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International Chair on Cardiometabolic Risk
My Healthy Waist

Effects of Weight Loss on Adipose Tissue Distribution

Managing CMR

Key Points

  • Visceral fat is a strong predictor of metabolic abnormalities, disease, and mortality.
  • As little as 20 minutes of daily exercise can reduce visceral fat by 10%. Increasing exercise to 60 minutes a day can lead to even greater reductions (~30%).
  • Reducing daily caloric intake by 400 to 700 kcal can cause a 15 to 30% reduction in visceral fat.
  • For a given amount of weight loss, exercise preserves muscle mass and causes greater reductions in total and visceral fat compared to diet-induced weight loss.
  • Although reducing body weight causes the greatest reduction in visceral fat, exercise training can significantly reduce visceral fat, even when weight is maintained.

Weight Loss and Abdominal Obesity

In the 1950s, Jean Vague [1] noted that upper body or android obesity was an important predictor of atherosclerosis, diabetes, gout, and other diseases. While the association between abdominal obesity and metabolic risk may be explained by excess fat accumulation in either of two distinct depots within the abdomen, namely visceral fat and abdominal subcutaneous fat, the literature points to visceral fat as the depot that carries the greatest health risk. Independent of subcutaneous abdominal fat, visceral fat is a strong predictor of dyslipidemia [2,3], glucose intolerance [4,5], insulin resistance [6], systemic inflammation [7], hypertension [8], cardiovascular disease [9], type 2 diabetes [10], and all-cause mortality [11]. Accordingly, the ability of exercise and/or diet to significantly reduce body weight and visceral fat is a key consideration for reducing the health risk among abdominally obese patients.

Exercise-induced Weight Loss and Visceral Fat Reduction

Cross-sectional data shows that individuals who are more physically active have lower amounts of visceral fat [12,13,14]. Even for a given degree of obesity, individuals who are more active tend to have the lowest levels of visceral fat compared to their sedentary counterparts [15,16]. In addition, numerous intervention studies have demonstrated that exercise training can reduce visceral fat through weight loss [17-28].

It was originally suggested that exercise alone produced only a marginal (1 to 2 kg) decrease in body weight [29]. These earlier conclusions were based on evidence from intervention studies wherein the prescribed negative energy balance was too low to induce substantive weight loss [30]. The literature suggests, however, that exercise can produce a wide array of visceral fat changes, from a minor reduction of approximately 5% [21] up to a 50% reduction [20]. These changes also correspond to a wide array of reductions in body weight. In general, the highest levels of exercise cause the highest energy deficit, which leads to greater weight loss and a greater reduction in visceral fat. For example, approximately 60 minutes of daily exercise over 3 months caused a 1.0 and 0.7 kg (-28 and -26%) reduction in visceral fat along with a 7.7 and 6.6 kg weight loss in obese men and women, respectively [17,18].

Conversely, approximately 20 to 25 minutes of daily exercise reduced visceral fat by only 6 to 10%, for a modest weight loss of 1.4 to 1.8 kg in overweight women [21] and obese women with diabetes [31]. Illustrating a dose-response relationship between exercise dose, weight loss, and visceral fat loss, Irwin et al. [21] found that women who were highly active (>28 min/day) lost 6.9% of visceral fat, compared to a 5.9% loss among intermediate active (19 to 28 min/day), a 3.4% loss in low active (≤18 min/day), and a 0.1% gain in controls over a year-long intervention.

For a given amount of exercise-induced weight loss, the relative amount of visceral fat lost is generally greater than the amount of abdominal subcutaneous fat lost [17,18,24,26,28,31,32]. This suggests that visceral fat may be more sensitive to exercise-induced weight loss than other fat depots. In general, exercise training reduces visceral fat by approximately 0.5 kg for every 4 kg of body weight lost in both men and women [17,18]. Also, it appears that as little as 20 minutes of daily exercise with an energy expenditure of less than 1,500 kcal/week can spur modest reductions in visceral fat (5 to 10%). Increasing daily exercise to 60 minutes with an energy expenditure of 3,500 to 4,500 kcal/week causes much greater reductions in visceral fat (~30%). While visceral fat cannot be readily measured, waist circumference is recommended as a reliable measure of visceral fat [33,34].

Diet-induced Weight Loss and Visceral Fat Reduction

The second weight reduction method focuses on energy intake. A calorie-restricted diet has traditionally been the cornerstone of obesity reduction treatment [35]. A number of studies have assessed the effects of chronic caloric restriction on weight loss and visceral fat reduction [17,18,26,36-43]. Much like in exercise interventions, there are a range of responses in terms of weight loss (5 to 18 kg) and visceral fat reduction (15 to 47%) with varying degrees of caloric restriction (from a 400 kcal/day reduction to a very low calorie diet of 800 kcal/day). The interventions that prescribe a very low calorie diet ranging from 800 to 1,200 kcal/day and lasting 3-6 months tend to produce the most marked reductions in weight (10 to 18 kg) and visceral fat (24 to 47%) [36,40,41]. The more moderate approaches that reduce caloric intake by 400 to 700 kcal/day produce more modest reductions in body weight (5 to 9 kg) and visceral fat (15 to 30%) [17, 18, 37-39, 42]. Overall, approximately 3 months of a 500 kcal/day reduction in caloric intake is enough to reduce body weight by approximately 5 kg and visceral fat by about 0.5 kg [17,18].

Is Exercise or Diet Better at Reducing Visceral Fat?

Since weight loss generally causes a reduction in visceral fat, the interventions that produce the greatest weight loss will inevitably cause the greatest loss of visceral fat. Caloric restriction is better at inducing significant weight loss than exercise. This is supported by the degree of weight loss reported among diet versus exercise weight loss studies (5 to 18 kg versus 1 to 8 kg reduction, respectively). For example, some of the very low calorie diets prescribed limited patients’ caloric intake to only 800 kcal/day [36], which is a very large (2,000 kcal/day) energy deficit for an obese adult man. In order for that obese man to produce the same energy deficit and expend 2,000 kcal, he would require approximately 3 hours of daily, moderate-intensity exercise [17].

However, if the goal is moderate weight loss, exercise and diet are equally effective. Carefully controlled studies have shown that when reduction of caloric intake is equal to the calories expended through exercise, which creates an equivalent energy deficit, the weight loss is identical between strategies [17,18].

Although diet and exercise may both lower body weight equally, the composition of the weight lost differs according to the strategy used (Figure 1). It has been shown repeatedly that for a given weight loss, exercisers lose more fat mass than dieters [17,18,24,38]. Exercise therefore seems to prevent or at least attenuate the loss of lean muscle mass that occurs during diet-induced weight loss [17,18,24,38].

The ability of diet to induce a marked caloric deficit, combined with the ability of exercise to maintain muscle mass and readily mobilize fat from the visceral depot, likely provides the best of both worlds [45, 46]. Data from the National Weight Control Registry suggests that individuals who are most successful at attaining and maintaining significant weight loss are likely to use a combination of diet and exercise to achieve their goal [47]. Additionally, during weight loss interventions, physical exercise has been shown to improve cardiorespiratory fitness [17,18], which would be expected to further reduce risk of morbidity and mortality independent of changes in weight and visceral fat [48-50]. The combination of diet and exercise is therefore the ideal strategy for losing weight and reducing visceral fat.

Figure 1:
Composition of a 10-kg weight loss due to exercise and diet in obese men and women

Exercise Without Weight Loss and Visceral Fat Reduction

Although weight loss is the ideal outcome of chronic exercise in overweight individuals, the evidence suggests that even when body mass does not change, regular exercise can markedly reduce visceral fat and shrink waist circumference accordingly [17,18,25,26,51,54] (Figure 2). For example, approximately two months of regular, moderate-intensity aerobic exercise can substantially reduce visceral fat (-41 to -45%) without causing weight change in samples of type 2 diabetic patients (45, 46). Even non-obese premenopausal women experience a significant reduction in visceral fat (-25%) after 6 months of aerobic exercise despite no significant change in weight [53]. Several studies have specifically examined the effect of exercise on abdominal adiposity when weight is maintained by having study participants consume compensatory kilocalories equivalent to the amount expended during exercise [17,18,54]. The length of each intervention was roughly 3 months and consisted of an energy expenditure of approximately 3,500 kcal/week. The primary findings suggest that in obese Caucasian men and women, as well as in individuals with type 2 diabetes, exercise training can significantly reduce total and abdominal obesity even with little or no change in body weight.

Although the above suggests that regular exercise can reduce visceral adiposity independent of weight loss, it is important to note that exercisers who lose weight generally lose more visceral fat than exercisers who maintain body weight [17, 18] (Figure 2). From a clinical perspective, exercise-induced weight loss therefore causes the greatest reduction in visceral fat and the greatest improvements in metabolic status. However, given the challenges associated with losing large amounts of weight, it is equally important to reduce visceral adiposity and related health risk with minimal weight loss.

Sex and Visceral Fat Reduction With Weight Loss

A number of studies that have failed to find significant reductions in visceral fat in women have raised the possibility that women may be resistant to exercise and/or diet-induced reductions in visceral fat [24,42,55,57]. For example, 16 months of supervised aerobic exercise at the same exercise intensity and of the same duration reduced 5% of the visceral fat in young men but failed to produce a significant reduction in young women [24]. Further evidence from a trial using either diet or diet with exercise suggests a similar pattern [42]. In that study, even though both sexes lost approximately 8.5 kg of body weight in response to the diet-only intervention, the men reduced their visceral fat by 1.4 kg compared to only 0.4 kg for the women.

In stark contrast, several well-controlled studies have reported that exercise can significantly reduce visceral fat (5 to 30%) in women, much like in men [18,20,21,53,57]. For example, 14 weeks of a 700 kcal/day deficit through diet or exercise has been shown to significantly reduce visceral fat (21 to 30%) in association with a 5 to 6 kg weight loss [18]. Another study demonstrated that both men and women reduced visceral fat in response to the same aerobic exercise prescription, though the reduction was slightly smaller in women (-7 and -5% in men and women, respectively) [57].

With respect to exercise-induced visceral fat reduction, studies that claim women are resistant to visceral fat loss may be confounded by sex differences in exercise energy expenditure. Since men have a greater exercise capacity compared to women [58], matching men and women on exercise intensity and duration alone results in a higher exercise energy expenditure in men and, consequently, a higher expected total and visceral fat loss. It has also been noted that the amount of visceral fat lost through intervention is contingent on the initial amount of visceral fat [59]. Women generally have less visceral fat than men [60], which may also play a role in any sex differences. In light of these findings, it seems doubtful that women are actually resistant to visceral fat loss. However, further research is needed to shed light on any possible sex differences in visceral fat reduction.

Numerous cross-sectional studies have found that for a given amount of total fat mass, Asians have more visceral fat than Caucasians [61], who in turn have more visceral fat than African-Americans [62-64]. Racial differences in visceral fat reduction may therefore be a possibility. Unfortunately, most of the current literature is based mainly on Caucasian populations, which hinders the identification of any possible racial differences. The limited evidence available suggests that Caucasians and African Americans do not differ in terms of visceral fat loss in response to a 20 week exercise intervention [57]. More research is needed to pinpoint the influence of race on visceral fat reduction.

Abdominal obesity has long been identified as the phenotype that conveys the greatest health risk, independent of total body weight. Whether it is induced through exercise and/or diet, weight loss leads to a marked reduction in visceral adiposity. As little as 20 to 60 minutes of daily exercise or a 400 to 700 kcal/day energy restriction can cause a 10 to 30% reduction in visceral fat. For a given amount of weight loss, exercise can induce a greater relative reduction in visceral fat and better maintain muscle mass. Lastly, of key importance is the notion that total body weight needs not change for visceral fat to decrease significantly. The waist circumference tape may therefore be a more reliable marker of obesity treatment success than the bathroom scale.

Figure 2:
Effects of exercise with and without consequent weight loss on changes in visceral fat (IAF)

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Reference 1 CLOSECLOSE

Vague J. The degree of masculine differentiation of obesities: a factor determining predisposition to diabetes, atherosclerosis, gout, and uric calculous disease. Am J Clin Nutr 1956; 4: 20-34.

PubMed ID: 13282851
Reference 2 CLOSECLOSE

Nguyen-Duy TB, Nichaman MZ, Church TS, et al. Visceral fat and liver fat are independent predictors of metabolic risk factors in men. Am J Physiol Endocrinol Metab 2003; 284: E1065-71.

PubMed ID: 12554597
Reference 3 CLOSECLOSE

Nieves DJ, Cnop M, Retzlaff B, et al. The atherogenic lipoprotein profile associated with obesity and insulin resistance is largely attributable to intra-abdominal fat. Diabetes 2003; 52: 172-9.

PubMed ID: 12502509
Reference 4 CLOSECLOSE

Brochu M, Starling RD, Tchernof A, et al. Visceral adipose tissue is an independent correlate of glucose disposal in older obese postmenopausal women. J Clin Endocrinol Metab 2000; 85: 2378-84.

PubMed ID: 10902782
Reference 5 CLOSECLOSE

Janssen I, Fortier A, Hudson R, et al. Effects of an energy-restrictive diet with or without exercise on abdominal fat, intermuscular fat, and metabolic risk factors in obese women. Diabetes Care 2002; 25: 431-8.

PubMed ID: 11874926
Reference 6 CLOSECLOSE

Ross R, Aru J, Freeman J, et al. Abdominal adiposity and insulin resistance in obese men. Am J Physiol Endocrinol Metab 2002; 282: E657-63

PubMed ID: 11832370
Reference 7 CLOSECLOSE

Forouhi NG, Sattar N and McKeigue PM. Relation of C-reactive protein to body fat distribution and features of the metabolic syndrome in Europeans and South Asians. Int J Obes Relat Metab Disord 2001; 25: 1327-31.

PubMed ID: 11571595
Reference 8 CLOSECLOSE

Hayashi T, Boyko EJ, Leonetti DL, et al. Visceral adiposity is an independent predictor of incident hypertension in Japanese Americans. Ann Intern Med 2004; 140: 992-1000.

PubMed ID: 15197016
Reference 9 CLOSECLOSE

Fujimoto WY, Bergstrom RW, Boyko EJ, et al. Visceral adiposity and incident coronary heart disease in Japanese-American men. The 10-year follow-up results of the Seattle Japanese-American Community Diabetes Study. Diabetes Care 1999; 22: 1808-12.

PubMed ID: 10546012
Reference 10 CLOSECLOSE

Boyko EJ, Fujimoto WY, Leonetti DL, et al. Visceral adiposity and risk of type 2 diabetes: a prospective study among Japanese Americans. Diabetes Care 2000; 23: 465-71.

PubMed ID: 10857936
Reference 11 CLOSECLOSE

Kuk JL, Katzmarzyk PT, Nichaman MZ, et al. Visceral fat is an independent predictor of all-cause mortality in men. Obesity (Silver Spring) 2006; 14: 336-41.

PubMed ID: 16571861
Reference 12 CLOSECLOSE

Kanaley JA, Sames C, Swisher L, et al. Abdominal fat distribution in pre- and postmenopausal women: The impact of physical activity, age, and menopausal status. Metabolism 2001; 50: 976-82.

PubMed ID: 11474488
Reference 13 CLOSECLOSE

Major GC, Piché ME, Bergeron J, et al. Energy expenditure from physical activity and the metabolic risk profile at menopause. Med Sci Sports Exerc 2005; 37: 204-12.

PubMed ID: 15692314
Reference 14 CLOSECLOSE

Hunter GR, Kekes-Szabo T, Treuth MS, et al. Intra-abdominal adipose tissue, physical activity and cardiovascular risk in pre- and post-menopausal women. Int J Obes Relat Metab Disord 1996; 20: 860-5.

PubMed ID: 8880355
Reference 15 CLOSECLOSE

Wong SL, Katzmarzyk P, Nichaman MZ, et al. Cardiorespiratory fitness is associated with lower abdominal fat independent of body mass index. Med Sci Sports Exerc 2004; 36: 286-91.

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