Introduction
Exercise should be prescribed for primary and secondary prevention of cardiovascular and other chronic diseases and conditions, and to enhance physical fitness and function (1–4). However, about 45% of U.S. adults are insufficiently active, and more than 80% do not achieve the recommended target volumes of aerobic and muscle strengthening exercise. Furthermore, obese individuals more frequently are insufficiently active compared with persons of healthy weight (5). See Supplemental Digital Content 1, Video S1 (https://links.lww.com/CSMR/A31).
There is no doubt that people who are overweight or obese accrue irrefutable and substantial benefits of regular physical activity, and adults who are overweight or obese gain similar benefits from physical activity as do those of healthy weight (1,2,6). Beyond its beneficial effects on body weight and adiposity, participation in regular exercise and physical activity lowers the risks of developing cardiovascular disease (CVD), type 2 diabetes mellitus, some cancers (e.g., breast, colon, colorectal, prostate), depression, anxiety, and other diseases, and, in some cases, physical activity can be as or more effective than standard pharmacological therapies (1,2,7–9).
Higher risks of premature all-cause and disease-specific mortality occur in people who are overweight or obese (compared with individuals of healthy weight) (10). Moreover, people with overweight or obesity have increased risk of cardiometabolic diseases, cancer (i.e., endometrial, colon, breast, kidney, liver, gallbladder) osteoarthritis, sleep apnea, disability, and mental illness (2,11,12). Given that more than 30% of adults in 30 U.S. states are obese, when combined with the considerable health consequences of obesity and overweight, these statistics highlight the urgent need for effective interventions at the population, clinical, and community levels (5,13).
Current guidelines for the treatment of overweight and obesity advise comprehensive lifestyle interventions that may be combined with adjunctive therapies, such as pharmacotherapy or bariatric surgery (14). Healthy dietary changes and increasing physical activity form the foundation of lifestyle interventions, with a goal to achieve an energy deficit of ≥500 kcal·d−1 to promote weight loss (14). Physical activity in the range of 150 to 250 min·wk−1 can prevent weight gain and also can result in a modest weight loss, but it seems that volumes of physical activity greater than 250 min·wk−1 are needed to achieve a clinically significant weight loss (6,15). The U.S. Preventive Services Task Force recommends intensive behavioral counseling for the promotion of physical activity and healthy diet for overweight and obese adults as part of CVD prevention (3). The American Heart Association recommends physical activity as part of “Life's Simple 7” for comprehensive CVD prevention in all adults at risk for CVD (4).
Physicians can be very influential in promoting physical activity in their patients; adults advised by their physician to exercise are more likely to do so (16). What is more, scientific evidence supports the effectiveness and feasibility of promoting physical activity in clinical practice (4). Only about a third of all patients are advised by their health care provider to adopt or maintain a program of physical activity, although it seems that people who are obese or who have diabetes are about two times more likely to receive physical activity counseling from their physician (17). There are a number of perceived barriers to counseling patients about physical activity including lack of knowledge or skill, time constraints, uncertainty about the effectiveness of treatments, and lack of confidence to engage in counseling with patients (18,19). Therefore, the purpose of the article is to review evidence supporting the role of exercise in treating people with overweight and obesity and to support a shift in the paradigm for the role of exercise in treating people with obesity or overweight from a single target of weight loss to aiming toward multiple health targets. See Supplemental Digital Content 2, Video S2, https://links.lww.com/CSMR/A32.
Physical Activity and All-Cause Mortality and Disease-Specific Morbidity
The health-related beneficial effects of physical activity occur in a dose-response manner, and a number of physiological benefits in several body systems underlie the reported reductions in all-cause and disease-specific mortality associated with physical activity (1,9). For example, within the ranges of 15 to 100 min of exercise per day, the risks of all-cause mortality are reduced by about 4% with every additional 15 min·d−1 of exercise (20). Low to moderate volumes of physical activity are associated with reduced mortality compared with insufficiently active individuals—even in the presence of obesity, diabetes, smoking, hypertension, metabolic syndrome, or kidney disease (2,20). Moreover, these beneficial effects on mortality are realized across physical activity of any intensity (i.e., light, moderate, and vigorous) and of any duration (21).
Muscle strengthening (resistance) exercise, alone or in combination with aerobic exercise, also confers substantial health benefits, including delaying mortality; the mortality benefits are independent of aerobic exercise participation (1,22). A recent study, using a large pooled sample, reported that muscle strengthening exercise participation of any frequency was associated with a 23% reduction in all-cause mortality and 40% reduction in cancer mortality (23). This is comparable to those who met the target recommendations of 150 min·wk−1 of moderate to vigorous aerobic physical activity where all-cause mortality was 25% lower and CVD mortality was reduced by 20%. Those who adhered to both muscle strengthening and aerobic exercise targets had nearly a 30% reduction in all-cause and cancer mortality (23). Participation in muscle strengthening exercise also has been linked to a lower risk of developing type 2 diabetes mellitus and metabolic syndrome (24).
Cardiorespiratory Fitness
Cardiorespiratory fitness (CRF) is a stronger predictor of mortality than traditional cardiovascular (CVD) risk factors, such as smoking, dyslipidemia, hypertension, and diabetes, and this association is independent of physical activity and overweight or obesity (25,26). Having better CRF reduces the risks of developing coronary heart disease, heart failure, and diabetes mellitus, and CRF may attenuate the elevated CVD and heart failure risks associated with excess adiposity (27).
In men and women, there is a strong association between CRF and mortality, and risk of mortality has been reported to improve by 16% and 17% for every 1 MET increase in CRF (28). Furthermore, Fogelholm (29) showed that overweight and obese adults who were fit had similar all-cause mortality risks as did healthy weight fit participants, while overweight and obese unfit individuals had about a two-fold elevated mortality risk. Similarly, studies of heart failure patients who were overweight and obese and fit had better survival over a 5-yr period compared with those of poorer fitness (30). A systematic review and meta-analytical study reported all-cause cancer mortality is lower in people who have better CRF, independent of body adiposity (31). The studies show there is a delay in mortality associated with being more fit and these benefits are realized even in the presence of overweight, obesity, and chronic disease.
The Vicious Cycle of Physical Inactivity, Functional Limitation, and Disability
Functional limitations and disability are common in people with obesity or overweight, and nearly 40% of middle-aged and 70% of older adults report functional limitations, with obesity being a strong contributory factor (12,32). A sedentary lifestyle and insufficient participation in regular physical activity are associated with weight gain, increased body fat, visceral adiposity, inflammation, and loss of muscle mass and bone density (22). These physiological adaptations to sedentary behavior result in decrements in muscular strength and CRF, which, in turn, can exacerbate functional limitations, disability, and the risk of falling and falls-related injury (33). Moreover, functional limitations can present a barrier to participation in exercise and physical activities, and, thereby, accelerate the individual's loss of fitness and functional decline (33).
Sarcopenia refers to a syndrome associated with aging that entails an excessive overall loss of muscle mass and muscle strength that is linked to an increased risk of mortality, functional limitations, disability, and poorer quality of life (34). When sarcopenia co-exists with excessive body fat — termed sarcopenic obesity — it is associated with underlying cardiometabolic abnormalities, a greater burden of CVD risk factors, poorer quality of life, and higher risks of falling (35). A report from the National Health and Nutrition Examination Survey indicated that risk of mortality was about 30% higher in women with sarcopenic obesity when compared with women who had sarcopenia without obesity, although this excess mortality was not observed in men (34).
A physically active lifestyle is associated with attenuated risk of developing sarcopenic obesity, while higher amounts of sedentary time are linked to greater risk. As an illustration, among male participants in The British Regional Heart Study, sedentary time of 30 min·d−1 was associated with a 40% greater risk of sarcopenic obesity, compared with nonobese men without sarcopenia. Conversely, taking frequent activity breaks, participating in 30 min·d−1 of light or moderate to vigorous intensity exercise were associated with a 30% decreased risk of sarcopenic obesity, and muscle strengthening exercise reduced the risk by nearly 70% (36).
Exercise that includes aerobic and strength training is effective in improving physical function (37). Furthermore, markers of frailty and sarcopenia (e.g., functional limitations, impaired motor performance, and muscle weakness) may be improved by progressive resistance training, and aerobic exercise in older adults, including those with sarcopenic obesity, especially when combined with dietary interventions and weight loss (38). It is clear that intentional exercise is an essential component of a health-promoting lifestyle contributing toward maintaining function and independence by its effect on muscle mass and strength (1).
Acute and Chronic Effects of Exercise
Engaging in regular aerobic or muscle strengthening exercise training results in many adaptations in multiple body systems (39). Regular aerobic and resistance exercise training improves cardiorespiratory and muscular fitness, respectively, and results in more healthful body composition, enhanced bone health, better cognitive function, and other gains (1,2). Mental health problems, such as depression and anxiety and poor quality of life, are often comorbid with obesity, and aerobic, muscle strengthening, and other types of exercise can be effective in treating these conditions (40). Adding biological plausibility of these effects, regular exercise alters a number of biomarkers that are associated with depression, such as hypothalamic-pituitary-adrenal axis, regulation of monoamine metabolism and neuroimmune function (41).
Improvements in CRF occur in most people who engage in a regular program of aerobic exercise, especially when it meets or exceeds the target recommendations for aerobic exercise (2). Aerobic exercise participation improves several cardiometabolic risk factors and biomarkers, such as blood pressure, body composition (total body fat; visceral abdominal fat), glucose intolerance (blood glucose, hemoglobin A-1c), insulin resistance, and dyslipidemia (elevated blood triglycerides; low density lipoprotein (LDL) cholesterol; low high-density lipoprotein (HDL) cholesterol), HDL functionality and inflammatory markers (2,42). When exercise is combined with loss of body weight, especially with favorable body composition changes, these cardiometabolic risk factors are further improved.
Resistance exercise is an effective tool in improving muscle mass and strength (2). Improved blood glucose and glycosylated hemoglobin and mitigating insulin resistance and inflammatory markers can result from muscle strengthening exercise training in people with type 2 diabetes (2). Moreover, these effects are enhanced when resistance-type exercise is combined with aerobic training (2,43). Additional health-related benefits occur as a result of muscle strengthening and resistance exercises, particularly when these are used as part of a multimodal program of exercise. Resistance exercise can reduce pain and augment function in people with osteoarthritis, improve gait, better bone health, and reduce the risks of fall-related injuries (when part of a falls reduction program), alleviate depression and anxiety, modestly decrease blood pressure, and may result in more healthful CVD-related biomarkers (2,44).
Exercise effects can last hours to days (i.e., acute effects) or they may be longer lasting with repeated bouts of exercise (i.e., chronic). One exercise session can acutely improve several health-related factors, including blood pressure, insulin sensitivity, better sleep, reduction in symptoms of anxiety, and improved cognition. For many desired outcomes, such as glucose or blood pressure control, it is optimal to recommend daily exercise for the greatest benefit (45).
Without accompanying weight loss or reductions in adiposity, the effects of exercise on cardiometabolic risk factors are modest and variable, in part due to individual and exercise program characteristics (46). Furthermore, there appears to be little common variation in the effects of a single program of exercise across the various cardiometabolic risk factors; that is, the dose of exercise to effect changes in blood glucose may be different than the dose required to change blood pressure. The changes in one cardiovascular factor often occur independently of a change in another (47).
Regular aerobic or resistance exercise can reduce systolic blood pressure by about 2.6 mm Hg and diastolic blood pressure by 1.8 mm Hg in normotensive individuals, with larger reductions in blood pressure in people with hypertension (48). In those with hypertension, an acute hypotensive occurs following exercise, with decreases of 5 to 7 mm Hg in both systolic and diastolic blood pressure—an effect persisting for as long as 22 h after an aerobic exercise bout (48).
The effects of aerobic exercise alone on biomarkers of cardiometabolic risk is impressive and include reductions in insulin resistance, blood glucose, hemoglobin A-1C, and total and visceral abdominal fat (48,49). A study of older adults at risk for diabetes found that aerobic exercise at a moderate to vigorous intensity for ≥45 min on 5 d·wk−1 resulted in a 12.7% increase in CRF, a 4% decrease in blood insulin levels, a 2% decrease in insulin resistance, and a 7% decrease in serum leptin levels following 1 yr of training (50). Reductions in waist circumference, visceral abdominal fat, and total body fat, even without accompanying weight loss, occur consequently to exercise interventions at exercise volumes of one half that recommended (51,52). Visceral abdominal fat is associated with increased cardiometabolic disease risk and abnormal metabolic biomarkers and has been proposed as part of an important link between insulin resistance and inflammatory processes associated with cardiometabolic disease (53). When combined with intensive lifestyle change, aerobic exercise of at least 150 min·wk−1 at a moderate to vigorous intensity reduces the risk of developing type 2 diabetes mellitus by 48% to 66% in people who are at risk (54).
Exercise and Weight Loss
Exercise is recommended to prevent weight gain and promote weight loss (6). Exercise alone has a modest (~2–6%) impact on short term (≤6 months) weight loss, and greater loss of weight can be expected in the long-term with exercise over longer periods of time (12–18 months) (6). Perhaps, explaining the lack of short-term effect on body mass, aerobic exercise training resulting in big increases in CRF has no effect on resting metabolic rate, even when accompanied by changes in body composition (55). Even more important to metabolic health, it is helpful to keep in mind — as discussed previously — the healthful changes in abdominal visceral adiposity and total adiposity which are associated with metabolic syndrome and increased cardiometabolic diseases.
Referral to a certified Obesity and Weight Management Specialist, a Certified Specialist in Sports Dietetics, a Registered Dietician or an ACSM Certified Clinical Exercise Physiologist® can help an individual with obesity to adopt healthier lifestyle patterns and to realize a clinically meaningful sustained weight loss of ~3% to 5% of body weight (1,14). Working with a specialist can be especially important because they can address common factors that can affect an obese individual’s interest and willingness to engage in physical activity, such as consciousness of weight stigma, high physique anxiety, physical discomfort and other factors such as lack of time and lack of social support (56).
Conclusions
Participation in regular exercise results in a myriad of healthful benefits in people with obesity or overweight and is recommended for nearly all adults. Exercise forms an important part of lifestyle intervention as part of a program of weight loss or weight management; however, the health benefits of exercise extend far beyond its role in weight loss. Exercise improves the functioning of several body systems, resulting in improved cardiorespiratory and muscular fitness, cardiometabolic risk factors, reduced adiposity, enhanced muscle mass and quality, and bone health.
The author declares no conflict of interest and does not have any financial disclosures.
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