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4600-JSM
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The role of resistance training for treatment
of obesity related health issues and for changing health status
of the individual who is overfat or obese: A review
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While there is reinforcement of the idea that loss of body mass
(BM) will lead to an improvement in overall health status for
the individual that is overfat, or obese. The long held recom-
mendation for reduction of BM focusing solely on establish-
ing a reduction on caloric intake, via caloric restriction (CR)
in diet alone tends to limited impact on overall health status
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changes for these individuals. In contrast, the reduction of
BM attained through employment of therapeutic exercises
produces a significant change in the health status of individu-
als that are overfat, or obese. While endurance training (ET)
is readily recommended, it may be far less effective at cor-
recting these underlying issues relative to changes noted in
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response resistance training (RT) programs. Therefore this
review will examine the differential responses seen with the
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application of RT related to the positive adaptations in BM
modifications, regardless of changes in Body Mass Index
(BMI), and proper hormonal responses leads to modifica-
tions of health status and eventually returning the individual
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who is overfat, or obese, back to a normal health status with
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the employment of RT in a therapeutic exercise program.
Key words: Obesity - Exercise - Resistance training - Health.
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O ver the last half-century, and in particular with-
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in the last couple of decades, there has been an
epidemic rise in cases of obesity and health issues re-
sulting from hyperadiposity (overfatness) which has
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occurred across all races and genders without a per-
ceived terminus, with the most drastic rise of obes-
ity appearing in areas, and within subpopulations,
where there has been a drastic increase in sedentary
activities.1-3 Coupled with this movement away from
an active lifestyle is an increase in the caloric den-
Corresponding author: J. Clark, Division of Mathematics, Science
and Health Careers, Department of Science, Manchester Community
College, Institute Address: MS 29, PO Box 1046, 60 Bidwell Street,
Manchester, CT, USA 06045-1046. E-mail: JClark@mcc.commnet.edu
Vol. 55 - No. 2 THE JOURNAL OF SPORTS MEDICINE AND PHYSICAL FITNESS 1
J SPORTS MED PHYS FITNESS 2015;55:1-2
J. E. CLARK 1, D. T. GOON 2
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1Division of Mathematics, Science
and Health Careers, Department of Science
Manchester Community College, Manchester, CT, USA
2Centre for Biokinetics, Recreation and Sport Science
University of Venda, Thohoyandou
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Republic of South Africa
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sity of the foods and nutritional composition (e.g.,
higher fat and carbohydrate components of meal)
being consumed, leading to the imbalance in caloric
load resulting in an increase body mass (BM), espe-
cially fat mass (FM). This increase in BM especially
the increased FM, and the associated Body Mass In-
dex (BMI), is linked very closely with a modifica-
tion to hormonal (cytokine), enzymatic, genetic, and
epigenetic regulations that impact a milieu of physi-
ological functions and trigger health related issues
for the overfat individual, e.g., metabolic syndrome,
cardiovascular disease and a host of cancers, Table
I.1-7 While the establishment of caloric imbalance
leads to gain (or loss) of BM, however, the overall
complexity surrounding the issues of adiposity and
health 4, 8 no one single theory for explaining all of
the associated health issues has shown to be “entirely
true”.
In response to understand the complexity of is-
sues pertaining to obesity or overfatness, a pattern of
thought has developed that has begun to examine the
issue of obesity based not on the issue of body mass
changes, established by the interaction of calories
in-to-calories out, obesity should be viewed based
a health status standpoint. Health status, as previ-
ously outlined,4 is derived from the interaction of
CLARK THE ROLE OF RESISTANCE TRAINING FOR TREATMENT OF OBESITY RELATED HEALTH ISSUES

the factors of fitness (i.e. the level of cardiovascular,
musculoskeletal and neurological functionality for
an individual) and factors of fatness (i.e. the level
and amount of adipose tissue that comprise the to-
tal amount of body tissue and subsequent adipokine
signaling). And as previous described,4 these factors
develop based on the contribution of genetic, envi-
ronmental, social and hormonal influences that allow
for the examination of not only medical and physi-
ological issues but social and psychological issues.
Indicating that the issues of “fatness” that while
the entire population) by focusing on the “image”
of health (i.e. what does the scale say) for a person
rather than health of that person (i.e. one’s health sta-
tus) and encourage deleterious behaviors (e.g., eat-
ing disorders and or exercise bulimia) by continual
encouragement for the idea CR as the sole means
to achieve health. Furthermore, misleads many in-
dividuals about the simple principle that 1-kg of fat-
free mass and 1-kg of fat mass have equal weight on
a scale measure of one’s body weight. In contrast to
this opinion, there are a number of experimental and

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perceived as being “preventable” may not really be anecdotal observations showing that many changes
“preventable” simply by means of controlling caloric in health status occur, well before any changes in
balance and leads to the question. Which leads to the body morphology, when physical activity (PA) is

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development of question, can loss of BM via caloric utilized as a means for re-establishing caloric bal-
restriction (CR) alone provide the mechanisms for
O ance and leads to improvement in overall health for

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changing health status? any individual, regardless of current level of adipos-
While this is a position that many health-related ity or recognition of obesity.1, 6, 10, 13-16 Moreover, the
organizations and companies have taken over the resultant change in health status is comprised on the

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past 50-years, in actuality, decrease in body mass via interaction of the responses to PA based not on the
CR alone may not directly equate to improvement specific type but more on the total level of activity
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in one’s health and fitness.4, 9-13 But with this focus (Figure 1) that one utilizes throughout their every-
on body mass as the indication of “health”, one may
be doing a disservice to a large population (if not E
day life regardless of the level of fatness, and allows
for the concept of that has been labeled as “Fat-but-
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Figure 1.—The overlapping of the fitness and fatness factors in a continuum of ongoing interaction establishing either an increasing
or decreasing relative risk for development of diseases related to impact of elevated (­) or decreased (¯) influence of either the fitness
or the fatness factor for the individual who is overfat based on the contribution of physical activity retarding the impact of deleterious
adipokine signals and anabolic dysregulation at the central and peripheral tissues with a production of advantageous myokines and
adipokines that alter metabolic pathways at various systems throughout the body. Further details on fitness and fatness factors can be
found in the following reference.4

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THE ROLE OF RESISTANCE TRAINING FOR TREATMENT OF OBESITY RELATED HEALTH ISSUES CLARK

Fit”, “Obesity Paradox”, and or “Fit-Fat”.4, 10, 13, 17-19
While the concept of hormonal and morphological
changes from therapeutic PA occur leading to im-
provements in health has been noted by a number of
authors, few have looked at the impact of the issues
of fitness and fatness based on the flow of adapta-
tions that occur through the modifications of upper
regulatory elements (URE) that have been attributed
to responses in resistance training (RT) to individu-
als who are overfat. Therefore the purpose of this
review is to examine the role of overfatness, PA and
Fatness impact on physiological response
The nature of changes and adaptations to stresses
imparted on the body, regardless of degree of fatness,
or amount of fat mass (FM), is determined by the
impact of the URE on the cellular responses within
the tissues.20 As described in Figure 2, the responses
for the individual who is overfat, or obese, is typi-
cally derived from a low exercise stimulus, typically
restricted to activities of daily living (ADL) or even
less, that may originate in low psychological attrac-

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especially RT for this population based on modifi- tion towards the what has been seen as socially ac-
cations that occur to the URE thus modifying the ceptable exercise patterns for the individual which
physiological and morphological responses and ad- can begin as early as in childhood.18, 21-25 Com-

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aptations that occurs within the cells and tissues of pounding this low exercise stimulus is generally a

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the body that ultimately changes the health status of high level adipokine signals that interfere with nor-

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the individual who is overfat, or obese. mal cellular signalling responses to stresses of the

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Figure 2.—Examination of the downstream and reverberating upstream effects of cellular signalling and responses at the various sys-
tems of the body to elevated adiposity and a low total level of physical activity resulting from limited exercise stimulus based on the
idea of the upper regulatory elements trigger responses physiological responses to exercise stress leading to an elevated (­) or decreased
(¯) response or hormone production. The key factors in this flow of biochemical and neuroendocrinological pathway activation is seen
with tissues inability to respond to, or produce, the required anabolic hormones necessary for normal tissue functioning. Image and
concepts are modified and synthesized from images previously published by Clark 4 and Spiering et al.20

Vol. 55 - No. 2 THE JOURNAL OF SPORTS MEDICINE AND PHYSICAL FITNESS 3

CLARK THE ROLE OF RESISTANCE TRAINING FOR TREATMENT OF OBESITY RELATED HEALTH ISSUES

Table I. Summary of hormone, cytokine signals that are altered with increases adiposity along with responses noted to exposure to
resistance (RT) training stress stimulus.
Impact of
Impact of prolonged
Hormone Tissue of production over-fatness resistance
exercise
Testosterone/adrenal androgen Testes/adrenal cortex ↓* ↔, ↑$
Growth Hormone Anterior pituitary gland ↓* ↔, ↑$
Insulin Pancreas ↑** ↓
Insulin-like growth factor (IGF) & mechanogrowth factor (MGF) Liver ↓* ↔, ↑$
Skeletal muscle
Bone
Cortisol Adrenal cortex ↑¥ ↔,↓

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Triiodothyronine (T3) Thyroid ↓+ ↔,↑
Thyroxin (T4) Thyroid ↓+ ↔,↑
Catecholamines (Epinephrine/norepinephrine) Adrenal medulla; Neurons ↑ ↔,↓

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Adiponectin Adipose tissue ↓ ↑
Visfatin Adipose tissue ↑ ↓/↔
Leptin

O Adipose tissue ↑** ↑,↓

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Resistin Adipose tissue macrophage ↑ ↓/↔
Retinol Binding Protein-4 (RBP-4) Adipose tissue ↑ ?
Tumor Necrosis Factor-a (TNF-a) Adipose tissue macrophage ↑ ↓
Interluekin-6 (IL-6) Macrophage, adipose tissue ↑ ↑,↓$

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Ghrelin Gut tissue ↓ ↑
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Interluekin-1b (IL-1b) Macrophage adipose tissue ↑ ↓
MIF Skeletal muscle ? ↑
MCP-1
PPAR-β/δ
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Skeletal muscle
Skeletal muscle
?
↓
↑
↑
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PPAR-γ Skeletal muscle ↑ ↓
PPAR-α Skeletal muscle ↓ ↑
Irisin Skeletal muscle ? ↑$
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Neuropeptide Y (NPY) Gut tissue, hypothalamus ↓,↔ ?

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Serotonin (5-HT) Hypothalamus, peripheral sensory ↓,↔ ↑,↔

Peptide-YY (PYY) Gut tissue ↓ ?
Glucagon-like Peptide 1 & Oxyntomodulin Gut tissue pancreas ↓ ?
Endocannabinoids Nervous ↑ ?
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↑Increased plasma concentration; ↓decreased plasma concentration; ↔ no change in plasma concentration; ? unknown (or not studied) change in plasma
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concentration; $possible differential response between RT and those seen with ET; *increase in hormone specific binding proteins with those hormones
that show a decrease in concentration from overfatness, no indication for changes in cortisol binding proteins, ¥some evidence for changes in activation
enzyme (11-βHSD) and conversion to active form of cortisol; +hypothyroidism highly associated with obesity, however there is an unknown causality of
the relationship; **insulin and leptin associated with general reduction in response and “sensitivity” at peripheral and central tissues.
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normal ADL for the individual establishing a gener- Furthermore, this low exercise stimulus is general-
alized diseased state, e.g., high level of inflammatory ly coupled with poor nutrition (i.e. high kcal content
response, reduced anabolic hormone concentrations, with excessive doses of carbohydrates and fats) com-
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and poor metabolic flexibility at the tissues.4, 26-29
Chronically the inappropriate levels of stimulation
leads to modifications in hormonal signals (Table I),
that systematically produce an internal environment
that inhibits the retention and maintenance of fat-free
mass (FFM), i.e. skeletal muscle, bone and connec-
tive tissue, leading to an increase in deposition of li-
pids within the skeletal tissue along with adipocytes
at various locations throughout the body undergoing
hypertrophic and hyperplasic differentiation.30-36
prising one’s diet which further accentuates changes
in the cellular signalling cascades allowing for the
accumulation of lipids within tissues (Figure 3),5 and
a reduction in basilar circadian levels of androgens
and anabolic hormones which leads to the normal re-
duction in FFM that further alters metabolic profiles
(e.g., reduced metabolic flexibility), and mitochon-
drial biogenesis within the various peripheral tissues
of the body, thus reducing the capacity for local mus-
cle endurance and overall aerobic capacity for the

4 THE JOURNAL OF SPORTS MEDICINE AND PHYSICAL FITNESS ?? 2015

THE ROLE OF RESISTANCE TRAINING FOR TREATMENT OF OBESITY RELATED HEALTH ISSUES CLARK

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Figure 3.—Diagram describing the impact of altering PPAR signals on the cellular functions of adipose tissue and adipose cells based
on upper regulatory impact of diet, especially the high fat and high carbohydrate diet typical of “western” diets, leading to accumula-
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tion of lipid deposition and Adipogenesis or the impact of pharmacological agents and exercise cytokine signals (irisin and IL-6), lead-
ing to lipolysis, increased fatty-acid oxidation and possible apoptosis of adipocytes. Note that the solid and directional arrow indicates
a stimulatory effect while the dashed and blocked arrow indicates an inhibitory effect.

individual leading to a greater ease for the develop- estrogen and progesterone).34, 35, 40-45 This dysregu-
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ment of fatigability within tissues.30, 31, 37, 38 While lation of anabolic hormones is coupled with an al-
the same stimulus place on adipose tissues leads to a tered hypothalamic-pituitary axis (HPA) output, in
flux in the types and quanta of adipokines being pro- addition to changes in inflammatory biomarkers,
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duced and released in circulation,39 further altering and an increased lipid depositions that have been
the ability for tissues to perform normal physiologi- attributed to changes in peroxisome proliferator-
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cal functions or respond to prolonged stress stimulus activated receptors (PPAR) activation resulting in
from any form of PA. increased deposition of lipid droplets (Figure 3).46-49
As the responses, and chronic adaptations, to low In response to these changes, individuals who are
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exercise stimulus and high caloric diet reverberate
between the upstream and downstream loci, the is-
sue of too much “fatness” and too little “fitness”
(Figures 1, 2), combine to produce the neuroendo-
crinological symptoms of obesity, most notably are
aforementioned issues of metabolism (e.g., meta-
bolic syndrome) along with the dysregulation of
anabolic hormones (e.g., thyroid hormones, insulin,
growth hormone, testosterone and androgens), and a
limited efficacy of sex hormone (e.g., testosterone,
overfat, or obese, may experience episodic periods
of chronic inflammation responses, hyperglycemia/
hyperinsulemia, insulin-resistance, leptin-resistance
and adiponectin-resistance that occur both centrally
(e.g., hypothalamic nuclei) and at peripheral tissues
(e.g. liver, skeletal muscle and adipose) and finally
changes in downstream cellular activation along the
hypertrophy (e.g., mTOR activated) pathways at pe-
ripheral tissues that limit the accumulation of FFM
while perpetuating the accumulation of FM.36, 47-50

Vol. 55 - No. 2 THE JOURNAL OF SPORTS MEDICINE AND PHYSICAL FITNESS 5

CLARK THE ROLE OF RESISTANCE TRAINING FOR TREATMENT OF OBESITY RELATED HEALTH ISSUES
Modification of health status via physical activity
It has been understood for some time now that
increasing amount of PA, via exercise, serves as a
means to reduce not only chronic inflammation but
reduce the plasmal load of inflammatory markers
that are known to reduce metabolic efficiency of
many tissues of the body and leads to the develop-
ment of what the American College of Sports Medi-
cine (ACSM) has labeled as “exercise as medicine”
that has been the foundation for a series of recent
campaigns and established the principles for ideals
of treatment by both government and non-govern-
ment programs for youth and adults who are over-
fat.8, 51-57 Unfortunately, there is a highly elaborate
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interrelationship between the various psychological,
and more importantly societal factors, that influence
the development of the health behaviors, and ergo
body morphology, for the individual that eventually
forms the overall health for any individual 4, 8 and
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influence of self-selection towards any type of PA
or exercise, principally based on morphology, and
attrition for continuing exercise within the ideal of
the “socially acceptable” pattern of PA for the indi-
vidual.1, 6, 22, 23, 58-61
It is to this later point regarding the “socially
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acceptable” patterns of PA, which needs to be ad-
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dressed, especially given the very low attrition for
prolonged use of exercise that has been noted for
individuals within this population.61 And if we fol-
low the train of thought from some recent studies by
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Brock,22 Garland,58 and Fogelholm,18 if one is en-
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couraged to perform PA based on their innate drive
toward a distinct pattern of PA, then that pattern
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will become psychologically appeasing and lead to
greater attrition in the short-term. This short-term in-
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crease in attrition is compounded as the innate desire
is matched with the psychological rewards attained
through morphological and metabolic adaptations
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leading to more pronounced changes in health status,
strength and work capacity of the individual who is
overfat.27, 62-64 And thus the individual is intrinsically
encouraging additional and prolonged engagement
in PA, ultimately provide the foundation greater uti-
lization of PA throughout the lifespan and the desired
chronic responses to necessary to maintain, and fur-
ther establish, improvements in health status.18, 59, 65
Unfortunately, the view of therapeutic exercise for
treatment related to individuals who are overfatness,
6 THE JOURNAL OF SPORTS MEDICINE AND PHYSICAL FITNESS ?? 2015
and obesity, have focused not on the use of the innate
selection for PA but rather on the development of an
acute caloric deficit, most often accrued via endur-
ance style exercise selection. This choice of thera-
peutic exercise focused on the possible creation of
caloric deficit while also eliciting changes in cardio-
vascular response to improve cardiac cycle function-
ing and maximize fatty-acid mobilization and oxi-
dation via endurance style of training.66-70 As such
endurance activity (ET) appears to be continually
advised and promoted, by medical and health pro-
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fessionals, for leading to improvements in the health
status for individuals who are overfat or obese,
it may not be the best choice. First, there is previ-
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ously noted by several authors,4, 30, 31, 37, 38, 47, 48, 56
there are issues related to fatigability, immune and
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cardiovascular health status of the individual that is
overfat, which may impede the implementation of
ET activity for either duration or intensity to induce
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any physiological singaling to improve health status.
Second, since ET tends to be applied through a long
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duration of PA at a constant training modality (e.g.,
greater than 30-minutes, at a moderate intensity, 65-
85% of VO2max) that because of the aforementioned
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impaired health status and high rate of fatigability
for the person couple to lead to poor attrition pri-
marily due to a low psychological appeasement, in-
ability to have physical performance match cogni-
tive desire. Because of the low appeasement from
ET for the individual who is overfat, or obese, there
is a generalized withdrawal from exercise and that
may be generalized to all forms of PA and thus com-
pounds the health status issues of being overfat. In
an attempt to change the duration of exercise, ET has
applied as a short duration training modality, via in-
terval training.71-74 Interval training, as has been pre-
viously described,71-75 utilizes short duration high in-
tensity endurance training followed by brief periods
of rest, or lower intensity endurance training, in a
repeated fashion with high intensity training lasting
as brief as 10-seconds at 100% of VO2max with rest
periods of up to 3-minutes, or as long as 5-minutes at
75-90%VO2max with rest (or active rest) periods of
equal duration, that may not induce a greater level of
attrition, as the level of intensity of required for this
model of ET may lead to greater withdrawal from
exercise for individuals who are overfat. Lastly, ET
tends to have very little chronic stimulus to increases
in prolonged caloric expenditure (beyond acute re-
THE ROLE OF RESISTANCE TRAINING FOR TREATMENT OF OBESITY RELATED HEALTH ISSUES CLARK

sponse to exercise stress), lipolytic signals, or chang-
es the hormonal issues (Table I), which all serve as
foundation for many of the diseases associated with
overfatness and obesity.76, 77
Resistance training and
improvements in health status
In contrast to this view regarding the selection of
ET in a therapeutic treatment, there is speculation by
have indicated health and functional improvements
across a variety of age groups of individuals who are
overfat, or obese, with employment of RT.9, 76, 78, 80-85
Moreover, individuals who are overfat, or obese, tend
to exhibit neuroendocrine and physiological respons-
es similar to older individuals 7, 86 and as described
through a series of studies of older individuals and
a review of responses in overfat individuals, there is
positive adaptations following RT in return of ana-
bolic and androgen hormone responses for the older
individuals.77, 87-91 In addition to these modifications

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Shaibi et al.78, 79 and from an ongoing-unpublished in anabolic and androgenic hormones, there are also
survey data that RT may be more likely to be uti- noted beneficial changes to cytokine signals (Table
lized, and independently followed, by the individual I), from skeletal muscles and adipocytes that dictate

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who is overfat, or obese. Additionally, several studies systemic changes metabolically,92, 93 and eventually

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Figure 4.—Examination of the downstream and reverberating upstream effects of cellular signalling and responses at the various
systems of the body to an increase in total level of physical activity resulting from greater level of exercise stimulus then previously
encountered based on the idea of the upper regulatory elements trigger responses physiological responses to exercise stress leading to
an elevated (­) or decreased (¯) response or hormone production. The key factors in this flow of biochemical and neuroendocrinologi-
cal pathway activation is seen with tissues with a resolution of the previously noted anabolic dysregulation and resultant signals of
myokines and advantageous adipokines altering metabolic pathways that chronically allow for the morphological adaptations being
sought in the treatment of overfatness and obesity. Image and concepts are modified and synthesized from images previously published
by Clark 4 and Spiering et al.20

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CLARK THE ROLE OF RESISTANCE TRAINING FOR TREATMENT OF OBESITY RELATED HEALTH ISSUES

morphologically, following employment of RT which
may not be seen to the same extent with ET, modi-
fying the intracellular signalling cascade leading to
greater lipolysis and protein accretion (Figures 4-7).
As had been noted with increases in adiposity there
is a degradation of testosterone via modifications of
output along the hypothalamic-pituitary-gonadal
(HPG) axis and at the gonads (Figure 7), resulting
in the androgen and anabolic dysregulation that is
associated with the deleterious health status changes
for individuals who are overfat, or obese, which is
who are overfat, or obese.44, 45, 94-97 The anabolic
and androgenic issues appear to be reversed by first
providing an acute metabolic stimulus to truncate
inhibitory signals within the gonads and secondar-
ily by chronically modifying the HPG-axis primarily
through increases luetinizing hormone (LH) signal-
ling and therefore production and release of testo-
sterone following the using of RT as a chronic ex-
ercise modality (Figure 7).88-91, 94-98 When coupled,
these acute and chronic responses establishes a bi-
phasic response seen in individuals that are overfat,

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countered by the application of RT for individuals or obese, and first involves an improvement of meta-

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Figure 5.—Diagram describing the impact of altering PPAR signals on the cellular cascades based on upper regulatory impact of diet
(typified by low-carbohydrate diets) and exercise (via cytokine signals, irisin and IL-6, anabolic hormones and reduced inflammatory
signals) leading to lipolysis, increased fatty-acid oxidation and possible apoptosis of adipocytes, and diminished intracellular inflam-
mation. While both endurance (ET) and resistance (RT) exercise will cause changes in the cellular cascade, however RT>ET due to
inducing signalling change secondarily to calcium-induced intracellular changes and interstital cytokine changes (e.g., irisin, IL-6,
adiponectin, leptin induced) along with much greater responses to GH, T, IGF changes (hormone, receptor, and intracellular signal-
ling). Note that the outcome from the inhibition of PPAR-γ is the reduction of inflammation, lipogenesis, or adipogenesis if PPAR-γ
is activated leads to increase in lipogenesis and adipogenesis with secondary inflammation signalling additionally inhibition of IL1,
TNFα and COX2 leads to the reduction of the inflammation (cellular) however if any of these are activated leads to inflammation (cel-
lular) NFκB limits the inflammatory pathway and has a series of activators beyond those shown here including cortisol. Legend:GH-
growth hormone, T-testosterone, IGF-insulin-like growth factor. Also, within the pathway, the solid and directional arrow indicates a
stimulatory effect while the dashed and blocked arrow indicates an inhibitory effect.

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THE ROLE OF RESISTANCE TRAINING FOR TREATMENT OF OBESITY RELATED HEALTH ISSUES CLARK

bolic (health) status, via cytokine singaling, that is
then followed by changes in body composition and
tissue morphology, via anabolic hormone singal-
ing. Most notable amongst the anabolic hormone
changes are relative to increases in testosterone as-
sociated with a truncation of binding globulins, and
altering conversion enzymes (e.g., reductions in both
aromatase [P450], 11-β-HSD2, and increase in 5-α
reductase) both in circulation and at peripheral tis-
sues following exercising in the overfat individual
that associates with the noted anabolic and andro-
RT should provide the stimulus that truncates the in-
hibitory signals acutely and when combined should
provide the physiological stimulus for the increase
in testosterone and resultant anabolic and androgen-
ic responses (Figure 7). And it is these changes in
anabolic hormone and cytokine signaling responses
leads to a very interesting phenomenon in morpho-
logical adaptations for the individual that is overfat,
or obese. As several authors have noted, changes is
that while BM loss through CR or ET leads to a total
loss from all tissues, both FM and FFM, RT provides

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genic changes seen.94-97, 99, 100 While modification the stimulus for maintaining FFM while allowing for
in testosterone tends to be delayed, the metabolic greater loss of FM relative to either CR or ET as a
modifications that occurs systemically in response to means for BM reduction (Table II).76, 80, 82, 83, 101

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Figure 6.—Diagram describing the impact of altering signalling and the resulting cellular cascades based on idea that resistance
exercise leads to anabolic hypertrophic responses to skeletal and skeletal muscle tissue and catabolic (apoptotic) responses to lipid
droplets and adipose tissue following the acute episode of muscle contraction, or to the chronic RT stimulus. Responses are generated
by imparting greater anabolic signalling by increases to T, GH, IGF and MGF while truncating the impact of cortisol and estrogen (via
inhibition of ERRα) on the peripheral tissues and inhibiting the converting enzyme aromatase along with intracellular response cascade
following activation of CaMKII, MEF2 and MIF.
GH: growth hormone; IGF: Insulin-like growth factor; MGF: mechanogrowth factor; T: testosterone; ERRα: estrogen-related receptor;
MEF2: myocyte enhancing factor 2; CaM: calmodulin; CaMKII: calcium-calmodulin dependent kinase II; MIF: myocyte ischemic
factor. Also, within the pathway, the solid and directional arrow indicates a stimulatory effect while the dashed and blocked arrow
indicates an inhibitory effect.

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O
E
M
R

Figure 7.—Description of the inhibition and activation of Leydig cells based on the exposure to either high levels of circulating fatty-
VA

acids (FFA) seen with individuals who are overfat and then with exposure to resistance training for the same individuals leading to the
normalization of gonadal function related to testosterone (T) production and downstream anabolic and androgenic responses at the
peripheral tissues. Note that there is no indication for high FFA limiting the function of Sertoli cells and therefore there is no change
in the production of binding globulin (SHBG) and hence should be the rationale for having high levels of SHBG in males relative to
lower levels of T in individuals who are overfat.94-97 Also, within the pathway, the solid and directional arrow indicates a stimulatory
P
R

effect while the dashed and blocked arrow indicates an inhibitory effect.

While there appears to be advantageous changes a normal health status for the individual that is over-
E

in how body composition is modified, in particular fat. One such issue is cardiovascular and cardiores-
the retention of FFM with greater reduction of FM, piratory functions, i.e. aerobic fitness, to address this
IN

reflecting a distinct advantage toward utilizing RT issue RT can be prescribed in such a way to elicit a
as a therapeutic intervention (Table II) 76, 80, 82, 83, 101 cardiorespiratory response that equates to responses
there are physiological conditions can also be alle- following ET 75, 102, 103 and when chronically em-
M

viated through the use of RT and allow for return to ployed RT can lead to improvement in aerobic fit-

Table II.—Summary of comparison of changes (average change±SD) reported in body mass (BM) along with the subset of changes
in fat-free (lean body) mass (FFM) and fat mass (FM) for diet (Diet), diet and endurance training (Diet & ET), or diet and resistance
training (Diet & RT). Note that comparisons where across similar treatment duration and caloric deficit from intervention (approxi-
mately -500 kcal/day) with reduction in mass is indicated as negative number while gain in mass indicated in positive value.
Diet Diet & ET Diet and RT
Average change in BM (kg) -9.433±7.7 -4.267±4.14 -4.775±7.05
Average change in FFM (kg) -2.507±2.02 -0.56±1.49 0.2748±2.67
Average change in FM (kg) -6.927±5.72 -3.707±2.88 -6.0948±4.18

10 THE JOURNAL OF SPORTS MEDICINE AND PHYSICAL FITNESS ?? 2015

THE ROLE OF RESISTANCE TRAINING FOR TREATMENT OF OBESITY RELATED HEALTH ISSUES CLARK
ness.104, 105 Coupling these changes in cardiovascu-
lar and cardiorespiratory functions with changes in
body composition and physiological function leads
to improved independence thus a greater quality of
life (QOL) for the individual that is being treated for
issues of overfatness.9, 76, 82, 84, 85, 101
Most of these changes do not originate in the clas-
sical structural (e.g., hypertophication) responses to
RT but from metabolic changes seen in the skel-
etal and skeletal muscle tissues. These metabolic
changes elicit cytokine signaling that induce down-
stream modifications in other tissues, most notably
seen with “browning” of adipose tissue, that occurs
both acutely and chronically to RT and leads to in-
creases lipolytic activity, fatty-acid oxidation and
O
thermogenic rates, which leads to a differentiated
adipokine signals that perpetuates these metabolic
changes to additional peripheral tissues (Figures 3,
5, 6).69, 93, 106 Additionally, RT generates upstream
modification in the HPA-axis output, that leads to
O
normalization of cortisol and epinephrine along
with a reduction in the inflammatory biomarker out-
put all of which improves immune function while
simultaneously reducing the level of chronic inflam-
mation.47, 56, 107, 108 These beneficial modifications in
immune functions are coupled with the modifica-
R
tion in hormonal signals, in particular anabolic and
VA
androgenic hormones (Table I), at the level of pe-
ripheral tissues (e.g., adipose, bone, liver and skel-
etal muscles) providing the scaffolding for return to
normal tissue function systemically (Figures 3-6).
P
Moreover, changes in circulating metabolites, along
R
with cytokine and endocrine, signaling leads to
positive adaptations within cardiovascular function
E
changes (e.g., increased vasculature compliance, a
reduction in vascular adhesions along with the state
IN
of inflammation).56, 109 These peripheral changes
are accompanied by central cardiac responses to
the transient exposures to increases in total periph-
M
eral resistance and increases in venous return to the
heart, via muscle pump action, that increases car-
diac functions by increasing ejection fraction and
stroke volumes, which indicates that RT provides
a mean for reducing risk for cardiovascular disease
that may have developed over the lifespan of over-
fatness, or obesity.33, 104, 107
While it is true that body compositional changes
only develop through prolonged use of the exercise
regimen, positive health status changes to begin to
Vol. 55 - No. 2 THE JOURNAL OF SPORTS MEDICINE AND PHYSICAL FITNESS 11
form prior to changes in body composition from use
of both RT and ET for the individual who is obese,
or overfat.9, 107, 110, 111 However, there have been few
studies of comparison between the two modes of
exercise, and when there is a comparison RT tends
to elicit a much greater response that ET at modi-
fying the hormonal and regulatory signals.92, 101, 112
The difference in response between the training
modalities can most likely be attributed to the lim-
ited impact on anabolic signalling pathway that ET
exhibits relative to that of RT (Table I) even if ET
F
acutely elicits a greater acute caloric expenditure,
indicating greater chronic benefits from RT.20, 64, 113
Principally this occurs due to the systemic response
A
to the exercise stress, impacting upon the cellular
signally cascades leading to the increased FFM and
IC
decreased FM, and improved health status (e.g., an
increase in the coordination of physiological func-
tion of the various systems of the body), ensuring
D
an increased independence of living for the person
and therefore an improved QOL for the individual.
E
Additionally, because of the increased psychologi-
cal appeasement of RT versus ET for the individual
who is overfat, or obese, there is an increased likeli-
M
hood for the person to become a lifelong exerciser
and continual improvements along the continuum of
health status (Figure 1).
Practical application and issues of program devel-
opment
Which raises the question, if RT is as good as it
appears to be, then why is it that RT is not as widely
utilized and recommended as ET in treatment op-
tions? It appears to be more about the apparent at-
titude toward RT based on older theorems and prac-
tices of what is best exercise for individuals who are
overfat. Evident by what appears to be appeasement
by researchers and medical professionals for the
application of exercise into the appearance of “so-
cially acceptable” use of exercise for the individual
related to body image (e.g., obese person should be
utilizing ET and not RT to establish caloric deficit)
and gender response (e.g., females misperception of
RT making the female body appear to be “bulky”).
Additionally, there is continual emphasis from or-
ganizations such as the American College of Sports
Medicine (ACSM) through position stands 53, 57 that
intervention programs should utilize large compo-
CLARK THE ROLE OF RESISTANCE TRAINING FOR TREATMENT OF OBESITY RELATED HEALTH ISSUES
nent of ET style activities within the exercise pro-
gram, developed from the premise that ET has been
indicated to elicit a greater energetic expenditure
than RT.11, 18, 19, 51, 52 Which this author speculates
may have more to do with methodical means for
measurement then true energetic demand for activ-
ity, as it is becoming more accepted that postexer-
cise oxygen consumption (EPOC) and therefore ca-
loric expenditure appear to be higher following RT,
or intermittent exercise. Moreover, there appears
to be poor application of models of periodized and
progressive RT in many of the popular exercise pro-
grams and gymnasium settings toward the appease-
ment for developing acute caloric deficits within the
period of activity instead of developing RT regi-
O
mens that devise the overload necessary for stimu-
lus required for adaptations from RT 20, 63, 114, 115 and
thus metabolic stimulus for chronic energy expen-
ditures for the individual. These are coupled with
poor appreciation of the health responses that may
O
be seen quickly and without changes in morphol-
ogy 11, 111 and lead to poorly focused outcome of
training, focusing more on caloric deficits and the
changes in body morphology (particularly in the
measure of simple body mass) as opposed to chang-
ing the health status for the individual that can be
R
generated by changes to the fitness factors for that
VA
individual.4, 8 This in opposition to developing an
RT program that provide the stimulus to elicit URE
modification 20, 64, 113 and induce the cytokine sig-
nals to lead to resolution of many of the health is-
P
sues (e.g., chronic inflammatory signals, metabolic
R
syndrome, hypogonadalism, Figures 4-7).88-91, 93-97
As it relates to individuals who are overfat there
E
are two distinct models of RT that have been exam-
ined empirically as a therapeutic intervention. First,
IN
several authors 9, 76, 78, 80-85, 88-91 have indicated that
a traditional RT model, that utilizes a training in-
tensity level that is initially 70% of one-repetition
M
maximum (1RM) and progresses to 80-90% 1RM
over the length of the training program with a total
volume of 18-to-30 repetitions (broken into 3-to-4
set and progressing up 6 sets with repetitions within
sets decreasing in accordance to increases in level
of resistance) with rest intervals ranging from 2-to-
3 minutes (based on training status and/or level of
training intensity) between each set of exercise.
Within this model of RT, exercise selection within
focuses on the large complex exercises movements
12 THE JOURNAL OF SPORTS MEDICINE AND PHYSICAL FITNESS ?? 2015
(e.g. bench/chest press, squat/leg press, dead lifts)
as opposed to isolated exercise movements (e.g.
biceps brachii curls) with the weekly microcycles
of training should involve resistance training begin-
ning at least twice a week and increase to three and
four sessions per week over the course of interven-
tion. It is this model of RT which would have the
greatest likelihood to induce the modifications in
hormonal and cytokine signals to assist with resolu-
tion of health status for the individual that is overfat
(Figures 4-7).
F
Additionally, several authors 75, 92, 102, 103, 111, 116
have noted that the use of an integrated circuit train-
ing model (CRT) can also be an effective means of
A
therapeutic treatment for individuals that are over-
fat. Most of the CRT programs utilized the large
IC
complex exercises with a similar total volume of
training (18-to-30 repetitions) as the more tradition-
al progressive program, but utilized a much lower
D
training intensity (50-70% of 1RM) with a very lim-
ited, to no, rest period and employed an interspersed
E
ET style exercise between sets of exercises as op-
posed to inactive rest that is utilized in the more
traditional RT model. While use of CRT can pro-
M
vide a means for developing a caloric deficit, there
is limited evidence to support the metabolic impact
of such training to elicit the hormonal modifications
(Figures 4-7), that would allow for resolution of the
anabolic dysregulation from chronic employment of
the training model. Therefore, use of CRT style RT
programs may have benefit, reduction in BM along
with improving aerobic capacity and metabolic flex-
ibility, it should not be utilized as the sole therapeu-
tic exercise modality, because of the limited impact
on the hormonal modification, for individuals who
are overfat.
While the exercise stimulus provided by RT ap-
pears necessary for reversal of many of the health
issues in the individual who is overfat (Figures 3-5)
there distinct physiological limitations that must be
taken into account when developing an RT program.
These limitations originate in the chronically low
level of exercise stimulus (Figure 2) for individuals
who are overfat and therefore should be considered
highly detrained when initiating an exercise pro-
gram. Hence, the high level of detraining results in a
low total muscle mass that can be recruited, regard-
less of the level of training intensity, or apparent
training volume. And will lead to the resultant great-
THE ROLE OF RESISTANCE TRAINING FOR TREATMENT OF OBESITY RELATED HEALTH ISSUES CLARK
er level of muscle stimulation and total recruitment
of skeletal muscle tissue at even what appears to be
an apparent low absolute level of resistance, but in
actuality provides a high level of stimulation.117, 118
Which indicates that training intensity, particularly
early in RT programs, should be matched with the
appropriate level of rest and recovery to allow to
subsequent recruitment at the appropriate intensity,
or subsequent intensity modified based on level of
rest and recovery provided. This lack of modifica-
tion in either rest, or level of intensity, is one of the
key components to RT program development that
many of the popular exercise programs appear to
lack leading to the poor application of RT that has
been previously mentioned.
O
Additionally, at least early in the therapeutic con-
ditioning program this large exercise stress is cou-
pled with the previously indicated chronic state of
inflammation for the individual who is overfat, leads
to an increased likelihood for individual to succumb
O
to issues of overtraining syndromes.119, 120 With
overreaching and overtraining developing from what
might label as a low exercise stress, based solely on
training volume, for a healthy individual which for
the individual that is overfat, should be classified as
an excessive training stimulus even at very low total
R
external stress from exercise. All of which implies,
VA
for the practitioner, that when determining appro-
priate therapeutic exercise intervention for individu-
als who are overfat it may require additionally pe-
riods of recovery (both within and between bouts)
P
at the beginning of a program. As these individuals
R
actually have exposure to a greater total volume and
thus level of stimulation, if all things are equal to a
E
comparable fit person, leading to greater stress to
respond to.117, 121
IN
Second to the level of detraining and chronic
inflammatory state impacting the health of the in-
dividual that is overfat at the initiation RT (or any
M
exercise protocol), there is also the need to under-
stand that level of resistance for weight-bearing (or
whole body) exercise is not uniform regardless of
the use of equivalent external load, once again one
of the poorly applied aspects of RT in the popular
exercise programs. This is due to the simple fact,
that seems to regularly ignored that individuals who
are overfat tend to have larger percent of total body
mass, from both non-active tissue (i.e. FM) and ac-
tive tissue (i.e. FFM), which must be overcome in
Vol. 55 - No. 2 THE JOURNAL OF SPORTS MEDICINE AND PHYSICAL FITNESS 13
addition to the external load that is applied in the
RT session. This indicates that for the individual
who is overfat, they are able to reach the point of
overload at much lower threshold than would be ex-
pected, which occurs regardless of the total amount
of recruitable tissue (i.e. FFM) available to the indi-
vidual.122 Therefore it is key that when determining
the total training intensity (i.e. level of resistance)
and volumes (i.e. total repetitions times total level
of resistance) this additional mass must be taken
into account especially when determining the total
F
training intensity and volume of training especially
for whole body exercises (e.g., squats, lunges, dead-
lifts, step-ups).122 By doing so, this will allow for
A
not only equating training intensities across training
cycles for the individual, but will allow for deter-
IC
mining of absolute strength gains obtained from RT
therapeutic exercise programs.
Hence, there are distinct precautions that should
D
be included in the development of the therapeutic
exercise program for the individual who is over-
E
fat. First, training programs should utilize train-
ing intensity to maximize metabolic and hormo-
nal adaptations and not the development of acute
M
(within session) caloric demand. Thus establishing
upstream and downstream signals (Figures 4-7) to
ensure that there can be resolution of health issues
associated with overfatness. Second, due to the im-
pact that the diseased state for the individual who is
overfat, there is a need to establish a base level of
training response. This base level of response can be
established throughout the familiarization phase to
the exercise program but should still be progressive
in nature and begins at absolute levels of intensity
that appear to be less than the aforementioned level
to induce chronic changes in hormonal. Principally
due to limited total recruitable tissue, but as Sale
notes,117 will quickly increases as neurological ad-
aptations provide the initial scaffolding for greater
levels of training intensities leading to progressive
and continual metabolic and hormonal adaptations
in response to RT. Moreover, because of the large
total amount of recruitment (as training intensity
may appear absolutely low but in effect is as a %
of 1RM quite large) pattern of exercise sessions
must include appropriate recovery periods for both
between (up to 72 hours), and within (up to 3-to-5
minutes between sets), exercise sessions. And may
be combined with some level of ET, ideally utilized
CLARK THE ROLE OF RESISTANCE TRAINING FOR TREATMENT OF OBESITY RELATED HEALTH ISSUES
on days of recovery from RT. It should be noted that
because of the changes that CRT can elicit, CRT can
easily and effectively be implanted as the training
model to be used at the initiation of training to as-
sist with developing the base level of training for the
individual who is overfat.
There are also several generalizations that should
be incorporated into the development of the RT pro-
tocol within the therapeutic exercise program for the
individual who is overfat. First, exercise selections
while focusing on large whole body (or gross com-
plex) movement, they should vary in both pattern of
muscle recruitment and level of intensity of training
within and between training sessions. In addition,
RT should be progressive in nature and periodized,
O
see Bird 63 and Kraemer 115 for details, so as to re-
cruit muscle tissue across the spectrum of muscle
fibers so as to induce continual metabolic, morpho-
logical and hormonal adaptations. Second, RT ses-
sions should be interspersed with at least 48 hours of
O
recovery between sessions that employ similar exer-
cise patterns at the same level of intensity utilizing a
similar fashion of recruitment. With the rest and re-
covery within exercise sessions should be patterned
in such a way as to maximize changes in hormonal
signals following the exercise session, while provid-
R
ing the necessary time for the recruited tissues to
VA
prepare for subsequent recruitment. Third, if ET is a
desired component of the training regimen it should
be used on days of recovery so as to maximize the
postexercise hormonal responses to the RT in an ef-
P
fort to offset the effect of concurrent ET and RT has
R
on such responses. If ET is utilized concurrently to
the RT within a single session it should be at least
E
in the form of intermittent (or interval) ET within
the CRT model of RT exercise. Lastly, since reduc-
IN
tion in BM is global (e.g. from all body tissues) RT
should be employed at an intensity and training vol-
ume that induces changes to maintain (or increase)
M
the amount of FFM while providing the metabolic
and cytokine (hormonal) signalling to induce reduc-
tion in FM when coupled with the chronic caloric
deficit that is required for reduction in BM.
Conclusions
While there is the historic use of therapeutic ex-
ercise programs that encourage the use of ET over
14 THE JOURNAL OF SPORTS MEDICINE AND PHYSICAL FITNESS ?? 2015
RT, ET may not provide the stimulus to encourage
both changes in health status along with the expect-
ed body compositional changes, which is provided
by RT. This historical perspective is coupled with
the misconception about differential mass loss, i.e.
all mass loss is “good mass loss”, results in a sense
of stagnation of progress and results in discourage-
ment for continual use of exercise by the individ-
ual who is overfat. However, therapeutic exercise
programs that incorporate RT, allow for changes
in body composition and improvements in health
F
status that may not reflect absolute changes in BMI
classification for the level of obesity. When these
programs are coupled with a chronic caloric deficit
A
elicit a reduction in BM that is comprised primarily
of FM loss with at least the maintenance (if not in-
IC
crease) of FFM. Together the reduction in FM and
an improvement in health status produced by the
positive cascade of physiological events occurring
D
at the tissues of the body in response to RT provides
for an increased independence for completion of
E
ADL’s and improved QOL for the individual who is
overfat, regardless of age.
Even with this level of appreciation for the use of
M
RT in a therapeutic exercise program, there is still
a need for additional research. This is especially
evident regarding our understanding of aspect of
changing health status due to the impact of over-
fatness on responses to RT across the age spectrum
from adolescent through adulthood and into old age.
While we make many assumptions regarding ex-
pected responses based on findings in other popula-
tions there are still a number of questions left to ad-
dress. Particular amongst these questions are related
to the ability effectively compare RT and ET to the
differential hormone response to training modality;
the ability to induce BM loss especially in light of
the differential responses that and individual has to
either training modality (especially RT) based on
training status and length of time of overfat status;
and lastly the impact of familiarization to RT on
endocrine and metabolic responses for individuals
who are overfat. Each of these will have an impact
on the effective design for therapeutic exercise stud-
ies for comparison between various modalities that
can be implemented for individuals who are overfat.
Still, based on our current understanding for the
benefits that can be obtained from RT for the in-
dividual that is overfat, RT should be continually
THE ROLE OF RESISTANCE TRAINING FOR TREATMENT OF OBESITY RELATED HEALTH ISSUES CLARK
encouraged as part of a total conditioning program,
that involves both RT and some ET, in holistic treat-
ment protocols for individuals who are overfat, or
obese. To ensure greatest benefit employment of
the RT programs in treatment protocols should be
designed utilizing a progressive periodized method
that is based on the individual physiological re-
sponses from the exerciser. By doing so, one will
ensure that the acute program variables are being
manipulated in such a manner as to elicit the correct
response within the URE for the desired outcome
of training. Lastly, as has been indicated, access
to a pattern of activity that appears to have great
psychological appeasement for individuals who are
overfat, or obese, encourages a greater innate drive
toward exercise. Therefore, if possible RT can, and
O 19. Sieverdes JC, Sui X, Lee DC, Church TS, McClain A, Hand GA
should, be employed early in life (i.e. as a juvenile),
thus increasing the likelihood for the person to have
a lifestyle shift towards increased healthy behaviors
across their lifespan. Ultimately it is this increase in
activity that will lead to resolution of health status
O
from diseased to normal health and throughout the
progression of the exercise program allows the indi-
vidual who is overfat to have ever-greater degrees of
independence within their life.
R
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Funding.—No author has received any external funding for the pro-
duction or publication of this manuscript.
Acknowledgements.—Author would like to especially thank Dr. Wil-
liam Kramer and Brett Comstock for their insight and clarification lead-
ing to the finalization of materials in the practical role for RT in the
therapeutic exercise program.
Conflicts of interest.—The authors certify that there is no conflict of
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interest with any financial organization regarding the material discussed
in the manuscript.
Received on April 23, 2013.
Accepted for publication on June 20, 2013.
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