is reduced in physically active individuals compared with sedentary individuals. In addition, physical activity reduces the risk of hypertension with weight gain. As such, regular aerobic exercise is recommended for patients with elevated BP.49 Meta-analyses indicate that regular aerobic exercise produces clinically significant reductions in systolic and diastolic BP; the effect is largest in those with hyperten- sion.50


Importantly, the systolic BP–lowering effect of exercise appears similar to some commonly used antihypertensive medications.51 be effective for lowering BP.52


to be independent of baseline adiposity and changes in body composition53,54 impact of reduction in visceral fat on BP is less clear.


Resistance exercise may also


The reduction in BP with regular exercise appears ; the


Lipid and Lipoprotein Concentrations Dyslipidemia, particularly an elevated level of low-density lipoprotein (LDL) cholesterol, has been causally linked to the development of atherosclerosis.55,56 Perhaps the most successful strategy in the prevention and treatment of CVD has been through the use of statins.55


However, CVD remains the leading cause of


death in the United States, and substantial residual risk attributable to lipid and lipoprotein concentrations remains.57


Obesity is associated with an adverse lipid


and lipoprotein profile. Elevated levels of small, dense LDL particles (and apolipo- protein B) and triglycerides and reduced levels of high-density lipoprotein (HDL) cholesterol occur more frequently in patients with an accumulation of abdominal visceral fat.58


Weight loss, regardless of the mode used to achieve it, is associated


with reductions in most lipid and lipoprotein levels with the exception of HDL cholesterol,59


and magnitude of change in lipid and lipoprotein concentrations.60


but diet composition can have a profound impact on the direction A high intake of


saturated fatty acids and dietary fiber are associated with increases and decreases in LDL concentrations, respectively.61,62 Regular aerobic exercise has a positive impact on fasting lipid and lipoprotein concentrations, independent of weight loss.63


The effect of exercise on levels of


lipoprotein subclasses is beyond the scope of this chapter but, in general, exercise reduces triglyceride concentrations and results in a distribution of LDL and HDL particles toward larger species.64


Importantly, exercise reduces the number of more


atherogenic, small, dense LDL particles. Reductions in total body fat, and particu- larly visceral fat, with exercise training are associated with more favorable changes in lipid and lipoprotein levels than is exercise without changes in body composition and regional fat distribution.63


Insulin Resistance and Type 2 Diabetes


Impaired insulin-stimulated glucose disposal (ie, insulin resistance) is common in individuals with obesity,65


particularly those with abdominal obesity.66 defect in the development of type 2 diabetes.68 Obesity


and insulin resistance are associated with a high risk of developing type 2 diabetes, as well as CVD.67


skeletal muscle can be improved even after a single bout of exercise.69,70


Skeletal-muscle insulin resistance has been implicated as a key Fortunately, insulin resistance in However,


repeated bouts are needed to ensure durability of the effect. Exercise training improves insulin sensitivity in individuals with obesity with and without type 2 diabetes.71


affect insulin sensitivity,72 improved insulin sensitivity in individuals with obesity.73


Exercise does not have to be prolonged or of high intensity to favorably although recent findings suggest that low-volume HIIT Importantly, daily exer-


cise does not have to be completed in a single session (eg, 30 minutes) to improve insulin sensitivity but can be accumulated throughout the day.74


202 SECTION 3: Interventions for the Treatment of Overweight and Obesity


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