HUMAN MOVEMENT (ISSN 1899-1955)

2022; 23(3): 1–14

A PROPOSED MODEL TO TEST THE HYPOTHESIS OF EXERCISE-

INDUCED LOCALIZED FAT REDUCTION (SPOT REDUCTION),
INCLUDING A SYSTEMATIC REVIEW WITH META-ANALYSIS
© Wroclaw University of Health and Sport Sciences
review paper
doi: https://doi.org/10.5114/hm.2022.110373

RODRIGO RAMIREZ-CAMPILLO1,2 , DAVID C. ANDRADE3, FILIPE MANUEL CLEMENTE4,5 ,

JOSÉ AFONSO6, ALEJANDRO PÉREZ-CASTILLA7, PAULO GENTIL8
1
Department of Physical Activity Sciences, Universidad de Los Lagos, Santiago, Chile
2
Exercise and Rehabilitation Sciences Laboratory, School of Physical Therapy, Faculty of Rehabilitation Sciences,
Universidad Andres Bello, Santiago, Chile
3
Centre of Physiology and High Altitude Medicine, Biomedical Department, Faculty of Health Sciences,
University of Antofagasta, Antofagasta, Chile
4
Escola Superior Desporto e Lazer, Instituto Politécnico de Viana do Castelo, Viana do Castelo, Portugal
5
Instituto de Telecomunicações, Delegação da Covilhã, Covilhã, Portugal
6
Centre of Research, Education, Innovation, and Intervention in Sport, Faculty of Sport, University of Porto, Porto, Portugal
7
Department of Physical Education and Sports, Faculty of Sport Sciences, University of Granada, Granada, Spain
8
Faculty of Physical Education and Dance, Federal University of Goiás, Goiânia, Brazil

Abstract
Purpose. The process in which specific exercises reduce localized adipose tissue depots (targeted fat loss) and modify fat
distribution is commonly termed spot reduction. According to this long-held popular belief, exercising a limb would lead
to greater reduction in the adjacent adipose tissue in comparison with the contralateral limb. Aside from popular wisdom,
scientific evidence from the 20th and 21st century seems to offer inconclusive results. The study aim was to summarize peer-
reviewed literature assessing the effects of unilateral limb training, compared with the contralateral limb, on the localized
adipose tissue depots in healthy participants, and to meta-analyse its results.
Methods. We followed the guidelines of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses. We searched
PubMed, Web of Science, and Scopus electronic databases using several relevant keyword combinations. Independent experts
were contacted to help identify additional relevant articles. Following the PICOS approach, we included controlled studies that
incorporated a localized exercise intervention (i.e., single-leg training) to cohorts of healthy participants (i.e., no restriction for fitness,
age, or sex) compared with a control condition (i.e., contralateral limb), where the main outcome was the pre-to-post-intervention
change of localized fat. The methodological quality of the studies was assessed with the Physiotherapy Evidence Database
scale. Pre- and post-intervention means ± standard deviations of the fat-related outcome in the trained and control groups (limbs)
were converted to Hedges’ g effect size (ES; with 95% confidence intervals [CI]) by using a random-effects model. The impact of
heterogeneity was assessed with the I2 statistic. Extended Egger’s test served to explore the risk of reporting bias. The statistical
significance threshold was set at p < 0.05.
Results. From 1833 search records initially identified, 13 were included in the meta-analysis, involving 1158 male and
female participants (age, 14–71 years). The 13 studies achieved a high methodological quality, and presented results with
low heterogeneity (I2 = 24.3%) and no bias (Egger’s test p = 0.133). The meta-analysis involved 37 comparisons, with 17 of
these favouring (i.e., greater reduction of localized fat) the trained limb, and 20 favouring the untrained limb, but the ES
ranged between –1.21 and 1.07. The effects were consistent, with a pooled ES = –0.03, 95% CI: –0.10 to 0.05, p = 0.508,
meaning that spot reduction was not observed.
Conclusions. Localized muscle training had no effect on localized adipose tissue depots, i.e., there was no spot reduction,
regardless of the characteristics of the population and of the exercise program. The popular belief concerning spot reduction
is probably derived from wishful thinking and convenient marketing strategies, such as influencers seeking increased
popularity and procedure sellers interested in increasing advertising.
Key words: exercise, human physical conditioning, resistance training, high-intensity interval training, body composition,
subcutaneous fat

Correspondence address: Rodrigo Ramirez-Campillo, Exercise and Rehabilitation Sciences Laboratory, School of Physical
Therapy, Faculty of Rehabilitation Sciences, Universidad Andres Bello, Campus Casona, Fernández Concha 700, Las Condes,
Santiago, postal code 7591538, Chile, e-mail: [email protected], https://orcid.org/0000-0003-2035-3279
Received: August 16, 2021
Accepted for publication: October 18, 2021
Citation: Ramirez-Campillo R, Andrade DC, Clemente FM, Afonso J, Pérez-Castilla A, Gentil P. A proposed model to test
the hypothesis of exercise-induced localized fat reduction (spot reduction), including a systematic review with meta-analysis.
1
Hum Mov. 2022;23(3):1–14; doi: https://doi.org/10.5114/hm.2022.110373.
HUMAN MOVEMENT
R. Ramirez-Campillo et al., Exercise-induced spot reduction

Introduction based spot reduction to persons seeking a desperate

solution to their problems [36] may be very appealing.
A man may box and fence, and even walk, without If the notion of spot reduction is correct, then per-
losing his terrible abdominal accumulation; but if forming a regimen of unilateral exercise should lead
he centres his efforts at muscular exertion on the to higher reduction in adipose content in that region
abdomen itself the fat cannot stand the attack and than in the contralateral limb. To the best of our knowl-
will gradually disappear.
edge, the debate regarding exercise-based spot reduc-
(E. Checkley, 1895) [1]
tion seems to be active, even after (at least) 3 centu-
ries [1]. To contribute to settling down the debate,
Since (at least) the 19th century, the notion that spe-
a systematic review with meta-analysis was conducted
cific exercises can reduce localized adipose tissue de-
to qualitatively assess and quantitatively summarize
pots (i.e., targeted fat loss) and modify fat distribution
the evidence in the field, but also circumvent the prob-
has remained a very popular belief, with the process
lem of most exercise-related studies: a reduced sample
itself commonly termed spot reduction [2]. From the
size [37]. Our aim was to summarize peer-reviewed
middle to nearly the end of the 20th century, several
literature assessing the effects of unilateral limb train-
studies were performed on the subject, suggesting that
ing, compared with the contralateral limb, on the lo-
spot reduction might be feasible [3–6]. However, during
calized adipose tissue depots in healthy participants
the same period, several studies disproved the notion
across the life span, and to meta-analyse its results.
of spot reduction [2, 7–13]. Toward the end of the 20th
century, there seemed to be a consensus among the
Material and methods
scientific community that spot reduction was a myth.
Nonetheless, during the 21st century, new studies We followed the guidelines of the Preferred Report-
[14–24] have relaunched the debate. ing Items for Systematic Reviews and Meta-Analyses
Why is the notion of spot reduction so appealing (PRISMA) [38, 39]. The methods were established be-
across centuries [1, 25, 26]? Why have researchers not fore initiating the research, and protocol registration
reached a definitive answer to the problem? This might preceded the search.
be explained by 3 main factors. The first one may be
the difficulty inherent in addressing the hypothesis of Search strategy
spot reduction. There are complex interactions among
(i) different exercise programming characteristics (e.g., We searched through PubMed, Web of Science,
exercise modality, periodization, load management, and Scopus electronic databases from the inception of
adherence to the program); (ii) diverse regional re- indexing to June 2021, with no restriction on language.
sponses of adipose tissue depots to exercise (i.e., lipoly- Potentially relevant keywords were collected through
sis, re-esterification, mobilization of free fatty acids); authors’ consensus on the basis of previous studies
and (iii) inter-individual differences in the modulators conducted in relation to spot reduction; organized vo-
of the fat metabolism in response to exercise (e.g., sex, cabulary (i.e., Medical Subject Headings [MeSH]) was
obesity) [19, 27–32]. The second factor of controversy also incorporated. As a result, the following keywords
may arise from the different concepts of spot reduction were introduced in the electronic databases in different
[16, 33]. Various models of study were used to test the combinations by using Boolean search syntax with
hypothesis of spot reduction, such as cross-sectional the operators ‘AND,’ ‘OR’: activity, arm, body, clinical,
studies [7, 14, 34, 35], as well as long-term intervention composition, conditioning, controlled, distribution,
studies involving exercise compared with nutrition dominant, elbow, exercise, extension, fat, flexion, fore-
[22, 23], trunk-localized exercise [8, 20], limb-localized arm, high, human, intensity, interval, knee, leg, local,
exercise [5, 9, 18, 21], and whole-body exercise [15, 16]. localized, loss, mass, modalities, model, motor, move-
The third factor is the difficulty to conduct rigorous ment, muscle, musculoskeletal, non-dominant, phe-
experimentation to test such a hypothesis (e.g., con- nomena, physical, physiological, reduction, regional,
trol the participants’ diet and their compliance to the resistance, running, single, sport, spot, strength, sub-
program, use valid measurement techniques [18]). The cutaneous, targeted, therapy, thigh, training, treatment,
difficulty encountered by scientists is in contrast with trial, unilateral. Electronic searches were conducted in
the ease with which personal beliefs (or publicity) can accordance with the specific characteristics of each
be communicated [1, 25, 26]. Marketing and science electronic database search engine. For example, in the
often collide [33], and marketing the notion of exercise- PubMed database, the following search syntax was

2
Human Movement, Vol. 23, No 3, 2022
 HUMAN MOVEMENT
R. Ramirez-Campillo et al., Exercise-induced spot reduction

used: controlled clinical trial [Publication Type] AND or syndromes potentially affecting adipose tissue or
training [Title/Abstract] OR single-leg [Title/Abstract] its response to training [24, 42, 43]).
AND body composition [MeSH Terms] AND fat [Title/ (ii) Involved a localized exercise intervention (with-
Abstract]. out restriction for the mode of exercise, e.g., resistance
After the initial search in June 2021, we created training, endurance training) where one limb was
accounts in the respective databases. Through these trained and the contralateral limb was the control. In-
accounts, the lead investigator received weekly auto- terventions lasting a minimum of 2 weeks were con-
matically generated e-mails for updates regarding the sidered [44, 45]. Studies that incorporated a non-lo-
search terms used (if available). All studies that were calized exercise intervention (e.g., running, bilateral leg
published before August 2021 were considered for in- press) were excluded. Cross-sectional studies were also
clusion. We excluded studies on the basis of the review excluded. Studies were not excluded if they lacked di-
of the title or abstract, or (when needed) after reading etary control and/or involved nutritional supplemen-
the full text. Conference proceedings were consid- tation, as this is not a critical factor for experimental
ered if the full-text was available. The reference list models using the contralateral limb as a control con-
of included studies was searched for potentially rel- dition [46].
evant studies. Two authors (RRC, DCA) conducted the (iii) Compared localized exercise with a control
process independently, with potential discrepancies condition (i.e., contralateral limb), with the only differ-
resolved by consensus. ence between the conditions being the exercise inter-
Thereafter, the list of included articles and the in- vention.
clusion criteria were sent to 2 independent world ex- (iv) Employed a pre-to-post-intervention assess-
perts in the field of body composition (https://www.ex- ment of at least 1 fat-related parameter (e.g., fat mass,
pertscape.com/ex/body+composition) to help identify fat volume) by using dual-energy X-ray absorptiom-
additional relevant articles. Additionally, the experts etry, magnetic resonance imaging, computerized to-
(i) hold a Ph.D. in sports sciences or a related field mography, skinfold callipers, ultrasound, or the micro-
(e.g., health sciences); (ii) have peer-reviewed publica- scopic method (i.e., subcutaneous fat biopsy). Secondary
tions on body composition in journals with impact fac- outcomes were considered, including potential adverse
tor according to the Journal Citation Reports®. The effects derived from the intervention (e.g., injury).
experts were not provided with our search strategy to (v) Utilized a randomized or non-randomized con-
avoid biasing their own searches. Upon completion of trolled design, as long as at least 1 comparator group
all these steps, the databases were again consulted in existed.
search for errata or retractions of any included study.
Data extraction
Eligibility criteria
Two authors of the review (RRC, DCA) performed
To elaborate the PICOS eligibility criteria, we first the data extraction independently, using a predefined
elaborated a definition of the investigated problem. form created in Microsoft Excel (Microsoft Corpora-
Namely, spot reduction (in humans) is defined as tion, Redmond, WA, USA). If there were any discrep-
a greater reduction of the non-intramuscular fat-re- ancies between the authors in the extracted data, the
lated depot(s) (e.g., subcutaneous fat) adjacent to a vol- accuracy of the information was re-checked in the
untarily exercised muscle compared with the same studies. We extracted the following data: participants’
depot from the contralateral non-exercised muscle, after sex, age (years), body mass (kg), height (cm), and pre-
an intervention period. vious experience with training. If applicable, infor-
Accordingly, and following the PICOS criteria, we mation about the type and level (e.g., professional, ama-
incorporated studies that: teur) of sports practice was also retrieved. Regarding
(i) Included cohorts of healthy (e.g., with medical training characteristics, the extracted data included
or ethics review board clearance to participate in training frequency (days/week) and training dura-
a training programme) participants (humans), with no tion (weeks), intensity level and marker of intensity
restriction for fitness/sport background, age, or sex. (e.g., % of one-repetition maximum [1RM]), total volume
Excluded participants were those with a physical trau- (e.g., repetitions, minutes), types of exercises performed,
ma (e.g., limb amputation [40]) or certain diseases (e.g., combination of exercise with diet, and progressive over-
stroke leading to paretic limb [41], genetic conditions load techniques (if any).

3
Human Movement, Vol. 23, No 3, 2022
HUMAN MOVEMENT
R. Ramirez-Campillo et al., Exercise-induced spot reduction

The means and standard deviations (SDs) of de- sidered as being of ‘high quality’. Two authors (RRC,
pendent variables were extracted at pre- and post-in- DCA) performed the methodological quality assessment
tervention time points from the included studies. In independently. Disagreements in the assessments be-
cases where the required data were not clearly or com- tween the reviewers were resolved through discussion
pletely reported, the authors of the study were contacted and consensus.
for clarification. If no response was obtained from the
authors (after 2 attempts) or if the authors could not Statistical analysis
provide the requested data, the study outcome was
excluded from the analysis. However, even when no Pre- and post-intervention mean ± SD of a given
numerical data were provided by the authors upon con- fat-related outcome in the trained and control groups
tact, in cases where data were displayed in a figure [9], was converted to Hedges’ g effect size (ES). A meta-
the meta-analysis used validated (r = 0.99, p < 0.001) analysis for a given fat-related outcome was conduct-
[47] software (WebPlotDigitizer; https://apps.automeris. ed if at least 3 studies provided sufficient data for the
io/wpd/) [48] to derive the relevant numerical data. calculation of ES [56–58]. The data were standard-
ized by using post-score SD. For studies that reported
Methodological quality assessment standard errors, SDs were calculated by multiplying
the standard error with the square root of the sample
The Physiotherapy Evidence Database (PEDro) scale size [59]. In all analyses, we used the random-effects
was used to assess the methodological quality of the model to account for differences between studies that
included studies [49]. There are 11 items on the PEDro might affect the treatment effect [60, 61]. The ES values
checklist, but item 1 is not included in the total score. are presented with their respective 95% confidence
Therefore, the methodological quality of the included intervals (CIs). The calculated ES values were inter-
studies was rated from 0 (lowest quality) to 10 (high- preted with the following scale: < 0.2, trivial; 0.2–0.6,
est quality). The scale evaluates different aspects of small; > 0.6–1.2, moderate; > 1.2–2.0, large; > 2.0–4.0,
the study design, such as participant eligibility criteria, very large; > 4.0, extremely large [62]. The impact of
randomization, blinding, attrition, and reporting of heterogeneity was assessed with the I2 statistic, with
data. The validity and reliability of the PEDro scale was values of < 25%, 25–75%, and > 75% considered to rep-
established previously [49–51]. Additionally, its agree- resent low, moderate, and high levels of heterogeneity,
ment with other scales (e.g., Cochrane risk of bias tool) respectively. Extended Egger’s test (2-tailed) served
has been reported [52]. Also, the PEDro scale is prob- to explore the risk of reporting bias [63]. To adjust for
ably one of the most frequently used scales in the litera- publication bias, a sensitivity analysis was conduct-
ture, which helps to make comparisons between meta- ed with the trim and fill method [64], with L0 as the
analyses. In accordance with the cut-off scores, the default estimator for the number of missing studies
methodological quality was rated as ‘poor’ (< 4), ‘fair’ [65]. All analyses were carried out by using the Com-
(4–5), ‘good’ (6–8), or ‘excellent’ (9–10) in some sub- prehensive Meta-Analysis program (version 2; Biostat,
fields, however, it is not possible to satisfy all scale Englewood, NJ, USA). The statistical significance
items in some areas of physiotherapy practice [53]. threshold was set at p < 0.05.
Moreover, in the context of this study, the definition of
spot reduction, and the proposed experimental model Ethical approval
to test the hypothesis of spot reduction, is not possi- The conducted research is not related to either hu-
ble to blind the participants regarding whether they man or animal use. The protocol for this systematic
trained or not one of their limbs, which makes item 5 review with meta-analysis was registered at the Inter-
from the PEDro scale an unfair criterium to assess national Platform of Registered Systematic Review and
the methodological quality of studies involved in our Meta-Analysis Protocols (INPLASY) on June 28, 2021
review. Therefore, as outlined in previous systematic (registration number: INPLASY202160103).
reviews in some sub-fields of physiotherapy [54, 55],
the methodological quality of the studies was inter- Results
preted by using the following convention, based on the
summary score: studies that scored 3 points were Study selection
considered as being of ‘poor quality,’ studies scoring
4 or 5 points were considered as being of ‘moderate A total of 1833 search records were initially iden-
quality,’ and studies that scored 6–10 points were con- tified. After excluding the duplicates and studies on

4
Human Movement, Vol. 23, No 3, 2022
 HUMAN MOVEMENT
R. Ramirez-Campillo et al., Exercise-induced spot reduction
Identification
Screening
Included

Figure 1. PRISMA 2020 flow diagram

the basis of the title or abstract, 83 studies remained, reported among the included studies; only mild-mod-
and their full texts were read. From these, 13 were erate delayed-onset muscle soreness was observed.
included in the meta-analysis [5, 9, 10, 18, 21, 46, However, most of the studies in this meta-analysis
66–72]. Figure 1 provides a diagram of the study se- failed to report specific information regarding ad-
lection process. The included studies involved 1158 verse health effects. This reflects a larger problem in
participants (acting as both experimental and control sports sciences and produces unbalanced accounts, as
groups). The characteristics of the participants from authors present the main effects, but not the potential
the included studies, the programming parameters adverse health effects.
of the training interventions, and the fat-related out-
comes (for both the control and experimental limbs) Methodological quality
are presented in Table 1.
Briefly, training interventions were applied dur- In accordance with the PEDro checklist, the 13 stud-
ing 2 up to 20 weeks, with a training frequency of ies achieved 6–8 points and were classified as being
3 sessions per week, up to 7 sessions per week (i.e., of ‘high’ methodological quality (Table 2).
daily training). The training intensity (i.e., single-leg)
varied from 10% to 90% of 1RM for those interventions Meta-analysis results
that applied resistance training exercises, and equalled
ca. 40% of peak oxygen consumption (VO2max) in the The meta-analysis included 13 controlled studies,
intervention that used endurance (i.e., cycling) train- involving 37 comparisons, with 17 of these favouring
ing. Of note, the interventions with resistance training (i.e., greater reduction of localized fat) the trained
exercises commonly utilized elbow flexors/extensors- limb, and 20 favouring the untrained limb, but the
related exercises (e.g., dumbbell biceps concentration ES ranged between –1.21 and 1.07. The effects were
curls, overhead triceps extension) or knee extensors- consistent, with a pooled ES = –0.03, 95% CI: –0.10
related exercises (e.g., seated leg press, seated leg ex- to 0.05, p = 0.508, I2 = 24.3%, Egger’s test p = 0.133
tension); none of the included studies applied knee (Figure 2), meaning that spot reduction was not ob-
flexors-related exercises. No major adverse effects were served.

5
Human Movement, Vol. 23, No 3, 2022
HUMAN MOVEMENT
R. Ramirez-Campillo et al., Exercise-induced spot reduction

Table 1. Included studies characteristics

Study Participants Training Outcomes
Brinkworth Healthy physically 8 weeks, 4 sessions per week. Muscle: elbow flexors non- Arm skin and
et al., 2004 active men supplemented dominant arm. Exercises: dumbbell biceps concentration subcutaneous fat
[66] with bovine colostrum curls. Velocity: controlled (slower during lengthening). (cm2; MRI)
(n = 17; age, 21.4 years; Sets/repetitions/intensity: 6 sets to failure at 80% 1RM.
height, 179 cm; body mass, Progressive overload: yes
77.8 kg) or whey protein
(n = 17; age, 23.8 years;
height, 179 cm;
body mass, 81.5 kg)
Devries 30 healthy men 2 weeks, 3 sessions/week. Unilateral leg press and leg Leg fat mass
et al., 2015 (age, 70 years; height, extension. Equipment: air-resistance strength machines. (g; DEXA)
[67] 180 cm; body mass, 84 kg) Sets, intensity: 3, 30% 1RM until volitional fatigue
Hanson Sedentary (without medical 10 weeks, 3 sessions per week. Knee extensions for the Knee extensor
et al., 2009 condition) women dominant leg (pneumatic [air-powered] knee extension subcutaneous
[46] (n = 25; age, 71 years; machine). Sets: 4–5 (4 for participants > 75 years of age fat (cm2; CT)
height, 161 cm; and 5 for those < 75 years of age). First set: 5 repetitions,
body mass, 75.5 kg; 50% 1RM. Second set: 5RM value (initially, 85% of basal Knee extensor
BMI, 29.2 kg ∙ m–2) 1RM). Third set: 5RM, then a drop-set of 1–2 repetitions intermuscular
and men (n = 22; age, until reaching 10 repetitions. Fourth set: 5RM, then fat (cm2; CT)
71 years; height, 174 cm; a drop-set of 1–2 repetitions until reaching 15 repetitions.
body mass, 86.4 kg; Fifth set: 5RM, then a drop-set of 1–2 repetitions until
BMI, 28.4 kg ∙ m–2) reaching 20 repetitions. Full ROM was required during
repetitions. Repetition duration: 2–3 (shortening-lengthen­
ing). A seat belt was worn throughout the exercise session,
with arms across the chest. Progressive overload was
monitored session by session
Kostek 45 men and 59 women, 12 weeks, 2 sessions per week (45–60 minutes per session). Biceps sub­cu­
et al., 2007 Caucasian (94%) Progressive, supervised resistance training of the non- taneous fat
[18] (age, 24.1 years; dominant arm. Exercises: biceps preacher curl, overhead (mm; skinfold
BMI, 24.2 kg ∙ m–2) triceps extension, biceps concentration curl, triceps kick­ callipers)
back, and standing biceps curl. Dose per exercise: 3 sets of
12 repetitions at 65–75% 1RM (i.e., 12RM). Each contraction Arm sub­cu­
involved 2 seconds for the concentric phase and 2 seconds taneous fat
for the eccentric phase. A 2-minute rest followed each set. volume (ml; MRI)
The number of repetitions was decreased to 8 (i.e., 8RM)
at week 5 and then to 6 (i.e., 6RM) at week 10. Consequently,
the exercise intensity at weeks 5 and 10 increased to 75–82%
and 83–90% 1RM, respectively. Experienced investigators
supervised the training sessions and adjusted the weight
accordingly
Krotkiewski 10 women 5 weeks, performed daily. Three sets of 10 maximal Thigh adipose
et al., 1979 (age, 24–29 years; voluntary isokinetic right knee extensions tissue thickness
[9] height, 166.2 cm; (constant angular velocity of 60° ∙ s–1) (cm; ultrasound)
body mass, 72–81 kg;
body fat, 19–28 kg) Fat cell weight
(µg; microscopic
method)
Miura et al., 8 women, Japanese, 12 weeks, 3 sessions per week (60 minutes per session). Thigh fat cross-
2009 [68] sedentary (age, 21–23 The right or left leg was assigned to cycling at 40% sectional area
years; height, 157 cm; of single-leg peak VO2 (i.e., below lactate threshold), (cm2; ultrasound)
body mass, 49.4 kg; equivalent to 25.3 W and a heart rate of 90–110 bpm
VO2max, 32.4 ml ∙ min–1 ∙ kg–1)

6
Human Movement, Vol. 23, No 3, 2022
 HUMAN MOVEMENT
R. Ramirez-Campillo et al., Exercise-induced spot reduction

Nickols- 70 women, white (95%) 20 weeks, 3 sessions per week. Concentric (or eccentric) Arm fat mass
Richardson (age, 20.2 years; slow-velocity (60° ∙ s–1) isokinetic training of the non-dominant (kg; DEXA)
et al., 2007 BMI, 22.1 km ∙ m–2) leg and arm. During week 1, one set of 6 repetitions was
[69] performed for knee extension and elbow flexion. In weeks Leg fat mass
2–5, one set was added each week, so by week 5, the partici- (kg; DEXA)
pants completed 5 sets of 6 repetitions. In weeks 6–20, the
volume was maintained. Torque output was not controlled
during training, but was free to vary (i.e., increase) as partici-
pants performed each repetition at maximal volitional effort.
Of note, one group of women (n = 37) performed concentric
training, and the other group (n = 33) eccentric training
Olson and 32 boys, with no experience 6 weeks, 3 or 5 days per week (half of the participants exer- Triceps sub­
Edelstein, in weight training cised 5 days a week and the other half exercised 3 days per cutaneous fat
1968 [5] (age, 14–16 years) week; however, data from all the participants were mixed). (mm; skinfold
Right arm curl with dumbbell and triceps extension with callipers)
dumbbell, for 3 sets of 7RM each exercise (with as many
repetitions as possible in the second and third sets). When
a sufficient gain in strength allowed 7 repetitions to be per-
formed in all 3 sets, the resistance was increased. There was
no warm-up prior to the exercises. The boys did not partici-
pate in physical education or in intramural or interscholastic
athletics during the study
Orkunoglu- 320 women (age, 22.9 years; See: Kostek et al., 2007 [18] Arm sub­cu­
Suer et al., body mass, 64.7 kg; height, taneous fat
2008 [70] 164.2 cm; BMI, 23.7 kg ∙ m–2) volume
and 197 men (age, 23.9 years; (mm3; MRI)
body mass, 78.8 kg; height,
178.5 cm; BMI, 24.7 kg ∙ m–2);
all European descents (white)
Ramirez- 11 physical education 12 weeks, 3 sessions per week (80 minutes per session). Leg fat mass
Campillo students (7 men and Localized muscle endurance resistance training for the non- (kg; DEXA)
et al., 2013 4 women; Latin American) dominant leg muscles. Subjects completed one set of leg press
[21] (age, 23.0 years; per session, at 10–30% 1RM (10% during weeks 1–4, 20% Leg fat
BMI, 25.0 kg ∙ m–2) during weeks 5–6, and 30% during weeks 7–12). Subjects percentage
completed 960–1200 consecutive repetitions for their set (DEXA)
(no rest between repetitions), with 4–5 seconds per repetition
Roby, 1962 15 male college students 10 weeks, 3 sessions per week. Dominant arm triceps Triceps sub­
[10] (age, 21.1 years) extension, for 3 sets of 10–15 repetitions at 50% 1RM. cutaneous fat
Overload was applied when participants were able to (mm; skinfold
perform 15 repetitions in all 3 sets callipers)
Walts et al., Men (n: 78–82) and women See: Hanson et al., 2009 [46] Knee extensor
2008 [71] (n: 95–98), relatively healthy, subcutaneous fat
physically inactive (cm2; CT)
(age, 63.0 years); self-
reported Caucasians (n = 114) Knee extensor
or African Americans (n = 52) intermuscular fat
(cm2; CT)
Yao et al., Men (n = 46; age, 64.4 years; See: Hanson et al., 2009 [46] Knee extensor
2007 [72] height, 174 cm; body mass, intermuscular fat
84 kg; % body fat, 27.4) and (cm2; CT)
women (n = 52; age, 62.7 years;
height, 163 cm; body mass,
73.2 kg; % body fat, 38.8)
1RM – one-repetition maximum, BMI – body mass index, bpm – beats per minute, CT – computed tomography,
DEXA – dual-energy X-ray absorptiometry, MRI – magnetic resonance imaging, ROM – range of motion,
VO2 – volume of oxygen consumption
7
Human Movement, Vol. 23, No 3, 2022
HUMAN MOVEMENT
R. Ramirez-Campillo et al., Exercise-induced spot reduction

Table 2. Methodological quality of the included studies based on the PEDro rating scale
Study
Study name Q1 Q2 Q3a Q4 Q5 Q6 Q7 Q8 Q9 Q10 Q11 Total*
quality
Brinkworth et al., 2004 [66] 1 0 1 1 0 1 1 1 1 1 1 8/10 High
Devries et al., 2015 [67] 1 1 1 1 0 0 0 1 1 1 1 7/10 High
Hanson et al., 2009 [46] 1 0 1 1 0 0 0 1 1 1 1 6/10 High
Kostek et al., 2007 [18] 1 0 1 1 0 1 1 1 1 1 1 8/10 High
Krotkiewski, et al., 1979 [9] 1 0 1 1 0 0 0 1 1 1 1 6/10 High
Miura et al., 2009 [68] 1 1 1 1 0 0 0 1 1 1 1 7/10 High
Nickols-Richardson et al. 2007 [69] 1 0 1 1 0 0 0 1 1 1 1 6/10 High
Olson and Edelstein, 1968 [5] 1 0 1 1 0 0 0 1 1 1 1 6/10 High
Orkunoglu-Suer et al., 2008 [70] 1 0 1 1 0 0 0 1 1 1 1 6/10 High
Ramirez-Campillo et al., 2013 [21] 1 0 1 1 0 0 0 1 1 1 1 6/10 High
Roby, 1962 [10] 1 0 1 1 0 0 0 1 1 1 1 6/10 High
Walts et al., 2008 [71] 1 0 1 1 0 1 1 1 1 1 1 8/10 High
Yao et al., 2007 [72] 1 0 1 1 0 0 0 1 1 1 1 6/10 High
A detailed explanation for each PEDro scale item can be accessed at https://www.pedro.org.au/english/downloads/pedro-scale.
Q3 was considered to be attained even if concealed allocation was not reported, since the decision about whether or not
to include a person in a trial could not be influenced by knowledge of whether the subject was to receive treatment or not.
a
in the context of this study, * for a possible maximal punctuation of 10

Study name Statistics for each study Hedges's g and 95% CI

Hedges's Standard Lower Upper
g error Variance limit limit Z-Value p-Value
Brinkworth et al., 2004, bovine colostrum 0.044 0.335 0.112 -0.613 0.700 0.130 0.896
Brinkworth et al., 2004, whey protein -0.108 0.335 0.112 -0.765 0.549 -0.321 0.748
Devries et al., 2015 0.045 0.255 0.065 -0.454 0.545 0.177 0.859
Hanson et al., 2009 (all) subcutaneous -0.222 0.205 0.042 -0.625 0.180 -1.083 0.279
Hanson et al., 2009 (men) subcutaneous 1.072 0.317 0.101 0.450 1.694 3.378 0.001
Hanson et al., 2009 (women) subcutaneous -1.209 0.304 0.092 -1.804 -0.614 -3.982 0.000
Hanson et al., 2009 (all) intermuscular fat -0.242 0.205 0.042 -0.644 0.161 -1.176 0.239
Hanson et al., 2009 (men) intermuscular fat 0.255 0.297 0.088 -0.328 0.838 0.857 0.391
Hanson et al., 2009 (women) intermuscular fat -0.240 0.279 0.078 -0.788 0.307 -0.860 0.390
Kostek et al., 2007 (men and women) biceps -0.096 0.149 0.022 -0.387 0.196 -0.644 0.520
Kostek et al., 2007 (men) biceps -0.216 0.228 0.052 -0.662 0.230 -0.948 0.343
Kostek et al., 2007 (women) biceps -0.046 0.195 0.038 -0.428 0.335 -0.237 0.813
Kostek et al., 2007 (men and women) arm -0.023 0.138 0.019 -0.294 0.248 -0.164 0.869
Kostek et al., 2007 (men) arm -0.173 0.209 0.044 -0.584 0.237 -0.828 0.408
Kostek et al., 2007 (women) arm -0.020 0.183 0.033 -0.378 0.339 -0.108 0.914
Krotkiewski, et al., 1979, subcutaneous -0.751 0.444 0.198 -1.622 0.120 -1.690 0.091
Krotkiewski, et al., 1979, cell fat -0.735 0.444 0.197 -1.604 0.135 -1.655 0.098
Miura et al., 2009 0.005 0.473 0.223 -0.921 0.932 0.011 0.991
Nickols-Richardson et al. 2007 (concentric), arm -0.033 0.230 0.053 -0.484 0.418 -0.141 0.887
Nickols-Richardson et al. 2007 (eccentric), arm 0.034 0.243 0.059 -0.442 0.511 0.142 0.887
Nickols-Richardson et al. 2007 (concentric), leg 0.010 0.230 0.053 -0.441 0.460 0.042 0.967
Nickols-Richardson et al. 2007 (eccentric), leg 0.053 0.243 0.059 -0.424 0.530 0.217 0.828
Olson and Edelstein, 1968 -0.504 0.251 0.063 -0.996 -0.012 -2.008 0.045
Orkunoglu-Suer et al., 2008 (women) 0.015 0.079 0.006 -0.140 0.170 0.190 0.849
Orkunoglu-Suer et al., 2008 (men) 0.033 0.101 0.010 -0.164 0.231 0.333 0.739
Ramirez-Campillo et al., 2013, fat mass 0.046 0.380 0.144 -0.699 0.791 0.121 0.903
Ramirez-Campillo et al., 2013, fat percentage 0.000 0.380 0.144 -0.744 0.744 0.000 1.000
Roby, 1962 0.080 0.355 0.126 -0.616 0.777 0.226 0.821
Walts et al., 2008 (men), subcutaneous 0.000 0.155 0.024 -0.305 0.305 0.000 1.000
Walts et al., 2008 (women), subcutaneous 0.101 0.142 0.020 -0.178 0.380 0.707 0.480
Walts et al., 2008 (Caucassians), subcutaneous 0.150 0.132 0.017 -0.110 0.409 1.131 0.258
Walts et al., 2008 (African American), subcutaneous 0.153 0.195 0.038 -0.229 0.535 0.783 0.434
Walts et al., 2008 (men), intermuscular fat 0.119 0.156 0.024 -0.186 0.424 0.767 0.443
Walts et al., 2008 (women), intermuscular fat -0.096 0.142 0.020 -0.375 0.183 -0.677 0.498
Walts et al., 2008 (Caucassians), intermuscular fat 0.000 0.132 0.017 -0.259 0.259 0.000 1.000
Walts et al., 2008 (African American), intermuscular fat -0.065 0.195 0.038 -0.446 0.317 -0.332 0.740
Yao et al., 2007 0.122 0.142 0.020 -0.157 0.401 0.857 0.391
-0.025 0.037 0.001 -0.098 0.048 -0.661 0.508
-2.00 -1.00 0.00 1.00 2.00

Favours trained Favours untrained

Figure 2. Forest plot for changes in localized fat (spot reduction) in trained compared with untrained limbs.
Negative values denote that the trained limb reduced more fat than the untrained limb. Values shown are effect sizes
(Hedges’ g) with 95% confidence intervals (CI). The size of the plotted squares reflects the statistical weight of each study.
The white diamond reflects the overall result

8
Human Movement, Vol. 23, No 3, 2022
 HUMAN MOVEMENT
R. Ramirez-Campillo et al., Exercise-induced spot reduction

Discussion tion), a valid model to test the hypothesis of spot reduc-

tion would be one in which, essentially, the muscles in
In the context of the definition of our proposed model one part of the body are trained, whereas the muscles
to test the hypothesis of spot reduction, our aim was in the contralateral side are not. Indeed, the use of an
to summarize peer-reviewed literature assessing the appropriate research model is fundamental for re-
effects of unilateral limb training, compared with the searchers to avoid flawed experiments that may lead
contralateral limb, on the localized adipose tissue de- them to inappropriate (or even intended) results. For
pots in healthy participants across the life span, and to such definition and proposed model we considered
meta-analyse its results. From the 13 studies included [19, 27–30, 32, 71] (i) fat depots from different body
in our meta-analysis, all achieved 6 or more points in regions are not equally comparable within a given
the PEDro scale. This may increase the perceived qual- individual (i.e., comparing arms and legs); (ii) for the
ity of research included in our analyses and the con- same body fat depot, significant inter-individual dif-
fidence in evidence. Further, results were obtained with ferences might occur (e.g., abdominal fat may respond
low impact of heterogeneity (I2 = 24.3%) and no sig- differently to exercise in males compared with females)
nificant risk of reporting bias (Egger’s test p = 0.133). [28, 77, 78]; (iii) contrary to neuromuscular-related
In addition, a total of 1158 participants were included outcomes, there is no evidence for a cross-education
in the 13 studies, a strength when compared with the between subcutaneous fat depots through exercise;
relatively reduced number of participants involved in (iv) the effects of exercise training on one limb com-
sports sciences literature [37]. Although exercise is pared with the contralateral non-exercised limb allow
a potent contributor to fat reduction [73], our meta- a tight control for dietary (even if this is not manipu-
analysis indicated no significant (trivial) effect of lo- lated) and other possible intervening factors (e.g., meth-
calized muscle training on localized adipose tissue de- odology, seasonal variation, genetics, biology, variations
pots, i.e., no spot reduction was observed. Therefore, in attention and motivation between experimental and
long-term exercise-based localized adipose tissue control groups) [46, 71]; (v) studies seeking to validly
reduction would not be an expected result of an ad- test the hypothesis of spot reduction should consider
equately planned exercise intervention. The result of the size of the adipose tissue depots adjacent to the
our meta-analysis is based on interventions with a mean trained and respective non-trained muscles before and
duration of 11 weeks (range, 2–20 weeks) involving after an intervention period (with a relatively high
different training approaches (e.g., cycling, resistance volume of work to impact fat tissue), not just after an
training) in participants of different sex, age, and physi- acute exercise bout [14]; (vi) valid studies should use
cal fitness level (e.g., sedentary, physically active). De- valid measurement techniques, avoiding techniques
spite the heterogeneity in samples, protocols, and study that may provide biased results owing to changes in
designs, the lack of effect was consistent, denoting muscle mass [18] or other factors not related to biologi-
a robust phenomenon that is largely independent of cal changes in fat content [79]. For example, reduc-
the characteristics of the population or of the exercise tions of 3–14% (mean, 7.5%) were noted in the trained
program. It is indeed intriguing from a physiological arm compared with the non-trained arm when subcu-
and anatomical perspective how exercise-based inter- taneous fat was measured in the biceps with a skinfold
ventions may induce a localized effect on skeletal mus- calliper [18]. In contrast, when MRI was used to meas-
cle tissue [74], bone tissue [75], or even skin tissue [76], ure arm subcutaneous fat volume, the reduction was
but not on adipose tissue. nearly 3-fold lower (range, 0–7%; mean, 2.8%) [18].
Such an intriguing phenomenon has generated con- Additionally, valid studies should report the reliabil-
troversy since (at least) the 19th century [1, 25, 26], ity of measurement (e.g., coefficient of variation, total
with several studies performed on the subject from the error of measurement), as not all studies in this field
middle of the 20th century up to recently [2–24]. It is have reported this essential element [4–6, 15].
possible that the controversy regarding spot reduction In contrast to our proposed definition and model to
relates to its definition. For example, if spot reduction test the hypothesis of exercise-induced localized fat
considers the intramuscular fat stores, a localized re- reduction, 2 cross-sectional studies [14, 17] found acute
duction may occur, contrary to the subcutaneous fat localized lipolysis. However, the studies did not dem-
depot [24]. Considering our definition of voluntary onstrate spot reduction (i.e., localized reduction of
exercise-based localized fat reduction (i.e., spot reduc- adipose tissue). Moreover, in the 2 aforementioned
tion; see methods section, eligibility criteria sub-sec- cross-sectional studies [14, 17], although they reported

9
Human Movement, Vol. 23, No 3, 2022
HUMAN MOVEMENT
R. Ramirez-Campillo et al., Exercise-induced spot reduction

that exercising one leg promoted an increase in lipoly- compared with nutrition, trunk-localized exercise,
sis in the subcutaneous fat adjacent to the muscles whole-body exercise) currently proposed in the scien-
being exercised (e.g., anterior thigh), the effect was tific literature to test the hypothesis of spot reduction
highly local, meaning that any significant long-term through exercise training. Considering our proposed
effect (i.e., fat reduction) would be unlikely. Further, definition and model, we conducted a systematic re-
compared with the aforementioned cross-sectional view with meta-analysis that included studies with
studies [14, 17], some authors observed contradicting participants across a wide range of ages, with no re-
findings, with intense exercise (e.g., resistance train- striction for sex or training status, and that included
ing) reducing subcutaneous adipose tissue blood flow different protocols (e.g., training, assessment tech-
and lipolysis [31]. Aside the controversial findings, niques). Owing to the high heterogeneity between the
the fact that an acute increase in lipolysis does not included studies, a high heterogeneity in results might
translate into chronic reduction in fat depots is anal- been expected. However, the meta-analysis clearly de-
ogous to the fact that exercise at a given intensity may notes that lack of spot reduction is ubiquitous, i.e., the
allow maximal acute rate of fat oxidation [80], without effect is very strong and seems to be sample- and proto-
long-term effect on body composition [81]. Indeed, even col-independent. Although our results appear highly
if acute localized lipolysis occurs during exercise, sev- consistent, we discuss some potential limitations.
eral additional physiological processes are needed Firstly, exercising one limb might induce a partial
before free fatty acids enter the blood stream for later activation of the contralateral limb [84], and contralat-
oxidation in tissues [28, 29, 82]. Moreover, the au- eral strength gains have been reported [85–87]. How
thors from one of the aforementioned cross-sectional much activation of the control limb might have oc-
studies [14] indicated that ‘More calories are expended curred and to what extent this affected study out-
during aerobic, whole body exercise than by exercise comes is unclear. Additionally, studies usually con-
with local muscle groups, and, accordingly, a person
trolled for the correct technical execution of training
seeking to loose fat must be advised to perform whole
exercise by proper spotters and researchers. There-
body exercise’ (p. E398). Indeed, high-intensity exer-
fore, it is assumed that participants recruited for ex-
cise has been found to promote large reduction in body
ercise interventions had an adequate exercise technique
fat in different body parts, with many different activi-
and supervision that made them able to activate the
ties [83]. From a practical point of view, if the main aim
target muscle while maintaining the contralateral
of a training programme were to improve body compo-
muscle relatively inactive. Secondly, the lack of nutri-
sition, including reductions of adipose tissue, the most
tional control was not considered as an exclusion cri-
logically defendable approach would be to include
terion in our meta-analysis. Nonetheless, the effects of
a training programme allowing a considerable energy
expenditure density. To this aim, compared with local- exercise training on one limb compared with the con-
ized exercise, non-localized exercise involving large tralateral non-exercised limb allow a tight control for
muscles groups would be preferable. Of course, local- dietary (even if this is not manipulated) and other
ized exercise may still offer important practical rele- possible intervening factors (e.g., seasonal variation,
vance, improving the endurance of trunk muscles (e.g., genetics, biology) [46, 71]. Thirdly, we only considered
abdominal muscle training), inducing a cross-educa- voluntary training protocols in this meta-analysis.
tion effect on injured limbs, or improving localized-pe- Therefore, non-voluntary muscle activation strategies
ripheral adaptations with a minimization of central and their potential to affect the trained limb [88, 89]
responses (e.g., blood pressure), among others. But the were not investigated. Fourthly, the studies included in
current literature does not support its use for regional our meta-analysis consisted of training programmes
fat reduction. lasting 2–20 weeks; longer-term interventions were
not addressed. However, on the basis of the current
Limitations findings and those derived from some cross-sectional
studies involving athletes with several years of training
According to our definition, a valid model to test using one limb more than the contralateral one (e.g.,
the hypothesis of spot reduction would be one in which tennis) [7, 35, 90], longer-term interventions would
the muscles in one limb are trained, whereas the mus- probably help to confirm the presented findings.
cles in the contralateral limb are not. To our knowl-
edge, this model is less prone to bias compared with
the rest of the models (e.g., cross-sectional, exercise

10
Human Movement, Vol. 23, No 3, 2022
 HUMAN MOVEMENT
R. Ramirez-Campillo et al., Exercise-induced spot reduction

Conclusions 10. Roby FB. Effect of exercise on regional subcutaneous

fat accumulations. Res Q. 1962;33(2):273–278; doi:
Localized muscle training had no effect on localized 10.1080/10671188.1962.10613202.
11. Ingemann-Hansen T, Halkjaer-Kristensen J. Lean and
adipose tissue depots, i.e., there was no spot reduction,
fat component of the human thigh. The effects of immo-
regardless of the characteristics of the population and bilization in plaster and subsequent physical training.
of the exercise program. Scand J Rehabil Med. 1977;9(2):67–72.
12. Schwartz KV. “Spot” reduction of fat. Ann Intern Med.
Disclosure statement 1971;75(2):316; doi: 10.7326/0003-4819-75-2-316_1.
No author has any financial interest or received any 13. Krotkiewski M. Can body fat patterning be changed?
financial benefit from this research. Acta Med Scand Suppl. 1988;723:213–223; doi: 10.1111/
j.0954-6820.1987.tb05946.x.
Conflict of interest 14. Stallknecht B, Dela F, Helge JW. Are blood flow and
lipolysis in subcutaneous adipose tissue influenced by
The authors state no conflict of interest.
contractions in adjacent muscles in humans? Am J
Physiol Endocrinol Metab. 2007;292(2):E394–E399;
Data availability doi: 10.1152/ajpendo.00215.2006.
The datasets generated and/or analysed during the 15. Scotto di Palumbo A, Guerra E, Orlandi C, Bazzucchi I,
current study are available from the corresponding Sacchetti M. Effect of combined resistance and endur-
author on reasonable request. ance exercise training on regional fat loss. J Sports Med
Phys Fitness. 2017;57(6):794–801; doi: 10.23736/S00
References 22-4707.16.06358-1.
16. Paoli A, Casolo A, Saoncella M, Bertaggia C, Fantin M,
1. Checkley E. A natural material method of physical
Bianco A, et al. Effect of an endurance and strength
education training making muscle and reducing flesh mixed circuit training on regional fat thickness: the
without dieting or apparatus. New York: William C. quest for the “spot reduction”. Int J Environ Res Public
Bryant and Co.; 1895. Health. 2021;18(7):3845; doi: 10.3390/ijerph18073845.
2. Roby FB. The effect of exercise on regional subcuta- 17. Heinonen I, Bucci M, Kemppainen J, Knuuti J, Nuu-
neous fat accumulations. Doctoral thesis. Champaign: tila P, Boushel R, et al. Regulation of subcutaneous adi-
University of Illinois; 1960. pose tissue blood flow during exercise in humans. J
3. Mohr DR. Changes in waistline and abdominal girth Appl Physiol. 2012;112(6):1059–1063; doi: 10.1152/
and subcutaneous fat following isometric exercises. japplphysiol.00732.2011.
Res Q. 1965;36(2):168–173; doi: 10.1080/10671188. 18. Kostek MA, Pescatello LS, Seip RL, Angelopoulos TJ,
1965.10614676. Clarkson PM, Gordon PM, et al. Subcutaneous fat altera-
4. Noland M, Kearney JT. Anthropometric and densito- tions resulting from an upper-body resistance train-
metric responses of women to specific and general exer- ing program. Med Sci Sports Exerc. 2007;39(7):1177–
cise. Res Q. 1978;49(3):322–328; doi: 10.1080/10671 1185; doi: 10.1249/mss.0b0138058a5cb.
315.1978.10615541. 19. Nindl BC, Harman EA, Marx JO, Gotshalk LA, Fryk­
5. Olson AL, Edelstein E. Spot reduction of subcutaneous man PN, Lammi E, et al. Regional body composition
adipose tissue. Res Q. 1968;39(3):647–652; doi: 10.1080/ changes in women after 6 months of periodized physical
10671188.1968.10616592. training. J Appl Physiol. 2000;88(6):2251–2259; doi:
6. Bailey HR. Localized tissue reduction. Med J Aust. 10.1152/jappl.2000.88.6.2251.
1976;1(21):780–781; doi: 10.5694/j.1326-5377.1976. 20. Vispute SS, Smith JD, LeCheminant JD, Hurley KS.
tb141054.x. The effect of abdominal exercise on abdominal fat. J
7. Gwinup G, Chelvam R, Steinberg T. Thickness of sub- Strength Cond Res. 2011;25(9):2559–2564; doi: 10.1519/
cutaneous fat and activity of underlying muscles. Ann JSC.0b013e3181fb4a46.
Intern Med. 1971;74(3):408–411; doi: 10.7326/0003- 21. Ramírez-Campillo R, Andrade DC, Campos-Jara C,
4819-74-3-408. Henríquez-Olguín C, Alvarez-Lepín C, Izquierdo M. Re-
8. Katch FI, Clarkson PM, Kroll W, McBride T, Wilcox A. gional fat changes induced by localized muscle endur-
Effects of sit up exercise training on adipose cell size and ance resistance training. J Strength Cond Res. 2013;
adiposity. Res Q Exerc Sport. 1984;55(3):242–247; doi: 27(8):2219–2224; doi: 10.1519/JSC.0b013e31827e8681.
10.1080/02701367.1984.10609359. 22. Kordi R, Dehghani S, Noormohammadpour P, Rosta-
9. Krotkiewski M, Aniansson A, Grimby G, Björntorp P, mi M, Mansournia MA. Effect of abdominal resistance
Sjöström L. The effect of unilateral isokinetic strength exercise on abdominal subcutaneous fat of obese wom-
training on local adipose and muscle tissue morphol- en: a randomized controlled trial using ultrasound im-
ogy, thickness, and enzymes. Eur J Appl Physiol Occup aging assessments. J Manipulative Physiol Ther. 2015;
Physiol. 1979;42(4):271–281; doi: 10.1007/BF00423297. 38(3):203–209; doi: 10.1016/j.jmpt.2014.12.004.

11
Human Movement, Vol. 23, No 3, 2022
HUMAN MOVEMENT
R. Ramirez-Campillo et al., Exercise-induced spot reduction

23. Redman LM, Heilbronn LK, Martin CK, Alfonso A, etry: physical measures of human form in health and
Smith SR, Ravussin E, et al. Effect of calorie restriction disease. New York: Springer; 2012; 1989–2005.
with or without exercise on body composition and fat 37. Abt G, Boreham C, Davison G, Jackson R, Nevill A,
distribution. J Clin Endocrinol Metab. 2007;92(3): Wallace E, et al. Power, precision, and sample size esti-
865–872; doi: 10.1210/jc.2006-2184. mation in sport and exercise science research. J Sports
24. Gorgey AS, Shepherd C. Skeletal muscle hypertrophy Sci. 2020;38(17):1933–1935; doi: 10.1080/02640414.
and decreased intramuscular fat after unilateral resist- 2020.1776002.
ance training in spinal cord injury: case report. J Spinal 38. Liberati A, Altman DG, Tetzlaff J, Mulrow C, Gøtzsche
Cord Med. 2010;33(1):90–95; doi: 10.1080/10790268. PC, Ioannidis JPA, et al. The PRISMA statement for re-
2010.11689681. porting systematic reviews and meta-analyses of studies
25. Dedrick A, Merten JW, Adams T, Wheeler M, Kassie T, that evaluate healthcare interventions: explanation
King JL. A content analysis of Pinterest belly fat loss and elaboration. BMJ. 2009;339:b2700; doi: 10.1136/
exercises: unrealistic expectations and misinformation. bmj.b2700.
Am J Health Educ. 2020;51(5):328–337; doi: 10.1080/ 39. Page MJ, McKenzie JE, Bossuyt PM, Boutron I, Hoff-
19325037.2020.1795754. mann TC, Mulrow CD, et al. The PRISMA 2020 state-
26. Kieffer SH. Myths and truths from exercise physiology. ment: an updated guideline for reporting systematic
J Phys Educ Recreat Dance. 2008;79(8):23–25; doi: reviews. BMJ. 2021;372:n71; doi: 10.1136/bmj.n71.
10.1080/07303084.2008.10598227. 40. Sherk VD, Bemben MG, Bemben DA. Interlimb muscle
27. Idoate F, Ibañez J, Gorostiaga EM, García-Unciti M, Mar- and fat comparisons in persons with lower-limb ampu-
tínez-Labari C, Izquierdo M. Weight-loss diet alone or tation. Arch Phys Med Rehabil. 2010;91(7):1077–1081;
combined with resistance training induces different doi: 10.1016/j.apmr.2010.04.008.
regional visceral fat changes in obese women. Int J 41. Jørgensen L, Jacobsen BK. Changes in muscle mass, fat
Obes. 2011;35(5):700–713; doi: 10.1038/ijo.2010.190. mass, and bone mineral content in the legs after stroke:
28. Horowitz JF. Fatty acid mobilization from adipose tissue a 1 year prospective study. Bone. 2001;28(6):655–659;
during exercise. Trends Endocrinol Metab. 2003;14(8): doi: 10.1016/s8756-3282(01)00434-3.
386–392; doi: 10.1016/s1043-2760(03)00143-7. 42. Precone V, Barati S, Paolacci S, Salgarello M, Visconti G,
29. Jensen MD. Lipolysis: contribution from regional fat. Gentileschi S, et al. Genetic syndromes with localized
Annu Rev Nutr. 1997;17:127–139; doi: 10.1146/annurev. subcutaneous fat tissue accumulation. Acta Biomed.
nutr.17.1.127. 2019;90(10-S):90–92; doi: 10.23750/abm.v90i10-S.8767.
30. Nindl BC, Friedl KE, Marchitelli LJ, Shippee RL, 43. Herbst KL. Subcutaneous adipose tissue diseases: Der-
Thomas CD, Patton JF. Regional fat placement in physi- cum disease, lipedema, familial multiple lipomatosis,
cally fit males and changes with weight loss. Med Sci and Madelung disease. In: Feingold KR, Anawalt B,
Sports Exerc. 1996;28(7):786–793; doi: 10.1097/0000 Boyce A, Chrousos G, de Herder WW, Dhatariya K, et al.
5768-199607000-00003. (eds.), Endotext. South Dartmouth: MDText.com, Inc.
31. Heinonen IHA, Boushel R, Kalliokoski KK. The circu- 2000–2019.
latory and metabolic responses to hypoxia in humans – 44. Tassone EC, Baker BA. Body weight and body compo-
with special reference to adipose tissue physiology and sition changes during military training and deployment
obesity. Front Endocrinol. 2016;7:116; doi: 10.3389/ involving the use of combat rations: a systematic litera-
fendo.2016.00116. ture review. Brit J Nutr. 2017;117(6):897–910; doi:
32. Thompson D, Karpe F, Lafontan M, Frayn K. Physical 10.1017/S0007114517000630.
activity and exercise in the regulation of human adipose 45. Sánchez-Muñoz C, Zabala M, Muros JJ. Nutritional
tissue physiology. Physiol Rev. 2012;92(1):157–191; intake and anthropometric changes of professional road
doi: 10.1152/physrev.00012.2011. cyclists during a 4-day competition. Scand J Med Sci
33. Pinto H. Local fat treatments: classification proposal. Sports. 2016;26(7):802–808; doi: 10.1111/sms.12513.
Adipocyte. 2016;5(1):22–26; doi: 10.1080/21623945. 46. Hanson ED, Srivatsan SR, Agrawal S, Menon KS, Del-
2015.1066534. monico MJ, Wang MQ, et al. Effects of strength train-
34. Poliszczuk T, Mańkowska M, Poliszczuk D, Wiśniew­ ing on physical function: influence of power, strength,
ski A. Symmetry and asymmetry of reaction time and and body composition. J Strength Cond Res. 2009;23(9):
body tissue composition of upper limbs in young fe- 2627–2637; doi: 10.1519/JSC.0b013e3181b2297b.
male basketball players. Pediatr Endocrinol Diabetes 47. Drevon D, Fursa SR, Malcolm AL. Intercoder reliability
Metab. 2013;19(4):132–136. and validity of WebPlotDigitizer in extracting graphed
35. Maughan RJ, Abel RW, Watson JS, Weir J. Forearm data. Behav Modif. 2017;41(2):323–339; doi: 10.1177/
composition and muscle function in trained and un- 0145445516673998.
trained limbs. Clinic Physiol. 1986;6(4):389–396; doi: 48. Rohatgi A. WebPlotDigitizer, version 4.4. Available
10.1111/j.1475-097x.1986.tb00244.x. from: https://automerisio/WebPlotDigitizer 2020.
36. Greenway FL, Pekarovics S. Anthropometry of local fat 49. Maher CG, Sherrington C, Herbert RD, Moseley AM,
reduction. In: Preedy VR (ed.), Handbook of anthropom- Elkins M. Reliability of the PEDro scale for rating quality

12
Human Movement, Vol. 23, No 3, 2022
 HUMAN MOVEMENT
R. Ramirez-Campillo et al., Exercise-induced spot reduction

of randomized controlled trials. Phys Ther. 2003;83(8): 61. Kontopantelis E, Springate DA, Reeves D. A re-analysis
713–721; doi: 10.1093/ptj/83.8.713. of the Cochrane Library data: the dangers of unobserved
50. De Morton NA. The PEDro scale is a valid measure of heterogeneity in meta-analyses. PLoS One. 2013;8(7):
the methodological quality of clinical trials: a demo- e69930; doi: 10.1371/journal.pone.0069930.
graphic study. Aust J Physiother. 2009;55(2):129–133; 62. Hopkins WG, Marshall SW, Batterham AM, Hanin J.
doi: 10.1016/s0004-9514(09)70043-1. Progressive statistics for studies in sports medicine and
51. Yamato TP, Maher C, Koes B, Moseley A. The PEDro exercise science. Med Sci Sports Exerc. 2009;41(1):3–
scale had acceptably high convergent validity, construct 13; doi: 10.1249/MSS.0b013e31818cb278.
validity, and interrater reliability in evaluating method- 63. Egger M, Davey Smith G, Schneider M, Minder C.
ological quality of pharmaceutical trials. J Clin Epi- Bias in meta-analysis detected by a simple, graphical test.
demiol. 2017;86:176–181; doi: 10.1016/j.jclinepi.2017. BMJ. 1997;315(7109):629–634; doi: 10.1136/bmj.315.
03.002. 7109.629.
52. Moseley AM, Rahman P, Wells GA, Zadro JR, Sher- 64. Duval S, Tweedie R. Trim and fill: a simple funnel-plot-
rington C, Toupin-April K, et al. Agreement between based method of testing and adjusting for publication
the Cochrane risk of bias tool and Physiotherapy Evi- bias in meta-analysis. Biometrics. 2000;56(2):455–463;
dence Database (PEDro) scale: a meta-epidemiologi- doi: 10.1111/j.0006-341x.2000.00455.x.
cal study of randomized controlled trials of physical 65. Shi L, Lin L. The trim-and-fill method for publication
therapy interventions. PLoS One. 2019;14(9):e0222770; bias: practical guidelines and recommendations based
doi: 10.1371/journal.pone.0222770. on a large database of meta-analyses. Medicine. 2019;
53. Cashin AG, McAuley JH. Clinimetrics: Physiotherapy 98(23):e15987; doi: 10.1097/md.0000000000015987.
Evidence Database (PEDro) scale. J Physiother. 2020; 66. Brinkworth GD, Buckley JD, Slavotinek JP, Kurmis AP.
66(1):59; doi: 10.1016/j.jphys.2019.08.005. Effect of bovine colostrum supplementation on the com-
54. Ramirez-Campillo R, Gentil P, Negra Y, Grgic J, Gi- position of resistance trained and untrained limbs in
rard O. Effects of plyometric jump training on repeated healthy young men. Eur J Appl Physiol. 2004;91(1):53–
sprint ability in athletes: a systematic review and meta- 60; doi: 10.1007/s00421-003-0944-x.
analysis. Sports Med. 2021;51(10):2165–2179; doi: 67. Devries MC, Breen L, Von Allmen M, MacDonald MJ,
10.1007/s40279-021-01479-w. Moore DR, Offord EA, et al. Low-load resistance train-
55. Stojanović E, Ristić V, McMaster DT, Milanović Z. Ef- ing during step-reduction attenuates declines in muscle
fect of plyometric training on vertical jump performance mass and strength and enhances anabolic sensitivity in
in female athletes: a systematic review and meta-analy- older men. Physiol Rep. 2015;3(8):e12493; doi: 10.14814/
sis. Sports Med. 2017;47(5):975–986; doi: 10.1007/ phy2.12493.
s40279-016-0634-6. 68. Miura A, Yamamoto N, Yamaoka Endo M, Ueoka H,
56. Skrede T, Steene-Johannessen J, Anderssen SA, Resa­ Yamada M, Kuno S-Y, et al. Effect of aerobic leg exercise
land GK, Ekelund U. The prospective association be- training on subcutaneous adipose tissue of thigh in
tween objectively measured sedentary time, moderate- young Japanese women. J Physiol Anthropol. 2009;
to-vigorous physical activity and cardiometabolic risk 28(5):247–250; doi: 10.2114/jpa2.28.247.
factors in youth: a systematic review and meta-analysis. 69. Nickols-Richardson SM, Miller LE, Wootten DF,
Obes Rev. 2019;20(1):55–74; doi: 10.1111/obr.12758. Ramp WK, Herbert WG. Concentric and eccentric isoki-
57. García-Hermoso A, Ramírez-Campillo R, Izquierdo M. netic resistance training similarly increases muscular
Is muscular fitness associated with future health ben- strength, fat-free soft tissue mass, and specific bone
efits in children and adolescents? A systematic review mineral measurements in young women. Osteoporos
and meta-analysis of longitudinal studies. Sports Med. Int. 2007;18(6):789–796; doi: 10.1007/s00198-006-
2019;49(7):1079–1094; doi: 10.1007/s40279-019-010 0305-9.
98-6. 70. Orkunoglu-Suer FE, Gordish-Dressman H, Clark-
58. Moran J, Ramirez-Campillo R, Granacher U. Effects of son PM, Thompson PD, Angelopoulos TJ, Gordon PM,
jumping exercise on muscular power in older adults: et al. INSIG2 gene polymorphism is associated with
a meta-analysis. Sports Med. 2018;48(12):2843–2857; increased subcutaneous fat in women and poor re-
doi: 10.1007/s40279-018-1002-5. sponse to resistance training in men. BMC Med Genet.
59. Higgins J, Deeks J. Selecting studies and collecting 2008;9:117; doi: 10.1186/1471-2350-9-117.
data. In: Higgins JPT, Green S (eds.), Cochrane hand- 71. Walts CT, Hanson ED, Delmonico MJ, Yao L, Wang MQ,
book for systematic reviews of interventions, version Hurley BF. Do sex or race differences influence strength
5.1.0 (updated March 2011). The Cochrane Collabo- training effects on muscle or fat? Med Sci Sports Exerc.
ration; 2011; 168–182. 2008;40(4):669–676; doi: 10.1249/MSS.0b013e3181
60. Deeks JJ, Higgins JP, Altman DG. Analysing data and 61aa82.
undertaking meta-analyses. In: Higgins JP, Green S 72. Yao L, Delmonico MJ, Roth SM, Hand BD, Johns J,
(eds.), Cochrane handbook for systematic reviews of in- Conway J, et al. Adrenergic receptor genotype influence
terventions. The Cochrane Collaboration; 2008; 243– on midthigh intermuscular fat response to strength
296.
13
Human Movement, Vol. 23, No 3, 2022
HUMAN MOVEMENT
R. Ramirez-Campillo et al., Exercise-induced spot reduction

training in middle-aged and older adults. J Gerontol 85. Carroll TJ, Herbert RD, Munn J, Lee M, Gandevia SC.
A Biol Sci Med Sci. 2007;62(6):658–663; doi: 10.1093/ Contralateral effects of unilateral strength training: evi-
gerona/62.6.658. dence and possible mechanisms. J Appl Physiol. 2006;
73. Donnelly JE, Blair SN, Jakicic JM, Manore MM, Ran­ 101(5):1514–1522; doi: 10.1152/japplphysiol.00531.
kin JW, Smith BK. American College of Sports Medicine 2006.
position stand. Appropriate physical activity interven- 86. Cirer-Sastre R, Beltrán-Garrido JV, Corbi F. Contralat-
tion strategies for weight loss and prevention of weight eral effects after unilateral strength training: a meta-
regain for adults. Med Sci Sports Exerc. 2009;41(2): analysis comparing training loads. J Sports Sci Med.
459–471; doi: 10.1249/MSS.0b013e3181949333. 2017;16(2):180–186.
74. American College of Sports Medicine. American Col- 87. Green LA, Gabriel DA. The effect of unilateral train-
lege of Sports Medicine position stand. Progression ing on contralateral limb strength in young, older, and
models in resistance training for healthy adults. Med patient populations: a meta-analysis of cross education.
Sci Sports Exerc. 2009;41(3):687–708; doi: 10.1249/ Phys Ther Rev. 2018;23(4–5):238–249; doi: 10.1080/
MSS.0b013e3181915670. 10833196.2018.1499272.
75. Kohrt WM, Bloomfield SA, Little KD, Nelson ME, 88. Shiba N, Matsuse H, Takano Y, Yoshimitsu K, Omoto M,
Yingling VR. American College of Sports Medicine posi- Hashida R, et al. Electrically stimulated antagonist
tion stand. Physical activity and bone health. Med Sci muscle contraction increased muscle mass and bone
Sports Exerc. 2004;36(11):1985–1996; doi: 10.1249/01. mineral density of one astronaut – initial verification on
mss.0000142662.21767.58. the international space station. PLoS One. 2015;10(8):
76. Armstrong LE, Casa DJ, Millard-Stafford M, Moran e0134736; doi: 10.1371/journal.pone.0134736.
DS, Pyne SW, Roberts WO. American College of Sports 89. Keller BA, Katch FI. Transcutaneous electrical muscle
Medicine position stand. Exertional heat illness during stimulation does not alter regional arm adiposity and
training and competition. Med Sci Sports Exerc. 2007; muscularity. Am J Hum Biol. 1998;10(3):317–326; doi:
39(3):556–572; doi: 10.1249/MSS.0b013e31802fa199. 10.1002/(SICI)1520-6300(1998)10:3<317::AID-
77. Sanal E, Ardic F, Kirac S. Effects of aerobic or combined AJHB7>3.0.CO;2-F.
aerobic resistance exercise on body composition in over- 90. Sanchis-Moysi J, Serrano-Sánchez JA, González-Hen-
weight and obese adults: gender differences. A rand- ríquez JJ, Calbet JAL, Dorado C. Greater reduction in
omized intervention study. Eur J Phys Rehabil Med. abdominal than in upper arms subcutaneous fat in 10-
2013;49(1):1–11. to 12-year-old tennis players: a volumetric MRI study.
78. Leibel RL, Edens NK, Fried SK. Physiologic basis for Front Pediatr. 2019;7:345; doi: 10.3389/fped.2019.
the control of body fat distribution in humans. Annu Rev 00345.
Nutr. 1989;9:417–443; doi: 10.1146/annurev.nu.09.
070189.002221.
79. Zachariah T, Rawal SB, Pramanik SN, Singh MV,
Kishnani S, Bharadwaj H, et al. Variations in skinfold
thickness during de-acclimatisation and re-acclimati-
sation to high altitude. Relation to body fat content. Eur
J Appl Physiol Occup Physiol. 1987;56(5):570–576;
doi: 10.1007/BF00635372.
80. Achten J, Gleeson M, Jeukendrup AE. Determination
of the exercise intensity that elicits maximal fat oxida-
tion. Med Sci Sports Exerc. 2002;34(1):92–97; doi:
10.1097/00005768-200201000-00015.
81. Venables MC, Jeukendrup AE. Endurance training and
obesity: effect on substrate metabolism and insulin sen-
sitivity. Med Sci Sports Exerc. 2008;40(3):495–502;
doi: 10.1249/MSS.0b013e31815f256f.
82. Maughan RJ, Shirreffs SM (eds.). Biochemistry of ex-
ercise IX. Champaign: Human Kinetics; 1996.
83. Maillard F, Pereira B, Boisseau N. Effect of high-inten-
sity interval training on total, abdominal and visceral
fat mass: a meta-analysis. Sports Med. 2018;48(2):269–
288; doi: 10.1007/s40279-017-0807-y.
84. Howe L, Goodwin J, Blagrove R. The integration of uni-
lateral strength training for the lower extremity with-
in an athletic performance programme. Prof Strength
Cond J. 2014;33:19–24.

14
Human Movement, Vol. 23, No 3, 2022