The Effect Of 12 Weeks Of Aerobic, Resistance Or Combination Exercise .

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Ho et al. BMC Public Health 2012, 4RESEARCH ARTICLEOpen AccessThe effect of 12 weeks of aerobic, resistance orcombination exercise training on cardiovascularrisk factors in the overweight and obese in arandomized trialSuleen S Ho1, Satvinder S Dhaliwal1, Andrew P Hills2 and Sebely Pal1*AbstractBackground: Evidence suggests that exercise training improves CVD risk factors. However, it is unclear whetherhealth benefits are limited to aerobic training or if other exercise modalities such as resistance training or acombination are as effective or more effective in the overweight and obese. The aim of this study is to investigatewhether 12 weeks of moderate-intensity aerobic, resistance, or combined exercise training would induce andsustain improvements in cardiovascular risk profile, weight and fat loss in overweight and obese adults comparedto no exercise.Methods: Twelve-week randomized parallel design examining the effects of different exercise regimes on fastingmeasures of lipids, glucose and insulin and changes in body weight, fat mass and dietary intake. Participants wererandomized to either: Group 1 (Control, n 16); Group 2 (Aerobic, n 15); Group 3 (Resistance, n 16); Group 4(Combination, n 17). Data was analysed using General Linear Model to assess the effects of the groups afteradjusting for baseline values. Within-group data was analyzed with the paired t-test and between-group effectsusing post hoc comparisons.Results: Significant improvements in body weight ( 1.6%, p 0.044) for the Combination group compared toControl and Resistance groups and total body fat compared to Control ( 4.4%, p 0.003) and Resistance( 3%, p 0.041). Significant improvements in body fat percentage ( 2.6%, p 0.008), abdominal fat percentage( 2.8%, p 0.034) and cardio-respiratory fitness (13.3%, p 0.006) were seen in the Combination group comparedto Control. Levels of ApoB48 were 32% lower in the Resistance group compared to Control (p 0.04).Conclusion: A 12-week training program comprising of resistance or combination exercise, at moderate-intensityfor 30 min, five days/week resulted in improvements in the cardiovascular risk profile in overweight and obeseparticipants compared to no exercise. From our observations, combination exercise gave greater benefits for weightloss, fat loss and cardio-respiratory fitness than aerobic and resistance training modalities. Therefore, combinationexercise training should be recommended for overweight and obese adults in National Physical Activity Guidelines.This clinical trial was registered with the Australian New Zealand Clinical Trials Registry (ANZCTR), registrationnumber: ACTRN12609000684224.Keywords: Obesity, Overweight, Cardiovascular risk factors, Exercise training* Correspondence: s.pal@curtin.edu.au1School of Public Health; Curtin Health Innovation Research Institute, CurtinUniversity of Technology, GPO Box U1987, Perth, Western Australia,Australia 6845Full list of author information is available at the end of the article 2012 Ho et al.; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the CreativeCommons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, andreproduction in any medium, provided the original work is properly cited.

Ho et al. BMC Public Health 2012, 4BackgroundPhysical activity is a major modifiable determinant ofchronic disease [1]. The Australian National PhysicalActivity Guidelines for Adults recommend that for goodhealth, adults should “put together at least 30 min ofmoderate-intensity physical activity on most, preferablyall, days [2].” However, it is not known if this recommendation is adequate for improvement in cardiovascular disease (CVD) risk factors in overweight and obeseindividuals [3]. Despite the acknowledged role of 30 minutes of daily physical activity on general health improvements in an otherwise healthy but sedentary population,less is known of the adequacy of this level of exercise forhealth improvements in those who are overweight orobese. In addition, as many people have difficulty findingtime to exercise, it is important to better understandwhich mode(s) of exercise is the most effective.Numerous studies have investigated the effects of exercise training, demonstrating significant improvements toCVD risk factors after aerobic exercise training [4,5].However, it is unclear whether health benefits are limited to aerobic training or if other exercise modalitiessuch as resistance training or a combination are as effective or more effective in the overweight and obese.Sigal et al. [6] investigated the effects of aerobic, resistance and combined aerobic and resistance training inadults with Type 2 diabetes. However, the combinedintervention used both aerobic (45-min walking/cycling)plus resistance training (2–3 sets of 7 exercises with 7–9repetitions), that is, participants completed a double doseof exercise. They observed significant decreases in bodyweight, body mass index (BMI) and abdominal subcutaneous fat in the aerobic and resistance groups comparedto control.Davidson et al. [7] also examined different exercisemodalities in older adults. Calorie intake was strictlycontrolled and results were due solely to the energy deficit of the exercise interventions. They observed significant improvements to total, abdominal and visceral fatand cardio-respiratory fitness in the aerobic and combination exercise groups. It was concluded that the combination of the resistance and aerobic exercise was theoptimal exercise strategy for improvements to insulin resistance and functional limitations [7].A recent study by Church et al. [8] compared equivalent time durations (140 min/week) of aerobic, resistanceand combination exercise. They observed significantimprovements in HbA1c and maximum oxygen consumption in the combination group compared to controlas well as decreases in weight and fat mass in the resistance and combination groups compared to control.Research comparing the effect of resistance and aerobictraining on CVD risk factors is limited and few studieshave compared aerobic, resistance and a combination ofPage 2 of 10this training. Given the increasing burden of chronic disease, more research is needed to better understand theeffect of different exercise modalities on these risk factors. Australian Physical Activity Guidelines promote30-min of moderate-intensity exercise on most days ofthe week; therefore the aim of this study was to investigate whether a 12-week training program with aerobic,resistance, or combined exercise at the same intensityand duration would improve the cardiovascular riskprofile in overweight and obese adults compared to noexercise.MethodsParticipantsNinety-seven overweight or obese men (n 16) andwomen (n 81) (BMI 25 kg/m2 or waist circumference 80 cm for women and 90 cm for men), aged 40 to 66 ywere recruited from the general population from April2006 - April 2007 (Figure 1). Participants were requiredto be sedentary or relatively inactive, participating in lessthan 1 h of moderate-intensity physical activity per weekover the last 3 months. Participants were recruited froman existing database of volunteers from previous studiesthat concluded at least 6 months prior and from thecommunity using local newspapers and radio. Interestedindividuals were screened via telephone. Exclusion criteria included diabetes mellitus, pre-existing heart conditions, lipid lowering medication, beta-blockers, pregnantor lactating women, smokers, gastrointestinal tract surgery, major illness (acute or chronic) including any thatwould limit the ability to perform the necessary exercises.Figure 1 Participant flow chart.

Ho et al. BMC Public Health 2012, 4Study procedures were approved by the Curtin University Ethics Committee (HR 166/2004) and participantsgave written informed consent.Study designThis 12-week study was a randomized parallel designexamining the effects of different exercise regimes onfasting measures and changes in body weight, fat massand dietary intake. Participants were randomized to fourdifferent groups as they were recruited by the researcher(using a randomization sequence [9]). Group 1 (Control)were not given any exercise intervention (placebo dietarysupplement only). This was to ensure participants didnot know they were in the control group and followedstudy procedures similarly to those in the interventiongroups. Control participants were asked to take a teaspoon of supplement in a glass of water once/day whichcontained approximately 2 grams breadcrumbs and 0.1grams “Equal” artificial sweetener. Group 2 (Aerobic)performed 30-min of aerobic exercise, 5 days/week, consisting of treadmill walking. Group 3 (Resistance) performed 30-min of resistance exercise, 5 days/week usingweight resistance machines. Group 4 (Combination)performed 15-min of aerobic and 15-min of resistanceexercise 5 days/week. Three assessment visits were conducted in clinical rooms at Curtin University for bloodsamples, body composition and other measurements. Allparticipants were requested to keep food intake andphysical activity the same as before the study, except forthose in the exercise groups, who were instructed to doadditional exercise as per their program. Participantscompleted baseline measurements over one week beforeattending an initiation session at the Curtin FitnessCentre where their exercise program was demonstratedby Centre staff.Exercise interventionsThe exercise interventions were either 30-min aerobicexercise on a treadmill at 60% heart rate reserve (HRR) 10 beats/min, with HRR estimated using the Karvonenequation (220-age-resting heart rate) [10]; 30-min of resistance exercise (four sets of 8–12 repetitions at 10-RMfor leg press, leg curl, leg extension, bench press andrear deltoid row, with each set completed in approximately 30-sec with 1-min rest) with the 10-RM leveldetermined during the initial session by Fitness Centrestaff; or a combination of 15-min aerobic exercise and15-min of resistance exercise (two sets of each exercise).10-RM would be approximately 75% of 1-RM [11]. Starting workload levels for each piece of equipment weretested by participants and if more than 10 repetitionswere achieved, the weight was increased and after ashort rest participants tried again. Likewise, if less than 8repetitions were achieved, the weight was decreased andPage 3 of 10after a short rest participants tried again. Participantsbegan by exercising three days/week for two weeks before exercising at recommended levels for five days/weekthereafter. Participants reported to the Curtin FitnessCentre three days/week to complete the required exercise and either exercised at home the other two days orat the Centre. If exercises were completed at home,dumbbells (adjustable weight 1.5-10.5 kg) were providedfor resistance exercises (three sets of 10 repetitions forbiceps curls, lunges, dumbbell raise, calf lift, triceps extension for Resistance group while the Combinationgroup did 2 sets of biceps curls and lunges and 1 set fordumbbell raise, calf lift and triceps extension; back extension, push ups and sit ups exercises were also included). Treadmills were equipped with heart ratesensors and participants were instructed to increaseweight loads by 2.5 kg increments when they couldcomplete more than 12 repetitions. Participants keptfood diaries to monitor dietary intake and were giveninstructions during the briefing session. Data was analysed with Foodworks Professional 2007, Xyris Software,Australia.Measurement of biochemical markersParticipants reported for fasting blood samples at baseline and at the completion of 8 and 12 weeks of training.Serum triglyceride (TG) and total cholesterol were measured by enzymatic colorimetric kits (TRACE ScientificLTD, Melbourne, Australia). High density lipoprotein(HDL)-cholesterol was determined after precipitation ofapoB-containing lipoproteins with phosphotungstic acidand MgCl2 [12]. Low density lipoprotein (LDL)-cholesterol was determined using a modified version of theFriedewald equation [13]. Non-esterified fatty acid wasdetermined in serum using the WAKO NEFA C Kit(Wako Pure Chemicals Industries, Osaka, Japan) according to instructions, but scaled down 1:10 to use onmicrotiter plates. Plasma glucose was measured usingRandox glucose GOD-PAP kits (Randox, Antrim, UnitedKingdom). Plasma insulin was measured by a solid phaseEnzyme Amplified Sensitivity Immunoassay (INS-EASIAkit, BioSource, Belgium). Homeostasis model assessmentof insulin resistance (HOMA2-IR) was calculated fromfasting glucose and insulin concentrations [14].Anthropometric measuresAnthropometric measures were completed and BMI calculated. Weight was measured using electronic scales(Tanita Corporation, Tokyo, Japan). Waist circumferencewas measured at the mid-point between the bottom ofthe rib cage and the iliac crest and hip circumferencewas measured at the widest point at the hip. Abdominaland total body fat was measured by DXA (dual-energyX-ray absorptiometry) at baseline and 12 weeks (GE-Lunar

Ho et al. BMC Public Health 2012, 4Page 4 of 10Prodigy DXA scanner, GE Healthcare, Chalfont St. Giles,UK). The analysis program automatically defines theabdominal fat region with a rectangle from the upperedge of the second lumbar vertebra extended to the loweredge of the fourth lumbar vertebra.Apolipoprotein B48 determinationPlasma samples and purified apoB48 standards (previously prepared according to Zilversmit and Shea [15])were separated by SDS-PAGE using precast NuPAGE3-8% gradient gels in a Novex Mini-Cell (Novex Instruments, CA, USA) at 150 V for 80 min as described previously [16]. Separated proteins were electro-transferredat 30 V for 90 min onto 0.45 μm polyvinylidine diflouride (PVDF) membrane. Membranes were blocked overnight at 4 C in TBST (tris-buffered saline with Tween20) (10 mmol/L Tris–HCl buffer, pH 7.4, containing154 mmol/L NaCl) and 10% (w/v) skim milk powder.After washing in TBST, membranes were incubated with5 μg/ml rabbit anti-human apoB antibody in TBST for60 min. After washing in TBST, membranes were incubated with 0.5 μg/ml donkey anti-rabbit IgG linked tohorseradish peroxidase in TBST for 45 min. After washing in TBST, membranes were incubated with enhancedchemiluminescence substrate solution for detection ofhorseradish peroxidase and exposed to hyper-film ECL.The film was developed using an AGFA CP1000 automatic film processor, and apoB48 determined by densitometric scanning using the ScanMaker 9800XL(Microtek International, USA) scanner and Scion Imageprogram (Scion Inc).Post-absorptive energy expenditureResting energy expenditure (REE) and respiratory quotient (RQ) were measured in the fasted state for 30 minat baseline and week 12 by indirect open-circuit calorimetry using a ventilator canopy attached to the DeltatracII Metabolic Monitor (GE Healthcare). All metabolicTable 1 Participant characteristics at baselineCharacteristicControl (n 16)Aerobic (n 15)Resistance (n 16)Combination (n 17)Male/Female1/153/123/133/14Age (years)52 1.855 1.252 1.153 1.3(40 – 66)(44 – 62)(43 – 59)(43 – 64)Weight (kg)Body Mass Index (kg/m2)Body Fat % (DXA)Waist Circumference (cm)Waist: Hip RatioFasting Triglyceride (mmol/L)Fasting Total Cholesterol (mmol/L)Fasting HDL Cholesterol (mmol/L)85.1 4.291.9 4.189.3 4.590 4(64.8 – 123)(65.9 – 124.1)(71.9 – 127.5)(62.2 – 122.3)32.4 1.432.7 1.333 1.333.3 1.2(26 – 48)(25 – 45.6)(25.8 – 44.6)(23.4 – 40.2)46.5 1.744.6 1.943.7 1.345.8 1.6(35.9 – 59.9)(30.7 – 52.5)(34.6 – 52.2)(28.8 – 55.5)100.3 3.6103.7 2.6104 3.2102.2 3.2(80 – 131)(82 – 118)(83.5 – 135.5)(81.5 – 124.5)0.85 0.020.87 0.020.88 0.020.86 0.02(0.75 – 1.01)(0.76 – 1)(0.78 – 1.03)(0.74 – 1.02)1.25 0.171.36 0.191.27 0.121.1 0.1(0.48 – 2.6)(0.62 – 3.01)(0.51 – 2.14)(0.48 – 1.91)5.51 0.295.83 0.325.49 0.385.71 0.31(2.59 – 7.12)(3.58 – 7.87)(2.92 – 8.95)(3.74 – 9.2)1.42 0.111.38 0.091.34 0.081.43 0.11(0.9 – 2.28)(0.91 – 1.99)(0.91 – 2.19)(0.71 – 2.08)Fasting LDL Cholesterol (mmol/L)3.51 0.263.89 0.33.56 0.333.78 0.27(1.42 – 5.26)(2.08 – 6.06)(1.58 – 7.02)(2.4 – 6.88)Fasting Glucose (mmol/L)5.35 0.135.68 0.175.81 0.465.38 0.13(4.55 – 6.22)(4.39 – 7.11)(4.91 – 7.17)(4.2 – 6.46)HOMA2-IR1.92 0.281.72 0.521.86 0.181.86 0.13(1 – 4.7)(0.9 – 2.5)(0.7 – 3.5)(1.2 – 2.8)NEFA (mmol/L)0.51 0.030.5 0.040.49 0.040.46 0.03(0.3 – 0.79)(0.17 – 0.87)(0.18 – 0.94)(0.29 – 0.7)Values are mean SEM and (range) for n 64 participants at baseline. BIA: bioelectrical impedance analysis. DXA: dual-energy x-ray absorptiometry. HOMA2-IR:homeostasis model assessment of insulin resistance. NEFA: non-esterified fatty acid.

Ho et al. BMC Public Health 2012, 4measurements were conducted using proven methodology [17] under standardized conditions used in our laboratory. Gas calibration was conducted once a day, priorto any measurements. Before measurements were taken,participants rested in a supine position for 10–15 min.Cardio-respiratory fitness assessmentCardio-respiratory fitness (CRF) was assessed using theAstrand-Rhyming Submaximal Cycle Ergometer Test[18] (Monark Exercise AB, Sweden). This was a singlestage, 6-min test to estimate maximal oxygen consumption (VO2max) from prediction tables of maximal oxygenconsumption at baseline and week 12. A submaximalprotocol was chosen as this method is less stressful andsafer for overweight or obese individuals who are alsosedentary.Statistical analysisSample size calculations were based on a minimum predicted 15% change in fasting triglyceride and total cholesterol levels between the intervention groups, with anexpected standard deviation of 15%. A sample size of 16participants per group was predicted to provide sufficient power (80%) to detect significant changes at the5% significance level. However, we aimed to recruit 20participants per group (a total of 80) to accommodatefor a 20% attrition rate and elimination due to noncompliance.Data was assessed for normality to ensure that theassumptions of the analysis were met. The data for fasting total cholesterol, LDL cholesterol, HDL cholesterol,triglyceride, glucose, insulin and anthropometric measures was analysed using General Linear Model to assessthe effects of the groups after adjusting for group andbaseline values. Within-group data was analyzed withthe paired t-test.When significant between-group effects were present,post hoc comparisons were made using the LSDmethod. Statistical analysis was carried out using SPSS14.0 for Windows (SPSS Inc., Chicago, IL, USA).ResultsParticipant characteristics at baseline can be seen inTable 1.The average daily energy intake from 3-day food diaries at baseline, week 8 and week 12 can be seen inTable 2. When comparing within-group changes, theAerobic and Resistance groups had significantly lowerdaily energy intake (EI) at week 12 compared to baseline(18%, p 0.041 and 11%, p 0.039 decrease, respectively). However, there were no significant differences intotal energy intake between groups at week 12. Participants attended 67-74% of exercise sessions, with no significant difference between intervention groups.Page 5 of 10Table 2 Changes in nutritional variablesBaselineWeek 8Week 12Control7085.1 550.87535.6 1197.8 6723.2 585.9Aerobic8741.6 1052.7 7471.7 706.77179.4 502.3*Resistance7776.6 418.07234.5 478.06937.1 471.6*Combination7675.3 324.87726.5 428.66920.2 402.7Control41.8 3.042.1 1.840.7 2.5Aerobic42.5 3.144.4 2.641.2 2.3Resistance40.2 1.641.7 1.939.4 2.0Combination44.2 1.944.8 1.943.4 1.9Control18.9 1.520.1 1.118.5 1.2Aerobic18.3 1.319.7 1.420.8 1.4*Resistance19.8 1.119.0 0.720.2 1.0Combination19.1 0.918.5 1.018.4 1.1Control33.5 2.234.0 1.537.1 1.8Aerobic35.2 2.633.1 1.935.1 1.8Resistance36.0 1.234.8 1.836.4 1.4Combination33.9 1.735.7 1.735.7 1.4Control41.6 2.140.2 1.543.6 2.1Aerobic41.6 2.341.8 1.642.5 1.9Resistance40.4 1.843.3 1.842.6 1.0Combination45.4 1.645.5 1.642.8 3.0Control40.6 1.441.4 1.139.6 1.3Aerobic41.3 1.539.6 0.838.8 1.2Resistance39.9 0.940.3 1.040.8 1.2Combination38.9 1.039.5 1.039.5 1.1Control17.7 1.518.4 1.116.9 1.4Aerobic17.1 1.218.4 1.618.6 1.8Resistance19.6 1.516.6 1.216.8 1.1Combination15.9 1.015.2 0.817.5 2.4Energy Intake (EI)Carbohydrate % of EIProtein % of EIFat % of EISFA % of FatMUFA % of FatPUFA % of FatValues are daily mean SEM (n 53) of the nutritional data recorded in 3-dayfood diaries at baseline, week 8 and week 12. Statistical significance frombaseline is indicated by * p 0.05. SFA: saturated fatty acid. MUFA:monounsaturated fatty acid. PUFA: polyunsaturated fatty acid.In the Combination group, change in body weight wassignificantly lower compared to Control at week 8 ( 1.6%,p 0.018) and week 12 ( 1.6%, p 0.044) and also Resistance group at week 12 ( 1.6%, p 0.044) (Figure 2A).Change in BMI was significantly lower in the Combination group compared to Control ( 1.6%, p 0.016) andResistance ( 1.3%, p 0.042) at week 8 and Control ( 1.6%,p 0.040) and Resistance exercise ( 1.6%, p 0.042) atweek 12 (Figure 2B). Change in total body fat in the

Ho et al. BMC Public Health 2012, 4Page 6 of 10Figure 2 Comparison of changes from baseline between groups for body weight (A), BMI (B), body fat (C), body fat % (D) and androidfat % (E). Body fat was measured by DXA. Data represents mean SEM. Statistical differences between groups indicated by different superscripts,p 0.05.Combination group was significantly lower compared toControl ( 4.4%, p 0.003) and Resistance ( 3%, p 0.041) groups at week 12 (Figure 2C). This was also thecase for change in fat percentage, Combination vs. Control ( 2.6%, p 0.008) (Figure 2D) and for change in android fat percentage ( 2.8%, p 0.034) (Figure 2E). Theseresults are also summarised in Table 3.Table 4 summarises the results for biochemical markers and energy expenditure. Levels of HDL were significantly greater in the Resistance group compared toAerobic exercise at weeks 8 and 12. Resistance HDL wasalso significantly higher than Control at week 12. In theResistance group, apoB48 levels were significantly lowerthan in Controls at week 12, 32% (p 0.04). In the Resistance group, RQ was significantly lower compared toControl ( 4.5%, p 0.037), Aerobic ( 4.9%, p 0.027)and Combination ( 4.9%, p 0.022).VO2max significantly increased in the Combinationgroup compared to Control (13.3%, p 0.006) (Figure 3).DiscussionWe have previously demonstrated that a single, moderateintensity 30-min bout of aerobic or resistance exerciseimproves risk factors associated with cardiovascular disease in overweight and obese adults [19], however, fastinglevels of TG, cholesterol, glucose and insulin were notaffected in the short-term. It is possible that somephysiological changes are only seen after a longer periodof training. Thus, we conducted a 12-week chronic studyto explore the impact of aerobic, resistance, or combinedexercise at a moderate-intensity for 30 min, five days/week. Significant decreases in body weight, BMI and totalbody fat were seen in the Combination group comparedto Control and Resistance groups. Similarly, significantimprovements were demonstrated in fat percentage, abdominal fat percentage and cardio-respiratory fitness inthe Combination group compared to Control. Therefore,moderate-intensity training over 12-weeks using a varietyof training modalities has beneficial effects in CVD riskfactors in overweight and obese individuals compared tono exercise.Body weight and BMI in the Combination group weresignificantly lower than Control and Resistance groupsat 12 weeks but not Aerobic group. The absence of significant decreases in Aerobic and Resistance groups mayhave been due to the 30-min moderate-intensity exercise

Ho et al. BMC Public Health 2012, 4Page 7 of 10Table 3 Changes in body measurements andcardio-respiratory fitnessWeight (kg)Table 4 Changes in fasting blood measurements, restingenergy expenditure and respiratory quotientBaselineWeek 8Week 12Control85.1 4.285.5 4.385.1 4.3TG (mmol/L)Aerobic91.9 4.191.1 4.191.0 4.0ControlBaselineWeek 8Week 121.25 0.171.37 0.191.48 0.23Resistance89.3 4.589.3 4.389.2 4.4Aerobic1.36 0.191.29 0.111.40 0.16Combination90.0 4.088.8 3.6*88.4 3.6*Resistance1.27 0.121.21 0.161.38 0.18Combination1.10 0.101.08 0.101.36 0.17*Control32.4 1.432.5 1.532.4 1.5TC (mmol/L)Aerobic32.7 1.332.5 1.332.4 1.2Control5.51 0.295.88 0.325.49 0.28aResistance33.0 1.333.1 1.333.0 1.3Aerobic5.83 0.325.72 0.295.56 0.37aCombination33.3 1.233.0 1.1*32.8 1.1*Resistance5.49 0.385.76 0.366.15 0.44* bCombination5.71 0.315.74 0.275.75 0.26abBMIFat (kg)Control37.1 2.337.3 2.4HDL (mmol/L)Aerobic39.3 2.538.6 2.5Control1.42 0.111.45 0.11ab1.35 0.10aResistance37.6 2.337.2 2.4Aerobic1.38 0.091.31 0.08a1.28 0.07* a1.34 0.08b1.44 0.08* babCombination39.3 1.837.7 1.8*BF%ResistanceCombination1.44 0.081.43 0.111.44 0.101.41 0.11abControl46.5 1.746.7 1.8LDL (mmol/L)Aerobic44.6 1.944.1 1.8Control3.51 0.263.79 0.313.47 0.25aResistance43.7 1.343.2 1.4Aerobic3.89 0.303.82 0.273.64 0.33aCombination45.8 1.644.8 1.8*Resistance3.56 0.333.76 0.314.08 0.36* bCombination3.78 0.273.80 0.223.71 0.22aAndroid Fat %Control51.5 1.851.7 1.8NEFA (mmol/L)Aerobic50.7 1.650.4 1.9Control0.51 0.030.45 0.04a0.48 0.03Resistance49.2 1.349.3 1.3Aerobic0.50 0.040.59 0.05b0.47 0.04Combination52.2 1.450.9 1.4*Waist (cm)abResistance0.49 0.040.52 0.040.54 0.05Combination0.46 0.030.49 0.03ab0.54 0.045.35 0.135.46 0.105.26 0.18Control100.3 3.698.3 3.7*99.1 3.6Aerobic103.7 2.6102.5 2.6101.6 2.9*ControlResistance104.0 3.2102.4 3.2101.4 3.3*Aerobic5.68 0.175.78 0.185.73 0.10Combination102.2 3.2100.5 2.899.6 3.0*Resistance5.81 0.465.81 0.175.77 0.16Combination5.38 0.135.31 0.105.55 0.1314.76 1.69VO2max (mL/kg/min)Glucose (mmol/L)Control27.2 1.424.9 0.8Insulin (μUI/mL)Aerobic24.8 1.126.2 0.9Control14.89 2.2914.82 1.66Resistance24.8 1.826.8 0.8Aerobic13.05 1.0116.67 1.48*15.87 1.86Combination26.5 1.328.2 0.8*Resistance13.98 1.4016.82 1.33*13.48 1.24Combination14.24 1.0317.07 1.33*14.25 1.25Control6.75 0.746.23 0.587.08 0.77aAerobic5.68 0.595.57 0.785.58 0.77abResistance5.92 1.054.54 0.644.46 0.45* bCombination5.30 0.565.33 0.825.04 0.78abValues are mean SEM (n 64) at baseline, week 8 and week 12. Statisticalsignificance from baseline is indicated by * p 0.05.being insufficient stimuli compared to training loads reported in other studies [3,20-24]. However, Park et al.[20] also found that combination exercise was more effective for body composition improvements than aerobicexercise alone.The Combination intervention produced the greatestimprovements in body composition, significant decreasesin total body fat, fat percentage, android fat percentageand gynoid fat percentage. Park et al. [20] also observedthat combination exercise was more effective in decreasing visceral fat than aerobic exercise. High levels of fat,ApoB48 (μg/mL)REE (kJ/day)Control6088.4 392.7Aerobic6388.2 281.26081.9 384.86283.5 264.6Resistance6468.3 312.16431.2 302.5Combination6328.2 319.76252.1 291.1

Ho et al. BMC Public Health 2012, 4Page 8 of 10Table 4 Changes in fasting blood measurements, restingenergy expenditure and respiratory quotient (Continued)RQControl0.84 0.0070.84 0.012Aerobic0.84 0.0100.84 0.014Resistance0.85 0.0160.81 0.016*Combination0.83 0.0230.84 0.017Values are mean SEM (n 64) of fasting blood measurements at baseline,week 8 and week 12. Statistical significance from baseline (within groups) isindicated by * p 0.05. Statistical differences between groups at week 8 or 12with baseline as a covariate indicated by different superscripts p 0.05. TG:triglyceride. TC: total cholesterol. HDL: high density lipoprotein. LDL: lowdensity lipoprotein. NEFA: non-esterified fatty acid. ApoB48: apolipoproteinB48. REE: resting energy expenditure. RQ: respiratory quotient.especially in the abdomen, increase the risk of developingType 2 diabetes and CVD [25], thus combination exercise training can be beneficial in reducing this risk.Interestingly, a similar study by Church et al. [8] observed a significant decrease in body mass in the Combination group compared to Control and Resistancegroups after 9 months of training, comparable to ourfindings. This indicates that the effects of aerobic and resistance exercise interact to have a greater effect than either type alone. However, the mechanisms involved areunclear and further investigations are warranted.We did not observe any significant reduction in lipids,glucose or insulin after 12 weeks of training, which is inconsistent with previous studies. Generally, those studiesinvolved higher levels of exercise [20,26]. ApoB48 wassignificantly lower after training in the Resistance groupcompared to Control but not compared to aerobic andcombination exercise. Changes to apoB48 were notreported in other studies investigating the effects of exercise training. As apoB48 is a marker for chylomicronparticles, a decrease indicates a

CVD risk factors after aerobic exercise training [4,5]. However, it is unclear whether health benefits are lim-ited to aerobic training or if other exercise modalities such as resistance training or a combination are as ef-fective or more effective in the overweight and obese. Sigal et al. [6] investigated the effects of aerobic, resist-

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̶The leading indicator of employee engagement is based on the quality of the relationship between employee and supervisor Empower your managers! ̶Help them understand the impact on the organization ̶Share important changes, plan options, tasks, and deadlines ̶Provide key messages and talking points ̶Prepare them to answer employee questions

Gestation, Length, and Size of Casket Age of baby at death 6 weeks 7 weeks 8 weeks 9 weeks 10 weeks 11 weeks 12 weeks 13 weeks 14 weeks 16 weeks 18 weeks 20 weeks

Chính Văn.- Còn đức Thế tôn thì tuệ giác cực kỳ trong sạch 8: hiện hành bất nhị 9, đạt đến vô tướng 10, đứng vào chỗ đứng của các đức Thế tôn 11, thể hiện tính bình đẳng của các Ngài, đến chỗ không còn chướng ngại 12, giáo pháp không thể khuynh đảo, tâm thức không bị cản trở, cái được

Preliminary English B1 Threshold 4.0 Pre-Intermediate 3.5 KET Key English 3.0 A2 Elementary Waystage 2.5 2.0 Beginner 1 - 1.5 A1 0 - 0.5 Breakthrough 12-15 weeks 12-15 weeks 12-15 weeks 12-15 weeks 12-15 weeks 12-15 weeks 8-10 weeks 9-12 weeks 9-12 9-12 weeks 9-