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TWO WEEKS OF HIGH-INTENSITY INTERVAL TRAINING IN COMBINATION WITH A NON-THERMAL
DIFFUSE ULTRASOUND DEVICE IMPROVES LIPID PROFILE AND REDUCES BODY FAT PERCENTAGE
IN OVERWEIGHT WOMEN

Publication dans Frontiers in Physiology – Christophe Hausswirth – Octobre 2019

Télécharger l’étude traduite

This study evaluated the effectiveness of an innovative strategy which combined
low-frequency ultra sound (LOFU) with high-intensity interval training (HIIT) to
improve physical fitness and promote body fat loss in overweight sedentary
women. A placebo controlled, parallel group randomized experimental design was
used to investigate the efficacy of a 2-week combined LOFU and HIIT program (3
sessions per week). Participants were allocated into either the Experimental
HIIT group (HIITEXP, n = 10) or Placebo HIIT group (HIITPLA, n = 10). Baseline
exercise testing (maximal oxygen uptake, lower limb strength and substrate
oxidation test), dietary assessment, anthropometric measures and blood sampling
were completed in week 1 and repeated in week 4 to determine changes following
the program (Post-HIIT). During each training session, the HIITEXP and HIITPLA
groups wore a non-thermal diffuse ultrasound belt. However, the belt was only
switched on for the HIITEXP group. Delta change scores were calculated for body
weight, body fat percentage (Fat%), muscle mass, V.O2max, hip and waist
circumferences, and all lipid variables from Baseline to Post-HIIT. Statistical
analysis was completed using a repeated-measures factorial analysis of variance
by group (HIITPLA and HIITEXP) and time (Baseline and Post-HIIT). Results showed
significant improvements in maximal oxygen uptake (HIITEXP; Baseline 24.7 ± 5.4
mL kg–1 min–1, Post-HIIT 28.1 ± 5.5 mL kg–1 min–1 and HIITPLA; Baseline 28.4 ±
5.9 mL kg–1 min–1, Post-HIIT 31.4 ± 5.5 mL kg–1 min–1) for both groups.
Significant decreases in Fat% (HIITEXP; Baseline 32.7 ± 3.2%, Post-HIIT 28.9 ±
3.5% and HIITPLA; Baseline 28.9 ± 3.5%, Post-HIIT 28.9 ± 3.4% kg), waist
circumference (HIITEXP; Baseline 95.8 ± 9.6 cm, Post-HIIT 89.3 ± 8.9 cm and
HIITPLA; Baseline 104.3 ± 3.5 cm, Post-HIIT 103.6 ± 3.4 cm) and triglycerides
(HIITEXP; −29.2%, HIITPLA; −6.7%) were observed in the HIITEXP group only. These
results show that HIIT combined with LOFU was an effective intervention to
improve body composition, lipid profile, and fitness. This combined strategy
allowed overweight, sedentary women to achieve positive health outcomes in as
little as 2 weeks.


INTRODUCTION

Sedentary behavior and physical inactivity are closely associated with the
development of risk factors for metabolic syndrome including glucose
intolerance, insulin resistance, hypertension, dyslipidemia, and obesity (Eckel
et al., 2010). Fat localization, particularly abdominal adipose tissue, is also
a major determinant in the occurrence of metabolic disorders (Wajchenberg,
2000). Due to the increasing prevalence of overweightness and obesity, combined
with the significant health costs and economic burden of sedentary behavior, it
is important to investigate strategies that induce a loss of body fat and
promote long-term weight management (Ogden et al., 2006). In this context, a
balanced diet and physical activity interventions are the main approaches used
to reduce body fat and improve an individual’s blood lipid profile (Donnelly et
al., 2009; Johns et al., 2014). Indeed, comparisons between sedentary and
physically active groups in cross-sectional studies have shown the positive
influence of exercise on blood lipid profile (Durstine et al., 2001).
Moderate-intensity continuous training (MICT) is currently recommended to
promote weight loss (Donnelly et al., 2009), as prolonged exercise has been
demonstrated to increase fat mobilization and oxidation (Katzmarzyk et al.,
2001; Lazzer et al., 2017). However, evidence suggests that high-intensity
interval training (HIIT) is also an effective strategy for reducing body fat
(Boutcher, 2011; Maillard et al., 2018) and could lead to a greater loss in fat
mass than MICT (Wewege et al., 2017).

High-intensity interval training sessions involve short periods of
high-intensity exercise [80–100% of maximum heart rate (HRmax)] interspersed
with passive rest, or low intensity exercise for recovery (Weston et al., 2014).
HIIT programs have shown similar fitness benefits to MICT, but can be completed
in a shorter amount of time and have been perceived as more enjoyable, which can
promote exercise adherence (Bartlett et al., 2011). Moreover, several studies
have shown that HIIT programs have a positive effect on fat loss (Tremblay et
al., 1994; Mourier et al., 1997; Gibala and McGee, 2008; Tjonna et al., 2009;
Boutcher, 2011) due to metabolic adaptations such as increased fat oxidation
(Talanian et al., 2007), increased oxidative metabolism (Tremblay et al., 1994;
Gibala and McGee, 2008) and enhanced insulin sensitivity (Babraj et al., 2009).
For example, Tremblay et al. (1994) compared the effect of a 20-week MICT and
HIIT program (5 sessions per week) on body fat loss. A nine-fold greater
reduction in subcutaneous body fat was observed following the HIIT program
compared to MICT, when the exercise sessions were corrected for total energy
cost. Moreover, a significantly greater expression of the enzyme
3-hydroxyacyl-coenyme A dehydrogenase which is involved in the β-oxidation
pathway was observed following HIIT. This lends support to the ability of HIIT
to improve fat oxidation to a greater extent than MICT. Similar findings were
reported by Trapp et al. (2008) using a shorter training duration (20-min per
session vs. 40-min) where a 15-week (3 sessions per week) led to a significant
decrease in total fat mass (−2.50 ± 0.83 kg) and reduction in central abdominal
fat (−0.15 ± 0.07 kg) compared to the MICT and sedentary control groups.
Collectively, these results demonstrate the efficacy of HIIT to improve fitness
and reduce body fat. However, there are other non-exercise based inventions that
may also promote fat loss and further improve blood lipid profile.

Low-intensity (up to 17.5 W/cm2), low-frequency (20–200 kHz) ultrasound (LOFU)
therapy is a safe, non-invasive body-contouring technique to reduce fat mass
(Hotta, 2010; Tonucci et al., 2014; Friedmann, 2015; Juhasz et al., 2018). This
technology uses ultrasound to produce a mechanical stress that disrupts the
cellular membrane of adipose tissue (Hotta, 2010). Specifically, microcavities
are created that subsequently cause cell destruction and fat liquefaction
(Tonucci et al., 2014). These mobilized fat cells are metabolized in the liver
or removed via catabolic processes. While LOFU is an emerging tool that requires
further well-controlled studies, the initial findings are promising. Studies
using LOFU have reported a significant reduction in abdominal circumference
(−2.1 cm) (Tonucci et al., 2014), decreased total fat mass (−3.5%) and reduced
subcutaneous adipose tissue (mean −2.4%) (Milanese et al., 2014) across a series
of treatments.

The aim of the present study was to evaluate an innovative weight loss strategy
coupling LOFU with a HIIT program on fitness level, body composition and lipid
profile in sedentary, overweight women. We hypothesized that in addition to the
benefits of HIIT on fat metabolism and fitness, the increased fat mobilization
induced by LOFU would lead to an increased uptake of fat by the exercising
muscles and further reductions in fat mass and body weight. It was also
anticipated that the added LOFU would lead to comparable changes in body
composition and lipid profile following a short-term 2-week training
intervention as a longer 15 to 20-week training intervention.


MATERIALS AND METHODS


PARTICIPANTS

Twenty-three healthy, sedentary women aged between 20 and 49 years old were
initially recruited. Participants volunteered after being fully informed of the
study purpose, protocols, procedures, and potential risks of involvement. All
participants provided informed consent and the investigation was approved by a
local ethic committee (University of Nice) in compliance with the Declaration of
Helsinki. On the initial visit to the laboratory, each subject underwent a
physical examination conducted by a cardiologist. Based on this examination,
participants with high blood pressure, extrasystoles or serious heart rhythm
abnormalities were excluded from the investigation. Participants were then
classified as sedentary with self-reported ≤ 15-min of moderate aerobic exercise
per week (Bartfay and Bartfay, 2014). A further medical screening was performed
and participants with recent infections, muscular and/or joint disability,
smokers and those using hormonal replacement therapy, antioxidant
supplementation or taking medication affecting lipid or lipoprotein metabolism
were excluded from the study. The phase of the menstrual cycle was also reported
and participants began the baseline exercise testing while in the follicular
phase. Participants were then randomly allocated via random number allocation
into one of two groups. Due to illness, three participants withdrew from the
investigation (Experimental n = 2, Placebo n = 1). The, we analyzed 20
participants: 10 for the Experimental HIIT group (HIITEXP) and 10 for the
Placebo HIIT group (HIITPLA). There was no significant difference in body
composition, anthropometric or fitness measures between the groups before the
study commenced.


PROCEDURES

A placebo controlled, parallel group randomized experimental design was used to
investigate the efficacy of a combined HIIT and LOFU program. The investigation
was conducted over a period of 4 weeks. Baseline exercise testing (maximal
oxygen uptake, lower limb strength, and substrate oxidation test), dietary
assessment, body composition, anthropometric measures and blood sampling were
completed in week 1 and repeated in week 4 to determine changes following the
program (Post-HIIT). Each group (HIITEXP and HIITPLA) were asked to complete the
same HIIT program in weeks 2 and 3 (3 sessions per week). During each training
session, the HIITEXP and HIITPLA groups wore a non-thermal diffuse ultrasound
belt (Slim Sonic L-1440, Lausanne, Switzerland) using the technology of SoniC
Resonance®. This device has been described in a previous study (Hafiz et al.,
2014). The system operated at a frequency ranging from 30 to 42 kHz. The
intensity applied was fixed between 5 to 8 W/cm2 cavitation power. The device
weighed 1.6 kg and was placed on each participant’s waist. It was switched on
for the HIITEXP group and switched off for the HIITPLA group for 45-min during
exercise. Participants were asked to maintain their typical dietary practices
throughout the investigation and were not informed that energy intake was a
variable that would be assessed. An overview of the experimental design is
outlined in Figure 1.

Figure 1
Overview of the experimental protocol. One repetition maximum on leg press (1-RM
Test), high-intensity interval training (HIIT), Maximal oxygen test (V.O2max
Test).


EXERCISE TESTING SESSIONS

Evaluation of the Lower Limb Maximal Strength

Measurements were undertaken 2-day before and 2-day after the six HIIT sessions.
Participants were familiarized with the testing procedure during a standardized
warm-up which consisted of jump squats (2 sets of 5 reps), countermovement jumps
(2 sets of 5 reps) and submaximal isokinetic bilateral lower limb extensions at
40% 1RM (2 sets of 15 reps) on a digital leg press (eGym, Munich, Germany).
Muscle strength was measured as peak force (Fmax) during an isokinetic maximal
voluntary bilateral lower limb extension on a digital leg press during a single
concentric movement. Velocity was regulated to move through the full range of
motion in 2-s. Customized software was then used to translate the torque values
into kilograms and calculate the Fmax, irrespective of joint angle. Strict care
was taken to ensure identical test protocols for all participants, which
included standardized verbal encouragement and visual feedback provided by a
real-time display of the force output. Successive trials were performed until
Fmax could not be improved any further, which typically included seven to nine
attempts (Aagaard et al., 2000).

Maximal Oxygen Uptake Test

One week before and 2 to 4 days after the training period, participants
undertook an incremental cycle test to exhaustion on a stationary
electromagnetically braked cycle ergometer (Monark LC6 novo, Vansbro, Sweden) to
determine maximal oxygen uptake (V.O2max) and maximal aerobic power (MAP). To
minimize the effects of diet on physical performance, participants standardized
their diet in the 24-h prior to each maximal oxygen uptake test. Furthermore,
2-h prior to each maximal oxygen uptake test, participants consumed a meal which
contained at least 2 g/kg/body mass of carbohydrate. This meal was recommended
by a dietician based on the participant’s 3-day dietary analysis. Following a
6-min warm-up at 60 W, the workload was increased at increments of 20 W every
2-min until exhaustion. During this test, oxygen uptake (V.O2) and expiratory
flow (V.E) were collected and respiratory exchange ratio (RER) was calculated
from the ratio between oxygen uptake and carbon dioxide output (V.CO2⋅V.O2–1)
using a breath by breath gas analyzer (Cosmed Quark CPET, Rome, Italy). Heart
rate (HR) was recorded using a chest belt (Cosmed wireless HR monitor, Rome,
Italy). The criteria used for the determination of V.O2max were threefold: a
plateau in V.O2 despite an increase in power output, a RER above 1.1, and a HR
above 90% of the predicted maximal HR (Howley et al., 1995). Expired gases and
HR values were averaged every 10-s. V.O2max and MAP were defined as the average
of the highest consecutive V.O2 and power output values recorded during a 1-min
period.

Substrate Oxidation Assessment

Following the maximal oxygen uptake test, participants returned to the
laboratory a minimum of 24–48-h later at the same time of day after an overnight
(12-h) fast to determine substrate oxidation. Before this trial, they were
required to record all food and drink ingested in the previous 24-h on a dietary
log and asked to confirm that they were indeed in a fasted state. This form was
photocopied and returned to each subject, and they were required to replicate
this dietary intake before the Post-HIIT assessment of substrate oxidation.
Before exercise, resting gas exchange data were acquired for 4-min to ensure
that participants were not hyperventilating. Exercise consisted of 4-min of
cycling (Monark LC6 novo, Vansbro, Sweden) at 40 W followed by 20 W increases in
intensity every 3-min until RER remained higher than 1.0 for at least 60-s. This
protocol is similar to the one employed by Achten et al. (2002) but adapted for
sedentary women. Cadence was maintained between 60 and 80 rpm. Gas exchange data
(Cosmed Quark CPET, Rome, Italy) and HR (Cosmed wireless HR monitor, Rome,
Italy) were continuously obtained, and the last 2-min of gas exchange data from
each stage was averaged to calculate V.O2 and V.CO2 and to determine RER.
Specifically, whole body rates of carbohydrate (CHO) and fat oxidation (g min–1)
were calculated from V.O2 and V.CO2 values measured during the submaximal
cycling test using the non-protein RER values and according to standard
equations (Jeukendrup and Wallis, 2005): CHO oxidation = 4.210 (V.CO2) – 2.962
(V.O2) and fat oxidation = 1.695 (V.O2) – 1.701 (V.CO2).


DIETARY INTAKE ASSESSMENT

To minimize a possible nutritional bias, all participants were instructed to
maintain their accustomed dietary habits throughout the investigation from 3-day
prior to Baseline testing in Week 1 to the completion of the post-testing in
Week 4. No attempt was made to modify the nutrient composition of the
individual’s diets or their total energy intake. However, the participants all
worked for the same organization and were asked to eat breakfast, lunch and
snacks from the cafeteria each day of the intervention. Participants were
instructed to record their dietary intake for 3-day before the Baseline maximal
oxygen uptake test, including 1 weekend day, and for 3-day during the second
week of training (HIITWK2). These 3-day dietary records were analyzed for total
energy intake and for composition of carbohydrates, fats and protein using a
commercially available computer software program (Nutrilog, Marans, France).


BODY COMPOSITION AND ANTHROPOMETRIC ASSESSMENTS

Body composition (body weight, lean mass, and body fat percentage [Fat%]) was
assessed following a 12-h fast with a bioelectrical impedance analysis device
(Tanita model MC780 MA; Tanita Europe B.V., Amsterdam, Netherlands) that has
been previously validated compared to dual-energy x-ray absorptiometry [fat mass
(kg) ICC: 0.88; Lin C: 0.89] (Verney et al., 2016), in compliance with the
manufacturer’s guidelines. Anthropometric assessment included height, hip and
waist circumference. Circumference measurements were evaluated at the same
height and under constant tension by the same tester using a calibrated tape
measure and standardized technique (Bernritter et al., 2011). Participants wore
light shorts and stood with arms crossed and hands tucked under the axillae and
were instructed to relax their abdominal muscles, exhale, and hold their
exhalation throughout each measurement. Measures were taken in duplicate and the
mean value was recorded. These assessments were performed at Baseline and
Post-HIIT.


BLOOD ANALYSES

Blood samples were collected before and after 2 weeks of HIIT, following a 12-h
fasting period. Participants were instructed to avoid alcohol and strenuous
physical activity 48-h before collection. Samples were collected from the
antecubital region into 4 ml ethylenediaminetetraacetic acid (EDTA)
anticoagulant and serum separator tubes (SSTs). Then plasma samples were
immediately transferred to pre-chilled microtubes and SST were immediately
placed in ice and centrifuged at 3000 rpm for 10-min. All samples were stored at
−20°C for later analyses at a commercial laboratory within 2 weeks of the
completion of the training program. Baseline and Post-HIIT samples were analyzed
in a single laboratory session to reduce interassay variation. Glycerol was
analyzed by fluorometric techniques (Randox Laboratories, County Antril, United
Kingdom) (Foster et al., 1978), triglycerides (TGs) (Bucolo and David, 1973) and
non-esterified fatty acids (NEFAs) were analyzed by an enzymatic colorimetric
technique (NEFA kit, Biomnis, Paris, France) by combining acetyl coenzyme A
synthetase and acetyl coenzyme A oxidase. The fasting glucose concentration was
analyzed using the Atellica® CH Glucose Oxidase test (Siemens Healthcare SA,
Renens, Switzerland) (Fossati et al., 1983).


HIGH-INTENSITY INTERVAL TRAINING PROTOCOL (HIIT)

HIIT was performed on Monark cycle ergometers (Monark LC6 novo, Vansbro,
Sweden), three times per week, for 2 weeks. Participants completed all training
sessions at a similar time of day. Two familiarization sessions were completed
prior to the Baseline V.O2max test to allow the participants to become
accustomed to wearing the LOFU device while exercising for 30-min at a low
intensity (RPE 11-12) (Borg, 1982). Training intensity was controlled through
the maximal HR (HRmax) obtained during the maximal oxygen uptake test. The HIIT
protocol was adapted from the training program previously described by Steckling
et al. (2016). All sessions began with a 10-min warm-up at 60% HRmax, included a
cool-down at 60% HRmax and total training session time was 45-min. Sessions 1
and 2 consisted of eight, 2-min intervals at 90% HRmax with 2-min active
recovery at 60% HRmax between each interval. Sessions 3 and 4 consisted of six,
3-min intervals at 90% HRmax with 2-min active recovery at 60% HRmax between
each interval. Sessions 5 and 6 consisted of five, 4-min intervals at 90% HRmax
with 2-min active recovery at 60% HRmax between each interval. All sessions were
supervised by staff.


PARTICIPANT SATISFACTION

At the end of the training period, a self-administrated questionnaire on
customer satisfaction was completed [Client Satisfaction Questionnaire (CSQ-8)]
(Attkisson and Zwick, 1982). The CSQ-8 can be easily scored and consists of
eight items designed to measure client satisfaction with different services.
Each item of the CSQ-8 can be scored from 1 to 4. The final score is calculated
by adding up the individual items’ scores (minimum satisfaction = 8 and maximum
satisfaction = 32).


STATISTICAL ANALYSIS

All data were stored in an electronic database and analyzed using specialized
statistical software (SPSS v20.0, Chicago, IL, United States). Results are
expressed as mean ± standard deviation (SD). Delta change scores were calculated
for body weight, Fat%, muscle mass, V.O2max, hip and waist circumferences, and
all lipid variables from Baseline to Post-HIIT. The normality of distribution
for each variable was tested using the Shapiro–Wilk test. Statistical analysis
was completed using a repeated-measures factorial analysis of variance (ANOVA)
by group (HIITPLA and HIITEXP) and time (Baseline and Post-HIIT). If significant
main effects were observed, a Tukey’s Honest Significant Difference test was
performed as post hoc analysis to further discern differences. When assumptions
of normality or homogeneity of variances were not met, the data was
log-transformed before analysis. Means were then de-transformed back to their
original units. The criteria to interpret the magnitude of effect size was > 0.2
small, > 0.5 moderate, > 0.8 large, and > 1.3 very large (Cohen, 1988;
Rosenthal, 1996). An a priori sample analysis revealed 10 pairs of subjects was
the minimum required in a matched pair design to be able to reject the null
hypothesis that this response difference is zero with probability (power) 0.8.
The Type I error probability associated with this test of this null hypothesis
is 0.05 (G∗Power version 3.1.3, Universität Kiel, Germany). Statistical
significance was accepted at P < 0.05. Correlation analysis was employed to
explore relationships among these change scores.


RESULTS


EXERCISE TESTING SESSIONS

Evaluation of the Lower Limb Maximal Force (Fmax)

Both groups improved their Fmax (HIITEXP: 16.0%; HIITPLA: 14.4%) with no
significant difference between groups (P = 0.77) (Table 1).


MAXIMAL OXYGEN UPTAKE TEST

Table 1
Mean ± SD values for fitness measures at Baseline and following the training
intervention (Post-HIIT) in Placebo (HIITPLA) and Experimental (HIITEXP) groups.

Both groups showed similar improvements in V.O2max (HIITEXP: 13.6%; HIITPLA:
10.4%, P < 0.01) and their MAP (HIITEXP: 10.3%; HIITPLA: 10.0%, P < 0.01),
following the HIIT training program (Table 1). However, no significant
difference was observed between groups in V.O2max (P = 0.72), MAP (P = 0.95) or
HRmax (P = 0.30).


SUBSTRATE OXIDATION ASSESSMENT

Figure 2
Change in RER (mean ± SD) before (Baseline) and after (Post-HIIT) the training
program in Placebo (HIITPLA) and Experimental (HIITEXP) groups. Figure 3
Individual change in RER (mean ± SD) before (Baseline) and after (Post-HIIT) the
training program at 60 W in Placebo (HIITPLA) and Experimental (HIITEXP) groups.
Figure 4
Individual change in RER (mean ± SD) before (Baseline) and after (Post-HIIT) the
training program at 60 W in Placebo (HIITPLA) and Experimental (HIITEXP) groups.

Across all participants, the change in RER (Figure 2) in response to training
was only examined up to 100 W in HIITPLA (n = 10) and in HIITEXP (n = 9), as
many women did not attain a power output greater than 120 W during the Baseline
maximal oxygen uptake test. No significant difference was observed between
groups. However, there was a tendency toward a greater rate of fat oxidation in
HIITEXP following combined HIIT and LOFU at 60 W (Baseline: 0.45 ± 0.03 g min–1
to Post-HIIT: 0.65 ± 0.4 g min–1) (Figure 3) and at 80 W (Baseline: 0.31 ± 0.02
g min–1 to Post-HIIT: 0.41 ± 0.4 g min–1) (Figure 4).


DIETARY INTAKE ASSESSMENT

Table 2
Mean ± SD values for changes in dietary intake at Baseline and during week 2 of
HIIT training program (HIITWK2) in Placebo (HIITPLA) and Experimental (HIITEXP)
groups.

Nutrient intake was similar (P > 0.05) for both groups at Baseline (Table 2).
Results revealed no effect of HIIT (P = 0.29) or difference between groups (P =
0.37) for total calorie intake. However, a significant increase (16.6%, P <
0.05) in CHO intake was observed in HIITPLA, from 46.8 ± 5.9% at Baseline to
54.6 ± 4.4% at HIITWK2. In addition, a significant decrease (17.6%, P < 0.05) in
fat intake was observed in HIITEXP, from 36.3 ± 6.4% at Baseline to 29.9 ± 3.2%
at HIITWK2. No significant difference was observed for protein (P > 0.05)
irrespective of group or period.


BODY COMPOSITION AND ANTHROPOMETRIC ASSESSMENT

Table 3
Mean ± SD values for body composition variables at Baseline and following the
training intervention (Post-HIIT) in Placebo (HIITPLA) and Experimental
(HIITEXP) groups.

Changes in body composition and anthropometric measures are presented in Table
3. There was a significant interaction (group × time) effect for body weight (P
< 0.01), with a significant −1.8% (P < 0.01) decrease in body weight for women
in the HIITEXP group following the HIIT program. This decrease in body weight
led to a decrease of BMI for the HIITEXP group (−1.9%; P < 0.01). No significant
variation in body weight or BMI was observed in HIITPLA group (P > 0.05).
Significant changes in body composition were also observed in the HIITEXP group
only, with a −4.5% (P < 0.01) decrease in Fat%. In comparison, no change (0.2%,
P > 0.05) in Fat% was observed in the HIITPLA group. No difference was noted in
either group for lean mass (P > 0.05). An interaction effect (group × time, P <
0.01) was observed for the hip circumference with a significant decrease for
HIITEXP group (hip: −4.1%, P < 0.01 vs. −0.7%, P > 0.05, for HIITEXP and
HIITPLA, respectively). Moreover, an interaction effect (group × time, P < 0.01)
was observed also for waist circumference with a significant decrease for the
HIITEXP group only (waist: −6.7%, P < 0.01 vs. −0.8%, P > 0.05, for HIITEXP and
HIITPLA, respectively).


BLOOD ANALYSES

Table 4
Mean ± SD values for biochemical assessment at Baseline and following the
training intervention (Post-HIIT) in Placebo (HIITPLA) and Experimental
(HIITEXP) groups.

Changes in biochemical variables are described in Table 4. There was a
significant interaction (group × time) effect for TG (P < 0.05), with a
significant reduction over time for the HIITEXP group only (−29.2% vs. −6.7% for
HIITEXP and HIITPLA, respectively). A significant interaction (group × time)
effect was calculated for NEFA (P < 0.05) with a decrease Post-HIIT for the
HIITEXP group (−33.9% vs. −5.7% for HIITEXP and HIITPLA, respectively). A
significant interaction effect (group × time) for glycerol was recorded (P <
0.05) with a decrease in glycerol concentration for HIITEXP group (−31.1% vs.
−8.4% for HIITEXP and HIITPLA, respectively). A significant interaction was
recorded for fasting glucose (P < 0.05) with a decrease over time for HIITEXP
only (−5.9% vs. 0.6% for HIITEXP and HIITPLA, respectively).




HIGH-INTENSITY INTERVAL TRAINING (HIIT)

The total weekly training duration was ∼135-min and adherence to training was
greater than 95%. The time taken to reach the target heart rate ranged from 20
to 90-s depending on the number of previous efforts completed (Sessions 1 and 2
HIITEXP: 72 ± 28-s; HIITPLA: 78 ± 37-s; Sessions 3 and 4 HIITEXP: 47 ± 19-s;
HIITPLA: 43 ± 24-s; Sessions 5 and 6 HIITEXP: 31 ± 17-s; HIITPLA: 28 ± 19-s).
Finally, HIITEXP and HIITPLA spent about 68.7 ± 10.1% and 69.1 ± 7.9%,
respectively, above 90% HRmax for the total training period.


CHANGE IN SUBJECT SATISFACTION

The completed CSQ-8 was returned by 18 women (9 in each group, HIITEXP and
HIITPLA), thus displaying a response rate of 90%. The median CSQ-8 after the
HIIT program was 29.2 and 16.1 for HIITPLA and HIITEXP, respectively. Thus,
indicating a very high level of satisfaction among women exercising using the
diffuse ultrasound compared with the placebo group of women. 92% of HIITEXP
group would have the procedure performed again compared to only 57% for HIITPLA
group. Moreover, the majority (85%) of women in the HIITEXP group would
recommend the program to a friend, but this was only the case for 50% in the
HIITPLA group. In addition, we observed a significant correlation between the
level of customer satisfaction in HIITEXP group and the reduction of
circumference measurements obtained after the HIIT program (r = −0.88; P <
0.05).


DISCUSSION

The main finding of this study was that HIIT combined with LOFU resulted in a
significant reduction in Fat% (−4.5%). Moreover, this improved body composition
occurred with significant decreases in plasma TG, NEFA and glycerol in the
HIITEXP group compared to the placebo control group. Both groups improved their
fitness level after the HIIT program, as demonstrated by increases in V.O2max,
MAP and Fmax. However, only the experimental group, who trained with LOFU
switched on, had positive changes in body composition, girths and lipid profile.

There is a growing body of evidence to support the efficacy of HIIT to improve
fitness (Batacan et al., 2017). In the current investigation, six HIIT-sessions
over a 2-week period led to significant increases in V.O2max for the previously
untrained women in both HIITPLA and HIITEXP groups. This finding supports the
beneficial effects of short bouts of HIIT on aerobic fitness (Boutcher, 2011)
compared to traditional prolonged steady-state training (Nybo et al., 2010).
Indeed, when 36 untrained men completed a 12-week program consisting of either
intense-interval running (HIIT), strength-training or prolonged steady-state
moderate-intensity running (MICT), the HIIT group reported a 14% increase in
V.O2max (Nybo et al., 2010). While only a 7% improvement in V.O2max was observed
in the MICT group and V.O2max in the strength training group remained unchanged.
It is also noteworthy that HIIT elicited this greater increase in fitness level
despite participants completing just a third of the total training duration
compared to the MICT and strength-training groups. This finding supports the
notion that training intensity is more important than training volume for the
development of cardiorespiratory fitness (Wenger and Bell, 1986). Several other
studies have reported a similar increase in V.O2max in untrained participants to
those observed in the present study. For example, Talanian et al. (2007), used a
similar protocol of 2 weeks of HIIT and reported a 13% increase in V.O2max in
previously untrained women. These improvements in fitness level suggest that a
combination of high training intensities (90% HRmax), short durations of each
bout (4-min) with intermittent recovery periods provide a strong stimulus for
physiological adaptation.

While reductions in fat mass with HIIT have previously been associated with
improvements in the fat oxidation pathway (Astorino et al., 2017), in the
present investigation, there was only a trend toward a decreased RER across a
range of submaximal workloads. This trend was greater in the HIITEXP compared to
the HIITPLA. Prior investigations have linked an improved capacity for fatty
acid oxidation following HIIT to an upregulation of key metabolic enzymes within
the mitochondria and skeletal muscle (Talanian et al., 2007; Burgomaster et al.,
2008; Perry et al., 2008; Boutcher, 2011). This includes a significantly greater
expression of the enzyme 3-hydroxyacyl-coenyme A dehydrogenase (Tremblay et al.,
1994), citrate synthase (Tremblay et al., 1994; Talanian et al., 2007; Perry et
al., 2008), muscle β-hydroxyacyl coenzyme A dehydrogenase (Talanian et al.,
2007, 2010; Perry et al., 2008), and total muscle fatty-acid-binding protein
(Talanian et al., 2007, 2010). Using a comparable number of HIIT sessions
(Katzmarzyk et al., 2001), training volume (10 × 4-min bouts) and intensity (90%
HRmax) to the current study, Talanian et al. (2007) reported a significantly
improved fat oxidation. However, in this study, and others that have found
positive changes in RER, substrate oxidation during exercise was determined
using a different protocol (Burgomaster et al., 2008; Perry et al., 2008;
Talanian et al., 2010). Rather than measuring RER during graded exercise, a
low-intensity prolonged, steady-state bout of exercise was used. This is a
limitation of the current investigation as it is possible that changes may have
been observed if the participants’ RER was assessed over a longer exercise
duration. Conversely, this result may also be explained by the time spent at 90%
of HRmax being insufficient to induce whole-body fat oxidation, compared to
other short-term (2 to 6 weeks) studies (Burgomaster et al., 2008; Perry et al.,
2008).

Similar to the findings in the present study for the HIITEXP group, HIIT has
previously been shown to induce fat loss. For example, Tremblay et al. (1994)
noted a reduction in fat mass after 20 weeks of HIIT. Trapp et al. (2008)
confirmed these results reporting a 2.5 kg reduction in fat mass following a
15-week HIIT program. However, the same positive changes in body fat mass were
not observed in the HIITPLA group. Despite completing the same HIIT program, fat
mass (−1.5%) and body weight were unchanged. Moreover, not all HIIT programs
have induced changes in body mass. A meta-analysis identified that collectively,
short-term (<12 weeks) HIIT showed no effect on body weight and fat mass in
either normal or over-weight populations (Batacan et al., 2017). This suggests
that the addition of the LOFU to a HIIT program contributed to the accelerated
rate of fat loss observed in the HIITEXP group.

The novel part of the present study was to add LOFU to a HIIT program.
Ultrasound devices have emerged with the increasing demand for non-invasive and
safe methods to reduce localized fat (Milanese et al., 2014; Tonucci et al.,
2014). In this technique, a dome shaped transducer emits pulsating low
frequency, low intensity ultrasound waves that are directed onto a small focal
point of unwanted fat tissue. Histological analysis and clinical studies have
shown that this focused ultrasonic energy is released specifically in the target
subcutaneous adipose tissue without causing damage to blood vessels, nerves,
connective tissue, or muscles (Brown et al., 2009). This strong mechanical
stimulus creates cavitation (breakdown of fat cell membranes), leading to
lipolysis in subcutaneous adipose tissue and a reduction of fat deposits
(Milanese et al., 2014; Tonucci et al., 2014). In this context, the reduction in
abdominal fat (i.e., localized adipose tissue) after LOFU is mainly the result
of mechanical disruption of subcutaneous adipocytes. The release of adipose
tissue also leads to a subsequent increase in circulating triglycerides within
the interstitial fluid. It has been suggested that once the mechanically
disturbed triglycerides are released into the circulation, they follow the
normal physiological fat metabolism pathways (Hotta, 2010). Therefore, by
wearing an ultrasound device during exercise, these disrupted fat cells may then
more easily enter the fat oxidation pathway to be metabolized as a fuel source.
This combined with the improved ability to oxidize fat through an augmented
hormonal response at both a systemic (i.e., increases in circulating
catecholemines and insulin sensitivity) (Boutcher, 2011) and local (i.e.,
elevated skeletal muscle irisin) (Archundia-Herrera et al., 2017) level
associated with HIIT demonstrates how the two modalities can have a synergistic
effect on reducing Fat%. Moreover, by having a higher level of circulating free
fatty acids this augmented fat oxidation may also continue during the
post-exercise recovery period (Greer et al., 2015; Wingfield et al., 2015). The
results of the current investigation show strong support for the efficacy of
combined HIIT and LOFU to target localized fat.

Significant reductions in circumferences were observed for the HIITEXP only
(waist: −6.5 ± 1.2 cm; hip: −4.6 ± 0.8 cm). These changes in circumference are
greater than those previously reported using ultrasound in isolation
(Moreno-Moraga et al., 2007; Teitelbaum et al., 2007; Tonucci et al., 2014). For
example, Tonucci et al. (2014) observed significant, but smaller reductions of
∼1.5 cm in the waist circumference, ∼2.1 cm in abdominal circumference and ∼1.9
cm in the umbilical circumference following five sessions (60 days) of
ultrasound therapy in 20 healthy, sedentary females. Moreno-Moraga et al. (2007)
observed a slightly larger 3.95 ± 1.99 cm reduction in circumference following
three sessions (monthly visits) in 30 healthy patients. Although, it should be
noted that these studies used a lower number of LOFU sessions than utilized in
the present investigation. Generally, a reduction in waist circumference is
associated with abdominal obesity and is correlated with both visceral and
subcutaneous fat (Pou et al., 2009). This is in line with the current findings,
where both a reduction in waist circumference and Fat% was observed. Other
studies have also shown similar reductions in fat mass with LOFU treatment
(Milanese et al., 2014; Shek et al., 2016). For instance, Milanese et al. (2014)
completed DXA scans on 28 non-obese women prior to and following a 10-week (2
sessions per week) ultrasound program and found that participants lost an
average of −3.4% fat mass, with a reduction of −3.9% in the trunk. Comparable
results have been observed with HIIT alone, with a significant reductions in
total abdominal and visceral fat mass (Maillard et al., 2018). Nonetheless,
considering the sizeable improvements in body composition observed in the
current investigation, it appears that there is a synergistic effect of HIIT and
LOFU.

A limiting factor of fat oxidation is the release of triglycerides from the
adipose tissue (Purdom et al., 2018). With the mechanical stress induced by the
LOFU belt, this release is artificially stimulated and is no longer regulated by
hormonal or enzymatic factors. HIIT has also been shown to promote increased
levels of circulating free fatty acids during and following exercise (Wingfield
et al., 2015). It is thought that these increases can promote increase fat
oxidation during both exercise and the post-exercise recovery period, leading to
body fat loss and an improved lipid profile (Greer et al., 2015). Indeed, in the
present investigation there was a tendency toward increased fat oxidation and
significant reductions in TG, NEFA, and glycerol concentrations in the HIITEXP
group. While some studies have reported decreases in TG (Elmer et al., 2016) and
NEFA (Salvadori et al., 2014), these results have not been consistently observed
with HIIT (Batacan et al., 2017). There is also limited evidence in the
literature on the impact of LOFU on changes in lipid blood profile as most
investigations focus on measures of body composition. Nonetheless, the
improvement in lipid profile found in the present study following 2 weeks of
exercise is comparable to previous HIIT interventions lasting 8 to 12 weeks
(Wisloff et al., 2007). This similar improvement suggests that using LOFU during
HIIT can promote greater positive changes in lipid blood markers than exercise
alone.

A limitation of this study is that while diet was monitored, it was not strictly
controlled for the duration of the training intervention. Both total caloric and
macronutrient intake can influence fuel utilization during exercise (Fletcher et
al., 2017). Moreover, hunger and hormonal responses were not recorded throughout
the training period. However, due to the similar total energy intake reported in
both groups, we hypothesized that there was no effect of training or LOFU on
appetite or hunger perceptions. Although, an increase in %CHO intake at the end
of the HIIT program was observed for the control group, with no change in body
fat, body weight, or total calorie intake. In this context, an assessment of
eating behaviors may have provided additional insight into their lack of weight
loss. As many aspects of eating behaviors are associated with long-term weight
control and changes in brain areas implicated in appetite control (McFadden et
al., 2013). A deeper understanding of hunger and hormonal responses could have
also provided additional insight into the reasons underlying the significant
decrease in fat intake (−6.4%) in the HIITEXP in the second week of training.
Another limiting factor, was the lack of non-exercise control group to assess
the effects of LOFU in isolation. It would also have been of interest to conduct
follow up testing, 1–2 months post-intervention to determine whether the changes
in body composition and lipid profile were stable. An additional limitation of
the investigation was the use of bioelectrical impedence (BIA) to assess body
composition rather than dual-energy x-ray absorptiometry (DXA). The BIA device
used in the current investigation has been found to be highly correlated with
DXA for measurement of fat mass and Fat% (Verney et al., 2016; Thivel et al.,
2018). However, less agreement has been reported between the BIA and DXA in the
measurement of muscle mass and a lower reliability has been observed with a high
initial body weight (Thivel et al., 2018). As changes in fat mass were the key
parameter and the groups were closely matched when the present study commenced,
BIA was considered a viable and cost-effective alternative to using DXA to
assess body composition. Nonetheless, taken together the collective findings of
the study indicate that the combination of HIIT and LOFU can positively impact
health, fitness, body composition and that further research into the exercise
intervention is warranted.

The high level of satisfaction among women exercising with LOFU further supports
future investigation into the implementation of HIIT and LOFU. In the HIITEXP
group 91.7% would complete the program again compared to only 57.1% for HIITPLA
group. These levels of satisfaction are higher than those reported using LOFU
alone (Tonucci et al., 2014). This may be due to the observable changes in body
composition with combined HIIT and LOFU in a shorter time period. Considering,
previous LOFU studies have provided less LOFU treatments over a longer time
period (Moreno-Moraga et al., 2007; Tonucci et al., 2014). Moreover, the
reduction in circumference measurements was strongly correlated with participant
satisfaction (r = −0.88) in the HIITEXP group. These findings suggest that the
level of satisfaction is high when participants experienced significant
improvements in body composition following a short-term intervention.

In summary, a 2-week, six session HIIT program combined with LOFU was an
efficient strategy to increase fitness level and improve body composition in
sedentary overweight women. Based on the findings of the present study, it
appears that the addition of LOFU to HIIT can further increase the mobilization
of free fatty acids from adipose tissue leading to greater losses in fat mass.
This combined approach also accelerated positive health outcomes, such as an
improved lipid profile and reductions in waist and hip circumference in a
short-term intervention. Further research is required to confirm these novel
findings and optimize the use of this strategy in both men and women.


DATA AVAILABILITY STATEMENT

The datasets generated for this study are available on request to the
corresponding author.


ETHICS STATEMENT

The studies involving human participants were reviewed and approved by the
University of Nice. The patients/participants provided their written informed
consent to participate in this study.


AUTHOR CONTRIBUTIONS

CH designed the research and project management. L-AM and XN collected and
analyzed the data. KS prepared and edited the manuscript.


CONFLICT OF INTEREST

XN is employed by the BESCORED company, which has no link with other companies.

The remaining authors declare that the research was conducted in the absence of
any commercial or financial relationships that could be construed as a potential
conflict of interest.


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