet. Individuals were recruited from football clubs throughout Scotland. After a successful pilot study (Gray et al. 2013) showed that the 12-week intervention was feasible and can have a positive effect on lifestyle choices, reduced obesity and increased physical activity, the project was expanded to include football clubs throughout Scotland.

The recent report on this study published in The Lancet (Hunt et al. 2014) details a follow-up of the 747 individuals who took part in the 12-week FFIT programme. Each week participants had one 90-minute session, which included combined advice on healthy diet with physical activity. After 12 weeks, average mass loss was 5.8 kg, waist circumference reduced by 6.7 cm, BMI by 1.9 kg/m2, body fat percentage by 3%, systolic BP by 8 mmHg and diastolic BP by 4 mmHg (all statistically significant). Improvements were reported in dietary intake with reduced fatty food intake, sugary food score, and alcohol consumption, and increased fruit and vegetable score (all significantly different from baseline). The 12 month follow-up reported waist circumference reduced from baseline by 7.3cm, BMI reduced by 1.8 kg/m2, body fat percentage by 2%, systolic BP by 8 mmHg and diastolic BP by 5 mmHg (all statistically significant). The alterations reported in diet were maintained at 12 months. Significant increases in self-esteem, mental and physical health, and quality of life were all noted after 12 weeks and remained higher than baseline at 12 months. The FFIT programme has been hugely successful at encouraging lifestyle changes and increases in physical activity for overweight and obese men. Furthermore, the study targeted a population who are generally reluctant to join exercise programmes, and there was a 90% retention of individuals in the programme – a key point in its ongoing success.

Another older success story of the positive effects of exercise and lifestyle changes on metabolic health is reported with the Diabetes Prevention Program, a large randomised clinical trial involving individuals who were at risk for developing type 2 diabetes in the USA (Knowler et al . 2002). The aim of the study was to investigate whether lifestyle intervention or treatment with metformin (a popular drug to treat diabetes) could prevent or delay the onset of diabetes. Participants in the study were at risk for type 2 diabetes, with BMI of ≥24 kg/m2 and fasting plasma glucose of 5.3 – 6.9 mmol/L. Individuals in the study were randomly assigned to one of three interventions: standard lifestyle recommendations with metformin (initially 850 mg once/day and increased to 850 mg twice/day after 1 month); standard lifestyle recommendations with placebo; or an intensive programme of lifestyle modifications. The intensive programme of lifestyle modifications involved a 16-lesson curriculum containing diet, exercise and behaviour modifications. The goal was to achieve and maintain a 7% weight reduction through low-calorie, low-fat diet and engage in physical activity of moderate intensity for at least 150 minutes/week. The study included 3234 individuals (average age 50.6 ±10.7 years) and the average follow-up was 2.8 years. At follow-up, the placebo group had incidence of diabetes with 11.0 cases/100 person years. The group given metformin had a reduced incidence of diabetes (7.8 cases/100 person years; 31% lower). However, the lifestyle intervention group had a significantly lower incidence of diabetes than both the placebo and the metformin group (4.8 cases/100 person years; 58% lower). The results show that individuals in the lifestyle group decreased energy intake by ~450 kcal/day and increased physical activity to the greatest degree. Thus, lifestyle interventions can be more effective than current prescription drugs for treating and preventing diabetes.

Finally, there has been a lot of recent attention on short-term high-intensity interval training (HIIT) and the benefits to metabolic health. Skeletal muscle is highly adaptable to exercise and short-duration high-intensity exercise bouts can significantly improve skeletal muscle metabolism. It appears that the disturbance in homeostasis at exercise onset, i.e. the beginning of a HIIT session, or the high rate of utilisation of glucose/glycogen is fundamental for upregulation of key regulators in skeletal muscle fat and carbohydrate metabolism. Thus, repeated rest-to-exercise transitions, which occur over a short period, appear to be a beneficial way to increase whole body fat metabolism. Adopting this approach in seven high intensity interval training sessions over 2 weeks led to an increase in whole body fat oxidation during exercise by 36%, and increased skeletal muscle capacity to oxidise FAs in women (Talanian et al. 2007). This type of exercise intervention has been reported to have great promise for individuals with impaired metabolic responses and has been shown to increase fat metabolism and reduce body fat stores in obese individuals. Alternatively, sprint interval training has also been shown to have similar effects on skeletal muscle metabolic adaptation in a time efficient manner (reviewed in Gibala et al. 2012). Furthermore, Gibala et al. (2012) discuss in detail how HIIT training has been used effectively to improve cardiorespiratory fitness in individuals at risk for CVD and metabolic disease.

In addition to the positive influences of exercise, dietary restriction and associated mass loss remain influential in the pursuit for health and reduction in obesity and consequential effects. A promising recent study reports evidence that the beta-cell dysfunction and insulin resistance characterised in type 2 diabetes can be reversed (Lim et al . 2011). The project undertaken at Newcastle University investigated the effects of a very low energy intake (600 kcal/day) on type 2 diabetes. Participants had type 2 diabetes (age 49.5 ± 2.5 years) and BMI of 33.6 ± 1.2 kg/m2. After 1 week of energy restriction, fasting plasma glucose concentration normalised to 5.9 mmol/L and remained stable throughout the 8-week study. Beta-cell function and hepatic insulin sensitivity were both restored to healthy function within the 8-week study timeframe. Average mass loss was 15 kg. These data clearly demonstrate the power of short-term reductions in energy intake alone, but exercise in combination with diet restriction would ensure healthy body composition changes to help retain lean mass while losing fat mass.

In summary, increasing physical activity and exercise, even in individuals who are obese, can have beneficial effects on reducing risk of mortality, increasing/maintaining muscle mass and improving metabolism in the face of mass loss, as well as overall health and wellbeing. The present article provides a very brief overview of a number of studies highlighting that provision of community based exercise programmes and appropriate lifestyle interventions are feasible and can be extremely beneficial for health outcomes in obese individuals. We have recently presented similar findings of a community-based exercise intervention in women from previously disadvantaged backgrounds in South African townships, demonstrating improvements in metabolic health are also observed in these individuals. Our data also demonstrate that community-based exercise programmes are feasible and effective in the South African township setting (Brooks et al. 2014).

It is clear from the details presented that there are a variety of ways to improve metabolic health including volume and intensity of exercise as well as dietary modification. While it is widely acknowledged that exercise is beneficial, we do not yet understand the optimal approach to exercise interventions. Perhaps the bigger question is how to maintain people in exercise programmes, which tend to have a large dropout rate. The Scottish FFIT programme provides evidence that retention and longer term behavioural changes are certainly possible in hard to reach groups when the correct approach is taken. It is clear that physical activity and exercise are beneficial for obese individuals with or without associated weight loss. As such, it is fundamental to incorporate a variety of exercise programmes and use the expertise of health scientists, exercise physiologists, behavioural change experts and nutritionists/dieticians when designing and implementing an exercise programme or physical activity intervention.

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• Published: 01 May 2024

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Shedding the weight of exercise for obesity management

• Gaurav Kudchadkar 1 ,
• Oluwatosin Akinsiku 1   na1 ,
• Marleigh Hefner 1   na1 ,
• Princess Uchechi Ozioma 1   na1 ,
• Holli Booe 1 &
• Nikhil V. Dhurandhar   ORCID: orcid.org/0000-0002-1356-1064 1  

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Physical activity or exercise is often considered essential for weight loss. Increasing physical activity, joining a gymnasium for exercise or weight training, or undertaking strenuous sports or activities such as jogging or running is often the top or the only consideration for weight loss. This perceived obligatory role of physical activity or exercise in weight loss may have some significant downside. It may deter individuals with obesity from attempting weight loss altogether if they are unable or unwilling to undertake an exercise regimen. Furthermore, while exercise or physical activity has significant health benefits, it needs to be carefully selected to match a user’s health status and other requirements, so as to avoid harm and maximize the benefits. Here we share our perspective about various considerations for avoiding as well as recommending types of exercises to supplement weight loss efforts.

Physical activity by itself may not produce substantial weight loss, but when paired with dietary intervention it does have numerous health benefits in the context of weight management [ 1 ].

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Department of Nutritional Sciences, Texas Tech University, Lubbock, TX, 79409, USA

Gaurav Kudchadkar, Oluwatosin Akinsiku, Marleigh Hefner, Princess Uchechi Ozioma, Holli Booe & Nikhil V. Dhurandhar

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Physical activity and exercise for weight loss and maintenance in people living with obesity

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Physical activity and exercise training programs are integral part of a comprehensive obesity management approach. In persons with overweight or obesity, exercise training, specifically aerobic (i.e. endurance) training, is associated with significant additional weight loss compared to the absence of training. However the magnitude of effect remains modest amounting to only 2–3 kg additional weight loss on average. Comparable effects have been observed for total fat loss. Exercise training, specifically aerobic training, is also associated with decreased abdominal visceral fat as assessed by imaging techniques, which is likely to benefit cardiometabolic health in persons with obesity. Based on data from controlled trials with randomization after prior weight loss, the evidence for weight maintenance with exercise training is as yet not conclusive, although retrospective analyses point to the value of relatively high-volume exercise in this regard. Resistance (i.e. muscle-strengthening) training is specifically advised for lean mass preservation during weight loss. Given the relatively limited effect of exercise training on weight loss as such, the changes in physical fitness brought about by exercise training cannot be overlooked as they provide major health benefits to persons with obesity. Aerobic, as well as combined aerobic and resistance training, increase cardiorespiratory fitness (VO 2max ) while resistance training, but not aerobic training, improves muscle strength even in the absence of a significant change in muscle mass. Regarding the overall management strategy, adherence in the long term to new lifestyle habits remains a challenging issue to be addressed by further research.

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Oppert, JM., Ciangura, C. & Bellicha, A. Physical activity and exercise for weight loss and maintenance in people living with obesity. Rev Endocr Metab Disord 24 , 937–949 (2023). https://doi.org/10.1007/s11154-023-09805-5

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Exercise in the management of obesity

Affiliations.

• 1 Laboratory of Evaluation of Human Biological Performance, School of Physical Education and Sport Science at Thessaloniki, Aristotle University of Thessaloniki, Greece.
• 2 Laboratory of Evaluation of Human Biological Performance, School of Physical Education and Sport Science at Thessaloniki, Aristotle University of Thessaloniki, Greece. Electronic address: [email protected].
• PMID: 30385379
• DOI: 10.1016/j.metabol.2018.10.009

Obesity is a multifactorial disease with increasing incidence and burden on societies worldwide. Obesity can be managed through everyday behavioral changes involving energy intake and energy expenditure. Concerning the latter, there is strong evidence that regular exercise contributes to body weight and fat loss, maintenance of body weight and fat reduction, and metabolic fitness in obesity. Appropriate exercise programs should ideally combine large negative energy balance, long-term adherence, and beneficial effects on health and well-being. Endurance training appears to be the most effective in this respect, although resistance training and high-intensity interval training play distinct roles in the effectiveness of exercise interventions. With weight regain being so common, weight loss maintenance is probably the greatest challenge in the successful treatment of obesity. There is an established association between higher levels of physical activity and greater weight loss maintenance, based on the abundance of evidence from prospective observational studies and retrospective analyses. However, proving a causative relationship between exercise and weight loss maintenance is difficult at present. Exercise has the potential to alleviate the health consequences of obesity, even in the absence of weight loss. All in all, exercise constitutes an indispensable, yet often underestimated, tool in the management of obesity.

Keywords: Energy balance; Exercise; Obesity; Weight maintenance; Weight management.

Copyright © 2018 Elsevier Inc. All rights reserved.

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The role of physical activity and exercise on obesity

News The role of physical activity and exercise on obesity

Today, on World Physical Activity Day, the World Obesity Federation (World Obesity) has released its first position statement on the role of physical activity and exercise on obesity.

In the statement, World Obesity champions the importance of physical activity for overall health and wellbeing, and advocates for the development of policies to increase physical activity levels.

Obesity is a chronic relapsing disease , defined by The World Health Organisation (WHO) as an ‘abnormal or excessive fat accumulation that presents a risk to health’, and has a wide range of drivers including genetics, biology and environmental factors. Yet, too often obesity is misunderstood and characterised as a lifestyle condition that can be solved if people ‘ eat less and move more’ , a message which undermines the complexity of the disease and overstates the impact of exercise.

The body uses energy in three main ways: during rest (basal metabolic rate), to break down food, and to perform physical activity. Although we have little control over our basal metabolic rate, it consumes most of our energy and accounts for 60% - 80% of total energy expenditure, while both body movement and body size determine the energy expenditure induced by physical activity. Physical activity should therefore not be seen as the silver bullet that ‘cures’ obesity, but rather should be pursued because it helps to improve overall health and can help maintain a healthy body weight. Treating obesity is not just about losing weight.

Physical activity refers to all movement and includes popular activities such as walking, cycling, play, sports and dance. To address physical inactivity levels the WHO published guidelines on physical activity and sedentary behaviour (2020), which provides global recommendations on the amount of physical activity required for different age and population groups. Most age groups are advised to do at least 150-300 minutes of moderate-intensity aerobic physical activity throughout the week to help maintain healthy body weight.

Yet, statistics from the WHO show that, globally, 1 in 4 adults (aged 18-64 years) do not meet the recommended levels of physical activity and current (pre COVID-19) global estimates show that 81% of adolescents do not do enough. Lockdowns around the world and movement restrictions in place to curb the COVID-19 pandemic have further limited the opportunities for people to be physically active due to the closure of schools, fitness studios and leisure centres, and the introduction of homeschooling and ‘work from home’ policies. All of this jeopardises the risk of seeing levels of physical activity decline even further.

Why should people participate in physical activity?

Failing to engage in the recommended amounts of physical activity increases the risk of cancer, heart disease, stroke, and diabetes by 20–30%, and shortens lifespan by three-five years. In contrast, regular physical activity leads to a reduction in blood pressure and a decrease in the risk of developing hypertension, type 2 diabetes, stroke and heart attacks. Research also shows that regular physical activity can significantly reduce the risk of developing dementia and Alzheimer's disease. Mental health can also be improved due to the release of feel-good hormones (endorphins). While the impact of physical activity on weight loss is minimal, exercise incontestably confers significant mental and physical health benefits, and can contribute to weight maintenance, depending on the levels and type of activity an individual engages in.

While the pandemic has undoubtedly had an adverse impact on physical activity levels it also presents an opportunity for the global community to make a change and prioritise health and wellbeing. In order to encourage an increase in global physical activity levels, policies need to be developed that enable everyone to engage in regular exercise, including through professional, school, home and community settings. Cross-sector and multi-stakeholder collaboration will be required for a range of initiatives including, building walking and cycling infrastructure, increasing and improving access to public spaces, and promoting active transport. It is also essential that children are provided with education that enables them to develop physically active lives, to help prevent them developing overweight or obesity and to reduce their risk of developing other non-communicable diseases.

Download our position statement

The role of physical activity and exercise in obesity.

A position statement from the World Obesity Federation

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We will be launching a new policy dossier and webinar on physical activity and obesity on Thursday 8 th March.  

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Lack of exercise, not diet, linked to rise in obesity, Stanford research shows

An examination of national health survey results suggests that inactivity, rather than higher calorie intake, could be driving the surge in obesity.

July 7, 2014 - By Becky Bach

An examination of national health survey records shows Americans are exercising less, which could be driving the rising obesity rates.  Shutterstock

Inactivity rather than overeating could be driving the surge in Americans’ obesity, according to a study by a team of Stanford University School of Medicine researchers.

Examining national health survey results from 1988 through 2010, the researchers found huge increases in both obesity and inactivity, but not in the overall number of calories consumed.

“What struck us the most was just how dramatic the change in leisure-time physical activity was,” said Uri Ladabaum , MD, associate professor of gastroenterology and lead author of the study. “Although we cannot draw conclusions about cause and effect from our study, our findings support the notion that exercise and physical activity are important determinants of the trends in obesity.”

The study will appear in the August issue of The American Journal of Medicine . It’s also available online now in a draft form.

The researchers analyzed data from the National Health and Nutrition Examination Survey, a long-term project of the Centers for Disease Control and Prevention that collects information from surveys and from physical examinations to assess Americans’ health. The researchers considered survey results from 17,430 participants from 1988 through 1994 and from approximately 5,000 participants each year from 1995 through 2010.

Survey participants recorded the frequency, duration and intensity of their exercise within the previous month. The team defined “ideal” exercise as more than 150 minutes a week of moderate exercise or more than 75 minutes a week of vigorous exercise.

Correlation, not causation

The research highlights the correlation between obesity and sedentary lifestyles, but because it is an observational study, it does not address the possible causal link between inactivity and weight gain.

Uri Ladabaum

The percentage of women reporting no physical activity jumped from 19 percent to 52 percent between 1988 and 2010; the percentage of inactive men rose from 11 percent to 43 percent over the same period.

Obesity also increased, climbing from 25 to 35 percent in women and from 20 to 35 percent in men.

Surprisingly, however, the number of calories consumed per day did not change significantly. Nonetheless, diet remains a proven and important component of health, and participants may have been tempted to under-report how much they ate, Ladabaum said.

He added that, although the reported average caloric intake did not change substantially during those periods, it didn’t mean that the number of calories consumed were optimal. “We simply did not detect a substantial increase over time,” he said, noting that caloric intake and physical activity are both important determinants of weight.

Both obesity and abdominal girth, which the team analyzed independently, contribute to a variety of well-documented conditions, such as cancer and cardiovascular disease, as well as increased mortality.

In 2010, 61 percent of women and 42 percent of men had too much belly fat, up from 46 percent and 29 percent in 1988. In addition, the waists of even normal-weight women swelled between 1988 and 2010, the study showed.

Ladabaum noted that the study did not follow one group of participants over that 22-year span; instead, the data came from different samples in each survey cycle. But the samples are constructed to be representative of the population.

Clarion call

In an accompanying editorial, the journal’s managing editor, Pamela Powers Hannley, MPH, called the study “a clarion call.”

Obesity is a complex, multifaceted problem linked to a variety of societal factors, Hannley said in an interview. “There are societal and economic forces at work that we must address,” she said. “Take, for example, the struggle of single mothers who are trying to balance work and child care. They may lack the time or resources to exercise. We shouldn’t assume that people are just lazy. Their lives might be overwhelming to them.”

Recommendations to exercise 30 minutes a day aren’t enough, Hannley added.

“It’s going to take widespread change,” she said. “We shouldn’t just tell patients they need to work out. We need to work with communities, employers and local governments to enable healthy lifestyles by ensuring that there are safe spaces to exercise that are cheap or free.”

Other Stanford co-authors of the study are Ajitha Mannalithara, PhD, social science research associate; Parvathi Myer, MD, a former postdoctoral scholar who is now at Kaiser Permanente, and Gurkirpal Singh, MD, adjunct professor of gastroenterology.

The study was funded by the National Institutes of Health (grant T32DK007056).

Stanford’s Department of Medicine  also supported the research.

About Stanford Medicine

Stanford Medicine is an integrated academic health system comprising the Stanford School of Medicine and adult and pediatric health care delivery systems. Together, they harness the full potential of biomedicine through collaborative research, education and clinical care for patients. For more information, please visit med.stanford.edu .

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Struggling with doing physical therapy exercises at home? Here's how to stay on track

by Jen A. Miller, Tufts University

Physical therapy can be a life changer, helping people address chronic pain, recovery from surgery or injury, or getting back to a beloved sport. But that's only if physical therapy is done—and done right.

Benton Lindaman, Michael Clarke, and Jeff Foucrier, physical therapy faculty members in the Tufts University School of Medicine Department of Rehabilitation Sciences have worked for years with patients who face challenges when it comes to keeping up with physical therapy exercises at home.

Faculty members in the Doctor of Physical Therapy programs in Seattle (Lindaman and Clarke) and Phoenix (Foucrier), they shared tips on finding motivation to keep doing the work, how to recognize soreness vs. pain , and how to best communicate with your physical therapist to keep yourself on track.

Our experts agree—if you have any doubt about what a physical therapist sent you home to do, or their assignments are proving to be impractical—speak up. Physical therapists want to work with you, instead of against you, towards progress.

Keep the why in mind

Not many people really want to do physical therapy exercises at home, and it's easy to let it slide when work, family, friends, and outside obligations are all fighting for your free time.

Keeping the reason for physical therapy in mind can help. Lindaman asks his patients "what brought you in the door in the first place?" Their answers become motivators, and it helps to make them specific, such as a patient wanting to recover from an injury to be able to walk or hike with their dog or play with their grandchildren.

Set realistic goals

When you first start physical therapy , you may be tempted to load up on exercises so you can make progress as fast as possible. That's a worthy goal, but it can be a set up for failure. Too much, too soon, can be overwhelming, even for experienced athletes who are used to long bouts of exercise.

"If you're given eight to 10 exercises to do at home, the likelihood of them not being performed goes up," says Clarke. It's just too much change at once.

Instead, work with your physical therapist to identify a handful of exercises— even just one or two—with related goals that will get you on track. And once those goals are met, celebrate! No matter how small those wins seem, they're important stepping stones on your physical therapy journey.

"If we don't celebrate wins, we have the tendency to lose steam," says Foucrier. "These are really subtle changes that can greatly impact your life over time, so it's important to cheer yourself on when you can."

Let images be your guide

Physical therapists are going to give you homework in the form of exercises to do at home, even if you're coming into the clinic a few days a week. Having a visual guide can help, which could be handouts or a video demonstrating the exercises that your physical therapist can point you to.

Lindaman has also taken videos of patients doing their workouts in clinic, using their own phones to do so. That way, they can refer to the videos of themselves doing the movement properly. "A video to reference can be extremely helpful and a way to self-monitor your own body," he says. "It's not uncommon to forget exactly what to do because it's been a couple of days since your session. Visuals can help."

If it hurts, stop

Even with printed and video guides, patients may still do exercises in a way that aggravates pain at home.

Instead of trying to get through the pain, stop, says Foucrier. If the pain goes away after four to five minutes, go back to the movement. If it continues to persist, wait another 20 to 30 minutes. And if it still hurts then, wait a day or two before trying again, and let your physical therapist know.

In general, Foucrier notes, "there's no bad movement unless pain increases." Part of his work is educating patients so that they're aware of what is happening to their bodies, and what is good pain (i.e., soreness after a good work out), bad pain (something's gone wrong), and lessening pain (where an ache still exists, but the severity has ebbed).

It's not always easy to differentiate, which is why even professional athletes will try to persist through pain and get hurt, so don't feel bad if you can't tell the difference right away.

Be open with your physical therapist

And, of course, tell your physical therapist if doing something at home hurts, if you're having trouble with a movement, or if your environment isn't conducive to the exercises they suggested. For example, doing exercises on the floor five to 10 times a day might be unrealistic for someone who works in an office, which means it just won't get done.

Your physical therapist wants you to speak up, says Clarke. "I very much appreciate and value when patients are coming back with questions and voicing those concerns or barriers they have," he notes, adding that there are so many different ways to address a problem. Physical therapists want to work together to "adjust and modify exercise so that it's more valuable to the patient, and will help them meet their goals."

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Exercise training in the management of overweight and obesity in adults: Synthesis of the evidence and recommendations from the European Association for the Study of Obesity Physical Activity Working Group

Jean‐michel oppert.

1 Assistance Publique‐Hôpitaux de Paris (AP‐HP), Pitié‐Salpêtrière hospital, Department of Nutrition, Institute of Cardiometabolism and Nutrition, Sorbonne University, Paris France

Alice Bellicha

2 INSERM, Nutrition and Obesities: Systemic Approaches, NutriOmics, Sorbonne University, Paris France

3 University Paris‐Est Créteil, UFR SESS‐STAPS, Créteil France

Marleen A. van Baak

4 Department of Human Biology, NUTRIM School of Nutrition and Translational Research in Metabolism, Maastricht University Medical Centre+, Maastricht The Netherlands

Francesca Battista

5 Sport and Exercise Medicine Division, Department of Medicine, University of Padova, Padova Italy

Kristine Beaulieu

6 Appetite Control and Energy Balance Group (ACEB), School of Psychology, Faculty of Medicine and Health, University of Leeds, Leeds UK

John E. Blundell

Eliana v. carraça.

7 Faculdade de Educação Física e Desporto, CIDEFES, Universidade Lusófona de Humanidades e Tecnologias, Lisbon Portugal

Jorge Encantado

8 APPsyCI—Applied Psychology Research Center Capabilities and Inclusion, ISPA—University Institute, Lisbon Portugal

Andrea Ermolao

Adriyan pramono, nathalie farpour‐lambert.

9 Obesity Management Task Force (OMTF), European Association for the Study of Obesity (EASO), Middlesex UK

10 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

Euan Woodward

Dror dicker.

11 Department of Internal Medicine D, Hasharon Hospital, Rabin Medical Center, Sackler School of Medicine, Tel Aviv University, Tel Aviv Israel

Luca Busetto

12 Department of Medicine, University of Padova, Padova Italy

Associated Data

Table S2 . Rating the strength of the recommendations 1

There is a need for updated practice recommendations on exercise in the management of overweight and obesity in adults. We summarize the evidence provided by a series of seven systematic literature reviews performed by a group of experts from across Europe. The following recommendations with highest strength (Grade A) were derived. For loss in body weight, total fat, visceral fat, intra‐hepatic fat, and for improvement in blood pressure, an exercise training program based on aerobic exercise at moderate intensity is preferentially advised. Expected weight loss is however on average not more than 2 to 3 kg. For preservation of lean mass during weight loss, an exercise training program based on resistance training at moderate‐to‐high intensity is advised. For improvement in insulin sensitivity and for increasing cardiorespiratory fitness, any type of exercise training (aerobic, resistance, and combined aerobic or resistance) or high‐intensity interval training (after thorough assessment of cardiovascular risk and under supervision) can be advised. For increasing muscular fitness, an exercise training program based preferentially on resistance training alone or combined with aerobic training is advised. Other recommendations deal with the beneficial effects of exercise training programs on energy intake and appetite control, bariatric surgery outcomes, and quality of life and psychological outcomes in management of overweight and obesity.

1. INTRODUCTION

Physical activity is recognized as a “pillar” in the management of overweight and obesity, in parallel with dietary counseling, behavioral support, medication, and, in some instances, bariatric surgery. 1 Physical activity is defined in broad terms as “any bodily movement produced by skeletal muscles that results in energy expenditure.” 2 Exercise is viewed as a subcategory of physical activity that is “planned, structured, repeated with a given purpose, to maintain or increase physical fitness” (see Glossary, Table  1 ). 2 Although the value of physical activity and exercise for maintaining health and preventing noncommunicable diseases is acknowledged as a public health “best buy,” 3 , 4 the role they may have for weight control remains debated both in the scientific 5 and lay literature. 6

Glossary of terms (adapted from WHO Guidelines 3 and PAGAC 4 )

Several important reviews and position statements have been issued on the topic of physical activity and exercise regarding management of obesity during the 2000s. 7 , 8 , 9 However, there has not been any systematic effort to get an overall update of more recent existing knowledge. Such overview would however be much needed to inform the design of practice guidelines for routine management of overweight and obesity in adults. In particular, there is a need for updated knowledge on the effects of various forms of exercise training programs (e.g., aerobic, resistance, or combined training) on weight loss, body composition changes with weight loss, and weight maintenance after weight loss in adults with overweight and obesity. Moreover, several topics of major importance have not been comprehensively addressed in previous reviews such as the effect of specific exercise training program in persons with overweight and obesity on intra‐hepatic fat, insulin sensitivity, blood pressure, cardiorespiratory and muscle fitness, eating behavior, hunger and satiety, and quality of life and psychological well‐being. To fill these gaps, a working group of European experts was convened in 2019 under the auspices of the European Association for the Study of Obesity (EASO 10 ). EASO is a federation of professional membership associations from 36 countries across Europe and it produces guidelines as a key element of the education about obesity management.

The goals assigned to the EASO Physical Activity Working Group were to synthesize the literature on topics of importance in the field of exercise in management of overweight and obesity as published since 2010 and to write down the evidence on each of these topics in the form of systematic review papers, with meta‐analyses when applicable. The working group included clinical and nonclinical obesity experts with specific expertise in the field of physical activity and exercise: physiology, health care, psychology, and behavior change techniques. The literature search addressed the overall effect of exercise training on a series of outcomes of major interest in the management of overweight or obesity: body weight and body composition changes, metabolic health, physiological outcomes (fitness), behavioral outcomes (energy intake and appetite), bariatric surgery outcomes, and psychological outcomes. Attention was also directed to specific outcomes that had not been extensively reviewed before in the population of persons with overweight or obesity, such as the effects of exercise training on visceral and intra‐hepatic fat, muscular fitness, energy intake and appetite, health‐related quality of life, and the comparison between different exercise training modes.

The present paper summarizes the approach taken to synthesize recent literature on the above‐mentioned issues. The resulting evidence statements on the role of exercise in management of overweight and obesity are presented and discussed. This text therefore represents a summary of the material detailed in the accompanying papers on each outcome of interest. Recommendations regarding exercise in the management of overweight and obesity are presented as a final output of this work.

All members of the working group followed the same methods to synthesize the evidence and format the recommendations, with variations as needed to reflect the evidence available in each field. The methodology followed a prespecified development process in three steps: (1) conducting of systematic reviews and meta‐analyses (SR‐MAs), (2) writing of evidence statements, and (3) designing of recommendations.

2.1. Systematic reviews and meta‐analyses

The systematic reviews followed the Preferred Reporting Items for Systematic Reviews and Meta‐Analysis (PRISMA) guidelines and were registered in the PROSPERO database (registration number CRD42019157823). Seven a priori defined research questions (Q1 to Q7) were addressed in the systematic reviews included in this supplement (Table  2 ). The details of methods used for each outcome under study are to be found in the corresponding papers of the series.

List of research questions

Briefly, depending on the topic, three to four electronic databases were searched (PubMed, Web of Science, Cochrane Library, EMBASE, PsychInfo, and SportDiscus) for original studies (Q2 to Q7) published up to 2020. The article addressing the first research question (Q1: effect of exercise on weight loss, body composition changes, and weight maintenance) was an overview of reviews, and the search was therefore limited to SR‐MAs. To avoid overlaps between SR‐MAs, we included only SR‐MAs published from January 2010 to December 2019.

Generic terms related to obesity and physical activity were used. Limits were set to include reviews/articles published in English. Reference lists from the resulting reviews and articles were also screened to identify additional articles. Articles were included if they involved adults (≥18 years including older adults) with overweight (body mass index, BMI ≥ 25 kg/m 2 ) or obesity (BMI ≥ 30 kg/m 2 ) as defined for Caucasian populations 18 participating in an exercise training program. Presence of obesity comorbidities was not an exclusion criterion; for example, an article on subjects with obesity and type 2 diabetes was not excluded, whereas an article focused on subjects with type 2 diabetes (who usually have overweight or obesity, but this was not specified as an inclusion criterion) was excluded. Specifically, subjects with the following comorbidities were not excluded: type 2 diabetes, hypertension, dyslipidaemia, metabolic syndrome, liver disease (NAFLD/NASH), and osteoarthritis. Those with the following comorbidities were excluded: cardiovascular disease (coronary artery disease, stroke, and heart failure), cancers, rheumatoid arthritis, inflammatory bowel disease, kidney failure, neuropathy, severe orthopedic disorders (with important mobility limitations), intellectual deficiency, psychiatric conditions, fibromyalgia, asthma, and sleep disorders.

No minimum intervention length criterion was applied. Exercise training programs included sessions with one or more types of exercise (aerobic and/or resistance and/or high‐intensity interval training, HIIT). Exercise sessions could be fully supervised, partially supervised, or non‐supervised. Four systematic reviews (Q1, Q2, Q3, and Q5) included only randomized or non‐randomized controlled trials and three systematic reviews (Q4, Q6, and Q7) also included single‐group interventions. One review (Q1) that was an overview of reviews included only SR‐MAs of controlled trials. Exercise interventions in combination with other interventions (e.g., diet) with appropriate controls were included, except for Q3 that focused on exercise‐only interventions. Comparators included no intervention or usual care (i.e., intervention that any patient would have received in the framework of obesity management) or dietary interventions without exercise training or drug treatment.

Data were extracted using standardized forms. The effects of exercise were assessed using random‐effects meta‐analyses (Cochrane Review Manager 5.3 or Comprehensive Meta‐Analysis version 3). Effect sizes were reported as mean difference, MD, or standardized mean difference, SMD, alongside their 95% confidence intervals (CI) and p values and were categorized as large, medium, small, or negligible. A p value < 0.05 was considered statistically significant.

To assess study quality (good, fair, or poor), we used the tool developed by the National Heart, Lung and Blood Institute (NHLBI, USA) that has been previously used for defining guidelines for the management of obesity. 19 The original assessment forms for SR‐MAs, controlled trials, cross‐over trials, and single‐group interventions were used. Publication bias was assessed by visual inspection of the funnel plots and when the number of included studies was >10, Egger's test and sometimes additional tests were performed (see individual papers for more details).

2.2. Evidence statements

Four to seven evidence statements were defined for each research question. The strength of each evidence statement was rated as high, moderate or low (Table  S1 ) using the tool developed by the NHLBI. 19 The strength of evidence represents the degree of certainty, based on the overall body of evidence, that an effect or association is correct. 19

2.3. Recommendations

Recommendations were mainly formatted based on evidence statements with moderate to high strength of evidence. Members of the working group graded the recommendations as Strong Recommendation (Grade A), Moderate Recommendation (Grade B), Weak Recommendation (Grade C), Recommendation Against (Grade D), Expert Opinion (Grade E), or No Recommendation for or Against (Grade N ) (Table  S2 ).

3. RECOMMENDATIONS

A total of 15 recommendations are proposed regarding exercise training for (1) weight and fat loss, (2) weight maintenance after weight loss, (3) preservation of lean body mass during weight loss, (4) visceral fat loss and intra‐hepatic fat loss, (5) insulin sensitivity, (6) blood pressure, (7) cardiorespiratory fitness, (8) muscular fitness, (9) eating behavior, (10) hunger and satiety, (11) quality of life (physical component), (12) additional weight and fat loss with exercise after bariatric surgery, (13) physical fitness after bariatric surgery, (14) preservation of lean body mass after bariatric surgery, and (15) behavior change techniques for promoting physical activity (Table  3 ).

Summary of recommendations

Abbreviations: ES, evidence statements; HIIT, high‐intensity interval training.

4. RESEARCH QUESTIONS AND CORRESPONDING EVIDENCE STATEMENTS

4.1. q1—weight loss, body composition changes, and weight maintenance, 4.1.1. statement of the question.

In adults with overweight or obesity

• 1‐a—What is the effect of exercise training programs on weight loss, changes in body composition (fat mass, visceral adipose tissue, and lean body mass), and weight maintenance?
• 1‐b—What are the effects of different types of exercise training (aerobic, resistance, aerobic and resistance combined, and HIIT) on these parameters?

4.1.2. Search

Q1 was restricted to SR‐MAs published between 2010 and December 2019. The titles and abstracts of 3320 articles were screened against the inclusion and exclusion criteria, which resulted in 2337 articles being excluded and 123 being retrieved for full‐text review to further assess eligibility. Of the 123 articles, 12 SR‐MAs met the criteria and were included. A total of 149 unique original articles were included in the meta‐analyses. Three (25%) SR‐MAs were rated as good quality, 8 (67%) as fair quality, and 1 (8%) as poor quality. The most recent SR‐MA that focused on weight maintenance was published in 2014 (Johansson et al. 20 ) and included only three original studies. Therefore, an additional search for original controlled trials on this outcome published between 2010 and July 2020 was performed. From 2422 articles identified and 13 articles retrieved for full‐text review, one controlled trial of fair quality was included.

4.1.3. Evidence statements

• Evidence statement 1.1: Aerobic training reduces body weight (by approximately 2 to 3 kg on average compared to controls without training and without dietary intervention and by 1 kg compared to resistance training alone) in groups of adults with overweight or obesity, independent of the duration of intervention.
• ➢ Strength of evidence: High
• Evidence statement 1.2: Aerobic training reduces body fat (by approximately 2 to 3 kg on average compared to controls without training and without dietary intervention and by 1 kg compared to resistance training alone) in groups of adults with overweight or obesity.
• ➢ Strength of evidence: Moderate
• Evidence statement 1.3: Aerobic training and HIIT lead to similar weight and fat loss in groups of adults with overweight or obesity, as long as the amount of energy expenditure is the same.
• Evidence statement 1.4: Aerobic training alone or combined with resistance training performed during a weight‐loss diet leads to an additional weight loss (of about 1.5 kg on average) and fat loss in groups of adults with overweight or obesity, compared to controls with diet only.
• Evidence statement 1.5: Aerobic training and HIIT, but not resistance training, reduce abdominal visceral fat as measured by CT‐ or MRI‐scanning techniques in groups of adults with overweight or obesity, compared to controls without training.
• Evidence statement 1.6: Resistance training, but not aerobic training, performed during a weight‐loss diet decreases the loss of lean body mass in groups of adults with overweight or obesity, compared to controls with diet only.
• Evidence statement 1.7: Adults who engage in large amounts of physical activity or aerobic exercise (≥250 min/week) are more likely to experience successful weight maintenance, according to retrospective analyses of randomized controlled trials (RCTs).

4.2. Q2—Cardiometabolic health

4.2.1. statement of the question.

• 2‐a—What is the effect of exercise training programs on insulin sensitivity, blood pressure, and intra‐hepatic fat?
• 2‐b—What are the effects of different types of exercise training (aerobic, resistance, aerobic and resistance combined, and HIIT) on these parameters?

4.2.2. Search

The literature search for Q2 was limited to controlled trials published up to April 2020. Of the 6768 articles initially screened, 242 full‐text articles were assessed for eligibility and 54 met the inclusion/exclusion criteria and were included. The effect of exercise on insulin sensitivity, blood pressure, and intra‐hepatic fat was assessed in 36, 30, and 13 studies, respectively. In addition, the effect of exercise on insulin sensitivity and blood pressure was assessed according to the status of participants (with or without type 2 diabetes, with or without hypertension, respectively). Study quality was rated as good, fair, and poor in 11 (20%), 20 (37%), and 23 (43%) studies, respectively.

4.2.3. Evidence statements

• Evidence statement 2.1: Exercise training programs (aerobic, resistance, or HIIT) improve insulin sensitivity in groups of adults with overweight or obesity with or without type 2 diabetes.
• ➢ Strength of the evidence: High
• Evidence statement 2.2: Exercise training programs (aerobic, resistance, or HIIT) reduce systolic blood pressure by approximately 3 mmHg on average in groups of adults with overweight or obesity and with hypertension compared to controls without training.
• Evidence statement 2.3: Exercise training programs (aerobic, resistance, or HIIT) reduce diastolic blood pressure by approximately 2 mmHg on average in groups of adults with overweight or obesity with or without hypertension compared to controls without training.
• Evidence statement 2.4: Exercise training programs (aerobic, resistance, or HIIT) reduce intrahepatic fat in groups of adults with overweight or obesity compared to controls without training.

4.3. Q3—Physical fitness

4.3.1. statement of the question.

• 3‐a—What is the effect of exercise training programs on cardiorespiratory fitness and muscle strength?
• 3‐b—What are the effects of different types of exercise training (aerobic, resistance, aerobic and resistance combined, HIIT) on these parameters?

4.3.2. Search

A systematic search of RCTs published up to December 2019 was performed. Of the 3068 articles initially screened, 162 full‐text articles were assessed for eligibility and 82 met the inclusion/exclusion criteria. Of these, 66 were included in the meta‐analyses. In these studies, comparisons were made either between an exercise group and a non‐exercise group, or between different types of exercise training. Study quality was rated as good, fair, and poor in 21 (32%), 28 (42%), and 17 (26%) studies, respectively.

4.3.3. Evidence statements

• Evidence statement 3.1: Aerobic, resistance, combined aerobic plus resistance, and HIIT interventions all increase VO 2 max compared with no exercise training in groups of adults with overweight or obesity.
• Evidence statement 3.2: HIIT interventions and interventions that include aerobic training are more effective in improving VO 2 max in groups of adults with overweight or obesity than resistance training alone.
• ➢ Strength of the evidence: Low
• Evidence statement 3.3: Resistance training interventions (resistance training alone or in combination with aerobic training) improves muscle strength compared with no exercise training in groups of adults with overweight or obesity.
• Evidence statement 3.4: Aerobic training interventions do not improve muscle strength in groups of adults with overweight or obesity.
• ➢ Strength of the evidence: Moderate

4.4. Q4—Energy intake and appetite control

4.4.1. statement of the question.

• 4‐a—What is the effect of exercise training programs on energy intake and appetite control (appetite ratings, eating behavior traits, and food reward)?
• 4‐b—What are the effects of different types of exercise training (aerobic, resistance, aerobic and resistance combined, and HIIT) on these parameters?

4.4.2. Search

A systematic search of controlled trials, cross‐over trials, and single‐group interventions published up to October 2019 was performed. Only exercise training interventions were included as the combination with other interventions (e.g., diet and cognitive behavioral therapy) may influence energy intake and/or appetite control. Additionally, only exercise training interventions where diet was free to vary were included in the energy intake analysis. Comparators included no‐exercise controls. Of the 4593 articles initially screened, 155 full‐text articles were assessed for eligibility and 48 met the inclusion/exclusion criteria and were included. Study quality was rated as good, fair, and poor in 2 (4%), 7 (15%), and 39 (81%) studies, respectively.

4.4.3. Evidence statements

• Evidence statement 4.1: Exercise training does not increase average energy intake compared to the intake at baseline, nor is average energy intake substantially greater (~100 kcal) to that of non‐exercise controls in groups of adults with overweight or obesity.
• Evidence statement 4.2: Exercise training leads to a small increase in fasting hunger compared to baseline, but there are no clear or consistent measurable effects on postprandial or daily hunger in groups of adults with overweight or obesity.
• Evidence statement 4.3: Exercise training improves the strength of satiety compared to baseline in groups of adults with overweight or obesity.
• Evidence statement 4.4: Exercise training leads to a small decrease in susceptibility to overconsumption through effects on behavioral traits and hedonic responses compared to baseline in groups of adults with overweight or obesity.

4.5. Q5—Bariatric surgery

4.5.1. statement of the question.

In adults with severe obesity undergoing bariatric surgery

• 5‐a—What is the effect of preoperative exercise training programs on weight loss, changes in body composition, physical fitness, cardiometabolic health, habitual physical activity, and health‐related quality of life?
• 5‐b—What is the effect of post‐operative exercise training programs on weight loss, changes in body composition, physical fitness, cardiometabolic health, habitual physical activity, and health‐related quality of life?

4.5.2. Search

Q5 was restricted to controlled trials published up to October 2019. Of the 2858 articles initially screened, 65 full‐text articles were assessed for eligibility and 31 met the inclusion/exclusion criteria and were included. A total of 22 distinct exercise training programs were analyzed, of which 18 programs were performed after bariatric surgery and 4 before surgery. The comparator was a group of adults undergoing bariatric surgery without exercise training. Study quality was rated as good, fair, and poor in 9 (43%), 4 (19%), and 8 (38%) studies.

4.5.3. Evidence statements

• Evidence statement 5.1: Exercise training (aerobic, resistance, or a combination of both) conducted after bariatric surgery results in an additional weight and fat loss (of 2.5 kg on average).
• Evidence statement 5.2: Exercise training (aerobic, resistance, or a combination of both) conducted after bariatric surgery improves cardiorespiratory fitness (VO 2 max, walking distance) and muscle strength.
• Evidence statement 5.3: Exercise training (aerobic, resistance, or a combination of both) conducted after bariatric surgery reduces the loss of lean body mass occurring during the first year after bariatric surgery, compared to controls without exercise after surgery.
• Evidence statement 5.4: Aerobic training improves insulin sensitivity after bariatric surgery compared to controls without exercise after surgery.
• Evidence statement 5.5: Exercise training (combination of aerobic and resistance) conducted before bariatric surgery may result in an additional weight loss after surgery and a larger increase in habitual physical activity.

4.6. Q6—Psychological outcomes and quality of life

4.6.1. statement of the question.

• 6‐a—What is the effect of exercise training programs on quality of life, depression, anxiety, perceived stress, body image, and other psychological outcomes?
• 6‐b—What are the effects of different types of exercise training (aerobic, resistance, aerobic and resistance combined, and HIIT) on these parameters?

4.6.2. Search

A systematic search of controlled trials and single‐group interventions published up to October 2019 was performed. Of the 1298 articles initially screened, 74 full‐text articles were assessed for eligibility and 36 met the inclusion/exclusion criteria. Twenty‐one studies were included in meta‐analysis. Most studies (32 out of 36) were RCTs. Study quality was rated as good, fair, and poor in 14 (39%), 14 (39%), and 8 (22%) studies, respectively. Supervised or semi‐supervised exercise interventions, assessing one or more psychosocial outcomes (both pre‐ and post‐exercise or compared with control), were included. Studies involving multicomponent interventions (e.g., exercise paired with a behavioral intervention or diet) were excluded if the isolated effect of exercise could not be determined (e.g., diet + exercise vs. control and behavioral intervention vs. control).

4.6.3. Evidence statements

• Evidence statement 6.1: Exercise training programs can increase quality of life's physical component in groups of adults with overweight or obesity.
• Evidence statement 6.2: Exercise training programs appear to be able to increase vitality and mental health in groups of adults with overweight or obesity.
• Evidence statement 6.3: Exercise training programs are not able to reduce depression‐related outcomes in groups of adults with overweight or obesity.
• Evidence statement 6.4: Exercise training programs appear to improve self‐efficacy and autonomous motivations for exercise in groups of adults with overweight or obesity.
• Evidence statement 6.5: Combined aerobic plus resistance exercise training programs appear to induce greater improvements in quality of life, compared to aerobic‐only or resistance‐only training programs, in adults with overweight or obesity.

4.7. Q7—Behavior change techniques

4.7.1. statement of the question.

• 7‐a—What are the most effective behavior change techniques for increasing physical activity in face‐to‐face interventions?
• 7‐b—What are the most effective behavior change techniques for increasing physical activity in digital interventions?

4.7.2. Search

The search for Q7 was restricted to RCTs published up to October 2019. Of the 1760 articles initially screened, 168 full‐text articles were assessed for eligibility and 53 met the inclusion/exclusion criteria and were included. From these, 35 studies referred to digital trials and 28 studies to face‐to‐face trials. Study quality was rated as good, fair, and poor in 15 (24%), 26 (42%), and 21 (34%) studies, respectively. No previous systematic review and meta‐analysis have examined the effectiveness of motivational behavior change techniques 21 along with the behavior change technique taxonomy (BCTTv1), 22 or separately analyzed behavior change techniques effectiveness in changing physical activity in digital and face‐to face interventions in adults with overweight or obesity. Behavior change interventions that primarily or secondarily aimed at increasing physical activity were included. Comparators included no intervention, standard care, or dietary intervention without a physical activity practice or counseling component.

4.7.3. Evidence statements

• Evidence statement 7.1: Effective behavior change techniques for increasing physical activity in digital behavior change interventions seem to differ from effective behavior change techniques in face‐to‐face interventions in groups of adults with overweight or obesity.
• Evidence statement 7.2: Digital behavior change interventions using goal setting, social incentive and graded tasks might result in greater increases in physical activity than interventions that do not use these behavior change techniques, in groups of adults with overweight or obesity.
• Evidence statement 7.3: Digital behavior change interventions using self‐monitoring of behavior might not result in increases in physical activity as high as those obtained with interventions that do not use this behavior change technique, in groups of adults with overweight or obesity.
• Evidence statement 7.4: Face‐to‐face behavior change interventions (taking place physically, on site) prompting behavioral practice and rehearsal might lead to more favorable physical activity outcomes, compared to face‐to‐face interventions that do not use this behavior change technique, in groups of adults with overweight or obesity.

5. GAPS IN EVIDENCE AND PRIORITY RESEARCH NEEDS

In general, findings of the series of reviews performed show gaps in current knowledge in a number of aspects:

• Interindividual variability in response to exercise and its consequences for management of persons with overweight or obesity needs further exploration.
• Better understanding of the importance of exercise, and different types and timing of exercise, on appetite control and eating behavior would greatly improve management strategies.
• The value of physical activity counseling versus structured exercise training should be better defined.
• Effects of HIIT were found of interest on several outcomes; however, feasibility and acceptability in real‐life settings would need further delineation in persons with overweight or obesity.
• More specific questions include defining the volume of physical activity required for weight maintenance after weight loss, including after bariatric surgery.
• Optimal timing of exercise training interventions after bariatric surgery would require investigation.
• Assessing whether the effects of aerobic and strength training in persons with overweight or obesity are of about the same magnitude as in lean subjects would help better tailor prescriptions.
• More evidence would be needed on psychological outcomes (such as body image, anxiety, perceived stress, and life satisfaction) as well as on effects of individual versus group‐based exercise training.
• Which combination of behavior change techniques (face‐to‐face or digital) are most effective for increasing physical activity and how they should be administered remains an open question.
• Improved knowledge of dose–response relationships between volume of exercise and effects on given outcomes would be needed to design quantitative guidelines specific to persons with overweight or obesity.
• The importance of reducing sedentary behavior (e.g., sitting time) should be assessed in management of overweight and obesity.
• Capacity building of instructors and coaches in offering exercise programs adapted to the needs and capabilities of persons with obesity should be developed.
• Finally, how to increase adherence to prescribed exercise, especially in the long term, should be explored in depth. The value of wearable devices and apps for this purpose needs to be examined in subjects with overweight or obesity.

6. IMPLICATIONS FOR CLINICAL PRACTICE

Based on the evidence gathered through our systematic search and analysis of the literature on exercise in the management of overweight and obesity in adults, some implications for practice can be proposed. It is important to emphasize the numerous health benefits to be gained with higher physical activity and fitness levels in persons with overweight or obesity. Given that effects on weight (and fat) loss as such were found of modest size, the implementation of exercise training programs in persons with overweight or obesity should primarily aim to increase physical fitness, reduce cardiometabolic risk, and improve quality of life. These benefits of exercise will very likely improve overall health, even without substantial change in body weight.

Within the scope of a comprehensive approach of management of overweight and obesity, exercise prescription will be carried out in conjunction with dietary advice, psychological interventions, pharmacotherapy when needed and/or available, and in persons with severe obesity, bariatric surgery. 19 , 23 The five A's strategy consisting Ask, Assess, Advise, Agree, and Assist (or Arrange) 24 , 25 appears well adapted in this perspective, especially for the aim to individually tailor the exercise prescription to the needs, preferences, capacity, corpulence, and health status of patients.

The topic of physical activity and exercise should be discussed as part of each encounter between a health professional and any patient with overweight or obesity (“Ask”). Information about the benefits expected should be provided. An evaluation of habitual physical activity and physical fitness is a logical follow‐up of dietary and lifestyle assessment in patients (“Assess”). Simple questionnaires designed for use in the setting of general practice can help. 26 There is currently no specific recommendation about when to perform a maximal exercise test in subjects with overweight or obesity (without diabetes). Such testing may however be important to search for underlying coronary heart disease in high‐risk patients and/or to adapt the exercise load on a quantitative basis. 27 A specific goal should be defined for the patient and specific activities or programs proposed to reach that goal (“Advise”). Goals will be shared between health professionals and patients (“Agree”). Counseling will be tailored to the individual needs of the patients taking into account physical fitness, co‐morbidities, stage of change regarding physical activity, barriers to increase physical activity, and opportunities offered in the living environment. The process of counseling will develop over time with frequent reassessment and subsequent adaptation (“Assist”). Interventions rest on behavior change and a major challenge is how to improve adherence to a new lifestyle over time. 28

When recommending exercise for adults with overweight or obesity, it is important to balance any positive with potential negative effects on health. In the general population, exercise is associated with an increased risk of musculoskeletal injuries and adverse cardiac events, but there is evidence from non‐randomized trials and observational studies that the benefits of exercise far outweigh the risks in most adults. 29 Musculoskeletal injuries are the most frequent negative side effects of exercise. There is however very little information on musculoskeletal injuries in adults with overweight or obesity during exercise interventions. Some studies in this setting did not find more injuries in the intervention group than in the control group, 30 , 31 while other studies reported more injuries in an exercise intervention group. 32 , 33 We are not aware of studies that directly compared the injury risk in adults with or without overweight or obesity. The incidence of both acute myocardial infarction and sudden death is greatest in the least habitually physically active individuals performing unaccustomed physical activity. 34 It is likely that a larger percentage of adults with overweight or obesity falls in this inactive group compared to lean subjects. On the other hand, the largest benefits on all‐cause mortality are attained when this group is moved to an at least “moderately active” level. 35 By analogy with the general population, overall it seems prudent to advise habitually inactive adults with obesity to become more active by a gradual progression of exercise volume by adjusting exercise duration, frequency, and/or intensity. 29

CONFLICT OF INTEREST

No conflict of interest statement.

AUTHOR CONTRIBUTIONS

All authors participated to the writing of evidence statements and recommendations. JMO and AB drafted the manuscript, and authors critically revised the manuscript.

Supporting information

Table S1. Rating the strength of the evidence 1

ACKNOWLEDGMENT

The authors would like to thank the European Association for the Study of Obesity (EASO) for support in conducting this work.

Oppert J‐M, Bellicha A, van Baak MA, et al. Exercise training in the management of overweight and obesity in adults: Synthesis of the evidence and recommendations from the European Association for the Study of Obesity Physical Activity Working Group . Obesity Reviews . 2021; 22 ( S4 ):e13273. 10.1111/obr.13273 [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]

PROSPERO registration number: CRD42019157823.