Obesidade

Research
Original Investigation
Effects of Aerobic Training, Resistance Training, or Both

on Percentage Body Fat and Cardiometabolic Risk Markers
in Obese Adolescents
The Healthy Eating Aerobic and Resistance Training
in Youth Randomized Clinical Trial
Ronald J. Sigal, MD, MPH; Angela S. Alberga, PhD; Gary S. Goldfield, PhD; Denis Prudhomme, MD, MSc; Stasia Hadjiyannakis, MD;
Rjeanne Gougeon, PhD; Penny Phillips, MA; Heather Tulloch, PhD; Janine Malcolm, MD; Steve Doucette, MSc; George A. Wells, PhD;
Jinhui Ma, PhD; Glen P. Kenny, PhD
IMPORTANCE Little evidence exists on which exercise modality is optimal for obese
Supplemental content at
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adolescents.
OBJECTIVE To determine the effects of aerobic training, resistance training, and combined
training on percentage body fat in overweight and obese adolescents.
DESIGN, SETTING, AND PARTICIPANTS Randomized, parallel-group clinical trial at
community-based exercise facilities in Ottawa (Ontario) and Gatineau (Quebec), Canada,
among previously inactive postpubertal adolescents aged 14 to 18 years (Tanner stage IV or V)
with body mass index at or above the 95th percentile for age and sex or at or above the 85th
percentile plus an additional diabetes mellitus or cardiovascular risk factor.
INTERVENTIONS After a 4-week run-in period, 304 participants were randomized to the
following 4 groups for 22 weeks: aerobic training (n = 75), resistance training (n = 78),
combined aerobic and resistance training (n = 75), or nonexercising control (n = 76). All
participants received dietary counseling, with a daily energy deficit of 250 kcal.
MAIN OUTCOMES AND MEASURES The primary outcome was percentage body fat measured
by magnetic resonance imaging at baseline and 6 months. We hypothesized that aerobic
training and resistance training would each yield greater decreases than the control and that
combined training would cause greater decreases than aerobic or resistance training alone.
RESULTS Decreases in percentage body fat were 0.3 (95% CI, 0.9 to 0.3) in the control
group, 1.1 (95% CI, 1.7 to 0.5) in the aerobic training group (P = .06 vs controls), and 1.6
(95% CI, 2.2 to 1.0) in the resistance training group (P = .002 vs controls). The 1.4 (95% CI,
2.0 to 0.8) decrease in the combined training group did not differ significantly from that in
the aerobic or resistance training group. Waist circumference changes were 0.2 (95% CI, 1.7
to 1.2) cm in the control group, 3.0 (95% CI, 4.4 to 1.6) cm in the aerobic group (P = .006 vs
controls), 2.2 (95% CI 3.7 to 0.8) cm in the resistance training group (P = .048 vs controls),
and 4.1 (95% CI, 5.5 to 2.7) cm in the combined training group. In per-protocol analyses
(70% adherence), the combined training group had greater changes in percentage body fat
(2.4, 95% CI, 3.2 to 1.6) vs the aerobic group (1.2; 95% CI, 2.0 to 0.5; P = .04 vs the
combined group) but not the resistance group (1.6; 95% CI, 2.5 to 0.8).
CONCLUSIONS AND RELEVANCE Aerobic, resistance, and combined training reduced total
body fat and waist circumference in obese adolescents. In more adherent participants,
combined training may cause greater decreases than aerobic or resistance training alone.
TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT00195858
JAMA Pediatr. 2014;168(11):1006-1014. doi:10.1001/jamapediatrics.2014.1392
Published online September 22, 2014.
1006
Author Affiliations: Author

affiliations are listed at the end of this
article.
Corresponding Author: Ronald J.
Sigal, MD, MPH, Faculties of Medicine
and Kinesiology, University of
Calgary, 1820 Richmond Rd SW,
Room 1898, Calgary, AB T2T 5C7,
Canada (rsigal@ucalgary.ca).
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Copyright 2014 American Medical Association. All rights reserved.
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Aerobic Training and Resistance Training Effects
hildhood obesity1,2 and physical inactivity3 are serious public health concerns. Obesity is associated with
adverse health outcomes in youth,4 and 80% of obese
adolescents become obese adults.5 Although exercise is recommended for obese adolescents, the optimal exercise prescription to reduce adiposity and its comorbidities is unclear.
We designed the Healthy Eating Aerobic and Resistance
Training in Youth (HEARTY) trial to determine the effects of
aerobic training, resistance training, or their combination on
percentage body fat and cardiometabolic risk markers in previously inactive postpubertal overweight and obese adolescents. The primary outcome was percentage body fat measured by magnetic resonance imaging (MRI). Secondary
outcomes included total body fat, anthropometric indexes of
body fat distribution, and risk markers for cardiovascular disease and diabetes mellitus (DM).
Methods
Design
This study was reviewed and approved by research ethics
boards of the Childrens Hospital of Eastern Ontario and the
Ottawa Hospital, Ottawa, Ontario, Canada. All participants (and
parents for participants younger than 16 years) provided written informed consent. This was a randomized clinical trial with
a parallel-group design. Details on the rationale, design, inclusion and exclusion criteria, and methods have been described previously.6 Outcome assessors (A.S.A. and P.P.) were
blinded to the study group of participants.
Participants
Participants (eTable 1 in the Supplement) were postpubertal (Tanner stage IV or V)7,8 adolescents aged 14 to 18 years with body mass
index (BMI) at or above the 95th percentile for age and sex (http:
//www.cdc.gov/growthcharts) or at or above the 85th percentile
plus an additional DM or cardiovascular risk factor. Exclusion criteria included habitual exercise more than twice weekly for more
than 20 minutes per session, DM, or any illness or disability rendering study exercise programs inadvisable or unfeasible. Routine school physical education classes were not an exclusion criterion. For participants taking medication likely to affect body
composition (metformin, oral contraceptives, or stimulants), the
dosage was required to have been stable during the previous 2
months and to remain unchanged throughout the trial.
Original Investigation Research
ence) during the run-in period. The exercise specialist used a

telephone-based central randomization program (IVRS, VBvoice, version 5.3; Pronexus) and informed participants of their
group assignments, allowing the research coordinator (P.P.) to
remain blinded to the study group of participants. Participants (N = 304) were randomized into the following 4 groups
for 22 weeks: aerobic training (hereinafter the aerobic group,
n = 75), resistance training (hereinafter the resistance group,
n = 78), combined aerobic and resistance training (hereinafter the combined group, n = 75), or nonexercising control (hereinafter the control group, n = 76). Randomization was in permuted blocks, stratified by sex and degree of overweight (85th
to 94th percentile vs 95th percentile).
Intervention
Participants in all 4 groups received counseling at baseline, 3
months, and 6 months by a registered dietitian to promote
healthy eating, with a daily energy deficit of 250 kcal. In addition to the dietary counseling, the 3 exercising groups were
asked to attend gymnasiums 4 times weekly. Exercise training progressed gradually in duration and intensity. The aerobic group exercised on treadmills, elliptical machines, or bicycle ergometers. Heart rate monitors (Polar FS1; Polar Electro
Oy) were used to adjust workloads to achieve target heart rates.
Participants gradually progressed in exercise duration (from
20 to 45 minutes per aerobic exercise session) and intensity
(from 65% to 85% of maximum heart rate). The resistance group
performed 7 exercises using weight machines or free weights,
progressing from 2 sets of 15 repetitions at moderate intensity to 3 sets of 8 repetitions at the maximum resistance that
could be moved 8 times (8-RM). The combined group performed the full aerobic training program plus the resistance
training program during each session. Details of the exercise
programs are in eTables 3, 4, and 5 in the Supplement.
Setting
Exercise training took place at 6 community-based facilities
in Ottawa (Ontario) and Gatineau (Quebec), Canada. Exercise
was supervised by personal trainers twice weekly during the
run-in period, weekly from randomization to 3 months, and
biweekly from 3 to 6 months. Personal trainers monitored attendance and exercise progression by reviewing sign-in sheets
and exercise logs. Intervention adherence was calculated as
the total number of exercise sessions the participant attended divided by the total number of sessions prescribed.
Run-in Period
Outcomes and Measurements
Participants entered a run-in period that included supervised

moderate-intensity exercise training 4 times weekly for 4
weeks. They performed 15 to 30 minutes of aerobic exercise
at 65% of measured maximum heart rate and 1 to 3 sets of 15
repetitions for each of 7 resistance exercises at each session.
Details of exercise programs (eTable 2 in the Supplement) were
described previously.6
Body Composition
Body composition was assessed by MRI with a 1.5-T system
(EchoSpeed, signal 11 version; GE Medical Systems) at baseline and 6 months. Participants lay prone for whole-body crosssectional images using protocols by Ross and colleagues.9,10
The MRIs were analyzed using a software program (Slice-OMatic, version 4.3; Tomovision).
Randomization
Anthropometry, Background Physical Activity, and Energy Intake

Weight, height, BMI, waist and hip circumferences, and blood
pressure were measured as described previously.6 Partici-
To qualify for randomization, participants needed to attend

at least 13 of 16 prescribed exercise sessions (81.3% adherjamapediatrics.com
JAMA Pediatrics November 2014 Volume 168, Number 11
1007
Research Original Investigation
pants were asked to wear pedometers (DIGI-WALKER SW700; Yamax Corporation) and maintain step-count logs for 7
days at baseline and 6 months to assess background physical
activity. Energy intake was assessed using 3-day food diaries
and analyzed using food composition analysis software (Food
324 Processor SQL 2006; ESHA Research) at baseline, 3 months,
and 6 months.
Cardiometabolic Risk Markers
Fasting insulin, glucose, glycated hemoglobin, and lipid levels were measured at baseline, 3 months, and 6 months as described previously.6 Samples were obtained 2 to 10 days after
the last exercise session to avoid potentially confounding acute
effects of exercise. A 75-g oral glucose tolerance test (fasting
and 2-hour postload glucose) was performed at baseline and
6 months.
Cardiorespiratory Fitness and Muscular Strength
O2peak, in milliliters of oxygen per
Peak oxygen consumption (V
kilogram of body weight per minute) was measured at baseline and 6 months by indirect calorimetry using a metabolic
cart (MOXUS Modular Metabolic System; AEI Technologies)
during a Balke-Ware treadmill test.11 Criteria for test termination included volitional exhaustion or the participants desire to stop. Treadmill time was defined as the time from the
O2peak.
start of the test until the time the participant reached V
An 8-RM test was performed on leg press, bench press, and
seated row machines to measure muscular strength at baseline, 3 months, and 6 months. The 8-RM test measured the
maximum weight that could be lifted 8 times while maintaining proper form.
1008
variates and an unstructured covariance matrix. Within the

mixed model, we calculated 95% CIs and P values for 4 prespecified intergroup contrasts and for change in percentage
body fat within each group over time. We used the same procedure for other continuous outcome variables, including
3-month values when available in addition to baseline and
6-month values. For all linear mixed-model analyses, we examined distributions of residuals and used transformations to
achieve normality when necessary. We also examined the effects of the exercise intervention in per-protocol analyses, restricted to participants with complete baseline and 6-month
data and at least 70% adherence throughout the exercise intervention, following the same procedures as in the intent-totreat analyses. We used statistical software (SAS, version 9.2;
SAS Institute) for all analyses.
Results
Adverse Events
Research staff (including P.P.) reported all directly observed
adverse events and those spontaneously reported by the participants. Participants were also questioned about adverse
events at each study visit.
Recruitment began March 1, 2005, and closed April 30, 2010. The
final follow-up visit was in May 2011. Of 358 participants who
entered the run-in phase, 304 (84.9%) were randomized. Reasons for prerandomization withdrawal included time demands, lack of interest, moving to a different town or city, or a
medical condition (Figure). Seven participants (1 from the aerobic group, 3 from the resistance group, 1 from the combined
group, and 2 from the control group) were excluded from MRI
analyses because images were technically inadequate. At 6
months, 54 participants in the aerobic group, 55 participants in
the resistance group, 55 participants in the combined group, and
57 participants in the control group completed MRI; an additional 6 completed all 6-month measures except MRI.
Table 1 and eTable 6 in the Supplement list baseline characteristics and potentially weight-altering medications, respectively. No significant intergroup baseline differences were
observed. Most participants (282 of 304 [92.8%]) were obese
(BMI 95th percentile for age and sex).
Statistical Analysis
Adherence
To assess the effects of exercise training modality on changes

in percentage body fat (primary outcome) over time, assuming a moderate effect size of 0.6 SD for the least-powered
planned comparison, we calculated a sample size of 248 participants (62 per group) completing the intervention to allow
80% power for each of 4 prespecified comparisons (aerobic
group vs control group, resistance group vs control group, combined group vs aerobic group, and combined group vs resistance group) tested simultaneously (overall = .05 overall). We
randomized 304 participants to allow for 18% to 20% dropout, similar to rates observed in previous exercise trials among
obese youth12 and adults with type 2 DM.13 We performed
analyses on an intent-to-treat basis that included all randomly allocated participants (including those who later withdrew). For the primary analysis, we used linear mixed-effects
modeling for repeated measures over time using percentage
body fat as the dependent variable and effects for time, group
(aerobic group, resistance group, combined group, or control
group), and time by group interaction, with age and sex as co-
From baseline to 26 weeks, the median exercise training adherence was 62% (interquartile range, 36%-81%) in the aerobic group, 56% (interquartile range, 37%-75%) in the resistance group, and 64% (interquartile range, 39%-75%) in the
combined group, with no significant differences between
groups. Seventy-five participants (24.7%) withdrew between
randomization and 6 months, including 18 (24.0%) from the
aerobic group, 21 (26.9%) from the resistance group, 17 (22.7%)
from the combined group, and 19 (25.0%) from the control
group. Reasons for withdrawal are shown in the Figure.
Adverse Events
Details of adverse events are listed in eTable 7 and eTable 8 in
the Supplement. Two participants, both in the aerobic group,
withdrew because of adverse events unrelated to study interventions, including hip fracture from a fall at school (1 participant) and a forearm fractured when playing football (1 participant). Overall, adverse events occurred in 49 of 228 exercise
group participants (21.5%) and in 18 of 76 controls (23.7%).
jamapediatrics.com
Figure. Healthy Eating Aerobic and Resistance Training in Youth Trial Flow Diagram
1285 Adolescents assessed for eligibility
840 Excluded
205 Age, too young/old
107 BMI too low
13 BMI too high
91 Too active
32 Medical conditions
392 Not interested/other reasons
445 Entered screening
87 Excluded
17 BMI too low
3 BMI too high
4 Too active
13 Medical conditions
50 Not interested/other reasons
358 Entered run-in
54 Excluded
51 Completed <13 sessions
2 Medical conditions (1 eating
disorder, 1 depression)
1 Moved away
304 Randomized
75 Randomized to aerobic
training group
78 Randomized to resistance
training group
75 Randomized to combined
training group
76 Randomized to control group
18 Discontinued intervention
6 Due to time obligation
10 Due to lack of interest
1 Due to dissatisfaction
with group
1 Due to move
with group
with group
2 Due to move
1 Due to medical condition
with group
1 Due to move
75 Included in analysis
1 Missing data for MRI
Those whose magnetic resonance imaging (MRI) files were technically inadequate and not analyzed for the MRI-related variables were still included in analyses of
other (non-MRI) variables. BMI indicates body mass index.
Musculoskeletal injury or discomfort requiring exercise program modification or temporary activity restriction occurred
in 27 of 228 exercise group participants (11.8%) and in 2 of 76
controls (2.6%). Adverse events definitely, probably, or possibly related to the intervention occurred in 18 of 228 exercise
group participants (7.9%) and in 1 of 76 controls (1.3%). Almost all related adverse events involved musculoskeletal injury or discomfort. Two medical adverse events were possibly related to the intervention, including postexertional malaise
(1 participant) and noncardiac chest pain (1 participant).
Primary Outcome of Percentage Body Fat

Body fat and lean body mass results are listed in Table 2. Percentage body fat did not change in the control group (0.3; 95%
CI, 0.9 to 0.3) but decreased in all exercising groups, by 1.1
(95% CI, 1.7 to 0.5) in the aerobic group (P = .06 vs control
group), 1.6 (95% CI, 2.2 to 1.0) in the resistance group
(P = .002 vs control group), and 1.4 (95% CI, 2.0 to 0.8) in
the combined group (not significantly different from the aerobic group or resistance group). In per-protocol analyses (70%
adherence) (eTable 9 in the Supplement), percentage body fat
changes in the combined group (2.4, 95% CI, 3.2 to 1.6) were
greater than those in the aerobic group (1.2; 95% CI, 2.0 to 0.5;
P = .04 vs combined group) but not significantly different from
changes in the resistance group (1.6; 95% CI, 2.5 to 0.8).
Secondary Outcomes
Anthropometry and Cardiometabolic Risk Markers
Table 3 lists the effects of the exercise interventions on anthropometric indexes. Waist circumference changes were 0.2 (95%
CI, 1.7 to 1.2) cm in the control group, 3.0 (95% CI, 4.4 to 1.6)
cm in the aerobic group (P = .006 vs control group), 2.2 (95%
CI, 3.7 to 0.8) cm in the resistance group (P = .048 vs control
group), and 4.1 (95% CI, 5.5 to 2.7) cm in the combined group.
In per-protocol analyses (eTable 10 in the Supplement), BMI decreased in the aerobic group vs the control group, and de-
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Table 1. Baseline Participant Characteristics
Characteristic
Total
Sample
(N = 304)
Aerobic
Training
Group
(n = 75)
Resistance
Training
Group
(n = 78)
Combined
Training
Group
(n = 75)
Control
Group
(n = 76)
Sex, No. (%)

Male
Female
Age, mean (SD), y
91 (29.9)
22 (29.3)
23 (29.5)
22 (29.3)
213 (70.1)
53 (70.7)
55 (70.5)
53 (70.7)
15.6 (1.4)
15.5 (1.4)
15.9 (1.5)
15.5 (1.3)
24 (31.6)
52 (68.4)
15.6 (1.3)
Race/ethnicity, No. (%)

White
219 (72.0)
54 (72.0)
55 (70.5)
47 (62.7)
Black
31 (10.2)
6 (8.0)
11 (14.1)
12 (16.0)
2 (2.6)
Mixed
14 (4.6)
5 (6.7)
2 (2.6)
3 (4.0)
4 (5.3)
Arabic
11 (3.6)
4 (5.3)
1 (1.3)
4 (5.3)
2 (2.6)
Asian
10 (3.3)
1 (1.3)
5 (6.4)
2 (2.7)
2 (2.6)
Hispanic
9 (3.0)
4 (5.3)
2 (2.6)
3 (4.0)
Other
6 (2.0)
1 (1.3)
2 (2.6)
2 (2.7)
1 (1.3)
Native Canadian
4 (1.3)
Weight, mean (SD), kg
98.0 (16.9)
Height, mean (SD), cm
167.8 (17.4)
0
96.7 (15.1)
166.8 (7.0)
0
168.3 (7.5)
97.5 (16.3)
167.5 (7.6)
2 (2.6)
97.9 (18.8)
168.8 (7.7)
BMI 95th percentile, No. (%)
282 (92.8)
69 (92.0)
71 (91.0)
71 (94.7)
71 (93.4)
Normal glucose tolerance, No. (%)
263 (86.5)
62 (82.7)
66 (84.6)
67 (89.3)
68 (89.5)
creases were greater in the combined group vs the aerobic group

and in the combined group vs the resistance group. Waist circumference decreased in the aerobic group and the resistance
group vs the control group and decreased significantly more in
the combined group compared with the aerobic group.
Results for cardiometabolic risk factors are listed in eTable
11 in the Supplement. Fasting insulin and triglycerides levels
were log transformed for analysis; geometric means are presented. No significant intergroup differences were observed in
the levels of fasting insulin, fasting or 2-hour glucose, triglycerides, glycated hemoglobin, high-density lipoprotein cholesterol, low-density lipoprotein cholesterol, or total cholesterol.
Cardiorespiratory Fitness and Muscular Strength
Treadmill time increased in all 3 exercise groups (eTable 12 in
O2peak in the aerobic group were
the Supplement). Increases in V
greater than those in the control group. Although within O2peak and treadmill time increased in the combined
group V
group, these changes were not significantly different from
those in the other groups. Treadmill time increased in the aerobic group vs the control group.
The aerobic group and the resistance group showed larger
increases in leg press than the control group (eTable 12 in the
Supplement), and the combined group showed larger increases in leg press, bench press, and seated row machines
compared with the aerobic group. The resistance group showed
greater increases in bench press than the control group.
Changes in muscular strength in the combined group did not
differ from changes in the resistance group on leg press, bench
press, or seated row machines.
Energy Intake and Background Physical Activity
Within-group energy intake (3-day food diaries) decreased similarly in all groups. No significant between-group differences
1010
2 (2.7)
99.9 (17.4)
63 (82.9)
Abbreviation: BMI, body mass index.
were observed in energy intake or background physical activity (pedometer logs, excluding exercise sessions that were part
of the intervention). Background physical activity data were limited because many participants did not wear pedometers or complete pedometer logs as instructed: per-protocol analysis results are listed in Table 4 and in eTable 13 in the Supplement.
Discussion
To our knowledge, this is the first randomized trial to date comparing the effects of aerobic training, resistance training, and
their combination on body composition and cardiometabolic
risk factors in a large sample of obese adolescents. The primary findings were that modest but clinically significant reductions in percentage body fat can be achieved through aerobic, resistance, or combined exercise training in obese
adolescents. In per-protocol analyses, combined aerobic and
resistance training produced greater decreases in percentage
body fat, waist circumference, and BMI than aerobic training
alone.
The modest decreases in percentage body fat in the
HEARTY trial were comparable to those observed by Lee et al,14
who examined the effects of thrice-weekly aerobic or resistance training vs a nonexercising control group during a
3-month period. They showed decreases in aerobic-only results (2.6%) and resistance-only results (2.5%) vs controls.
Although exercise prescriptions in the study by Lee et al were
similar to those of the HEARTY trial, Lee and colleagues showed
greater reductions in percentage body fat in both exercising
groups, possibly attributable to higher exercise adherence
(99%) or because their participants received some financial
compensation. Lack of financial compensation may have contributed to lower training adherence (66%) in the HEARTY trial.
jamapediatrics.com
Table 2. Intent-to-Treat Analysis of Percentage Body Fat and Lean Body Mass at Baseline
and Changes After 6 Monthsa
Mean (SE)
From Baseline to 6 mo, Mean (95% CI)

Between-Group
Difference
in Change
No.
Baseline
6 mo
Within-Group
Change
Aerobic training
74
49.1 (0.6)
48.0 (0.7)
1.1 (1.7 to 0.5)b
NA
Resistance training
75
49.7 (0.6)
48.1 (0.7)
1.6 (2.2 to 1.0)b
NA
Combined training
74
50.2 (0.6)
48.8 (0.7)
1.4 (2.0 to 0.8)b
NA
Control
74
48.6 (0.6)
48.3 (0.7)
0.3 (0.9 to 0.3)
Aerobic training vs control
NA
NA
NA
NA
0.8 (1.6 to 0)
Resistance training vs control
NA
NA
NA
NA
1.3 (2.1 to 0.5)c
Combined training
vs aerobic training
NA
NA
NA
NA
0.3 (1.2 to 0.5)
Combined training
vs resistance training
NA
NA
NA
NA
0.2 (0.7 to 1.0)
Aerobic training
74
47.1 (1.3)
45.9 (1.4)
1.2 (2.4 to 0)
NA
Resistance training
75
48.0 (1.3)
46.7 (1.4)
1.3 (2.5 to 0.1)d
NA
Combined training
74
48.4 (1.3)
46.8 (1.4)
1.7 (2.9 to 0.5)c
NA
Control
74
46.6 (1.3)
47.0 (1.4)
0.4 (0.8 to 1.6)
NA
NA
NA
NA
NA
Variable by Group
Percentage body fat, %
NA
Total body fat mass, kg
Abbreviation: NA, not applicable.

a
Data from 7 participants (1, 3, 1, and

2 from the aerobic training group,
resistance training group, combined
training group, and control group,
respectively) were excluded from
the intent-to-treat analysis, and 2
participants from the control group
were excluded in this table because
of technically inadequate magnetic
resonance images. The numbers of
participants who completed
magnetic resonance imaging at 6
months were 54, 55, 55, and 57 in
the aerobic training group,
resistance training group, combined
training group, and control group,
respectively.
P < .001.
P < .01.
P < .05.
1.6 (3.3 to 0.1)
NA
NA
NA
NA
1.7 (3.4 to 0)
Combined training
vs aerobic training
NA
NA
NA
NA
0.5 (2.2 to 1.2)
Combined training
NA
NA
NA
NA
0.4 (2.1 to 1.3)
Aerobic training
74
48.2 (0.7)
48.9 (0.7)
0.7 (0.0 to 1.3)d
NA
Resistance training
75
48.3 (0.7)
49.7 (0.7)
1.4 (0.7 to 2.0)b
NA
Combined training
74
47.7 (0.7)
48.4 (0.7)
0.8 (0.1 to 1.4)d
NA
Control
74
48.6 (0.7)
49.7 (0.7)
1.1 (0.5 to 1.7)b
NA
NA
NA
NA
Total body lean mass, kg
NA
0.4 (1.3 to 0.5)
NA
NA
NA
NA
0.3 (0.6 to 1.2)
Combined training
vs aerobic training
NA
NA
NA
NA
0.1 (0.8 to 1.0)
Combined training
NA
NA
NA
NA
0.6 (1.5 to 0.3)
Compared with the control group, we found decreases in

waist circumference in all 3 exercise groups, and perprotocol analyses showed greater decreases in the combined
group vs the aerobic group. Our results agree with previous
smaller studies showing decreases in abdominal fat through
aerobic training,14 resistance training,14 and combined aerobic and resistance circuit training15,16 performed 2 to 3 times
weekly compared with nonexercising controls. Abdominal fat
accumulation is associated with increased cardiometabolic
risk.17 Attenuating increases in abdominal fat during adolescence could confer important cardiometabolic protection because each additional year of abdominal obesity is associated
with a 4% greater risk of developing DM.18
We found no changes in glucose or lipid levels, possibly
due to mostly normal baseline values. Potential participants
who had DM at baseline were excluded from our study, and
86.5% of our participants had normal baseline fasting and
2-hour postload glucose levels, leaving little room for improvement. Two smaller randomized clinical studies by Lee et al14
and Shaibi et al19 showed that resistance exercise 2 to 3 times

per week increased insulin sensitivity by 27% (euglycemic
clamp) in black, white, and mixed racial/ethnic obese adolescent boys and by 45% (frequently sampled intravenous glucose tolerance test) in obese Latino adolescent boys, respectively. Lee and colleagues 14 found no changes in insulin
sensitivity in the aerobic group. The racial/ethnic background and sex of HEARTY participants (72.0% white and 70.1%
female) differed from previous research conducted with male
Latino youth,15,16,19 who are more likely to be insulin resistant than white youth independent of body fat.20
O2peak and treadmill time inAlthough within-group V
creased in the aerobic group and the combined group, only the
increases in the aerobic group were significantly greater than
those in controls. In the Diabetes Aerobic and Resistance Exercise (DARE) trial,21 with a design similar to that of the HEARTY
trial in adults with type 2 DM, findings were similar: aerobic
training and combined training each increased aerobic fitness, but the aerobic-only intervention did so to a slightly
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Table 3. Intent-to-Treat Analysis of Anthropometry at Baseline and Changes After 3 and 6 Monthsa
Mean (SE)
Variable by Group
Total body weight, kg
No.
Aerobic training
Resistance training
Combined training

Within-Group
Between-Group
Change
Difference in Change
Baseline
3 mo
6 mo
75
97.1 (1.8)
96.9 (1.8)
97.0 (1.9)
0.1 (1.7 to 1.5)
78
100.1 (1.7)
99.7 (1.8)
100.4 (1.9)
0.3 (1.3 to 1.9)
NA
75
97.8 (1.8)
97.3 (1.8)
97.0 (1.9)
0.8 (2.4 to 0.7)
NA
Control
76
97.9 (1.8)
98.5 (1.8)
99.2 (1.9)
1.3 (0.3 to 3.0)
NA
NA
NA
NA
NA
1.4 (3.6 to 0.8)
NA
NA
NA
NA
NA
1.0 (3.3 to 1.2)
Combined training vs aerobic training
NA
NA
NA
NA
NA
0.8 (3.0 to 1.4)
Combined training vs resistance training
NA
NA
NA
NA
NA
1.1 (3.3 to 1.0)
Aerobic training
75
34.7 (0.5)
34.2 (0.5)
34.2 (0.6)
0.6 (1.1 to 0)b
Resistance training
78
35.1 (0.5)
34.6 (0.5)
34.6 (0.6)
0.5 (1.1 to 0)
NA
Combined training
75
34.7 (0.5)
34.1 (0.5)
33.8 (0.6)
0.9 (1.4 to 0.4)c
NA
Control
76
34.2 (0.5)
34.0 (0.5)
34.2 (0.6)
0.0 (0.5 to 0.6)
NA
NA
NA
NA
NA
0.6 (1.3 to 0.1)
NA
NA
NA
NA
NA
0.5 (1.3 to 0.2)
NA
NA
NA
NA
NA
0.3 (1.1 to 0.4)
NA
NA
NA
NA
NA
0.4 (1.1 to 0.3)
Aerobic training
75
96.6 (1.2)
93.4 (1.2)
93.6 (1.3)
3.0 (4.4 to 1.6)c
NA
Resistance training
78
98.9 (1.1)
96.5 (1.2)
96.7 (1.3)
2.2 (3.7 to 0.8)d
NA
Combined training
75
97.0 (1.2)
92.7 (1.2)
92.8 (1.3)
4.1 (5.5 to 2.7)c
NA
Control
76
95.2 (1.1)
93.8 (1.2)
94.9 (1.3)
0.2 (1.7 to 1.2)
NA
NA
NA
NA
NA
2.8 (4.7 to 0.8)d
NA
NA
NA
NA
NA
2.0 (4.0 to 0)b
NA
NA
NA
NA
NA
1.1 (3.0 to 0.8)
NA
NA
NA
NA
NA
1.9 (3.8 to 0.1)
Aerobic training
75
115 (1)
111 (1)
111 (1)
5 (7 to 2)c
NA
Resistance training
78
116 (1)
111 (1)
112 (1)
4 (6 to 1)d
NA
Combined training
75
111 (1)
107 (1)
110 (1)
1 (3 to 2)
NA
Control
76
114 (1)
109 (1)
110 (1)
4 (6 to 1)d
NA
NA
NA
NA
NA
NA
1 (5 to 2)
NA
NA
NA
NA
NA
0 (4 to 4)
NA
NA
NA
NA
NA
4 (0 to 7)b
NA
NA
NA
NA
NA
3 (1 to 6)
Aerobic training
75
75 (1)
75 (1)
72 (1)
3 (5 to 1)d
NA
Resistance training
78
76 (1)
75 (1)
74 (1)
2 (5 to 0)b
NA
Combined training
75
75 (1)
73 (1)
73 (1)
2 (4 to 0)
NA
Control
76
74 (1)
73 (1)
73 (1)
1 (3 to 1)
NA
NA
NA
NA
NA
NA
2 (5 to 1)
Resistance training group vs control
NA
NA
NA
NA
NA
1 (4 to 2)
NA
NA
NA
NA
NA
1 (2 to 4)
NA
NA
NA
NA
NA
0 (3 to 3)
NA
NA
BMI
NA
NA
Waist circumference, cm
NA
Systolic blood pressure, mm Hg
Diastolic blood pressure, mm Hg
Abbreviations: BMI, body mass index (calculated as weight in kilograms divided

by height in meters squared); NA, not applicable.
a
The numbers of participants who completed physical examinations in the

aerobic training group, resistance training group, combined training group,
and control group, respectively, were 61, 65, 66, and 58 at 3 months and
greater extent. Similar to the present trial, DARE also reported no differences in fat-free mass changes between groups
but observed decreases in body weight and fat mass in the aerobic and combined training groups.13 The HEARTY trial find1012
55, 50, 57, and 56 at 6 months.

b
P < .05.
P < .001.
P < .01.
ings support that moderate-intensity to high-intensity aerobic or combined exercise training for at least 3 sessions per week
improves cardiorespiratory fitness in overweight and obese
adolescents.
jamapediatrics.com
Table 4. Intent-to-Treat Analysis of Changes in Energy Intake (3-Day Food Diaries) and Background Physical Activity (7-Day Pedometer Logs)
in the 4 Study Groupsa
Mean (SE)
Variable by Group
No.
Baseline
3 mo
6 mo
Within-Group
Change
Between-Group
Difference
in Change
Total energy intake, kcal/d

Aerobic training
75
2121 (72)
1920 (69)
1829 (67)
292 (463 to 121)b
NA
Resistance training
78
2315 (71)
1909 (69)
1938 (68)
377 (547 to 207)b
NA
Combined training
74
2199 (73)
1980 (67)
1874 (63)
325 (491 to 159)b
NA
Control
76
2134 (72)
1896 (72)
1873 (66)
261 (429 to 93)c
NA
NA
NA
NA
NA
32 (270 to 207)
NA
NA
NA
NA
NA
116 (355 to 123)
NA
NA
NA
NA
NA
33 (270 to 205)
NA
NA
NA
NA
NA
52 (185 to 289)
Aerobic training
38
7184 (613)
NA
7487 (1076)
303 (2039 to 2644)
NA
Resistance training
53
8288 (519)
NA
10 109 (1384)
1821 (1097 to 4739)
NA
NA
Total step counts per day,

excluding gymnasium sessions
Combined training
38
8210 (614)
NA
9169 (1383)
959 (1975 to 3893)
NA
Control
36
7565 (634)
NA
9789 (1539)
2224 (1122 to 5569)
NA
NA
NA
NA
NA
NA
1921 (6003 to 2161)
NA
NA
NA
NA
NA
403 (4851 to 4045)
NA
NA
NA
NA
NA
657 (3096 to 4410)
NA
NA
NA
NA
NA
862 (4996 to 3272)
group, resistance training group, combined training group, and control group,
respectively, were 10, 6, 6, and 5. Pedometer logs were not completed at 3
months.
Abbreviation: NA, not applicable.

a
There were no significant between-group differences in change in this table.

The numbers of participants who completed food diaries for energy intake
analysis in the aerobic training group, resistance training group, combined
training group, and control group, respectively, were 58, 58, 61, and 53 at 3
months and 48, 47, 54, and 50 at 6 months. The numbers of participants who
completed pedometer step-count logs at 6 months in the aerobic training
All 3 types of exercise training (aerobic, resistance, and

combined) increased lower body muscular strength. The
greatest increase was observed in the resistance group.
Adherence rates were similar, suggesting that adding aerobic training might attenuate leg strength development compared with resistance training alone. Nonetheless, com O 2 p e a k and muscular
bined training increased both V
strength.
We excluded adolescents with DM, so our results
do not necessarily apply to them. Our results may not be
generalizable to unsupervised exercise. The estimated
intervention cost per participant in 2010 was $1137.94 (Canadian dollars), including gymnasium membership ($30.00
per month times 6 months equals $180.00), personal training ($33.11 per hour times 20 sessions equals $662.20), and
counseling by a dietitian ($49.29 per hour times 6 hours
equals $295.74). Costs would decrease over time, assuming
the required frequency of personal trainer sessions would
decrease.
ARTICLE INFORMATION
Accepted for Publication: June 24, 2014.
Published Online: September 22, 2014.
doi:10.1001/jamapediatrics.2014.1392.
P < .001.
P < .01.
Conclusions
The HEARTY trial showed that aerobic training, resistance training, and their combination decreased percentage body fat in
obese adolescents. In participants adhering to the exercise protocol, combined aerobic and resistance exercise training tended
to be superior to aerobic training alone in decreasing percentage
body fat, waist circumference, and BMI. Combined training might
have additive effects through greater exercise volume or combinations of unique effects of aerobic training (improvement in
the oxidative metabolismdependent energy system, qualitative
changes in skeletal muscle fiber type, metabolic capacity, and cardiorespiratory fitness)22 and resistance training (quantitative
changes in skeletal muscle mass or fiber diameter and increased
muscular strength).23 Adolescents who want to maximize the effect of exercise on these variables should ideally perform both
aerobic and resistance exercise, but significant benefit can be
achieved through either type of exercise alone.
Author Affiliations: Department of Medicine,

University of Calgary, Calgary, Alberta, Canada
(Sigal); Department of Cardiac Sciences, University
of Calgary, Calgary, Alberta, Canada (Sigal);
Department of Community Health Sciences,
jamapediatrics.com
(Sigal); Faculties of Medicine and Kinesiology,

(Sigal); Clinical Epidemiology Program, Ottawa
Hospital Research Institute, Ottawa, Ontario,
Canada (Sigal, Phillips, Malcolm, Kenny); School of
Human Kinetics, University of Ottawa, Ottawa,
1013
Ontario, Canada (Sigal, Alberga, Kenny); Werklund

School of Education, University of Calgary, Calgary,
Alberta, Canada (Alberga); Healthy Active Living
and Obesity Research Group, Childrens Hospital of
Eastern Ontario Research Institute, Ottawa,
Ontario, Canada (Goldfield, Hadjiyannakis); Institut
de Recherche de lHpital Montfort, Ottawa,
Ontario, Canada (Prudhomme); Crabtree
Laboratories, McGill University Health Centre, Royal
Victoria Hospital, Montreal, Quebec, Canada
(Gougeon); Prevention and Rehabilitation Centre,
University of Ottawa Heart Institute, Ottawa,
Ontario, Canada (Tulloch); Department of
Community Health and Epidemiology, Dalhousie
University, Halifax, Nova Scotia, Canada (Doucette);
Cardiovascular Research Methods Centre,
University of Ottawa Heart Institute, Ottawa,
Ontario, Canada (Wells); Research Institute,
Childrens Hospital of Eastern Ontario, Ottawa,
Ontario, Canada (Ma).
Author Contributions: Drs Sigal and Alberga had
full access to all the data in the study and take
responsibility for the integrity of the data and the
accuracy of the data analysis.
Study concept and design: Sigal, Goldfield,
Prudhomme, Hadjiyannakis, Gougeon, Wells,
Kenny.
Acquisition, analysis, or interpretation of data: Sigal,
Alberga, Goldfield, Prudhomme, Gougeon, Phillips,
Tulloch, Malcolm, Doucette, Ma, Kenny.
Drafting of the manuscript: Sigal, Alberga, Kenny.
Critical revision of the manuscript for important
intellectual content: All authors.
Statistical analysis: Doucette, Wells, Ma.
Obtained funding: Sigal, Goldfield, Prudhomme,
Hadjiyannakis, Gougeon, Wells, Kenny.
Administrative, technical, or material support: Sigal,
Alberga, Phillips, Malcolm, Kenny.
Study supervision: Sigal, Alberga, Goldfield,
Prudhomme, Kenny.
Conflict of Interest Disclosures: None reported.
Funding/Support: The HEARTY trial was
supported by grant MCT-71979 from the Canadian
Institutes of Health Research. Dr Sigal is supported
by a Health Senior Scholar award from Alberta
InnovatesHealth Solutions and was previously
supported by a Research Chair from the Ottawa
Hospital Research Institute during part of this trial.
Dr Alberga was supported by a Doctoral Student
Research Award from the Canadian Diabetes
Association. Dr Goldfield was supported by a New
Investigator Award from the Canadian Institutes of
Health Research for part of the trial and
subsequently by an Endowed Research Scholarship
from the Childrens Hospital of Eastern Ontario
Volunteer Association Board. Dr Kenny was
supported by a University Research Chair from the
University of Ottawa.
Role of Funder/Sponsor: The funding sources had
no role in the design and conduct of the study;
collection, management, analysis, and
interpretation of the data; preparation, review, or
approval of the manuscript; and decision to submit
the manuscript for publication.
1014
Additional Contributions: We thank the HEARTY

trial participants. Krista Hind, BSc (deceased),
Bruno Lemire, PhD, Marta Wein, BSc, Kim
Robertson, BSc, Kim Fetch, BSc, Brittany Hanlon,
MHA, Jane Yardley, PhD, Nadia Balaa, BSc, Karen
Lopez, BSc, Pamela Martino, MSc, Kim Morin, BSc,
Colleen Gilchrist, BSc, RD, Pascale Messier, BSc, RD,
Kelley Phillips, MA, and students in the School of
Human Kinetics, University of Ottawa, who
contributed to study coordination, exercise
training, and evaluation of study participants.
Robert Ross, PhD (Queens University, Kingston,
Ontario, Canada), Alison Bradshaw, MSc, and
Jennifer Kuk, PhD (York University, Toronto,
Ontario, Canada), and Yves Martel, PhD
(Tomovision, Magog, Quebec, Canada) assisted
with training and provided ongoing advice on body
composition analysis. The Ottawa-Carleton
Regional YMCA/YWCA (Ottawa, Ontario, Canada),
RA Centre (Ottawa, Ontario, Canada), Childrens
Hospital of Eastern Ontario, and Nautilus Plus and
MRI Plus (both in Gatineau, Quebec, Canada)
collaborated throughout the trial. Robert Ross, PhD,
received financial compensation beyond his usual
salary.
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Research

Effects of Aerobic Training, Resistance Training, or Both

Author Affiliations: Author

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Aerobic Training and Resistance Training Effects

Original Investigation Research

ence) during the run-in period. The exercise specialist used a

Outcomes and Measurements

Participants entered a run-in period that included supervised

Anthropometry, Background Physical Activity, and Energy Intake

To qualify for randomization, participants needed to attend

JAMA Pediatrics November 2014 Volume 168, Number 11

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Research Original Investigation

Aerobic Training and Resistance Training Effects

variates and an unstructured covariance matrix. Within the

To assess the effects of exercise training modality on changes

JAMA Pediatrics November 2014 Volume 168, Number 11

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Aerobic Training and Resistance Training Effects

Original Investigation Research

76 Randomized to control group

Primary Outcome of Percentage Body Fat

JAMA Pediatrics November 2014 Volume 168, Number 11

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Research Original Investigation

Aerobic Training and Resistance Training Effects

Table 1. Baseline Participant Characteristics

Sex, No. (%)

Race/ethnicity, No. (%)

Weight, mean (SD), kg

Height, mean (SD), cm

BMI 95th percentile, No. (%)

Normal glucose tolerance, No. (%)

creases were greater in the combined group vs the aerobic group

Abbreviation: BMI, body mass index.

JAMA Pediatrics November 2014 Volume 168, Number 11

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Aerobic Training and Resistance Training Effects

Original Investigation Research

From Baseline to 6 mo, Mean (95% CI)

1.1 (1.7 to 0.5)b

1.6 (2.2 to 1.0)b

1.4 (2.0 to 0.8)b

0.3 (0.9 to 0.3)

Aerobic training vs control

Resistance training vs control

1.3 (2.1 to 0.5)c

0.3 (1.2 to 0.5)

0.2 (0.7 to 1.0)

1.3 (2.5 to 0.1)d

1.7 (2.9 to 0.5)c

0.4 (0.8 to 1.6)

Aerobic training vs control

Total body fat mass, kg

Abbreviation: NA, not applicable.

Data from 7 participants (1, 3, 1, and

1.6 (3.3 to 0.1)

Resistance training vs control